Download Xero Clinics

International Ophthalmology 16: 139-145, 1992.
9 1992 Kluwer Academic Publishers. Printed in the Netherlands.
Xerophthalmia clinics in rural eye camps
N.C. Desai*, Sanjiv Desai & Rajiv Desai
Tarabai Desai Eye Hospital, E-22 Shastri Nagar, Jodhpur - 342 001 (Rajasthan) India (* corresponding
author)
Accepted 9 October 1991
Key words: community education, desert, drought as a risk factor, prevalence rate, xerophthalmia clinics
Abstract
Even though the primary prevention of many eye diseases can be effectively incorporated into the existing
pattern of rural eye camps, efforts in this direction are restrained and insubstantial. We describe our
technique and experience in the prevention of xerophthalmia by organising a distinct entity called a
xerophthalmia clinic in our eye camps. The clinic consists of an Ophthalmologist or an Ophthalmic assistant
who will exclusively examine children who come to the eye camp. This is perhaps, the first report on rural
xerophthalmia clinics, in ophthalmic literature. Over a seven year period from 1984 to 1990 we have
conducted 71 xerophthalmia clinics amongst the ninty eye camps organised. A total of 11,370 children were
examined in the xerophthalmia clinic out of which 18.9% were afflicted with the disease. Therapeutic doses
of Vitamin A were administered on the spot to the afflicted and prophylactic doses were administered to the
rest. Intensive health education efforts are made through clinics to effectuate change in dietry habits towards
consumption of locally grown DGLV (Dark Green Leafy Vegetables) like Anthenum, Chenopodium and
Amaranthus. A bipronged offensive consisting of mega-dosing and health education is, for the present and
the foreseeable future, the best strategy to combat xerophthalmia in this desert region. A year by year
breakdown of prevalence rates in the present study shows that in years of severe drought the prevalence of
xerophthalmia increases three fold over the non-drought or mild drought years, thereby demonstrating that
drought is a substantial risk factor in developing countries leading to vitamin A deficiency and xerophthalmia.
Introduction
Xerophthalmia, the generic term for the ocular
manifestations of impaired Vitamin A metabolism,
has been the blinding scourge to countless children
since times immemorable. It is of special interest
and importance in desert regions because it is commonly linked to poor environmental conditions,
poor socio-economic status and poor nutrition.
Night blindness in itself is so common in the desert
region of Western Rajasthan that it has assumed
the proportions of a major endemic disease, being
called 'rathindo' in the vernacular [1]. Several reports originating from this area show a high prevalence of xerophthalmia [2-5]. Therefore it is imperative that something be done to reduce xerophthalmia related blindness. Over the years we had realised that feeding Vitamin A to the handful of
children who strayed into our eye camps would not
help in reducing nutritional blindness. Concerted
efforts would be required to reach out to children in
the village where the eye camp is organised and in
the hamlets surrounding it. A pragmatic solution
would be to attract as many children as possible to
140
N.C. Desai et al.
~ K m l .
~
5t ..L0 ~50
I00IjSOKlnl.
' ..L.
AS
-
-
. . . .
WESTERN RAJASTHAN BOUNDARY
DESERT AREA LINE
Fig. I. The arid plain of western Rajasthan occupies an area of 105,800 square kilometers and has at its heart the Grean Indian Thar
Desert. Low literacy rate, poverty, a harsh sun and poor transport and communication facilities are blatent handicaps.
the eye camp for mass administration of Vitamin A
and treating active disease when present. Thus,
was born the concept of rural xerophthalmia clinics
[6]. This communication describes our experience
of seven years in organising eye camp based xerophthalmia clinics where preventive ophthalmology steps out of its city shoes and goes to work in
outreach areas of the Great Indian Desert of Thar
(Fig. 1).
Materials and method
Western Rajasthan is an arid plain situated at the
western tip of India. Sixty two percent of the total
arid zone in India lies in western Rajasthan, thus
forming the principal arid zone of the country [7].
Nearly half of this region is a desert (Fig. 1) with
poor or no rainfall. The literacy rate is about 16
percent and the population close to eight million
(1981 census). The total number of ophthalmologists in this area is thirty and half of them reside in
Jodhpur city itself. Jodhpur, where our institution
is located, is a big city on the eastern frontier of this
desert land. The city is referred to as the key to the
Desert because it is an important access route for
trade, transport and communication with western
Rajasthan. From this strategic geographical location we cater to the ophthalmic needs of the inhabitants of this vaste inhospitable land. Apart from
hospital based eye care, our mobile outreach unit
organises on an average 12 comprehensive eye
camps annually in the interior of western Rajasthan. The basis of the current communication is
data derived from xerophthalmia clinics organised
in these eye camps.
The xerophthalmia clinic consists of a desk and a
chair set aside in our eye camps for use by an
ophthalmologist or an ophthalmic assistant who
will exclusively examine children below ten years
of age. Although being a part of the camp, the
segregation gives it a distinct identity. While publicizing the eye camp, adequate coverage is given to
this aspect of the camp, emphasising that a 'children's doctor' will be there to examine all children
Xerophthalmia clinics
coming to the camp. The clinic is conducted on the
first two days of the eye camp with the aims of:
- detecting xerophthalmia and instituting a cure,
- feeding a prophylactic megadose of vitamin A to
all children, and
- imparting health education to parents, older
children and community leaders on the role of
DGLV and other vitamin A rich foods in the
prevention of xerophthalmia.
All children attending the clinic are examined with
the aid of a binocular 1.4 X loupe magnifier. The
WHO classification of xerophthalmia [8] is used in
the clinics to detect the severity of the disease. A
history of Nightblindness obtained from parents of
the child is considered as valid evidence of active
xerophthalmia [9] but fundus examination is performed to rule out other causes. Rose Bengal 1% is
used to confirm doubtful areas of xerosis. In cases
showing corneal scarring, history of ocular injury is
excluded before catagorising the scar. Also, all
corneal scars occurring at three to four years of life
are classified as being caused by an episode of
xerophthalmia in the past in all probability [10].
All children attending to the clinic are fed a
standard WHO prophylactic dose of 200,000 IU
vitamin A in pearl form or as a syrup. Children who
have signs of xerophthalmia are instituted the
WHO schedule of vitamin A therapy [8]. Cases
with corneal ulceration or keratomalacia are admitted to the camp and treated appropriately. Children who have been brought to the camp by their
parents are not the only ones who get our attention.
The village school is also brought under the folds of
the xerophthalmia clinic. Each school is visited and
141
a xerophthalmia clinic conducted as described
above. Time permitting, a door to door visit is
made in the village and in surrounding hamlets to
feed vitamin A.
Audio-visual slide presentation is made on the
evening when the camp outpatient is held to educate the masses on the importance of vitamin A rich
foods in the child's diet. The slide presentation is
carried out on the evening of the camp outpatient,
so that the people who have come from other villages can also benefit from it. We have observed
that a large number of children are also attracted by
the slide show. Presented in the vernacular, it
forms an important modality of health inducation
for the young and old alike. Participants involvement in the form of a random quiz on vitamin A,
followed by a question and answer session, is then
conducted to assess the existing knowledge, attitudes and practices of the participants regarding
vitamin A and the impact of these educational activities. A little advanced training on vitamin A is
delivered to community leaders, public health
workers, traditional birth attendents (dais) and
trained birth attendents on the effects and use of
this prosperity vitamin.
Results
In the seven years between 1984 and 1990, ninty
eye camps were organised by our institution.
Amongst these, xerophthalmia clinics were organised in seventy one. A total of 29,344 patients
were treated for various ocular problems in these
Table 1. Profile of xerophthalmia clinics.
Years
Eye camps
Xerophthalmia clinics
Camp O.P.D.
Xerophthalmia O.P.D.
Afflicted children
1984
1985
1986
1987
1988
1989
1990
14
10
11
13
17
6
20
12
9
8
8
12
6
16
4709
2250
3005
2958
4464
2475
4686
703
352
2776
2688
1543
1428
1880
89
41
355
923
309
168
268
(12.4%)
(11.6%)
(12.8%)
(34.3%)
(20.0%)
(11.8%)
(14.2%)
Total
90
71
29344
11370
2153
(18.9%)
142
N.C. Desai et al.
I000
o--o
NUMBER
e--e
PERCENT
71 eye camps. In addition, 11,370 children attended
the xerophthalmia clinic (Table 1). This demonstrates that 38.7 per cent of the total number of
cases we examined in our rural eye camps were
children below ten years of age. Such a large turnover of children at the xerophthalmia clinics reflects upon the increased magnitude of pediatric
ocular morbidity in this region and the concern of
rural parents for the well being of their children.
From those attending the xerophthalmia clinics,
2153 children (Table 1) showed signs and symptoms of xerophthalmia and were at risk of going
blind. This gives a prevalence rate of 18.9% for
xerophthalmia in the rural population. A classification of cases into various grades of xerophthalmia
according to W H O is irrelevent to the theme of the
present study and is not discussed herein.
On the basis of metrological classification of
drought, if drought occurs in more than fourty per
cent of the year, it is classified as a chronically
drought prone area. Based on this criteria most of
western Rajasthan is a chronically drought prone
area [11]. The intensity of drought faced by a region
is denoted by the aridity index of Thornthwaite, Ia,
which is the per cent ratio of annual water defecit to
annual water need [12]. Based on this powerful
indicator, records of the percent frequency of occurrence of droughts of varying intensities in this
region have been documented from 1901 to 1990
and stored at the metrological archives at the Central Arid Zone Research Institute (CAZRI), Jodhpur, India. Analysis of the trend during the last
0
900
m
-4
800
BO
<
=;
700
7o
~:
600
m
u
/
500
X
400
300
z
m
o
x
40
-
//,/
200
I00
0=
60
r-
zo
"-"f-"
,o
,,,l
I
,,r
r
i
I
I
t
r
00
O~
Fig. 2. The year wise prevalence of xerophthalmia in a child
population aged less than 10 years shows a peak of 34.3% in
1987, the year of severe drought in western Rajasthan.
Table 2. Occurrance of drought in western R a j a s t h a n during the period of this study. (Western Rajasthan is divided into five
Geo-political units called 'districts'.)
Year
J o d h p u r district
Jaiselmer district
Barmer district
Pali district
Nagaur district
1984
1985
1986
1987
1988
1989
1990
Mo
Mo
S
S
.
M
Mo
S
S
-
M
M
S
S
Mo
-
Mo
Mo
Mo
S
Mo
Mo
Mo
Mo
-
.
.
.
.
Source: Dept. of Climatology, Central Arid Z o n e Research Institute ( C A Z R I ) , Jodhpur, India.
M = Mild, Mo = Moderate, S = Severe, - No drought (classification based on departure from normal aridity index, I,, in terms of
standard deviation of Ia).
Xerophthalmia clinics
decade (1981 to 1990) shows the highest rate of 4.29
drought years in this decade, indicating this to be
the worst decade as far as droughts in western
Rajasthan are concerned [13].
Table 2 demonstrates the occurrance of drought
in western Rajasthan, in areas where our xerophthalmia clinics were organised. Most of the regions
suffered from moderate to severe drought during
this period. Comparison of year wise prevalence of
xerophthalmia (Table 1 and Fig. 2) against the
background of drought intensity (Table 2) reveals
an interesting relationship. In 1987 there was a
sharp increase in the number of children showing
active lesions. The 923 children with xerophthalmia in this year do not include those cases which
died over time or other factors responsible for attrition. The prevalence of xerophthalmia in this year
was 34.3%. It then dropped in the next year
through 1990 to 14.2 per cent. The sudden upspike
in 1987 was commisurate with the worst drought of
the decade faced by the region at this time (Table 2)
and therefore the consequent three fold rise in
xerophthalmia cases as compared to the preceeding and following years. The implications of these
findings are that in times of severe drought, with
poor agricultural production and economic hardships on the community, a higher incidence of xerophthalmia must be expected.
Discussion
Vitamin A deficiency is a disease of poverty and
ignorance and is rife in desert and semi-arid regions
around the globe where an apalling mix of both
these social evils exist. A high overall prevalence
rate of 14.6 per cent has been reported by one of the
authors from western Rajasthan [3] and corraborated by others [2, 4, 5] which testifies to the
public health importance of this deficiency state.
The prevalence of Bitot spots alone far exceeds
W H O standards [8], it being 1.35 per cent [1],
which is about two and half times the minimum
prevalence rate stipulated by WHO. Data accumulated in the present study indicates a prevalence of
18.9% for xerophthalmia in this desert expanse.
143
The high overall prevalence of xerophthalmia
should be viewed in relation to the perennial
drought existing here. During drought the food
pattern of the inhabitants changes drastically to
ensure survival and there is at least one report from
western Rajasthan which documents that dietry
changes in drought situations produces nightblindness [14].
Sommer in his monograph on xerophthalmia [8]
does not recognize drought as a risk factor leading
to vitamin A deficiency. It has been suggested that
this may be an oversight because drought is unknown in Indonesia where Sommer carried out his
study and that drought should certainly raise the
incidence of xerophthalmia [15]. However this association has never been documented so far. The
current communication, although a camp based
approach, substantiates the association of drought
with an increased incidence of xerophthalmia. We
find a three fold rise in the number of children
showing xerophthalmia during the severe drought
of 1987 (Table 1, Fig. 2). In this year there were
34.3% afflicted children, whereas they averaged
12% in the preceeding years. This data establishes
a positive correlation between drought and xerophthalmia. Similar findings occurred in an independent cross section study carried out in six districts of
Rajasthan during the severe drought of 1987. In
this study the extent of xerophthalmia varied from
5 to 35% in children of the age group 5-15 years
residing in rural areas [16]. A subsequent study
carried out one year later in a desert district surveyed the previous year showed that the prevalence dropped to only 8.0% as against 30% observed earlier [17]. In 1986 and in 1987 the authors of
the present communication observed xerophthalmia associated with protein calorie malnutrition
but in the non-drought years of 1988 to 1990 xerophthalmia per se was documented. The interpretation of this finding is fascinating because it shows
that xerophthalmia due to pure vitamin A deficiency exists in non-drought years and drought contributes by increasing the prevalence of this deficiency by producing overall nutritional deprivation. Recurrent droughts which are characteristic
of this arid region are therefore expected to show
144
N. C. Desai et al.
wide swings in the vitamin A status of the child
population leading to 'epidemics' of xerophthalmia
over a passage of time.
An important contributing factor leading to vitamin A deficiency in this area is the nonavailability
of DGLV and allied foods rich in the vitamin. From
the entire cultivable land mass in this region only
0.049 per cent land is employed to cultivate DGLV
and other vitamin A rich foods which in turn accounts for a mere 0.045 per cent of the total annual
produce [3]. Assuming a linear relationship between availability and consumption of DGLV and
allied foods, whereby enough availability corresponds to increased consumption, it is easy to conclude that the inhabitants of this region do not
consume vitamin A rich foods to the extent which is
nutritionally advisable.
Under such settings the best means to improve
permanently the vitamin A status in a population
would be to improve the dietry habits, a difficult
and time consuming, if not an impossible proposition. But with the overall objective to decrease
xerophthalmia prevalence below 0.5% by the turn
of the centuary, an effective and pragmatic intervention strategy would be mass vitamin A supplimentation to the target population. This approach
is desert regions is also economic and does not
require invasive and prolonged intervention, in a
geographic area where recurrent droughts constantly keep the vitamin A status of a child compromised. Periodic massive dosing of vitamin A has
proved its mettle in clinical trials [18, 19] and is a
concept which will remain viable and result oriented [20, 21] until a sea change in the dietry habits
and programmes for food fortification take roots.
Rural eye camps in developing countries are a
highly successful strategy to curb unnecessary cataract blindness. With the accent in these camps
being primarily on the curative treatment of cataract and Glaucoma, the two leading causes of
blindness in the older population, little is done to
combat ocular diseases at the preventive level.
Within the existing framework of an eye camp,
vitamin A supplimentation in the form of mega
dosing can be easily included with economy of
time, manpower, resources and finances. Thus the
concept of xerophthalmia clinics described in this
communication is a new idea about incorporating a
vitamin A intervention activity within the rural eye
camps which are of proven success. At no extra
expenditure to the organisers the xerophthalmia
clinics offer an important means to prevent and
reduce morbidity and mortality due to vitamin A
deficiency in rural areas. Therefore in our opinion
xerophthalmia clinics must be conducted in all eye
camps in developing countries.
Xerophthalmia clinics go way beyond mere administration of massive vitamin A doses to the
target population. Since they bring the rural parents in direct touch with the ophthalmologist, they
offer an ideal opportunity to impart nutrition education and nutrition rehabilitation which have a far
reaching impact. For instance DGLV like Anthenum, Amaranthus, and Chenopodium grow in wild
abundance in the countryside or comitantly with
the wheat crops as a weed. A popular misconception about these is that people consider them to be
cattle fodder, unfit for human consumption. A
comprehensive message from our team is to adopt
consumption of these food.
Non formal education to the community leaders,
school teachers, PHC workers, traditional (Dais)
and trained birth attendents, practitioners of traditional medicine and the community at large, forms
an essential ingredient of the eye camp based xerophthalmia clinics. Teaching is aimed at understanding and recognising Night-blindness (XN)
and Bitot spots (XIB). These are initial stages in
the disease spectrum and may go unrecognised unless specifically sought after. This is more true for
the former when the child develops an adaptive
mechanism whereby he avoids activity in the evening and feings tiredness or sleep. These two stages
of xerophthalmia have been found to be useful as
screening criteria by school teachers [22] and their
clinical transparancies are repeatedly presented to
the masses in a slide show so that they become
permanently ingrained in their minds and may constantly alert them to spot cases of early vitamin A
deficiency in their own children and others in community and to seek appropriate intervention.
Xerophthalmia clinics
Acknowledgement
T h e a u t h o r s e x t e n d their t h a n k s to Mr. V. M a n g a ,
S e n i o r Scientist, C e n t r a l A r i d Z o n e R e s e a r c h Institute ( C A Z R I ) , J o d h p u r , for access to the metrological data o n d r o u g h t .
References
1. Desai S, Bhatia B. Xerophthalmia- a study in 1736children
of Jodhpur district with reference to their socio-economic
status. Proc Raj Oph Soc 1984; 10: 11-5.
2. Desai NC, Chauhan BS, Qureshi MS, Sharma SR. Eye
disease in primary school children in Jodhpur. Indian J
Ophthalmol 1977; 25(1): 11-2.
3. Desai NC. The xerophthalmia profile in desert regions.
Afr-Asian J Ophthalmol 1986; V(June): 20-2.
4. Sharma RG, Mishra YC, Verma GL, Maheshwari LN,
Sarda R. Survery of ocular diseases in arid zone (Jaiselmer)
with special reference to vitamin A. Indian J Ophthalmol
1983; 31: 42%33.
5. Nair SK, Mishra RK, Charan H. Ocular disorders in school
children - a survey of 10,000 cases. Raj J Ophthal 1987;
12(2): 81-6.
6. Desai NC, Bhargawa G. The xerophthalmia clinic- an
essential appendage to the rural eye camp. Raj J Ophthaltool 1986; 11: 50-2.
7. Ramakrishna YS. Climatic changes in relation to desertification in the Indian arid zone. In: Tewary AK, editor.
Desertification: monitoring and control. 1st ed. Jodhpur:
Scientific Publishers, 1988; 9%113.
8. Sommer A. Field guide to the detection and control of
xerophthalmia. Oeneva: WHO, 1982.
9. Sommer A, Hussaini O, Muhilal. History of Nightblind-
145
hess: A simple tool for xerophthalmia screening. Am J Nutr
1980; 33: 882-7.
10. Ommen HAPC. Nutr rev 1974; 32(6).
I1. Climate and Agriculture. Part IV. National Commission of
Agriculture, Govt of India, Ministry of Agriculture and
Irrigation. New Delhi, 1976.
12. Thornthwaite CW. An approach towards rational classification of climates. Am Geograph 1948; 37(2): 8%100.
13. Ramakrishna YS. Department Chief, Dept of Metrology,
Central Arid Zone Research Institute (CAZRI) [personal
communication[. January 30, 1991.
14. Malhotra SP. Socio-economic structure of population in
arid Rajasthan [monograph] Central Arid Zone Research
Institute (CAZRI) Jodhpur. 1986: 14.
15. Teply L. Xerophthalmia and disater unpreparedness
(drought). Xerophthalmia Club Bulletin 1985; 13: 102.
16. Annual report, Desert Med Research Centre (DMRC).
Jodhpur (India), 1987.
17. Annual report, Desert Med Research Centre (DMRC).
Jodhpur (India), 1988.
18. Djunaedi E, Sommer A, Pandji A, Kusdiono, Taylor HR.
Impact of Vitamin A supplimentation on xerophthalmia - a
randomised controlled community trial. Arch Ophthalmol
1988; 106: 218-22.
19. Sommer A, Tarwotjo I, Djunaedi E, West KP Jr, Loden
AA, Tilden R et al. Impact of Vitamin A supplimentation
on childhood mortality: a randomised controlled community trial. Lancet 1986; 1: 116%73.
20. West KP Jr., Sommer A. Periodic large oral dose of vitamin
A for prevention of vitamin A deficiency and xerosis: a
summary of experience. Washington (DC): Nutrition
Foundation, 1984; IVAGG Report.
21. Swaminathan MC, Susheela TP, Thinmayamma BVS.
Field prophylactic trial with a single annual oral massive
dose of vitamin A. Am J Clin Nutr 1970; 23: 11%22.
22. Desai NC, Lohiya S, Keshan S, Nag K. Xerophthalmia in
school children. Indian Mcd Assoc 1989; 87(9): 20%11.