Lions World Sight Day 2009 Lecture

Helping the Blind to SeeLions World Sight Day 2009 Lecture

Helping the Blind to See

In the year 2000, there were 45 million blind people in the world…

By next year (2010), there will be 58 million blind people…

Almost two-thirds of those who are blind are women or young girls…

90% of those who are blind live in developing countries…

ASIA, representing 60% of the world’s population, has the largest burden of

blindness (double that of Africa)…

http://en.wikipedia.org/wiki/Image:World_population.PNG

Asia has the largest burden of blindness

Global Estimate of Visual Impairment(WHO Report 2002)

Blindness in AsiaUp to 20-30 million Asians blind (WHO)

0

200000

400000

600000

800000

1000000

1200000

1400000

195019551960196519701975198019851990199520002005201020152020202520302035204020452050

Year

Population (x1000)

60- 64 65- 79 80+

Aging Asia

Major Causes of World Blindness(WHO Report 2002)

• Lions Club International and the Lions Club International Foundation (LCIF) are leaders in the restoration and preservation of sight.

• SightFirst is LCIF’s flagship sight initiative, and is the only service activity that Lions do world-wide

Lions Clubs International Sight Programs• Sight Programs remain one of Lions Clubs International’s defining causes.

• Lions Clubs International have gained worldwide recognition for work to improve sight :

- Recycle glasses at 17 centers worldwide

- Support Lions Eye Banks, which annually provide - quality eye tissue for 30,000 sight-saving surgeries, medical education and eye research

- Provide eye screening for hundreds of thousands of people every year

- Raise donations through programs like SightFirst and SightFirst II

Lions World Sight Day

• Lions World Sight Day was created to recognize and reinforce the importance of eradicating preventable blindness.

• It is held annually in October during which Lions clubs around the world conduct sight-related projects and programs:

- Collecting eyeglasses

- Conducting vision and diabetic eye screenings

- Planning educational programs to inform communities of the importance of eye health and diseases such as diabetes that can impair sight.

• Google search on “Lions Eye Banks”: 2,170,000 hits

• Lions have been helping eye banks around the world for 65 years

• Currently, there are 71 official Lions Eye Banks worldwide: - Americas: 50 - Europe: 5 - Asia-Pacific: 16

Lions Clubs International Sight Programs

• Lions Clubs International’s Sight Programs focus on fighting the global causes of preventable blindness:

- Cataract

- Glaucoma

- Age-related macular degeneration

- Diabetic eye disease

- Corneal blindness

- River Blindness

- Trachoma

Lions Clubs International SightFirst Program

The Lions SightFirst program was launched in 1989 to initiative the building of comprehensive eye care systems to tackle major causes of blindness and to provide care for the blind and visually impaired.

A total of US$143million was raised from the program throughout the 1990s providing millions of people in the world with the precious gift of sight.

The Lions SightFirst program has restored sight to 7.5 million people through cataract surgeries, prevented serious vision loss for 30 million people, and improved eye care services for hundreds of millions more - expansion of 300 eye centres, upgraded equipment in 372 centres and trained 345,000 eye care professionals in 100 countries

Lions SightFirst program

Lions Clubs International SightFirst Program

Lions Clubs International Key SightFirst initiatives include:

• Lions Eye Health Program (LEHP)- Main SightFirst-funded initiative- Community-based public awareness initiative encouraging early detection and timely

treatment of glaucoma and diabetic eye disease

• River Blindness / Trachoma Control- Supported more than 131 million treatments of

river blindness in Africa and Latin America since 1999.

• Eliminating Avoidable Childhood Blindness- Established 34 need-based Lions eye care

centre in countries around the world- Aimed at delivering preventative therapeutic

and rehabilitative eye care services for 100 million

children

Lions Clubs International SightFirst ProgramLions Clubs International SightFirst initiatives include:

• SightFirst China Action Project Phase I - Supported 2.1 million cataract surgeries in

China- Established surgical eye units in 104 rural

countries- Phase II SightFirst grant of US$15.5million was matched with US$200 million from Chinese government- Additional 3 million cataract surgeries were

performed in Phase II-Secondary eye units at hospitals in 200 under- developed provinces and Tibet

The three-year SightFirst II Program launched in 2005 raised US$203 million to continue to expand Lions’ SightFirst Programs.

Lions Clubs International SightFirst II Program

The Singapore area headed by Past District Governor Charlie Chan assisted by Sector Coordinator Lion Yap Bau Tan and District Coordinator Past District Governor Philip Chua, raised a total of US$400,000 over this period in support of Lions Clubs International SightFirst II program.

Lions Clubs of Singapore’s Sight Initiatives• Lions Clubs of Singapore (District 308-A1) undertakes the role of ‘Knights of the Blind’ through several initiatives:

-‘Gift of Sight’ overseas expedition project lending

assistance to 3rd world countries like Laos, Cambodia and Indonesia by providing used pairs of spectacles to the less fortunate

- Collaborating with other organizations to provide eye

health checks at various community centres and Lions Homes to benefit the elderly

- Donation of Corneas to Singapore Eye Bank for Cornea transplants

Lions Clubs of Singapore’s Sight Initiatives

- Conduct ‘Gift of Sight’ Symposia to educate the community of various blinding eye

diseases and treatment options available

- Sponsor cataract operations for the elderly as well as eye tests and spectacles to needy students

- Collection of used glasses for recycling

80% of blindness is preventable or treatable…

Still, every minute, 12 people around the world go blind…

So far during this talk, 144 people have gone blind…

By the end of this talk, 360 people will have gone blind…

In 2 weeks, 290,000 people, the size of the population in Bedok, will go blind…

Major Causes of Blindness in Singapore

Eye Diseases of the Elderly:

• Cataract• Glaucoma• Diabetes and age-related macular degeneration• Aging Corneal Degeneration

Blindness affects mainly the Elderly in Singapore

All are either treatable, or preventable if detected early

20-25 km

Singapore Malay Eye Study (SiMES)Singapore Indian Chinese Cohort (SICC) Eye Study

10,000 persons of 3 major racial/ethnic groups in Asia aged between 40-80 yrs old

SiMES: • 3,280 Malays • Aug 2004 – June 2006

SICC: • 2,600+ Indians (June 2007-)• Chinese (Nov 2008-)

Half of the Malay Population have low vision in at least one eye; half of these correctable by glasses

Wong TY et al. Arch Ophthalmology 2008

Visual Impairment and Blindness in Singapore

SiMES study:

• 1 in 6 Singapore Malays are visually impaired• In the elderly (70-80 yrs), nearly 1 in 2 are visually impaired• Leading causes of poor vision are fortunately, easily treatable:

- uncorrected refractive errors (glasses): 54.7%- cataract: 36.8%

• Other medical problems detected:- 6 out of 10 Malays have high blood pressure- 1 out of 3 have high cholesterol- 1 in 5 have diabetes

Cataract

• Natural aging of the human lens • Commonest operation performed in Singapore• Highly sophisticated operation using an ultrasound probe • SNEC performs over 10,000 cases a year, with near 100% success)• Cataract should no longer a major cause of blindness in Singapore

Lens implant

Corneal Blindness

• Age-related corneal degeneration (clouding) is the commonest cause of corneal blindness in Singapore, but is largely treatable by corneal transplantation• SNEC has one of the most advanced corneal transplantation programs in the world - our success rate of 94% 1 year graft survival is the highest in the published literature• The Singapore Eye Bank is one of Asia’s top eye banks, but only 40% of corneas come from Singaporean donors - we still need to import corneas

Rising number of corneal transplants grafts in Singapore (1991 to 2008)

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Number of Grafts

'91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08

YearSNEC currently performs 81% of all corneal transplants in Singapore

SNEC leads in developing new forms of Corneal Transplantation

We are global leaders in the 2 new forms of corneal

transplantation: Anterior Lamellar Keratoplasty (ALK) and

Endothelial Keratoplasty (EK) - 10 awards, and over 50

publications, including the 2009 Inaugural President’s Science

Award (PSA)

USA (2008/9) SNEC (2009)PK: 62% 37%EK: 33% 29%ALK: 2% 34%

97%

3%

93%

7%

90%

10%

82%

18%

75%

25%

74%

26%

55%

8%

29%

38%

21%

37%

37%

29%

34%

0%

20%

40%

60%

80%

100%

'91-'94 '95-97 '98-'00 '01-'03 2004 2005 2006 2007 2008

ALKEKPK

SNEC now performs the highest percentage of lamellar surgery globally (69% of cases)

Glaucoma

• Glaucoma is a condition in the elderly in which high eye pressure causes damage to the optic nerve, resulting in permanent blindness• commonest cause of irreversible blindness worldwide: 5.1 million people blind from glaucoma today• “the silent thief of sight” - often painless and only diagnosed too late• another Asian form of glaucoma (angle closure glaucoma) - sudden painful attack causes blindness without little warning signs

normal optic nerve damaged optic nervegradual loss of field of vision

Glaucoma

• 3.2% of all Singaporeans over the age of 50 years have glaucoma• this rises to 10-12% for those over 70 years old• early detection or screening may provide a solution, as we can treat glaucoma with eyedrops, laser treatment or by surgery • blindness from glaucoma can be preventable (Asian form), or treatable (chronic form) by reducing eye pressures or preventing sudden build-up of eye pressure - most come to late when there is already irreversible nerve damage and visual loss

normal optic nerve damaged optic nervegradual loss of field of vision

Diabetic Retinopathy

• Diabetes is a MAJOR cause of blindness globally, especially in Asia• Diabetes causes retinal vessels to leak and bleed, causing blindness • worldwide increase in DM, related to obesity and poor lifestyles • 1 in 3 diabetics here in Singapore have some degree of retinopathy• after 10 years, 50% of diabetics will have retinopathy• after 20 years, 90-100% will have retinopathy

mild retinopathy severe retinopathy endstage retinopathy

Diabetic Retinopathy

• Diabetes affects 8.9% of Singapore’s population (2004 National Health Survey): Indians: 15.3%

Malays: 11%Chinese: 7%

• 28% of Singapore’s elderly population suffer from diabetes • SNEC sees over 7000 new cases of diabetic retinopathy each year

mild retinopathy severe retinopathy endstage retinopathy

(our SiMES study shows that Singapore Malays with poorer blood sugar control have more retinopathy)

Diabetic Retinopathy

• good control of blood sugar levels can prevent diabetic retinopathy progression • diabetic retinopathy is preventable,with early detection and screening• early laser treatment prevents retinal bleeding and visual loss• late disease may still benefit from retinal surgery but this is complex, expensive, and often only partially restores vision

mild retinopathy severe retinopathy endstage retinopathy

Laser treatment prevents blindness

Diabetes Prevalence in Asia Pacific (2007)…increase with lifestyle changes

Sicree, Shaw, Zimmet. Diabetes Atlas. IDF www.idf.org. 2006

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NauruF PolyTongaBruneiMalaysiaSingapore

Fiji

Hong Kong

Macau

Korea (Rep)Philipines

SamoaTaiwanThailand

Guam

N ZealandKorea (DPR)

AustraliaCambodia

Japan

N Caledonia

China

Myanmar

LaoSol Isl

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PNG

VietnamIndonesiaMongolia

Timor

Adults aged 20-79Age-adjusted to world population

%

Sicree, Shaw, Zimmet. Diabetes Atlas. IDF www.idf.org. 2006

SingHealthStatistics of diabetic patients (2008)

Name of Institution

Number of patients who have at least one diabetic related visit

Total number of SOC attendance

Percentage of diabetic patients vs SOC attendances

CGH 19,372 344,719 5.6

KKH 2,588 494,233 0.5

NHC 10,857 98,494 11

SGH 30,196 677,358 4.5

SNEC 16,991 248,277 6.8

SHP 52,104 1,597,055 3.3

SNEC sees almost 17,000 diabetic patients a year

The increasing burden of age-relatedeye diseases in SNEC

Annual increase in patient load:

• Diabetic outpatients visits: 7% increase per annum• Retinal laser treatments: 9% increase per annum• Glaucoma outpatient visits: 4% increase per annum• Cataract surgeries: 5% increase per annum

Healthcare and the effect of our aging population

• Singapore has the second fasting aging population in Asia

• Those over 65 yrs old now account for 8.7% of our population - by 2030, this will rise to 23% - that’s about 900,000 elderly people (1 in 5 Singaporeans)

MOH recognizes that the care of the elderly, who will have the greatest burden of chronic illness is the priority (PM’s National Day Rally Speech)

Frail elderlyWell

RH

CH

NHPolyclinics

FPs Home Care

Rehab & support services

Screening & Prevention

Palliative Care

Primary CareAcute &

Intermediate Care

Long-Term Care

“Care Integrators”

Nurse educators + wellness coordinators

Patient education & empowermentIT Infrastructure

Manpower capability and capacity

Keep people healthy and out of hospitals as long as possible

Healthy ageing

Workplace health promotion

Structured Chronic disease management

Right-site patients

Strengthen clinical governance with non-public providers

Restructure existing clusters to improve integrated care

MOH is reorganising healthcare delivery for continuity of care of the elderly

Proposed Regional Health Services Concept

RH

CH

NHPolyclinics

FPs Home Care

Rehab & support services

Screening & Prevention

Palliative Care

RH

CH

NHPolyclinics

FPs Home Care

Rehab & support services

Screening & Prevention

Palliative Care

RH

CH

NHPolyclinics

FPs Home Care

Rehab & support services

Screening & Prevention

Palliative Care

RH

CH

NHPolyclinics

FPs Home Care

Rehab & support services

Screening & Prevention

Palliative Care

RH

CH

NHPolyclinics

FPs Home Care

Rehab & support services

Screening & Prevention

Palliative Care NUHS

RH

CH

NHPolyclinics

FPs Home Care

Rehab & support services

Screening & Prevention

Palliative Care OUTRAM

How do we change Eye Care in Singapore to meet the demands of our aging population?

Key Concepts for success:

• early screening and detection of major age-related eye diseases prevents visual loss and blindness - detection of disease referred to eye centres and eye depts for early and appropriate treatment (true “sight-saving”)

• step-down facility (right siting) - provision of primary eye care for chronic diseases - mainly for diabetes, glaucoma, but also for cataract and corneal aging

•community-based facilities - located near the community for ease of access - away from SNEC and general hospitals, and near GPs and polyclinics for easy coordination and linkages - bringing eye care to the community

• affordable and cost-effective - training of non-ophthalmologists to run clinics: general physicians (eg GPs), optometrists, advanced nursing practitioners, all extensively trained by SNEC

• holistic medicine approach - counseling, linkages with Singapore Diabetic Society, geriatric care programs - co-management of the elderly patient as a whole

Solving Challenges to Community Eye Care

These key concepts directly address the challenges of community eye care:

• shift some aspects of primary eye care and routine monitoring/screening away from the eye centres and hospital eye departments into the community (right siting)

• who to provide this service? - only 160 expensive ophthalmologists, not enough doctors (3rd med sch) - primary care currently served by GPs and polyclinic doctors (80/20 ratio) - untapped medical manpower - nurses; optometrists (still years away from complete training to provide primary eye care)

• providing high quality yet affordable primary eye care (training and supervision by SNEC)

• primary eye care still requires highly expensive equipment for basic eye exams, and extensive training to diagnose both common and rare diseases

• educating the public that the elderly have chronic, undiagnosed eye problems

The Eye Community Clinic (ECC)

A new concept of delivering primary eye care to the community:

• organized and coordinated by eye institutions (eg SNEC) in Singapore,thus tapping on supervision and expertise of SNEC to train ECC clinic teams

• cooperative involvement of SNEC, MOH, and VWOs (Lions) and other organizations (eg Singapore Diabetic Society)

• self-sustaining by cost-effective utilization of appropriately trained eye care practitioners (eye physician, nurse, optometrist, eye techs)

• supports MOH’s plan of integrated care of care - direct linkages and inter-referrals with:

- national specialist centre (SNEC)- general hospital, community hospital, nursing homes, etc.- primary care physicians (GPs, polyclinics)- VWO support infrastructures (Lions)

• may be stand-alone, co-located with community hospital, nursing home or govt polyclinic, but located to serve one major community/sector of Singapore (eventual need for 2-3 centres island-wide)

Proposed Regional Health Services Concept

RH

CH

NHPolyclinics

FPs Home Care

Rehab & support services

Screening & Prevention

Palliative Care

RH

CH

NHPolyclinics

FPs Home Care

Rehab & support services

Screening & Prevention

Palliative Care

RH

CH

NHPolyclinics

FPs Home Care

Rehab & support services

Screening & Prevention

Palliative Care

RH

CH

NHPolyclinics

FPs Home Care

Rehab & support services

Screening & Prevention

Palliative Care

RH

CH

NHPolyclinics

FPs Home Care

Rehab & support services

Screening & Prevention

Palliative Care NUHS

RH

CH

NHPolyclinics

FPs Home Care

Rehab & support services

Screening & Prevention

Palliative Care OUTRAM

= Eye Community Clinic

Lions SaveSight Centre - the first ECC? The Lions SaveSight Centre (Singapore) LSSC will be set up to provide patients with chronic eye diseases requiring long-term eyecare with quality step-down eye care in the most cost-effective setting to minimize waiting time and costs to these patients, but most importantly, save sight by screening, early diagnosis and referral for treatment to prevent disease progression and visual loss.

The LSSC will provide the following services:

• Detailed History Taking• Visual Acuity Test• Slit Lamp Examination• Diabetic Retinal Photography• Glaucoma Investigations• Periodic Follow-up• Counseling and Care Services

The Lions SaveSight Centre (Singapore) LSSC intends to :

• Establish a centre for the prevention of blindness with strong focus on eye diseases of the elderly, (but also on childhood problems such as myopia)

• Develop diagnostic and prevention of blindness programs primarily for diabetic retinopathy and glaucoma, and also for other age-related diseases such such as cataract and aging corneal diseases

• Create care services, education and training, screening and counseling and research to complement current developments in the prevention of blindness in Singapore, and also in Asia

• Establish eye banking and corneal transplantation programs with links to Lion Clubs International and its network for sight conservation and Lions eye banks, by collaborating with the Asia Cornea Society (ACS) and the Association of Eye Banks of Asia (AEBA), both headquartered in SNEC

• Coordinate outreach prevention of blindness programs

Lions SaveSight Centre - conforms to the ECC concept, and more…

Lions SaveSight Centre

Lions SaveSight Centre (Singapore) Management Board (FY2008-2009)

Chairman Honorary Lion Prof Arthur LimDeputy Chairman Honorary Lion Prof Donald TanSecretary PDG Han Thien FongAssistant Secretary Lion Charity Wai (COO, SNEC)Treasurer Lion Ho Lon GeeDirectors Lion Ho Ching Lin (Glaucoma Snr Con, SNEC)

Lion Richard SeeLion Jenny TanLion Edmund Wong (Retina Snr Con,

SNEC) Lion Yong Chiang Boon (President,

Singapore Diabetic Society)