1. Global Blindness Nicholas Seeliger, M.D.

2. Global Blindness Distribution of Blindness Distribution of Blindness Cataract Cataract Vitamin A Deficiency Vitamin A Deficiency Tropical Eye Diseases Tropical Eye Diseases

3. Global Blindness Distribution of Blindness Distribution of Blindness 90% of the worlds blind live in the developing world 90% of the worlds blind live in the developing world Over 2/3 rd of the cases are preventable / treatable Over 2/3 rd of the cases are preventable / treatable Every 5 seconds one person goes blind Every 5 seconds one person goes blind Every 1 minutes one child goes blind Every 1 minutes one child goes blind

7. Global Blindness Cataracts and Blindness Cataracts and Blindness Dominating cause of Global Blindness Dominating cause of Global Blindness Reports as high as 50% Reports as high as 50% Estimated 18 million people Estimated 18 million people Treatable at relatively low cost Treatable at relatively low cost Self-sustaining low cost cataract surgery programs exist on the Indian subcontinent Self-sustaining low cost cataract surgery programs exist on the Indian subcontinent Cheap manufacture of intraocular lenses has transformed outcomes Cheap manufacture of intraocular lenses has transformed outcomes

8. Global Blindness Cataracts and Blindness Cataracts and Blindness Cataract Cataract Latin = Waterfall Latin = Waterfall Clouding of crystalline lens Clouding of crystalline lens Varying in degree of opacification Varying in degree of opacification

10. Global Blindness Cataracts Cataracts Recent publications with twins indicated over 50% of risk due to genetics Recent publications with twins indicated over 50% of risk due to genetics Environmental risk is weak Environmental risk is weak Age, UV exposure, diabetes, tobacco, ect. Age, UV exposure, diabetes, tobacco, ect. Drugs Drugs Corticosteriods Corticosteriods ? Zetia ? Zetia Seroquel (CATIE study 2006) Seroquel (CATIE study 2006)

11. Global Blindess Cataracts & Blindness Cataracts & Blindness Increasing numbers blind because of demographics Increasing numbers blind because of demographics Surgeries not keeping up Surgeries not keeping up Treatment is surgical Treatment is surgical ECCE (extracapsular cataract extraction) ECCE (extracapsular cataract extraction) High frequency sounds waves break up lens High frequency sounds waves break up lens Lens removed leaving capsule intact Lens removed leaving capsule intact Lens replaced with plastic lens Lens replaced with plastic lens

13. Global Blindness Cataracts and Blindness Cataracts and Blindness Too few opthalmologists Too few opthalmologists Developed nations: 1/10,000 Developed nations: 1/10,000 Africa: 1/1,000,000 Africa: 1/1,000,000 Similar patterns throughout developing world Similar patterns throughout developing world Brain drain Brain drain

14. Global Blindness Cataracts and Blindness Cataracts and Blindness People’s Republic of China People’s Republic of China 22,000 opthalmologists 22,000 opthalmologists 1/60,000 for total population 1/60,000 for total population Public Health Approach Public Health Approach High-Volume at Low Cost High-Volume at Low Cost

15. Global Blindness Vitamin A Deficiency Vitamin A Deficiency “Xeropthalmia” “Xeropthalmia” Discovered in early 1900’s by McCollum Discovered in early 1900’s by McCollum Forgotten until “rediscovered” by Sommer in 1980’s Forgotten until “rediscovered” by Sommer in 1980’s Now understood as a major cause of childhood blindness and death Now understood as a major cause of childhood blindness and death Systemic features Systemic features Mortality estimated at 1-2.5 million children / year Mortality estimated at 1-2.5 million children / year

16. Global Blindness What is Vitamin A? What is Vitamin A? Retinol, its esters, and retinoic acid Retinol, its esters, and retinoic acid From diet From diet fat-soluble ester in animal and dairy products fat-soluble ester in animal and dairy products also carotene - naturally occuring precursor in certain fruits and veges also carotene - naturally occuring precursor in certain fruits and veges

17. Global Blindness Vitamin A deficiency Vitamin A deficiency Epidemiology Epidemiology Common where poor dietary intake of green leafy veges, eggs, milk Common where poor dietary intake of green leafy veges, eggs, milk Preschool children / pregnant / lactating women most at risk Preschool children / pregnant / lactating women most at risk Estimated 500,000 / year Estimated 500,000 / year Who gets this in the US? Who gets this in the US? CF patients, post-op bowel surgeries, alcoholics, fad diets CF patients, post-op bowel surgeries, alcoholics, fad diets

19. Global Blindness Vitamin A Deficiency Vitamin A Deficiency Results in: Results in: Night Blindness Night Blindness Earliest and most common sign of deficiency Earliest and most common sign of deficiency Rhodopsin dependency on Vit A Rhodopsin dependency on Vit A Conjunctival Xerosis Conjunctival Xerosis Abnormal tear secretion, loss of goblet cells resulting in keratomalacia and corneal scarring Abnormal tear secretion, loss of goblet cells resulting in keratomalacia and corneal scarring Bitot’s spots Bitot’s spots Buildup of keratin debri in the conjuctiva Buildup of keratin debri in the conjuctiva

21. Global Blindness Vitamin A Deficiency Vitamin A Deficiency Systemic Features Systemic Features Abnormal differentiation of epithelial cells Abnormal differentiation of epithelial cells GI tract and Respiratory tract GI tract and Respiratory tract Impair Immunity Impair Immunity Consequences Consequences Increased diarrhea and malnutrition Increased diarrhea and malnutrition Increased death from measles Increased death from measles Increased death from respiratory infections Increased death from respiratory infections

22. Global Blindness Vitamin A Deficiency Vitamin A Deficiency Treatment Treatment High-dose (200,000 IU) 1-2 times / year High-dose (200,000 IU) 1-2 times / year Cost: 0.02$ per capsule Cost: 0.02$ per capsule Food fortification Food fortification Rice, oils, milks, ect. Rice, oils, milks, ect. Vitamin Angels Vitamin Angels http://www.vitaminangels.org/ http://www.vitaminangels.org/

24. Global Blindness Tropical Eye Diseases Tropical Eye Diseases Trachoma Trachoma 3 rd Leading cause of World Blindness 3 rd Leading cause of World Blindness Onchocerciasis Onchocerciasis River Blindness River Blindness 2 nd leading infectious cause 2 nd leading infectious cause Next time … Next time …