Gangguan Penglihatan dan

Kebutaan
Trilaksana Nugroho
Sub-Dept Oftalmologi Komunitas
Dept. I.K. Mata FK Undip
 Pendahuluan
• Outline:
– Preventive ophthalmology
– Blindness
– Low Vision
 Millennium Development Goals
1. Eradicate extreme poverty and hunger
2. Achieve universal primary education
3. Promote gender equality and empower women
4. Reduce child mortality
5. Improve maternal health
6. Combat HIV/AIDS, malaria, and other diseases
7. Ensure environmental sustainability
8. Develop global partnership for development
 Besaran Masalah Kesehatan Mata
• Pembangunan kesehatan  peningkatan SDM
• Mata merupakan “jendela dunia”  jalur informasi
utama (83%)
• “Vision 2020  The Right to Sight”
• Program2:
– promosi kesehatan
– penanggulangan / yankes yg bermutu & terjangkau
– penggalangan kemitraan
 Prevalensi Kebutaan (Survey Kes Indra
Penglihatan & Pendengaran 1993 – 1996)

• Gangguan penglihatan berat 1,1%

• Gangguan penglihatan sedang 1,8%
• Angka kebutaan Indonesia 1,5%
• Penyebab kebutaan:
1. Katarak 0,78%
2. Glaukoma 0,20%
3. Kel Refraksi 0,14%
4. Kel Retina 0,13%
5. Kornea 0,10%
6. Lain-lain 0,15%
 Besaran Masalah GPK
• Survey Indera Penglihatan dan Pendengaran
1993 – 1996  angka kebutaan Indonesia
1,5%
• Bangladesh 1%, India 0,7%, Thailand 0,3%
• Jika ada 12 org di dunia mjd buta / jamnya 
4 org dr Asia Tenggara dan salah satunya pasti
dr Indonesia
 Besaran Masalah GPK …lanj
• Depkes RI (2000), pyb utama kebutaan:
– Katarak (0,78%), glaukoma (0,12%), kel refraksi (0,14%),
penyakit lain usila / degeneratif (0,38%)
– Angka katarak ~ peningkatan jml usila  th 2000 7,4%
(15,3 juta)  th 2025 peningkatan 414% dibanding 1990
– Indonesia (tropis)  15 th lbh cpt mnderita katarak  16%
- 22% diopx pd usia <56th
• Insidensi katarak Indonesia 0,1%  210 rb kasus
baru / th  kemampuan opx hanya 80 rb / th 
backlog
 Besaran Masalah GPK …lanj
• Hellen Keller International (1998):
– 10 jt balita defisiensi Vit A subklinis, 60rb Bitot’s
spot (+) (Xerophthalmia)
• 10% dari 68jt anak sekolah Indonesia
menderita kelainan refraksi  hy 12,5% yang
mendptkan kcmt koreksi

INTELEKTUALITAS & KUALITAS HIDUP

RENDAH pd Generasi Muda Indonesia
 Preventive Ophthalmology
• Logic in concept, not easy in practice
• Must be effective and acceptable to the target
population
• There must be cooperation among all segments
of society (not just the medical community)
• Major avenue:
– ocular injuries and infections, genetic and systemic
diseases with ocular involvement
– ocular diseases in which the early treatable stages
that unrecognized or ignored
 Prevention of Ocular Injuries #1
• One eye – both eyes
• Sight-threatening – not
• Young men and children are particularly
• Occupational - Nonoccupational Injuries
• Grinding or drilling  cornea or sclera 
penetrating the globe!
• Welding arcs  epithelial keratitis ("arc eye")
• Industrial chemical (high acid / alkalic)  serious
–bilateral ocular damaged  poor visual
outcome
• Chronic exposure of nuclear  rapid cataract
 Prevention of Ocular Injuries #2
• Must be:
– Workers  properly trained , assume that they are at
risk of injury
– Safety guards  fitted to all machinery  google
• Early recognition and urgent expert
ophthalmologic assessment of any injuries
sustained is essential.
• Chemical injuries  immediate copious lavage of
the eyes with sterile water/saline or tap water for
at least 5 minutes is the most important method!
 Prevention of Ocular Injuries #3
• Unexplained visual loss or intraocular
inflammation  accurate history is crucial 
occult intraocular foreign body!!!
• Traffic accident  seat belt
• Sports  plastic protective glass
• Home  bottle caps / corks, sharp injury
(scissors, pencils)
• Violent assaults, domestic violence, bombing
 Prevention of Ocular Injuries #4
• Ultraviolet irradiation:
– Acute keratitis (arc eye)  welding arc, skiing
– Pterygium, BCC  u.v protective filter / cream
– Long term  cataract, ARMD  still debate
• Phakic vs aphakic / pseudophakic eye
• Aging vs acquired
• Sunglasses / IOL with u.v filter
• Solar retinitis (eclipse retinopathy):
– young people under the influence of drugs.
– thermal burn  retinal / macular edema  atrophy of the
tissue
– Surest & safest way  TV
– operating microscope (u.v, blue light)  filter, corneal light
barrier, air injecton into a.c
Prevention of Acquired Ocular Infection #1

• Infections  major cause of preventable ocular

morbidity
• maintenance of the integrity of the normal
barriers
• Corneal & conjunctival epithelium  major
barriers
• Damaged:
– Direct / primary  trauma (surgical trauma, contact
lens, chemical, etc)
– Secondary  lid abnormalities, tear deficiency, 5th
and 7th nerve dysfunction  corneal protection
 Prevention of Acquired Ocular
Infection #2
• Infection after intraocular surgery:
– Preoperatively prevention  aseptic, prophylactic AB
in case of emmergency
– In elective surgery without any identifiable external
acular disease  prophylactic AB is still debate
– Staphylococcus epidermidis (from eyelid) is the major
causes of endophthalmitis after cataract surgery
– More important  sterility of surgery field,
medication, fluid, instrument
 Prevention of Acquired Ocular
Infection #3
• Contact lens wear:
– strongly associated with suppurative keratitis
– especially with extended wear
– low refractive errors  disposable lenses
– preservatives within the contact lens solutions  toxic
reactions
– preservatives free solution  pseudomonas and
acanthamoeba
– meticulous contact lens hygiene, keep a pair of spectacles
– In developing countries:
• CL is uncommon, trauma is most (agriculture)
• Corneal abrasion  bacterial & fungal infection  AB Eoint, 3 x, is
appropriate
 Prevention of Acquired Ocular
Infection #4
• Neonatal conjunctivitis:
– poorly developed immune mechanisms of the
neonatal eye
– Neisseria gonorrhoeae, chlamydiae, herpes simplex,
Staphylococcus aureus, haemophilus species, and
Streptococcus pneumoniae
– occurs during passage down the birth canal
– Prevention: mother, silver nitrate prophylaxis, topical
erythromycin
– Herpes simplex virus  shedding  routine viral
cultures ?...  elective cesarean section
 Prevention of Iatrogenic Ocular Infection

• Epidemic keratoconjunctivitis:
– Hands play a major role in the transmission of
infection  personal & hand hygiene
– Pseudomonas aeruginosa common
contaminant of ophthalmic solutions, particularly
fluorescein
– Ophthalmic instruments are improperly sterilized
– 70% isopropyl alcohol  effective for human
immunodeficiency virus type 1, herpes simplex
virus, and adenovirus
Prevention of Ocular Damage Due to Congenital
Infections
• Viral disease of the mother  retinopathy, infantile
glaucoma, cataract, uveal tract coloboma, etc
• Rubella  Vaccination
• Rubella during early pregnancy argument for abortion
• Cytomegalovirus  no vaccin
• Toxoplasmosis:
– Chorioretinitis
– cerebral or cerebellar calcification
– hydrocephalus
– severe central nervous system abnormalities
–  well cooked meat, washing vegetables and fruits, wearing
gloves
 Prevention of Genetic Diseases with
Ocular Involvement

• Family history of childhood diabetes, retinitis

pigmentosa, consanguineous mating,
retinoblastoma, neurofibromatosis, etc 
genetic counseling
• Down's syndrome (trisomy 21) prenatal test
of amniotic fluid cells  abnormality of
number of chromosome / sex chromosome
 Early Detection of Treatable Ocular
Disease
• Age-Related Macular Degeneration:
– Laser photocoagulation, photodynamic therapy
following intravenous verteporfin
– Intravitreal anti-VEGF (ranibizumab (Lucentis),
bevacizumab (Avastin))
• Primary Open-Angle Glaucoma:
– Undiagnosed!!!
– Prevalence 0,1% >40 y.o, 3% >70 y.o
– early performance of tonometry & direct
ophthalmoscopy of the optic disk  every 3 yrs, high
risk: every yr
 Prevention of Amblyopia ("Lazy Eye")

•  absence of organic eye disease

• Strabismus:
– Esotropia or exotropia  vision does not develop in
the unused eye
• Anisometropia:
– nearsighted (myopic) vs farsighted (hyperopic)  tend
to nearsighted
• Early Diagnosis:
– test the visual acuity of all preschool children
– "Home Eye Test“  no later than age 4 y.o
– Strabismus  no later than age 3 mo
 Prevention of Ocular Damage Due to
Systemic Diseases
• Diabetic retinopathy:
– administered before visual loss has occurred
• Uveitis associated with juvenile rheumatoid arthritis:
– Undetected unless clinically severe
– Regular ophthalmic screening  girls, ANA (+)
• Xerophthalmia:
– Poverty!!!
– alcoholism, weight-reducing diets, dietary management of
food allergy, or poor absorption from the gastrointestinal
tract, chronic diarrhea
– Bitot's spots, keratomalacia
–  comprehensive treatment!!!
Prevention of Visual Loss Due to Drugs
• All drugs can (potentially) cause adverse
reactions!!!
• Well packaged and labeled
• Atropine and scopolamine  precipitate acute
glaucoma
• Allergic, fibrotic / cicatrizing
• Corticosteroids  depress the local defense
mechanisms  corneal infection, open-angle
glaucoma, posterior subcapsular cataract
• History of previously prescribed  important
 Blindness #1
• Definition of Blindness:
– Visual acuity:
• Visual Impairment low vision: grd 1 (BCVA 6/18), grd 2 (BCVA
6/60)
• Visual Impairment blindness: grd 3 (BCVA 3/60), grd 4 (BCVA
1/60), grd 5 (NLP)
• US  partial blindness BCVA ≤20/200, VF ≤ 20 degree
• "Industrial blindness“, "automobile blindness"
– Visual Field:
• Category 3  5 – 10 degree
• Category 4  <5 degree
 World Prevalence of Blindness

INDONESIA 93-96 : 1.5%

© WHO Prevalences: < 0.4% 0.4 - 0.6 0.6 - 1 > 1%

 Blindness #2
• WHO: 50 million blind, 135 million significant
visual disability
• Ninety percent of the world's blind 
developing countries (mostly in Asia (±20
million) and Africa (±6 million)  rural areas
and urban slums
 Causes of Blindness & Methods of
Prevention & Treatment #1
• In developing countries:
– Cataract is the leading cause
– Followed by age-related macular degeneration, glaucoma, diabetic
retinopathy, herpes simplex keratitis, retinal detachment, and
inherited retinal degenerative disorders
– Trachoma, glaucoma, leprosy, onchocerciasis, and xerophthalmia 
important in developing countries
– WHO: up to 80% of blindness in developing countries is avoidable
(preventable or treatable)
– Cooperation between governments and nongovernmental charitable
organizations has proved to be essential to reduce blindness
• In developed countries:
– Glaucoma, diabetic retinopathy, retinal detachment, age-related
macular degeneration, and herpes simplex keratitis  less
preventable
– The inherited conditions  amenable to prevention by genetic
counseling.
 Causes of Blindness & Methods of
Prevention & Treatment #2
• Cataract:
– As life expectancy increases  incidence &
prevalence ↑
– Insufficiency to cope with the new cases &
backlog of existing cases  10 million worldwide
– Geographic exposure to ultraviolet radiation,
dehydration
– NO method for preventing or retarding cataracts
 antioxidants??
– Mobile eye camps, training of surgeons
ELDERLY POPULATION PROJECTION

US Bureau of Census
Age %
----------------------
>65 y 3-4
>55-65 y 8-10
----------------------

ESTIMATION OF
CATARACT INSIDENCE
0.01 %
 Causes of Blindness & Methods of
Prevention & Treatment #3
• Trachoma:
– Mostly of them in Africa, the Middle East, and Asia
– Tetracyclines, erythromycin, azithromycin
– in the past 10 years, the number of trachoma has
dropped from 6 million to 1.3 million.
– WHO's SAFE strategy (Surgery for trichiasis,
Antibiotic treatment, Face washing, and
Environmental changes such as latrine building).
 Causes of Blindness & Methods of
Prevention & Treatment #4
• Leprosy
– Up to 10% of leprosy patients are blind or visually
impaired
– Triple drug therapy (dapsone, clofazamine, and
rifampin)  effective
• Onchocerciasis (river blindness):
– keratitis, uveitis, retinochoroiditis, and optic atrophy
– bites of the blackfly
– tropical Africa and Central and South America
– insect eradication and personal protection
– ivermectin is extremely effective
 Causes of Blindness & Methods of
Prevention & Treatment #5
• Xerophthalmia:
– general dietary improvement, vitamin A supplementation
– close association of measles epidemics – blinding
complications of xerophthalmia  measles immunization
• Other Causes:
– Glaucoma:
• Second most common cause of blindness
• Treatment is also a major problem because of the poor
compliance for taking daily eye drops
– Diabetic retinopathy:
• the next generation of diabetics will benefit greatly from what is
being done now
– Hereditary conditions: genetic counseling
 Costs of Avoiding Blindness
• Some examples:
– To cure one person of trachoma in Saudi Arabia:
$1.25
– To restore vision to one person in India blinded by
cataracts: $30.00.
– To prevent blindness due to xerophthalmia in one
infant in Indonesia: 30 cents.
• WHO: Vision 2020  Indonesia, 2000
• Gov – NGO collaborated
 Rehabilitation of the Blind
• The aim of rehabilitation is to enable the patient
to lead as nearly normal a life as possible
• Rehabilitation must be individualized
• Agencies  PERTUNI, PPLVP, Eye Center
(optional)
• Mobility Training & Guide Dogs
• Braille
• Electronic Devices  sound, tactile, etc
 Financial Assistance Programs

• United States  essentially dependent on Social

Security and whatever local supplemental aid
• In many countries, the blind receive no financial
or other support from their governments and are
either cared for by their families or left to
manage by themselves in any way they can 
INCLUDING INDONESIA
• PT. Sidomuncul, Djarum Foundation, Dharmais,
Standard Chatered, Pegadaian, BMI / PPMTI, etc.
 Low Vision #1
• LV :
– impaired visual performance (cloudy vision,
constricted fields, large scotomas, glare sensitivity,
abnormal color perception, or diminished contrast)
–  visual acuity not correctable with conventional
glasses or contact lenses
• responsibility  ophthalmologist and
optometrist
• optimal medical and surgical intervention is
diminished functional vision  vision
rehabilitation
 Low Vision #2
• Age range: Over 75% age 65 /older, 9%
pediatric
• intervention  as soon as the patient
experiences difficulty performing ordinary
tasks
• Usually progressive  evaluation should
never be delayed!!!
• Devices ("low-vision aids“)  optical and
nonoptical devices