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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.