School Eye Screening and the National Program for

Control of Blindness
R JOSE AND SANDEEP SACHDEVA

From the Directorate General of Health Services, Ministry of Health and Family Welfare,
Nirman Bhawan, New Delhi.

Childhood blindness and visual impairment are as important and perhaps more
devastating and disabling than adult onset blindness, because of the long span of life still
remaining to be lived. Refractive errors and more particularly myopia, place a substantial
burden on the individual and society. School-age children constitute a particularly
vulnerable group where uncorrected refractive errors may have a dramatic impact on
learning capability and educational potential. This article provides an overview of school
eye screening from the perspective of National Program for Control of Blindness
(NPCB), Government of India; and challenges, future directions and thrust area
envisaged under the program for amelioration of childhood blindness.

Keywords: Blindness, Prevention, Refractive errors, School health.

Refractive errors are the second major separate subspecialty, is not yet well
cause of blindness in India after cataract established, and services targeting
and the most common reason for children are not often offered separately
patients to consult ophthalmologist or by ophthalmologists. Training to
ophthalmic assistant. Over a quarter of address ocular problems relating to
the outpatient attendance at all eye children is not always a part of every
clinics and hospitals is due to refractive residency program and very few
errors(1). The availability and access of institutions offer post-residency training
infrastructure, services, trained programs in pediatric ophthalmology(2-
manpower, cost of spectacles, and 5).
community awareness is an area of
concern. Pediatric ophthalmology, as a
Children form one of the main age have a correctable refractive error
groups requiring attention to refractive causing visual impairment (refractive
errors because of the high prevalence of bilateral visual acuity of <6/ 18). Though
myopia, hypermetropia and no population based nation wide survey
astigmatism. The ultimate molding of a has been undertaken on the prevalence
person’s personality and potentiality of blindness in India, is estimated to be
rests with his nature, surroundings and 0.8/1000 children in the age group of 0-
quality of eye sight. The school going 15 years. Currently, there are an
years are formative for children in estimated 270,000 blind children in
determining their physical, intellectual India(7,8). Most of the available studies
and behavioral development. Poor demonstrate that corneal and lenticular
vision in childhood affects performance conditions are the predominant causes of
in school and has a negative influence on blindness whereas amongst children
the development and maturity. Further, outside blind schools, refractive errors
most school children do not realize that are important causes of visual
they are suffering from the ocular impairment and blindness. Myopia is a
disability as they adjust to poor eye sight common cause of visual impairment
in different ways. They compensate for which is usually acquired and nearly
their poor vision by sitting closer to the always progressive. It rarely occurs
blackboard, or by holding their books before the age of 5 years and new cases
close to their eyes. They may also appear throughout childhood and
squeeze their eyes. They may also tend adolescence, particularly between the
not to undertake any work that needs ages of 6 to 15 years.
visual concentration, thus affecting their
performance(6). EYE CARE SERVICES IN INDIA

MAGNITUDE OF THE PROBLEM

Refraction services are primarily
It is estimated that there are 1.4 million provided by ophthalmologists and
blind children in the world. An paramedical workers and management
additional 7 million suffer from low of common eye care ailments is done by
vision and a further 10 million children general health care staff. It is estimated
that there are 12,000 ophthalmologists (SES) program became the integral part
and 9,000 paramedical ophthalmic of the NPCB since 1994 after successful
assistants working in the private or implementation at the five pilot districts.
public sector (medical colleges, Based on administrative, logistic, social
Regional Institutes of Ophthalmology, and medical reasons, it is envisaged
district/sub district hospital etc.) in the under the program to focus initially on
country. Out of 23,000 Primary Health screening of students in “middle and
Centers (PHCs) in the country, only secondary schools” or schools having
forty percent are equipped to provide 5th to 10th standard students. This is
refractive services. Ideally, ophthalmic because of the reason that age of the
assistant should be available at each pupils in these classes is around 10-14
PHC. However, currently, they are years and they are in the position to
serving a larger population as they are understand the purpose and need for
based at Community Health Centers vision screening. Administratively it is
(CHCs) or Block PHCs. Ultimately, it is easy to implement and the students can
envisaged that refraction facilities with carry the message home thereby creating
basic equipments will be created at all awareness in their respective villages.
PHCs. The activities under SES program
include identification of schools,
SCHOOL EYE SCREENING collection of information on number of
PROGRAM students and teachers, screening and
referral centres, training of school
National Program for Control of teachers, training of general health care
Blindness (NPCB) was initiated by personnel, confirmation of “suspect”
Ministry of Health and Family Welfare, students by ophthalmic assistant/
Government of India in the year 1976 ophthalmologist, prescription of glasses,
and primarily administered by and provision of free glasses to students
respective State Governments in from poor socioeconomic strata.
collaboration with district health
authorities through public and NGO ORGANIZATION OF SES
institutions. School Eye Screening PROGRAM
 For the initial screening, a single
The actual planning of SES is carried out optotype of the Snellen’s chart or the ‘E’
by respective District Health Societies chart can be easily administered by
(DHS) keeping various parameters minimally trained personnel. This is a
under consideration like holidays, low cost, non-invasive, rapid, reliable
examinations, involvement of teachers and acceptable method. The
in academic activities, availability of conventional Snellen’s charts with all
human resource, other events in the the 7-lines of the optotypes may be
district etc. In general, it is usually confusing for use by personnel like the
carried out during April-September of school teachers and staff. In addition, the
each year as the number of cataract conventional charts are easily
surgery increases from the month of memorized by the children thus
October onwards. From each school, one making them less useful for screening. A
teacher is selected for a one-day training single optotype like the ‘E’ can be
course. Preference is given to women, so rotated each time the child sees it, and
as to counteract prejudice against girls thus each eye can be tested differently.
wearing spectacles, and to teachers who With the limbs of the ‘E’ facing in
themselves wear spectacles as they are different directions, children are asked
likely to be more motivated. During the to identify at least three optotypes with
training, teachers are provided with a kit each eye (rotating the card for the second
for screening the children in their eye, so that the letters are in different
schools. The teacher’s kit contains a six- configuration) before labeling them as
meter (20 feet) measuring tape, standard having abnormal or normal vision.
vision screening “E” card, referral card The screening is carried out in the
for children with suspected poor vision, following way: From a distance of six
and educational material. meters (measured with the tape
provided), child is shown the vision
PROCEDURE FOR SCREENING card, which is white with four black
OF REFRACTIVE ERRORS “Es” of standard size (6/9 of Snellen’s
AMONGST SCHOOL CHILDREN chart). For each eye, child has to indicate
the direction of the open end of the “E”.
By simply rotating the card, the amongst the children and adults outside
sequence can be changed. The child the school as well, the additional
indicates the direction correctly clientage for the optician increases his
(eyesight “good”) or incorrectly volume of business. This serves as an
(eyesight “not good”). If there is any additional incentive for the opticians on
doubt, the teacher should record the contract and they agree for reduced rates
eyesight as “not good”. in the contract. If there is nonavailability
of optician in the concerned district,
PROVISION OF SPECTACLES arrangements are made with an outside
optician for supply of spectacles. In the
Spectacles are the most attractive event of nonarrangement of spectacles,
component of all the services under this SES is not started at all!
program. Each child with a refractive
error will require a specific frame SUSTAINABILITY AND QUALITY
according to his/her head size and power ISSUES: FUTURE DIRECTIONS
of corrective lenses depending on the
degree of error. Good coordination with Developing eye care programs targeting
the ophthalmic assistant and further with children is different from programs
ophthalmologist is crucial at this stage. targeting adults, as the primary decision
An agreement is usually made by maker in the case of children with eye
District Health Society with one or more problems is often not the subject with the
of the local opticians for supply of low problem. Additionally, the decision
cost quality spectacles (acetate frame maker is often not aware of the problem,
with white English lenses) for all as the child is unable to express his
children referred to them or orders discomfort. Knowledge regarding
placed with them under the program. perceptions and awareness of eye
Experience has shown that contractual diseases among parents is important in
agreement can be arrived at half the this context. The success of any program
usual retail price prevalent in the local or approach depends on its continuity,
area. Since this activity generates simplicity and adaptability ensuring
publicity about the need for spectacles quality at each stage.
The effective and efficient delivery of Vitamin A deficiency, eye injuries,
SES program is ensured by making the refractive errors, corneal opacities and
district education department and retinopathy of prematurity (ROP).
schools to run the program themselves
after the initial thrust and support. The EPILOG
cost of SES component is borne by
Government of India including It is a challenge to reach the community
provision of Rs 125/- for glasses for poor residing in under/unserved areas and
children through District Health Society out-of-school children within available
funds. This amount is being enhanced resources, infrastructure and trained
during 11th five year (2007-2012) plan manpower. However, Government of
period with additional provision of in- India is committed to the goal of
service training of ophthalmologist in amelioration of avoidable
pediatric ophthalmology. Other blindness in the country with
initiatives proposed by Government of involvement of stakeholders at all levels
India for ameliorating childhood in public and NGO sector. Eye screening
blindness for the 11th five year period of school children is one such effective
include development of Pediatric strategy. Similar to seeking of details in
Ophthalmology units, Low Vision context of childhood immunization, a
Services Centres, provision of latest concept of “missed opportunity” is also
equipment and Low-Visual aids at applicable in area of eye screening.
identified public institutions (Medical Physicians should be sensitive to the
colleges and Regional Institutes of issue of visual impairment especially for
Ophthalmology) and non-governmental premature babies and
organizations (NGO), strengthening of children/adolescent including their
eye banks and services for corneal siblings attending outpatient clinics for
transplantation, provision of financial some ‘other’ cause, to seek appropriate
assistance of corneal transplantation in eye referral and management.
NGO sector and development and
dissemination of resource material on
various childhood eye disease like