A vision for preventing blindness in Indigenous communities

Vision loss causes 11% of the health gap between Indigenous and non-Indigenous Australians. Rusty Stewart/Flickr, CC BY-NC-ND

The tragedy of vision loss and blindness in Indigenous communities is striking: Aboriginal and Torres Strait Islander adults have six times more blindness than non-Indigenous adults and nearly three times as much vision loss.

What’s worse, 94% of this vision loss is unnecessary; it can be corrected or prevented. Much of it could be corrected over night. You give someone a pair of glasses and they see right away; if you have cataract surgery, you can see the next day.

The problem is that more than one-third of Indigenous adults have never had an eye exam.

Getting the basics right

Good eye care starts in primary health care, with much of the focus on those people who have diabetes. Everyone with diabetes is at risk of losing their vision if they live long enough. But good control of blood sugar, blood pressure and blood lipids slows the development of vision loss and also prolongs life.

Up to 98% of the blindness from diabetes can be prevented by timely laser treatment. In order to know when treatment is required, however, people with diabetes need to have their regular eye exams – every two years for non-Indigenous Australians and at least [every 12 months]((http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/di15.pdf.) for Indigenous Australians. Only 20% of those Indigenous people with diabetes are currently getting these exams.

There are multiple small changes that are needed to address this, including educating patients and clinic staff, computer prompts and reminders, clinic audits, adjustments to Medicare, provision of visiting services and so on.

But the single most important issue is co-ordination and case-management to help the patient navigate the pathway of care, to help with instructions, appointments and transport arrangements.

Referrals to specialist care

More often than not, the co-ordinators and managers are already there in the clinics or health services. What is needed is the clear inclusion of eye care in their roles and responsibilities, and in their performance indicators and those of the clinics.

Indigenous Australians with diabetes should not be allowed to go for more than 12 months without an eye test. the_green_squirrel/Flickr, CC BY-NC-SA

Focusing on eye care for those with diabetes will lay the ground work for providing eye care for all. People with diabetes make up 75% of those who need an eye exam each year. So there is a clear need, already established national guidelines and most of the required resources.

People with diabetes may have changes in the back of their eyes (diabetic retinopathy) that need referral to an ophthalmologist for laser treatment. But they may have cataracts needing referral for surgery or they may need a pair of glasses and need to see an optometrist.

Either way, when the referral pathways for those with diabetes are established these pathways can be used as well by those without diabetes.

Overall, the unmet need for eye care is essentially the same in the towns and cities as it is in the most remote areas. It’s the same in Fitzroy as it is in Fitzroy Crossing. It’s also important to remember that 75% of Indigenous Australians live in the towns and cities.

Eliminating trachoma

One difference between the towns and the outback is that the blinding eye infection trachoma is now only seen in rural communities. Trachoma used to be called “sandy blight” and disappeared from mainstream Australia a hundred years ago. It persists in remote areas where family and community hygiene is poor, allowing children to repeatedly share the infection.

Trachoma causes inflammation of the eyes, scarring with in-turned eye lashes and blindness in older adults. Antibiotics are used to treat the infection and surgery is used to correct the in-turned lashes. But the key to stopping transmission and reinfection is to keep every child’s face clean.

We’re now making real progress in reducing rates of the infection. In 2006, then-health minister Tony Abbot established a national reporting framework. Having good national data convinced the Rudd government to commit Australia to eliminate trachoma in accordance to the World Health Organization goals.

Trachoma rates have fallen dramatically over the past few years. AAP Image/Neda Vanovac

When the national trachoma program started in 2009, 14% of the children in the endemic areas had trachoma, by 2012 the rate had dropped to 4%. When things are done right, they work. The current Abbott government has just recommitted to continue this work to eliminate trachoma.

Closing the vision loss gap

The success of the trachoma work is important. Not only are we ridding Aboriginal people of this ancient blinding scourge, it also shows that well-planned programs can work in these communities.

The plans to eliminate avoidable blindness in the Roadmap to Close the Gap for Vision build on this success. The proposals we have put forward are evidence-based, have strong sector and stakeholder support, are highly cost effective with significant efficiency savings. They are ready to go.

Vision loss causes 11% of the health gap, but unlike the other major causes of the health gap, such as heart disease, diabetes, trauma and alcoholism, most of this vision loss and the health gap it causes can be closed almost immediately.

Fortunately, the federal and state governments and other service providers are starting to listen. We are hopeful of some real change.

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