Module 8: The Significant Harm of Worst Practices in Eye Care

As with all health programs, eye care programs must be founded on best practice principles in public health.  The “worst practice” principles that are often employed by some organizations involved with eye care can do significant harm.

Worst Practice: Optometric “Medical Missions”

Providing optometric care solely in the form of presbyopic or refractive correction is counterproductive and can prevent patients from seeking eye care for other ophthalmic conditions. Many NGOs provide “optometric medical missions” in which they only prescribe eyeglasses during a short-term intervention to populations in developing countries.  A serious misconception behind these types of missions is the idea that providing some care is better than providing none at all. However, “optometric medical missions” can be wasteful, unethical, and harmful, and they often serve as medical tourism or “volunteer vacations.” These short-term interventions typically fail to partner with local eye doctors, thereby undermining the local healthcare system.  Additionally, patients who encounter such optometric medical missions will leave believing they have received a complete ophthalmic exam, no matter how cursory the vision screening, even if they are explicitly told otherwise. If a patient with cataracts, for example, is told that eyeglasses will not correct his sight, but an option for subsidized or free cataract surgery is not provided, the patient will continue to believe that nothing can be done to improve his sight. This visit to the “optometric medical mission” group is often the only time that a patient will seek eye care.

Though few would question the honorable intentions behind these interventions, short-term missions rarely produce tangible, lasting medical benefits.  Rather, they tend to be self-serving, ineffective, and provide only temporary, limited care, without addressing fundamental eye care needs. Further, there is generally no follow-up or quality control; most optometric missions identify their success based on whether a patient smiles upon receipt of the glasses, or whether the team is invited back for a future mission. These are not effective metrics for evaluating success. In the Indian state of Andhra Pradesh, for instance, 25.9% of those surveyed stopped using their eyeglasses because they felt that the prescription was not appropriate; 19.6% of those surveyed did not use their eyeglasses because they had lost them and could not afford to buy a new pair, and 17.9% found the eyeglasses to be uncomfortable. For these reasons and more, follow-up care must be available to all eye care patients, including those receiving glasses.(1)

“It is also important to recognize that while spectacles provide an easy answer to the need for presbyopic correction, the mere handing out of spectacles without an appropriate eye examination biases against quality eye care for everyone regardless of socioeconomic status, sex, or geographic circumstance. Coupling spectacle distribution to meaningful eye care is an important link in the blindness prevention chain from community to hospital. Random spectacle distribution breaks the chain of patient care and is counterproductive.”(2)

Instead, presbyopic treatment should be provided as one facet of complete eye care.(3)

Worst Practice: Eyeglass Distribution By Non-Eye Care Professionals

Allowing medical and non-medical providers to practice beyond their abilities is one of the worst practices in global health.  There are numerous examples of short-term medical missions involving students or other non-eye care professionals dispensing prescription eyeglasses, which is concerning:

Worst Practice: “The trial and error method is the most economic. One simply places all the differing strengths of eyeglasses in an ascending manner on the table and the patient tries each one beginning at the weakest continuing through the strongest until he/she finds the best lens strength for his/her refractive error. Essentially no cost is involved except the cost of the glasses which is $1 - 2 per pair.”(4)

Worst Practice: “Various government and private community health centres offer spectacles, usually donated ‘recycled’ spectacles selected by potential users on a trial and error basis, or handed out by health workers with no training in dispensing.”(5)

Worst Practice: “Attendees learned that medical mission trips aren’t just for professionals. Hospice care, offering free reading glasses and simple counseling are just a few examples of services that do not require much medical skill.”(6)

Some short-term groups bring advanced and expensive equipment, such as an autorefractor, in an attempt to have non-eye care professionals prescribe eyeglasses. Those prescribing the glasses have no background in eye health and cannot identify the difference between refractive error and other eye diseases. Some mission organizers claim to train their volunteers to use advanced optometric equipment, but such training is cursory and cannot qualify non-medical personnel to prescribe eyeglasses. It is important for organizations and NGOs to recognize that it is unethical and harmful for non-eye care professionals to prescribe eyeglasses. A concerning example is demonstrated by a short-term medical mission group:

Worst Practice: "One excellent method of ministry is to provide eyeglasses.  These eyeglasses not only allow the person to read their Bible but to also improve their standard of living.  Unlike providing a supply of medication, these glasses will typically be useful for several years. These teams are prevented from doing their best by a lack of training, professional assistance and proper equipment... [The organization] has assisted by providing numerous training manuals for the non-professional...With over 5 years in development, this program uses advanced optometry principles provided by experienced optometrists and described in textbooks. The intelligence built into this program gives the user the benefit of some of the experience and knowledge of these optometrists.”(7)

Additionally, visiting physicians on short-term medical trips often feel compelled to treat patients outside of their specialties, simply because there is no specialist available, or because the patients are unable to afford the cost of receiving care by the local specialist. In the developed world, internists do not treat children and general surgeons do not prescribe eyeglasses – why should this be different in the developing world? Lowering the standard of medical care for those in developing communities is unprofessional, unsafe, and unethical.

The Harm Caused By Distributing Glasses By Non-Eye Care Professionals

The dispensing of eyeglasses by non-eye care professionals can be problematic and harmful for various reasons.  First, prescribing corrective distance eyeglasses requires refraction by a skilled optometrist or ophthalmologist.  In the Western world, it is illegal for anyone but a licensed professional to prescribe eyeglasses.  Patients provided with the wrong prescription – which is almost always inevitable if non-eye care professionals are distributing glasses without refraction or examination – will experience headaches and discomfort, and will not wear the eyeglasses.  This perpetuates distrust of health providers.  Additionally, there is a common belief among patients that eyeglasses will help any visual problem.  If a patient with cataracts is given glasses, his vision will not improve.  Nevertheless, the patient might believe that he was given glasses to cure his eye ailment; when the glasses do not work, s/he might think that there is no cure for his visual problem, and will likely never seek eye care again.

Worst Practice: Training Community Members To Prescribe Eyeglasses

In an attempt to overcome barriers to eye care, local community members are sometimes trained to prescribe reading glasses.  However, research indicates that those trained solely to prescribe reading glasses may be perceived by those in villages to be licensed eye care professionals.

“There is an indication of relative inaccessibility of hospital eye services to the population. Reasons for this inaccessibility include the consumers' concept of who could provide eye care and their inability to distinguish between the different providers, and their perception of the hospital and its staff.”(8)

Module 2 described the high percentage of patients in developing countries who have never sought eye care and who have never had an eye exam.  When receiving reading glasses from a trained local community member, it can be impossible for a village patient to understand that receiving  reading glasses does not constitute a complete eye exam by an eye care professional.  Even if they receive reading glasses, patients may have a serious but curable condition such as cataracts or pterygium.  The reading glasses will not improve their vision; reading glasses only treat presbyopia.  A complete eye exam, diagnosis, and surgery would be required to improve a cataract patient's vision, and even then, barriers remain, preventing patients from receiving complete eye care from a licensed professional.  Training local community members to prescribe reading glasses only eliminates barriers for correcting presbyopia, and can negatively affect the identification and treatment of other treatable eye diseases. 

If community members are trained to provide any type of eye health service, they must be integrated into a local eye clinic's ongoing outreach programs by eye care professionals at the same location.  The primary role of the community members should be to help reduce the primary barriers to patient care, and their close involvement with local eye clinics can be highly beneficial to the patients.

Worst Practice: “Referrals” to Local Eye Doctors

Short-term medical missions or other organizations that claim to “refer” patients to local eye care professionals must reduce barriers to care.  “Referring” without reducing barriers to care will not enable a patient to access locally available resources.  It is the responsibility of the visiting global health organization to facilitate transportation from remote locations and subsidize cost, as well as maintain data on the number of patients receiving care by the local clinics.  Hundreds of thousands of patients can be referred to an eye doctor, but what actually matters is the number of patients who receive quality care.

Worst Practice: The Dangers of Short-Term “Surgical Safaris”

Of all the worst practices in global eye-care, short-term surgical missions can be considered the worst offenders. Even the best efforts of the most experienced ophthalmic surgical teams cannot overcome the risks of short term surgical missions. Post-surgical monitoring and follow-up care is necessary to prevent infection and to ensure the success of an operation.(9) When visiting doctors do not work with their local counterparts, there is no ophthalmologist to provide follow-up care or to treat infections that may arise after the operating surgeons depart, which is often the day after operating.  For information on the importance of partnering with local doctors, refer to Module 3 of the Unite For Sight Global Health Course (http://www.uniteforsight.org/global-health-course/module3). The ramifications of botched surgeries affect more than just the surgical patients and their families; a single poor surgical outcome can lead an entire village to fear doctors and surgery on a long-term basis.

“The perceived quality of the provided services had a strong influence on uptake. Patients who reported having spoken to someone who had good experiences with the service provider were more likely to avail themselves of the offered cataract surgery.  Conversely, patients who had heard negative aspects about the services provider were not inclined to take up services. Virtually everyone had discussed cataract surgery with relatives or friends.”(10)

The photo below shows a patient who lost all function in his eye due to poor quality surgery provided by a short-term visiting team of surgeons.

Additionally, while a limited number of patients may have received free surgical care by the visiting ophthalmologist - perhaps 50 to 100 during a one-week visit - the other patients from the region will not have had access to surgical care. Such interventions are thus minimally effective at best, as they do not encourage community members to seek regular eye care, nor do they build local capacity.  Furthermore, patients tend to view Western visitors as superior, which compromises the status of local doctors.(11) Patients may decide to wait until the next time that a Western doctor visits instead of seeking care by the local ophthalmologist. It is often rich patients who take advantage of free surgical care provided by visiting surgeons despite being able to pay, simply because they believe that the visitors provide higher quality surgery.

Large surgical missions of dozens of volunteers often focus heavily on numbers of patients treated instead of quality of care.  Quality of care must always be the paramount focus of any surgical or medical care.  According to The New York Times, Operation Smile, a nonprofit organization that sends surgeons to provide cleft lip and cleft palate surgery, has received criticism for failure to work collaboratively with local surgeons:

“Over five days, Operation Smile volunteers did 188 operations in Rooms 1 through 7; Chinese doctors did 61 operations in Rooms 8 and 9. The results were very different. According to a study done at the hospital, of the 61 operations with Chinese surgeons, only two caused any postoperative problems, in both cases minor bleeding. But over 40 patients under the care of Operation Smile had serious complications, the hospital study reported."(12)

“Last year alone, four children died during or after surgery, adding to at least 12 other patients that the charity acknowledges losing since it began operations in 1982. Repairing a cleft lip or palate in the developed world is rather low risk and deaths are rare. Physicians in China, where Operation Smile has performed many of its operations, have accused the surgeons of 'assembly line' medicine. In Bolivia, a pediatric surgeon branded the organization's practices 'a form of neo-colonialism.'

… 'This is a form of neo-colonialism,' argued Dr. Rosa, who said his hospital had performed about 2,000 of these surgeries. While his hospital would be eager to cooperate with surgeons from the United States, Operation Smile had committed 'surgical safaris against our children,' who are from poor families who are unlikely to complain, he said."(13)

It is equally important for ophthalmic surgery to be of the highest quality.(14)

Local doctors are often left to deal with complications following low quality surgeries, which is both time-consuming and a financial burden to the local clinics. What do local surgeons generally want? Instead of an overwhelmingly large team of visiting doctors, "they would like to see a small team of experts who would teach...new techniques. They would also like some help with equipment purchases and financial support to developing a [local] team of...surgeons."(15)

It is important to realize that those hit hardest by the dangers of surgical safaris are those who can least afford to correct such damage. 

“The other groups active in the field were service clubs, many of which held eye camps on a commercial basis. The poor, rural cataract patients were the worst affected, as much of the cataract surgery was sub-standard. Most damaging was the absence of post-operative services for the patients operated on in eye camps and many became blind due to post-operative complications. We have treated many eye camp patients like this at our Hospital’s outpatients’ department (OPD). The provision of post-operative care for the patient is not only essential for good service delivery, it must also be viewed as an individual human right. Eye camp organizers generally did not offer proper post-operative care. Why was this the situation?

People were not properly advised or educated. They were not aware of their needs. They were not informed as to how they should maintain their eye health. People are poor and totally unaware of their rights.”(16)

While some countries have regulations designed to encourage continuity of care after visiting providers have left, most developing nations do not have the infrastructure to support such regulations.(17) Thus, the burden of ensuring high-quality, comprehensive, continued care lies with the foreign medical providers.

Please see Module 8: The Significant Harm of Worst Practices for further discussion of worst practices in health care.

Footnotes

(1) Dandona, R., and Dandona, L. “Review of Findings of the Andhra Pradesh Eye Disease Study: Policy Implications for Eye-Care Services.” Current Ophthalmology. 49.4 (2001): 215-234.

(2) Holden, B.A., Fricke, T.R., Ho, M., Wong, R., Schlenther, G., Cronjé, S., Burnett, A., Papas, E., Naidoo, K.S., and Frick, K.D. “Global Vision Impairment Due to Uncorrected Presbyopia.” Archives of Ophthalmology. 126.12 (2008) 1731-1739.

(3) Ibid.

(4) “MedMissions: Optometric Diagnostic Equipment.” 2005. www.medmissions.org.

(5) Ramke, J., Williams, C., Ximenes, J., Ximenes, D., Palagyi, A., du Toit, R., and Brain, G. “A Public-Private Partnership to Provide Spectacles for Timor-Leste.” Community Eye Health. 20.63 (2007): 54.

(6) Hendricks, S. “Medical Professionals Challenged to Take Skills to Lost World.” July 2008. International Missions Board: Southern Baptist Convention.

(7) “Announcing support for Retinomax 3 autorefractor.” 15 January 2008. Kendall Optometry Ministry, Inc.

(8) Ntim-Amponsah, C.T., Amoaku, W.M.K., and Ofosu-Amaah, S. “Alternate Eye Care Services in a Ghanaian District.” Ghana Medical Journal. 31.1 (2006): 19-23.

(9) Eberlin, K.R., Zaleski, K.L., Snyder, H.D., and Hamdan, U.S. "Quality Assurance Guidelines for Surgical Outreach Programs: A 20-Year Experience." The Cleft-Palate-Craniofacial Journal. 45.3 (2008): 246-255.

(10) Finger, R.P., Ali, M., Earnest, J., and Nirmalan, P.K. “Cataract Surgery in Andhra Pradesh State, India: An Investigation into uptake Following Outreach Screening Camps.” Ophthalmic Epidemiology. 14 (2007): 327-332.

(11) Edward O’Neil Jr., A Practical Guide to Global Health Service (American Medical Association, 2006), 24.

(12) Rosenthal, E. and Abelson, R. "Whirlwind of Facial Surgery By Foreigners Upsets China." 25 November 1999. The New York Times.

(13) Abelson, R and Rosenthal, E. "Charges of Shoddy Practices Taint Gifts of Plastic Surgery." 24 November 1999. The New York Times.

(14) See, for example Purohit, S. “Right To Health Care In India: Guidelines For Holding Eye Care Camps.” National Law University.

(15) Ibid.

(16) Hannan, Z. "Case Finding in the Community: Experience of Jatiya Andha Kallyan Somiti in Comilla, Bangladesh." Community Eye Health. 15.44 (2002): 60-61.

(17) Wolfberg, A.J. "Volunteering Overseas - Lessons from Surgical Brigades." New England Journal of Medicine. 354.5 (2006): 443-445.