COMMUNITY EYE CARE

INTRODUCTION: Prevention of blindness has been integrated within Primary Health Care
system, this current approach signify the importance of eight (8) essential element of Primary
Health Care activities to prevent diseases that may lead to blindness, visual impairment and also
to facilitates referral for sight restoration surgery.

Some children were born either blind or with visual problems due to certain developmental
anomalies, infection, birth injuries or hereditary factors. Others may develop problems as they
grew up, while some adults may experience visual problems or become blind during their
working career or old age. Most of the causes of visual problems world over are preventable
through Promotive, Preventive measures or Curable by basic eye care delivery services.

Due to inadequate eye care eye care skills possessed by health care providers, facilities and
services many people becomes permanently blind or visually impaired.

Without appropriate and timely management, eye problem impose restrictions on the physical,
emotional and social development of those affected. For this reason therefore, upgrading the
skills of community based health workers become an imperative step in reducing the incidence
and prevalence of eye problems.

Element of Primary Health Care

 Immunization: The national programme on immunization (NPI) can result in prevention

of blindness from measles vaccine, Vitamin A supplements. Rubella immunization for
pregnant mother prevent congenital rubella syndrome including blindness.
 Nutrition: Good nutrition with Vitamin A supplementation food products can help in
preventing xerophthalmic and the resultant blindness.
 Water and sanitation: These have direct relevance to the prevention of blindness from
Trachoma where personal hygiene and environmental cleanliness are critical parts of the
SAFE strategy.
 Control of common diseases: Treatment of external eye diseases, Trachoma, and
Onchocerciasis can help to reduce the prevalence of visual loss from eye diseases.
  Reproductive health services: Better care of pregnant women and young child can help
to reduce the prenatal and neonatal childhood blindness.
 Health education: Many causes of blindness can be prevented by eye health education e.g
eye injuries, harmful effect of traditional eye medications and self-medications.
 Essential drugs supply: It is important that drug like tetracycline eye ointment be
available for Trachoma, and other eye infections, Vitamin A capsules for xerophthalmia,
and ivermectin for Onchocerciasis.
 Early diagnosis and prompt management of cases.

Definition: this refers to accessible, acceptable and affordable basic eye care services to
individual, families and communities. It could also define as basic eye services that should be
available and affordable to every individual and families where they live.

Aims: The overall aim of Community Eye Care is to ensure that management of simple eye
problem is accessible, acceptable and affordable to everyone in every community. It is also to
ensure that programmes are put in place to create awareness about how to prevent eye diseases.

Objectives:

i. Provide eye health education to prevent eye diseases, injuries and promote healthy habit.
ii. To promptly recognize common eye problems.
iii. Manage simple eye diseases, offer first aid for eye injuries and appropriate referral of
difficult cases.
iv. Mobilize the community to support and participates in all community eye activities.
v. Conduct periodic education and serving in school for early detection of those with eye
diseases.
vi. Advocate for support from individual groups and organizations.

Essential Component:

Promotive: - Creating awareness, food supply, comprehensive reproductive health services.

Preventive: - Immunization services, provision of adequate supply of safe water and basic
sanitation, control of locally endemic diseases and infection control.
Curative: - Early identification and prompt management of eye related diseases and eye injuries
and provision of essential drugs.

Rehabilitation: - Providing the centre for special care of those with visual impairment.

The success of Community Eye Care Programme will first depend on the following:

 Well trained Primary Health Workers preferably Community Health Practitioners

 Accessibility and availability of PHC system
 Acceptability and patronage of the programme by community members
 Inter-sectoral collaboration.

THE NORMAL EYE

The human eye is round like a ball about one inch or 2.5 cm diameter it is held in a bony socket
(orbital cavity) by muscles and connected in the brain by a nerve called OPTIC NERVE. It is
covered in the front by the upper and lower eye lids, which must open and close properly. The
eyeball is divided into two segments anterior and posterior chamber which are filled with fluids
called aqueous humor in anterior chamber while vitreous humor in the posterior chamber. The
fluids are responsible for maintaining shape and pressure.

The human eye is roughly spherical in shape. It is bounded by three distinct layers of tissue. The
outer layer, the Sclera/sclerotic coat, is extremely tough. It is white in colour (the “white" of the
eye) except in the front. Here it forms the transparent cornea, which admits light into the interior
of the eye and bends the light rays so that they can be brought to a focus. The surface of the
cornea is kept moist and dust-free by the secretion from the tear glands.

The eye ball consists of three (3) major layers:

 A protective layer: Cornea and Sclera.

 A middle vascular layer: (Uvea) Iris, Ciliary body and Choroid.
 An inner visual layer: Retina and optic nerve.
The four (4) Section of the eye

1. The protective coat consist of:

i. Sclera
ii. Cornea
iii. Aqueous
iv. Lens

2. Vascular layer consist of:

i. Iris
ii. Ciliary body
iii. Choroid
3. Visual layer :
i. Retina
ii. Optic nerve
4. Other contents are:
i. Aqueous humor
ii. Vitreous body

Outer part of the eye and its functions

Outer part

• Eyebrow which prevents the sweat from the forehead

• Eyelids which cover the eyes when not in use

• Eyelashes which catch dirt to prevent it from getting into the eyes

Visible part

• Cornea is the outer layer of an eye. It is thin and transparent.

• Iris lies behind the cornea and it is the coloured part of the eye

• Pupil controls the amount of light that enters the eye. It is black and round.

• Aqueous humor is a thick liquid that nourishes the bloodless, transparent cornea and the lens

Inner part

• Vitreous humor is a thick substance between the lens and the retina

• Retina is the innermost layer of the eyeball situated behind the vitreous humor.

• Optic nerve is the nerve cell that joins at the back of the retina. It sends message to the brain.

Diagram: Draw the cross section of the normal eye

Simple description of the eye layers

The Cornea: Is the clear cover in the front of the eye. It covers the colored part of the eye, called
the iris. The cornea focuses light into the eye.

The Sclera: This is the outer layer and is about one millimeter thick; it is composed by white
fibrous tissue given strength and support the eye ball from the front part.

The Conjunctivae: The conjunctivae is a clear or transparent membrane covering the front of
the sclera and folds over to line the inner part of the eye lids.

The Iris: Iris is attached to the central fringe of the ciliary muscles and is the colored part of the
eye; it forms a ciliary screen in front of the lens and is responsible for controlling the amount of
light entering the eye.

The Choroid: This is very thin layer, situated at middle coat of the eye; consist of dense net-
work of capillaries. It extends to the margin of the cornea, where it is joined to the ciliary body.
The Ciliary body: Is mainly muscular and circular consisting of 2 sets of fibres on in front of
the other. The posterior set is called the ciliary body is responsible for changing the thickness of
the lens so that light rays are to near vision and vis – a – vis.

The Pupil: This refers to the black round portion in the center of the iris, which controls the
amount of light entering the eye. In dim or dark areas the pupil dilates to let more light into the
eye, while in the bright light areas, the pupil constricts to let in less light (responsible for
adequate and proper light accommodation).

Anterior Chamber: Is located behind the cornea but in front of lens. It contains the clear fluids
called aqueous fluids, which escapes from the eye through small openings at the base of the iris
and cornea called the angle of the anterior chamber. This really helps to control the pressure
inside the eye.

The Lens: Is suspended behind the iris and pupil by the suspensory ligament attached to the
ciliary body. The lens focuses the light onto the retina.

Vitreous humor: The vitreous is a clear thick jelly – like liquid that fills the space between the
lens and the retina. Its help to give the eye ball round shape.

The Retina: The retina is the inner lining of the back portion of the eye ball; it can be seen with
the aid of a special instrument e.g ophthalmoscope. Retina contains the rods, cones and nerve.
The rod and cones respond to light and color. The rods helps individual to see at night while the
cones are essential for seeing things in details and also for seen colors. They carry sensation of
sight (an information of what eye sees) from the retina to brain. They leave the eye in the optic
nerve which connects the eye to the brain.

Eye lids and lacrimal system: The eyelids have the eyelashes that are directed away from the
globe. The eyelids have special muscles (orbicularies) for closure of the eyes and (levator
palpebrae superioris) for opening of the eyes, they cover the conjunctiva and with each blink
clean dust and other particles from the eye and moisten it with tears.
The eyelashes keep small objects from getting into the eye by trapping them. On the medial side
of each eyelid is a tiny opening called the punctum, the tears produced by the tear gland enter
into the punctum and drain through the tear passages.

Extrinsic muscles of the eye

For the human eye to function and move correctly, six muscles must work in union to provide
three-dimensional vision. The six muscles of the eye are:

• Superior rectus

• Medial rectus

• Lateral rectus

• Inferior rectus

• Superior oblique

• Inferior oblique

How the Eye Muscles Work

The eye muscles work in pairs and movement of the eye muscle is often only a very small
movement, a fraction of a degree. The muscles need to be coordinated for vision to be
stereoscopic (three-dimensional vision). For example, if you look to the left, the lateral rectus
muscle on the left side of your left eye contracts. At the same time, on the right side of the same
eye, the medial rectus relaxes.
Which Muscles Control Which Movements

• Lateral rectus and medial rectus control left and right movements

• Superior rectus and inferior rectus control up and down and medial movements

• Superior oblique and inferior oblique control up and down and outward movements

The four rectus muscles are attached at one end to a fibrous ring that encircles the optic nerve,
and the other end of these muscles attaches to the sclera, midline, or widest part of the eyeball.
The superior oblique muscle attaches at one end to the optic foreman (the passage through the
orbit of the eye), through the trochlea; a pulley-like 23 structure attached to the frontal bone (the
upper part of each orbit) and the other end to the top part of the eyeball.

These muscles form a ‘cone’ within the orbit. The inferior oblique muscle, however, passes
under the eye, near the floor of the orbit, and is attached to the eyeball (sclera) in between the
superior rectus and lateral rectus.

Common causes of visual impairment and blindness

 Cataract
 Trachoma
 Glaucoma
 Onchocerciasis
 Conjunctivitis
 Ophthalmia neonatorum
 Refractive errors
 Xerophthalmia due poor nutrition (Vitamin A deficiency)
 Infectious diseases e.g Measles, leprosy e.t.c
 Other medical condition e.g Diabetes Myelitis
  Harmful traditional practices
 Trauma/accident (leads to corneal opacity)
 Congenital abnormalities
 Old age

Blindness: According to W.H.O blindness refers to any vision that is less than 3/60 to NPL with
all possible correction in the better eye.

Visual acuity: This refers to the procedure rendered when measuring or testing to know how
well an eye can see both at far and near distance. Distance vision is been measured at 6 meters
away from patient while near vision at 33 cm.

Trachoma

Definition: Trachoma is a serious chronic infection of the conjunctiva (a contagious condition)

caused by bacterium Chlamydia Trachomatis. It is the greatest single cause of preventable
blindness world over.

Initial Sign and Symptoms:

- Inflamed conjunctiva
- Reddened/pink eye
- Irritation and gritty sensation
- Swelling of lymph nodes in front of the ears
- Turn in/misdirected eyelashes
- Slight yellowish discharge
- Excessive lacrimation
- Sensitivity to bright light

Incubation period: 5 to 12 days after which the infected person begins to experiences its
symptoms.

Features of its grading: Several stages can occur simultaneously:

 Stage I: Trachomatous inflammation follicles (TF) this is the presence of 5 or more

follicles in the upper tarsal conjunctiva, the follicles are whitish, grey or yellow elevation
and paler than the surrounding conjunctiva.
 Stage II: Trachomatous inflammation intense (TI) the upper tarsal conjunctiva is red,
rough and thickened. The blood vessels normally visible, are masked by a diffuse
inflammatory infiltration or follicles.
 Stage III: Trachomatous scarring (TS) follicles disappear, leaving scars; the scars are
white lines bands or patches in the tarsal conjunctiva.
 Stage IV: Trachoma Trachiasis (TT) due to multiple scars, the margin of the eyelids
turns inwards (entropion); the eyelashes rub on the cornea and cause ulceration and
chronic inflammation.
 Stage V: Trachoma or Corneal opacity (TO or CO) this is situation were by cornea
gradually loses its transparency and becomes opaque resulting to visual impairment and
subsequent blindness.

Trachoma is common in the areas with:

 Lack/poor water supply and sanitation

 Overcrowding, poor personal hygiene and excess flies
 Lack/inadequate health/eye care services
 Trachiasis in adults and active infection in children
 Poverty and low level of education

Mode of transmission:

 Through direct contact with eye, nose and throat secretion of the infected person
 Contact with fomites agents e.g towels, hand kerchief, eye kajal e.t.c
 Mechanical transmission e.g flies
  Cross infection e.g infected mother to child

Prevention and control measures: SAFE strategy is recommended by World Health

Organisation (W.H.O):

S – Surgery for (TT) to correct advanced stages of the disease.

A – Antibiotic for (TF and TI) e.g Azithromycin to treat the infection.

F – Facial cleanliness reduces disease transmission.

E – Environmental and water sanitation, to control flies and improved personal hygiene

Note: Successful intervention programme requires active participation of communities; they are
to be involved from planning phase up to the implementation stage.

Treatment:

 Stage I and II:

o Cleans eye and face several time per day
o Antibiotic therapy e.g Azithromycin per oral (PO) children over 6months or over
6Kg 20mg/Kg a single dose while Adults 1g start then apply occ. TCN
 Stage III: No treatment
 Stage IV: Surgical treatment for correction of trachiasis
 Stage V: No treatment

CONJUNCTIVITIS

Conjunctivitis is an acute inflammation of the conjunctiva usually caused by viruses, bacteria,

allergy, irritation or foreign body. Endemic or epidemic conjunctivitis may be associated with
measles or rhinopharyngitis in children. In the absence of hygiene and effective treatment
secondary bacterial infection may develop, affecting the cornea (keratitis) and leading to
blindness.

General Clinical Features

- Redness
- Irritation
- Photophobia
- Pain
- Swelling of the eyelid
- Lacrimation

The specific features is depending on the course e.g

 Bacterial conjunctivitis present with:

o Abundant and purulent secretion
o Eyelids stuck together on waking
o Unilateral infection at on set
 Viral conjunctivitis present with:
o Watery (serous) secretion
o No itching
 Allergic conjunctivitis present with:
o Excessive lacrimation
o Eyelids oedema
o Intense itching

Treatment

There is no known specific treatment, the condition is self-limiting and can be treated
symptomatically. Hot compress can be applied to the infected lid to relief swelling and pain,
analgesic can be administered.

Treatment of conjunctivitis depends on the cause. The eyelids should be gently bathed with clean
water of cloth to keep them clean and free of discharge.

 Bacterial conjunctivitis:
o Clean eye 4 to 6 times per day with boiled water or 0.9% sodium chloride
(hypertonic solution)
 o Apply 1% occ. TCN 12hrly into both eye for 7days
o Never use corticosteroid Gutt or occ.
 Viral conjunctivitis:
o Clean eyes 4 to 6 times per day with boiled water or 0.9% sodium chloride
(hypertonic solution)
o Apply local antibiotic if there is a (risk) of secondary bacterial infection (as
above)
 Allergic conjunctivitis:
o Local treatment as for viral conjunctivitis
o Antihistamine for 1 to 3 days

Note: in the event of a foreign body (injury) occur check tetanus immunization status.

Ophthalmia neonatorum

Ophthalmia neonatorum is the infection of the conjunctiva of the newborn which occur during
the first 28 days of a baby’s life. The disease is affecting the baby through birth canal of infected
mother or through unhygienic way of handling the baby, if care is not been taken immediately it
could lead to corneal perforation as complication and later blindness.

Causative organism: bacterial (Staphylococci)

Clinical manifestation

 Chemosed
 Purulent discharge or milky pus
 Swelling of the eyelid
 Redness of the conjunctiva

Management

 Irrigation – wash properly with sterilized syringe and cotton wool.

 Intensive Penicillin – dilute crystalline penicillin with 2mls of water for injection;
withdraw 1ml add into 49mls of water for injection to make 50mls of the solution.
 Procedure of administering the solution

 1 drop every 1 minute for 5 minutes

 1 drop every 5 minutes for 15 minutes
 1 drop every 15 minutes for 30 minutes
 1 drop every 30 minutes for 1 hour
 1 drop every 1 hour for 24 hours

Then continue with Gutt CPL 6hrly x 12 hours or Gutt Gentalek 1 drop q8h x 1/52

Occ. CPL or TCN at night x 2/52

Prevention and control measures

 Mass public mobilization about STI’s

 Proper screening of all expectant mothers
 Prompt treatment of infected mothers
 Ensure hygienic way of attending delivery
 Clean eyes of newborn as soon as the head is delivered
 Apply antibiotic preferably occ. TCN 1% before the eyes newborn are opened
 Discourage traditional practices in this regards

Hordeolum external (Stye)

Stye is an infection usually a staphylococcal infection of one or more of the glands at the edge of
the eyelid or under it. An abscess forms and tends to rupture, releasing a small amount of pus.
Stye sometimes forms simultaneously with or as a result of blepharitis (inflammation of eyelid).
A person may have one or two styes in a lifetime but some people develop them repeadly.

Sign and symptoms

  Swelling of the eyelid
 Redness
 Pain and possible discharge
 Non-malignant tumor (boil formation) at the root of eyelashes

Management

 Improve personal hygiene

 Hot compress to dilate the blood vessels
 Remove the affected eyelashes
 Antibiotic e.g occ. TCN 1%
 Simple analgesic

Hordeolum internal (chalazion)

Chalazion is an enlargement of a long thin oil gland in the eyelid that results from an obstruction
of the gland opening at the edge of the eyelid. It characterized with painless swelling found in the
upper and lower away from the eyelid but within eyelashes at first it resemble stye a few days the
symptoms disappear leaving the round painless in the eyelid that growth slowly for the first
week. A red or grey area may develop underneath the eyelid (more to the cornea).

Most chalazion disappears without treatment after a few months. If hot compress are applied
several times a day, they may disappear sooner.

Further management involved

 Incision and curettage (I & C)

 Incision and drainage (I & D)

Non-cancerous growths: Two kind of non-cancerous (benign) growths can develop on the
conjunctiva. A Pinguecula, and Pterygium.
  Pinguecula: A raised yellowish – white growth in the vulva conjunctiva next to the
cornea, caused by elastic degeneration. Is unsightly but generally doesn’t cause any
serious problem and needn’t be removed.
 Pterygium: This refers to a whitish, triangular growth of fibro vascular tissue extending
slowly from the fornix conjunctiva (medial cantus) to the cornea. It occurs most
frequently in patients who are exposed to wind, dust or rid climate and never disappear
spontaneously, the fleshy growth may spread across the cornea and distort its sharpness.
Possibly causing astigmatism (irregular curvature of cornea) and other visual changes. It
looks apex and base.

Clinical features and treatment (Two stages)

 Benign Pterygium develops slowly/ does not reach the pupil: No treatment
 Progressive vascularized Pterygium: Red and inflamed growth covers the pupil and may
impair vision.
o Clean eye with sterile water or 0.9% sodium chloride
o Surgical removal if skills and facilities are available preferably by an eye doctor
(ophthalmologist)

Cataract

Cataract is the condition when the normal crystalline lens of the eye loses its transparency and
becomes opaque. It makes the central hole in the eye (pupil) looks whitish or grey causes gradual
loss of vision and later blindness, the most interesting things about blindness from cataract is that
such blindness is reversible.

Causes

 Harmful traditional medication and other undue practices to the eye.

 Congenital
 Prolong use of drugs contains steroid
 Diabetes mellitus
 Trauma and eye injuries
 Aged
 Under nutrition

Treatment: Surgery is only treatment i.e

 intra-capsular cataract extraction (I C C E)

 extra-capsular cataract extraction (E C C E)