Many Hands Make Light Seen

Updated: Sep 25, 2019


A staggering 1.3 billion people live with a visual impairment worldwide; 36 million of these are completely blind[1]. Visual impairment is debilitating. Yet surprisingly, the effect it has on an individual’s quality of life is not solely dependent on the severity of the impairment. In fact, what if I told you that teamwork had a role to play?


The World Health Organisation suggests two main factors influence the degree of disability experienced by an individual[2]:

  1. How readily eye-care is available, including preventative, therapeutic and rehabilitative treatment.

  2. How well adapted the environment is to the individual, such as ease of accessibility to buildings, transport and information.

It’s no surprise that low-income countries underperform in both factors compared to middle- and high-income countries. Yet approximately 87% of the visually impaired live in low-income countries[3]. Surely if these individuals had equal access to eye-care and an environment adapted to their needs, the severity and impact of their visual impairment could be reduced and their quality of life improved. So how do we achieve this?

A Kenyan community queueing for eyecare services [Photograph courtesy of See Kenya]


It all comes down to teamwork. A collection of dedicated individuals: global leaders, national organisations, and local groups, all working together towards the common goal of improving the accessibility and quality of eye-care worldwide.

The Team


The causes of visual impairment are vast, yet 80% of cases are considered preventable[2].

VISION 2020 is a global initiative formed in 1999 with the aim of eliminating preventable blindness by the year 2020[4]. This was launched by the World Health Organisation (WHO), the specialised health agency of the United Nations (UN). A global organisation established in 1948, the main role of WHO is to direct international public health concerns and lead global health responses[5]. Although its headquarters are in Geneva, it consists of over 7000 employees, in 150 country offices, across six regional offices, within 194 Member States; it clearly holds a prominent position in the global network.

When VISION 2020 was created, WHO delegated the role of promoting the programme to the International Agency for the Prevention of Blindness (IAPB). This is an umbrella organisation established in 1975 to coordinate and lead international blindness prevention. It comprises more than 20 international non-governmental organisations (NGO), all passionate about improving eye-care[4,6]. The outcome? A global team set in motion to begin the transformation of universal eye-care.


VISION 2020 outlines three main goals[4]. For these to be fulfilled, each nation needs a driving force to coordinate change; for the most part, this is the country’s government and its partners. WHO recommends each country invests more money into the prevention and treatment of visual impairment. This is often seen as a financial strain on the country’s resources. However, governments are encouraged to place a greater priority on eye-care and to use funds donated from corporate philanthropy and charity organisations for this purpose[7].

Cataract of right eye [Photograph courtesy of MSD Manuals]

The first goal of VISION 2020 speaks of raising awareness about visual impairments, particularly regarding the causes of avoidable blindness and methods of prevention[4]. For example, cataract represents 51% of global blindness, due to clouding of the lens. However, it could largely be prevented, by reducing its major risk factors of smoking, ultraviolet light exposure, diabetes mellitus and high body mass index[8]. These risk factors are modifiable and therefore population education is crucial. Health promotion should ultimately be directed at encouraging behaviour change to reduce risk exposure and increase uptake of support services[9]. Yet in reality health education should begin in childhood. The most common causes of childhood blindness in low-income countries are vitamin A deficiency, measles, rubella, traditional eye remedies and ophthalmia neonatorum[10]. National eye-care programmes in schools can identify visual impairment early and treat children before irreversible blindness sets in[11,12].

Onchocerciasis [Photograph courtesy of CEH]

The second goal promotes the allocation of resources towards preventative and treatment programmes[4]. For example, Onchocerciasis (“river blindness”) is a disease particularly prevalent in West and Central Africa[13]. The parasite Onchocerca volvulus is transmitted by blackflies of the Simulium species and produces embryonic larvae called microfilariae, which when deposited in internal tissues of the eye, cause bleeding, inflammation and ultimately blindness. Not only is this a health concern, but also an economic issue; productivity in affected regions of the country declines, as inhabitants migrate to avoid the disease. Several programmes have been implemented to target this. The Onchocerciasis Control Programme (OCP) aims to control transmission of parasites, whilst The African Programme for Onchocerciasis Control (APOC) and the Onchocerciasis Elimination Programme in the Americas (OEPA) target treatment of the disease. Ivermectin is a medication effective against Onchocerciasis when taken annually, and therefore these programmes have established community-based Ivermectin treatment plans[13].


The third goal entails three core strategies that each country should strive to implement[4].

The first core strategy is disease control[4]. This involves developing methods to control or treat preventable blindness. For example, vision can be restored in cataract sufferers by surgically replacing the opaque lens with an artificial intraocular lens[8]. However this surgery obviously requires practical resources, such as operating space and instruments, as well as a workforce to perform it.

Testing eye sight [Photograph courtesy of See Kenya]

This is echoed by the second core strategy: development of a workforce[4]. Refractive errors (myopia and hyperopia) make up a large proportion of the visual impairment burden, and more than 25% of these individuals would benefit from optical correction and low vision devices[14]. To provide these devices, a workforce is required. No matter how brilliant a policy or programme may be, it cannot be implemented without manpower[7]. Therefore, in order to provide eye-care services, professionals and volunteers are essential. These personnel require adequate training and support, to develop both practical skills and the psychological resilience to work in these challenging environments. Professionals specialising in eye-care are needed, both from medical and technical backgrounds. This includes ophthalmologists and optometrists to assess eyesight and provide treatment, dispensing opticians and optometry technicians to create visual assistive devices, optics trainers and mentors for the workforce, as well as healthcare nurses to provide eye-care support. General practitioners play an additional valuable role, managing eye disease and other comorbidities affecting the individual’s health. Moreover, midwives and paediatricians provide tailored care for women, mothers and children, ensuring they receive essential treatment and empowering them to feel supported; women and children are often among the most marginalised in society and feel excluded from health services[15]. Administrative staff and general volunteers are also vital to assist with managerial and supportive roles.

Opticard [Photograph courtesy of Dr MT Omer]

The third core strategy is the expansion of infrastructure and technology[4]. This involves building regional infrastructure to improve accessibility to eye-care services, but also includes the promotion of modern technology[7]. Devices, such as fundoscopes, are expensive and there is now a drive to devise low cost equipment for use in low-income countries. In 2017, the concept of Opticard was invented, a plastic card with a light emitting diode (LED), copper wires, 3 Volt button cell and an aperture for direct fundoscopy[16]. It allows visualisation of the fundus either through the naked eye or when attached to a smartphone camera. Not only is this an inexpensive device, but if used with a smartphone, the images can be captured and sent to experts for evaluation and advice[17]. This ensures equality of patient care regardless of the eye-care expertise in that region. Following on from this, a study in 2019 by Song et al.[18] reports a new optical coherence tomography (OCT) system for retinal screening, which is affordable, portable and can be used completely stand-alone. Results showed it had a comparable performance to current more expensive commercial systems. Detecting retinal disease early is crucial to prevent permanent loss of vision and therefore this is a promising development.

Retinal screening using a smartphone [Photograph courtesy of The New Times]


Artificial intelligence (AI) systems have proven to be beneficial when used together with physicians’ clinical skills, particularly in diagnosing eye conditions, such as diabetic retinopathy[19]. Yet it seems they may also aid the diagnosis of other health conditions. A recent study by Yoon et al.[20] reports a possible link between retinal microvasculature changes and small vessel cerebrovascular changes in Alzheimer’s disease. Participants with Alzheimer’s appeared to show reduced macular vessel and perfusion density in the superficial capillary plexus, when compared to the mild cognitive impairment and control groups. This suggests it may be possible to pre-empt the onset of Alzheimer’s using retinal examination. AI systems come at a price however and are often inaccessible for those in low-income countries. With bright minds motivated to improve accessibility to eye-care worldwide, new exciting inventions are now on the rise. Perhaps artificial intelligence should also be regarded as a member of the multi-professional team working within eye-care.


Visual impairment is widespread and disabling for billions of people worldwide. Yet shockingly, most cases could be prevented or treated successfully. It is the inequalities in eye-care provision between countries which stands as a barrier. This needs to change. Teamwork is the driving force behind this change and a coordinated effort is needed from a multi-professional global, national and local level to succeed. VISION 2020, what’s next?


  1. Bourne RRA, Flaxman SR, Braithwaite T, et al. Magnitude, temporal trends, and projections of the global prevalence of blindness and distance and near vision impairment: a systematic review and meta-analysis. Lancet Glob Health. 2017. 5(9):888–97.

  2. World Health Organization. Blindness and vision impairment. Available at: https://www.who.int/en/news-room/fact-sheets/detail/blindness-and-visual-impairment [Accessed 1st Sept 2019].

  3. International Agency for the Prevention of Blindness. 2010 Report. Available at: https://www.iapb.org/wp-content/uploads/State-of-the-World-Sight_2010.pdf [Accessed 1st Sept 2019].

  4. World Health Organization. VISION 2020. Available at: https://www.who.int/blindness/partnerships/vision2020/en/ [Accessed 1st Sept 2019].

  5. World Health Organization. About WHO. Available at: https://www.who.int/about [Accessed 1st Sept 2019].

  6. International Agency for the Prevention of Blindness. About IAPB. Available at: https://www.iapb.org/about-iapb/ [Accessed 1st Sept 2019].

  7. Khanna RC, Marmammula S, Rao GN. International Vision Care: Issues and Approaches. Annu Rev Vis Sci. 2017. 15;3:53-68. doi: 10.1146/annurev-vision-102016-061407.

  8. World Health Organization. Priority eye diseases: Cataract. Available at: https://www.who.int/blindness/causes/priority/en/index1.html [Accessed 1st Sept 2019].

  9. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1856969/

  10. World Health Organization. Priority eye diseases: Childhood blindness. Available at: https://www.who.int/blindness/causes/priority/en/index3.html [Accessed 1st Sept 2019].

  11. Agaji AE, Ezeome IV, Ezeome ER. Evaluation of content and cost of traditional eye medication in a resource-poor country - Implications for eye care practice and policy. Niger J Clin Pract. 2018;21(11):1514-1519. doi: 10.4103/njcp.njcp_201_18.

  12. Burnett AM et al. Interventions to improve school-based eye-care services in low- and middle-income countries: a systematic review. Bull World Health Organ. 2018 1;96(10):682-694D. doi: 10.2471/BLT.18.212332.

  13. World Health Organization. Priority eye diseases: Onchocerciasis. Available at: https://www.who.int/blindness/causes/priority/en/index2.html [Accessed 1st Sept 2019].

  14. World Health Organization. Priority eye diseases: Refractive errors and low vision. Available at: https://www.who.int/blindness/causes/priority/en/index4.html [Accessed 1st Sept 2019].

  15. Pregel A et al. Ensuring universal access to eye health in urban slums in the global south: the case of Bhopal (India). Stud Health Technol Inform. 2016. 229: 302-13. Doi: 10.3233/978-1-61499-684-2-302.

  16. Omer MT, Abbas E. OptiCard: An inexpensive and portable method of bedside direct fundsocopy. J Coll Physicians Surg Pak. 2017. 27(11): 719-721. doi: 2751.

  17. Mohammadopour M et al. Smartphones, tele-ophthalmology, and VISION 2020. Int J Ophthalmol. 2017 18;10(12):1909-1918. doi: 10.18240/ijo.2017.12.19.

  18. Song G, Chu KK, Kim S et al. First clinical application of low-cost OCT. Translational Vision Science & Techology. 2019; 8 (3): 61. doi:10.1167/tvst.8.3.61

  19. Sayres R, Taly A, Rahimy E et al. Using a deep learning algorithm and integrated gradients explanation to assist grading for diabetic retinopathy. Ophthalmology. 2019; 126(4): 552-564.doi: 10.1016/j.ophtha.2018.11.016.

  20. Yoon SP, Grewal DS, Thompson AC et al. Retinal Microvascular and Neurodegenerative Changes in Alzheimer’s Disease and Mild Cognitive Impairment Compared with Control Participants. Opthalmology Retina. 2019; 3(6): 489-499. doi: 10.1016/j.oret.2019.02.002

Written by Lizzy Tan



We are a trainee-led group of anaesthetists, surgeons and obstetricians promoting trainee involvement, education and research in low and middle income countries.