Image credit: Emily W Gower; from the Community Eye Health Journal article, "Training trichiasis surgeons: ensuring quality"

We are close to eliminating blinding trachoma as a public health issue; however, 7 million trachomatous trichiasis (TT) surgical interventions need to be conducted and that remains a significant obstacle.

Clearly, there is a big demand for high-quality, high-volume surgery and to achieve that we need high-quality training. ‘Head Start’ provides surgical mannequins (soon available on the Standard List) that are a boon to those beginning live training. Before Head Start, people had to practice their technique on oranges and gloves!

A few weeks ago, Peter Ackland, IAPB’s CEO got to try ‘Head Start’. Here’s his story:

“I made a field visit in Ethiopia last year and was pleased to discover that it coincided with a trichiasis training and research programme being conducted on site. A number of nurses were being introduced to the surgical techniques using the Head Start mannequin. The trainers, who over the years had trained many nurses and others to perform the surgery, were enthusiastic about Head Start, a view seemingly shared by the trainees, who clearly appreciated being able to  practice making those first faltering cuts on a model, rather than a living being. The trainers explained to me how by using the mannequin they not only could demonstrate the key steps in the surgical procedure but also judge the manual dexterity of a trainee and how likely that person would be able to go on to perform good quality surgery. Part of the research that was being conducted in this training trial was to look at how the performance of trainees able to use the Head Start mannequin in the early stages of their training performed against others trained without the mannequin. It will be interesting to see the outcome of that research – though it would be surprising if it didn’t confirm the very positive comments I heard from everyone using it for this training programme.

I was kindly offered the opportunity to practice my first ever trichiasis surgery on the mannequin. On observing my technique, if it could have been called such, I was politely informed that it would be best if I didn’t give up the day job just yet.”

The Vula Eye Health mobile app aims to change the way that primary health workers access information, carry out eye tests, connect with specialists and  make referrals. 

Vula is  available on Android and iOS operating systems, and is already being used in five hospitals across South Africa, as well as one hospital in Swaziland. It currently connects 238 nurses and healthcare workers with 26 eye health specialists across these six hospitals. 

“It is very helpful in diagnosing and referring patients,” says Cape Town based Dr Johannes Vos, “it’s very well designed.” 

A recent study has shown that Vula is most effective when it is used by general health workers wanting to get advice from, or make referrals to, eye health specialists like ophthalmologists, ophthalmic nurses and optometrists. The full findings of the study, which was done through Stellenbosch University, will soon be published in a peer-reviewed publication. 

Vula is the brainchild of South African doctor William Mapham, who saw the potential for technology to improve referral networks while working in a hospital in rural Swaziland. “Inefficient referral networks are a drain on resources” says Dr Mapham. “We’re hoping that by applying mobile technologies to this issue, Vula can play a part in improving the way referrals are made and creating more robust health systems.”

Like other mobile health apps, Vula offers its users a library of information. This means that rather than lugging around medical tomes, rural healthcare workers can look up eye conditions on their mobile phone. 

It also allows healthcare workers to capture patient information and carry out eye tests using a smartphone. Sister Le Roux, a nurse from the Eastern Cape who regularly uses Vula, finds this particularly valuable. “Being able to test visual acuity on my phone makes my life so much easier,” she says.

But what really sets Vula apart is its chat function, which allows the healthcare workers making the referral to send photographs and chat directly with an experienced medical specialist. 

The app’s simple design and ituitive interface makes it very easy to use. As Sister Anthonissen, a nurse from Cape Town, South Africa, and a frequent Vula user says “Even somebody who knows nothing about eyes can use this App and will benefit from it.”

Kovin Naidoo, IAPB’s Chair for Africa has this to say: “Many of our people spend countless hours and limited cash resources to access eye care services when referred for further care from primary eye care centers. They often arrive at secondary or tertiary centers to find that the services are unavailable on that day or that the queues are so long that they have to return on another day.” 

He continues, “VULA supports the referral system to ensure that people are sent to the appropriate center and only when they need to. It develops a collaborative relationship between the primary and secondary and tertiary centers and also in the private sector between the various eye and health care practitioners. The ultimate outcome will be savings and better health care for those who have the least resources.”

Download the app from the AppStore or from the Google Play Store. For more informaiton, contact Dylan Edwards: 

During a recent visit to Johannesburg I attended the IAPB Africa Annual Conference, and had the opportunity to meet Dr Irmela Erdmann, Ophthalmologist and CBM West Africa Medical Advisor. Dr Erdmann described to me the dreadful situation that many of the survivors of Ebola were now developing serious complications including uveitis and other eye problems, which if not treated could result in blindness. Research is under way to find out what the connection is with Ebola, but to date the connection is not known.

Fortunately, the eye diseases are treatable and curable, but require urgent and immediate intervention. I was asked to source the following drugs for immediate shipment to Sierra Leone - Atropine Sulfate Ophthalmic Solution 1% 5ml, Prednisolone Acetate Ophthalmic Suspension 1% 5ml and Timolol Eye Drops 0.5% 5ml. I contacted a number of pharmaceutical distributors known to me, and during my negotiations our friends at Aurolab came up with the best deal – a donation of 500 of each of the above-mentioned drugs.

Dr Erdmann was absolutely delighted with this extremely generous offer from Aurolab, and together we put the deal into action and placed the order.

The donated drugs from Aurolab were shipped to Freetown this month and consigned to CBM’s partner organisation in Sierra Leone, Dr John Mattia of the Christian Health Association of Sierra Leone (CHASL). A further order of drugs was ordered from Aurolab at a discounted price which will be shipped later this month.

Dr Erdmann and Dr Mattia passed on their sincere thanks to Aurolab, saying that the “timing was perfect”. On behalf of IAPB, CBM and CHASL, I would like to take this opportunity to thank Mr Vishnu Prasad of Aurolab for the donation of drugs.

The World Health Organization (WHO) estimates that nearly 18 million people are bilaterally blind from cataract in the world, representing almost half of all global cases of blindness. Cataract remains the leading cause of blindness and an important cause of visual impairment across the globe.

A new IAPB essential list is now ready for download - to assemble a limited range of adequate supplies of essential items to perform high quality cataract surgery. Specifically, the list offers equipment suggestions for Extracapsular Cataract Extraction (ECCE), Manual Small Incision Cataract Surgery (MSICS) and Phacoemulsification procedures. These have been calculated for 1000 cataract cases per annum at a base hospital. Quantities can be easily adjusted for different caseloads.

This list provides additional general guidelines to facilitate planning / budgeting. Please note, however, all responsibilities for decisions remain entirely with ophthalmologist, programmes and partners. A number of leading organisations at the cutting-edge of delivering cataract surgical procedures to those in need, have made this essential list possible – our sincere thanks to them (a full list can be found in the document).

IAPB’s Essential Equipment Lists identify equipment and consumables considered essential, minimum requirements to perform high quality medical interventions in eye health contexts. IAPB produces these lists in collaboration with leading experts from around the world and updates them from time to time.

A Sponsor feature
The Henson range of visual field screeners have been used in optometry clinics for the last 30 years and the two current models build on the experience gained over this time to deliver quality devices with software that is appropriate to the modern practice workflow at affordable prices.

Henson 7000
The Henson 7000 is a small, portable, central field screener that utilises supra-threshold screening in single and uniquely, multiple stimulus arrangements allowing the operator to perform a glaucoma screening test on even the frailest of patients. The 7000 uses a sub-set of the Henson 9000 software and its portability has meant that many patients can now be screened on a domiciliary basis where mobility issues prevent them from travelling.

Henson 9000
The Henson 9000 visual field analyser encompasses all of the technology of its predecessors, whilst improving the integration into practice. By coupling the Henson with an external pc or laptop allows greater flexibility and a smaller in-use footprint. It’s compact “back to the wall “design means it can easily be installed into even the smallest test room.

The software controlling the Henson has common elements between all models and has been optimised for glaucoma screening and monitoring. 

Glaucoma screening and monitoring
For the screening, high sensitivity, coupled with full test customisation on a patient by patient basis, allows the specificity of the test to be raised, which helps to prevent false positive results.

The problems previously associated with using full threshold strategies to monitor glaucoma, all stem from the amount of time the test takes and the fact the time increases as the patient’s glaucoma progresses. There is an issue with patient fatigue causing issues towards the end of a longer test, meaning the results are not as sensitive as they could be.

Gains for the patient and practice
The Henson 9000, like its predecessor the 8000, incorporates the ZATA algorithm which offers the same accuracy of testing as the original full threshold program, by using a similar double-crossing staircase technique coupled with the 24-2 test pattern (which is extendable to the 30-2 during the test), with the addition of a testing algorithm which has variable terminating criteria for each test location based on the patient’s responses. This is even further enhanced if prior data is available meaning that a patient being monitored for progression of disease can perform the test well within the normal patient fatigue period usually associated with full threshold testing. The indices provided at the end of the test are industry standard format as is the printout.

Ease of use and reporting
The workflow of the Henson software has been optimised for the convenience of the operator as well as the patient. The functions and user interface are all streamlined to help the operator screen and test patients easily and efficiently. 

The in-built database allows the storage of the patient’s test and the standard-layout PDF format printout allows easy sharing with practice management systems, shared-care schemes or for referrals.

On the technical front, Henson perimeters are designed and manufactured to the highest quality in the UK. They use a solid state degradation free light source, meaning low maintenance costs and, coupled with the ability to connect to a variety of IT hardware, means they are easy to set up and use in a wide variety of testing scenarios.
The Henson 9000 is backed by the Elektron technology worldwide network of distributors and agents and our own service and spare parts network.

Conclusion
The Henson 7000 and 9000 offer the optometric practitioner a high quality, optimised, value for money glaucoma screening and monitoring solution at an affordable price with low maintenance costs.

The following blog-post is by Tom Cornsweet, Chief Scientist, Brien Holden Vision Diagnostics. This is a guest post from the IAPB Blog.

Standard digital fundus cameras form images of the fundus on an image sensor that consists of an array of sensing elements called pixels.  The greater the number of pixels per millimeter of the fundus, the greater the possible resolution of the image, up to a limit which is discussed below.   For example, the greater the pixels per millimeter, the smaller the microaneurysm that can be detected.  A typical image sensor consists of a square array 1,700 pixels on a side, for a total of about 3,000,000 pixels.  That would be called a “three megapixel” camera.  
 
To form a colored image, the pixel array is overlaid with an array of tiny red, green, and blue filters so that, if the fundus is illuminated with white light, that is, light that is a mixture of all wavelengths, the pixels under the red filters form an image from the red wavelengths, the ones under green filters form an image from the green wavelengths, and the blue an image from blue wavelengths.  In effect, the sensor is three separate sensors, one for each color.  The three images are then combined and displayed to form a full color image.
 
The typical color filter array covers half of the pixels with green filters, one fourth with red and the remaining fourth with blue filters.  Therefore, if the sensor is, for example, a 3 megapixel sensor, it is, in effect, a 1.5 megapixel sensor for green (red free) images, and a 0.75 megapixel sensor for the red and blue components of the image.  So the “megapixel” rating of a sensor can be misleading.  (A few fundus cameras collect color images using a technique called “sequential color”.  There, the fundus is illuminated by a red flash, an image is collected, then the fundus is illuminated by a green flash and an image is collected, and finally by a blue flash and an image.  The three separate images are then registered and combined to form a single full color image.  The result is identical with the more usual “simultaneous color” method, but, with sequential color, the full resolution of the sensor is available for each separate color.)
 
Pixel counts can also be misleading in another way.  Many digital image sensors are rectangular, for example 1700 pixels high by 2300 pixels wide, giving a 3.9 megapixel sensor.  However, because fundus images are almost always circular, the effective size of such a sensor is 1700 x 1700 = 2.9 megapixels.
 
Here is a third way in which pixel count can be misleading.  The potential resolution of a fundus image depends not upon the number of pixels in the image sensor but on the number of pixels corresponding to each square millimeter on the fundus.  The larger the area of the fundus in the image, the larger will be the number of pixels needed to achieve any given resolution.  

How Many Pixels Do You Really Need?It is physically impossible for an optical system to be perfect, that is, for an image to be a perfectly sharp representation of the scene.  But even if the optical system of a fundus camera were perfect, the fundus images it produced could not be perfect because the images must be collected through the optics of the patient’s eye, and the imperfections in the optics of even the best eye cause significant blurring.  Because of the blurring caused by the optics of the patient’s eye, there is a point beyond which packing more pixels into the image sensor will not improve image quality, it will simply provide a better image of the blur.  For eyes with very clear media and the very best optical quality, that point is about one pixel for each seven micrometers on the fundus.    For example, for a field of view 20 degrees in diameter, (assuming a square array of pixels and that the diameter of the image equals the length of each side of the sensor), image resolution will improve as the pixel count is increased up to about 0.78 megapixels.  More pixels than that will produce no improvement in the image.  That is for an eye of the very best optical quality.  For a typical “good” eye and a 20 degree field, there is no improvement beyond about .7 megapixels.
 
A procedure called “adaptive optics”, that corrects for some of the imperfections in the eye itself, has recently become commercially available.  This procedure significantly increases the possible resolution of fundus images.  However, it requires a dilated pupil, and at the time of this writing, its instrumentation is expensive and allows only a very small field of view.  
 
The tables below indicate the number of pixels beyond which there will be no improvement in image resolution, for several common field sizes.   It is assumed that the array is square and the diameter of the image equals the length of each side of the sensor; if the array is rectangular or the image does not fill the smaller dimension of the array, the required number of pixels is correspondingly larger.   The figures in the table are also based on the assumption that the image is well focused everywhere in the field of view.  That assumption will be discussed in some detail below.

Keeler Ltd and Volk Optical Inc, in conjunction with Harleys Ltd, recently conducted a three-day training workshop in Nairobi for optometry/ophthalmology students, Ophthalmic Clinic Officers, Bio Medical Engineers, and technical maintenance staff from the Kenyan Ministry of Health (MoH).

 The training included sessions dedicated to product familiarisation and user training, retinoscopy, visual fields, along with maintenance and device training.

Zara Rashid, optometrist, conducted the clinical training elements of the sessions, which were attended by optometry students from Kenya Medical Training College and OCOs from hospitals and clinics from across Kenya. The students thoroughly enjoyed Zara’s lively and fun interactive session. Product training featured a variety of instruments including slit lamps, indirect ophthalmoscopes, Intellipuff hand-held tonometers, and Volk’s Pictor hand-held fundus camera and lenses.

Local representatives from the Fred Hollows Foundation joined MoH engineers for basic product maintenance training and a number of the engineers also conducted more in-depth service training that included re-calibration of applanation tonometers, service and repair of hand-held instruments, slit lamps and Cryo-surgical systems.

Harleys Ltd hosted the three-day event at their excellent conference and training facility located in their offices on Westlands Road, and very kindly provided lunch and refreshments throughout the day for the attendees.

We have been delighted with the positive feedback we have received following on from this event and hope to repeat the activity in 2015.

The International Federation on Ageing (IFA), the International Diabetes Federation (IDF) and IAPB, working in collaboration with the New York Academy of Medicine (NYAM) are trying to gather evidence on knowledge, policies, standards of care, and supportive services for Diabetic Retinopathy and Diabetic Macular Edema across 42 countries.

Phase I used numerous interviews to better understand the level of awareness of: retinopathy as a condition and common complication of diabetes; the access, availability and pathway to retinopathy services; and the existence  and content of relevant governmental policy.

In Phase 2 - the current phase - two sets of surveys (Provider survey or Patient survey) will be implemented to gather statistically significant data to assist in the development of effective governmental policy. IAPB is seeking your valued support and insights in acting as respondents in the completion of a provider or a patient survey. Please also share the survey links (below) with relevant colleagues, organizations and people with diabetes.

Read here for more information on the Survey: New alliance for the global assessment of diabetic retinopathy

Available from : 
Anita Shah, 
 International Centre for Eye Health, 
London School of Hygiene &Tropical Medicine


Please send Anita your full postal address and give details of the institution you work in 

Cost
Free for ophthalmologists in low and middle-income countries. 25 $USD; £15; €20 for ophthalmologists in high income countries.

The Brien Holden Vision Institute is offering a clearance sale for a variety of good quality spectacles! You get a mix box of powers and models. Powers available from +1.00 to +4.00 at a price of approximately US $0.50 (Price excludes shipping and taxes). Actual readymades supplied may differ from pictures, as a variety of styles are available - Purchase them from the Standard List.