COMMON CAUSES OF

BLINDNESS
BY
WEST ABIYE A.
INTRODUCTION

• Blindness is defined in different ways in different countries according to the purpose of definition i.e. legal,
social, clinical etc.

• WHO recommends the ICD-10 –based definition

• On World Sight Day (12 October 2017) WHO joined partners around the world to issue a call to “Make Vision
Count”

• Globally, uncorrected refractive errors and un-operated cataract are the top two causes of vision impairment.

• World Sight Day, observed annually on the second Thursday of October, is an important opportunity to
advocate for implementation of WHO’s Universal eye health: a global action plan 2014-2019.

• Prevention can be via increasing access to quality comprehensive eye care services, including at the community
level
VISION

• Vision = eye translates light waves to electrical

impulses sent to the brain. Brain interpret
signals into an image with color and movement
• Light enters through the cornea, passes
through to the pupil (iris hole),focused by the
lens to a point in the retina.
• Most focus and understanding of color is
occurs in the macula.
• Rods and cones move the electrical version of
the light through the optic nerve to the brain.
• Vision loss can occur anywhere along the way.
VISUAL ACUITY

• Normal distance visual acuity is classified through

measurement on a Snellen chart as 20/20
• Using 6meter line of chart is delineated at
60,36,24,18,12,6,5,4
• Visual acuity moves to counting fingers or hand
motion
• Most severe classification of vision loss is Light
Perception Only (LPO) or No Light Perception (NLP).
• If a person goes to a low vision clinic, vision is
measured on a Feinbloom chart.
VISUAL ABILITY

• There are 4 levels of visual function, according to the International Classification of

Diseases -10
1. Normal vision
2. Moderate visual impairment- MI
3. Severe visual impairment-SI
4. Blindness-B
• 2 & 3- low vision
• 2,3,&4- Visual impairment
DEFINITION OF BLINDNESS

• Blindness is defined as a visual acuity

(VA) of less than 3/60 (20/400) in the
better eye with best possible correction

6 5 4 3 2 1
DEFINITION OF BLINDNESS

• A visual field in the better eye to less

than 100 from fixation
DEFINITION OF BLINDNESS- ICD-1O CATEGORY 3-5
LEGAL BLINDNESS
• Central visual acuity 20/200 or less in the
better eye with best correction
• 20/200; means seeing at 20 feet what a person
with normal vision sees at 200 feet.
• A person can see 20/20 and still be legally
blind when the field of vision is at 20 degrees
or less.
• When looking straight ahead, a person with
normal vision sees about 180-200 degrees to
the sides, overhead and below.
MAGNITUDE OF BLINDNESS- 10 IMPORTANT FACTS

1. 285 million people are estimated to be visually
impaired worldwide: 39 million are blind and 246 have
low vision.
2. About 90% of the world's visually impaired live in low-
income settings.
3. 82% of people living with blindness are aged 50 and
above.
4. Globally, uncorrected refractive errors are the main
cause of moderate and severe visual impairment;
cataracts remain the leading cause of blindness in
middle- and low-income countries.
6. The number of people visually impaired from infectious diseases has reduced in the last
20 years according to global estimates work. Blinding trachoma now affects fewer than
80 million people, compared to 360 million in 1985
7. Aging populations and lifestyle changes means that chronic blinding conditions such as
diabetic retinopathy & ARMD are likely to rise further
8. Women face a greater risk of vision loss than men
9. Restorations of sight, and blindness prevention strategies are among the most cost-
effective interventions in health care
10. An estimated 19 million children are visually impaired. Of these, 12 million children are
visually impaired due to refractive errors, a condition that could be easily diagnosed
and corrected. 1.4 million are irreversibly blind for the rest of their lives

5. 80% of all visual impairment can be prevented or

cured.
CAUSES OF BLINDNESS, GLOBAL LEVEL
DEVELOPED COUNTRIES DEVELOPING COUNTRIES

1.Age-related macular degeneration (ARMD) Cataract

2.Diabetic retinopathy & glaucoma Glaucoma & corneal opacity

3.Cataract Diabetic eye disease

(emerging) & ARMD
Avoidable Blindness;
Can be either treated or prevented by
known, cost-effective means
• Cataract
• Refractive errors
• Diabetic retinopathy
Unavoidable blindness
• Retinal causes of childhood blindness e.g.
ROP
• Age-related Macular Degeneration ARMD
CATARACT
CATARACT
• Lens opacity caused by either clumps of protein in the lens or a gradual
discoloration of the fluid in the lens
• Progressive with the intensity of the cataract varying markedly
• The development of cataracts is age related.
• Cataract affect 50% of those between 65 and 75 years of age and about
70% of those over 75
• Mostly bilateral
• Risk factors include diabetes, smoking, chronic dehydration, alcohol
abuse, prolonged exposure to ultraviolet light
CATARACT
• Symptoms include:
• hazy, cloudy vision becoming more progressively dense, poor night vision, halos around
lights at night, double vision or multiple vision in one eye
• There are several types of cataracts including:
• Secondary cataract in persons who have had eye surgery or glaucoma,
• Traumatic cataract
• Congenital cataract
• Radiation cataract.
• The only treatment is lens extraction with either intraocular lens (IOL) implant or the
use of contacts or glasses.
CATARACT
• Cataracts are usually removed and replaced with an IOL or glasses
but in extreme cases where one eye has not responded well to
surgery, surgery on the remaining eye may be delayed or not
deemed appropriate.
CATARACT – IMPLICATIONS FOR EMPLOYMENT

• Need for improved lighting, increased contrast and avoidance of glare.

• Colors are sometimes difficult to discern
• The person may need a low vision examination or some assistive
technology to assist with reading tasks such as completing paperwork
requirements, reading expiration dates, or reading overhead signage
• They may have difficulty recognizing faces as well
AGE-RELATED MACULAR DEGENERATION-
ARDM
• The macula is that part of the eye which is responsible for fine detailed vision and colors.
• A person with age-related macular degeneration (ARMD) requires good light to function
optimally.
• It is one of the primary causes of permanent legal blindness in the U.S. among persons over
65.
• Incidence increases with every decade over 50.
• It is painless and progressive.
• ARMD is more common in women, caucasians, those with a family history of the disease,
and people with a history of smoking.
AGE-RELATED MACULAR DEGENERATION

• Diagnosis includes the use of a dilated eye exam and Amsler grid to determine if
there is a distortion in the central vision.
• Symptoms include gradual or sudden loss of central vision, blurred vision and
scotomas (blind spots) which cause:
• Loss of central vision
• Difficulty in recognizing faces
• Faded colors and reduced contrast
• Distortion
• There are a broad spectrum of clinical and pathological findings, including Stargardt’s
Disease and various types of macular dystrophies that impact younger persons
AGE-RELATED MACULAR DEGENERATION
AGE-RELATED MACULAR DEGENERATION

• Macular degeneration manifests in two types:

• Dry (non-exudative)
• Wet (exudative)
• Both types are progressive and bilateral.
• The majority of persons who have ARMD have dry ARMD, and do not have
significant vision loss.
• The more severe “wet” form accounts for 90% of all cases of legal blindness due to
ARMD.
 ARMD – DRY
• Most common variety, yet most people do not experience severe vision loss in the early stages of the dry form.
• It is characterized by variable degrees of atrophy and degeneration of the outer retina, retinal pigment epithelium,
Bruch’s Membrane and choroid.
• Drusen, discrete yellow deposits thought to be waste products of cellular degeneration, calcify and increase in number.
• As the calcification increases areas of vision can be affected.
• There are three distinct stages of development: Early, Intermediate, and Advanced dry ARMD.
• Advanced Dry ARMD may cause significant vision loss.
• There is benefit of particular vitamins taken during the intermediate stage to minimize or slow progression of the disease
in about a quarter of those taking them-Nutrition seems to be a factor and getting nutrients to the retina can be beneficial.
• Exercise, diet, and vitamins are all seen as positive steps a patient can take to slow the progression of the disease.
ARMD – WET
• Sub-retinal neovascularization causes fluid to build up and lead from behind the retina.
• Macular edema and leakage are the main characteristics.
• Treatment includes anti-VEG-F (lantus or Avastin) injections in the affected eye, and
photodynamic therapy (injections of special photosensitive dye into the arm and following with
cool laser therapy).
• Neither treatment is a cure, but may slow the advancement of the disease and some patients show
improvement using the anti-VEG-F injections.
• There is experimentation with retinal transplants, healthy cell transplants into the macula, retinal
relocation, anti-inflammatory treatments, and regulation of diet and vitamin therapy.
ARMD – IMPLICATIONS FOR EMPLOYMENT

• A person with macular degeneration will not lose all his/her vision, but will be
missing that critically important central vision necessary for reading, recognizing
faces, and seeing colors.
• This may cause difficulty with tasks like reading, writing, checking expiration
dates, recognizing customers, keeping an area neat and clean, finding things and
doing credit card transactions or operating a cash register.
• Activity of daily living skills, low vision services, orientation & mobility services,
and assistive technology services may all be beneficial in assisting the individual
to become productive and confident.
GLAUCOMA
• Characterized by increased intraocular pressure (IOP) that causes a cupping of
the optic disk.
• Glaucoma itself is actually the cupping of the disk – and some people can have
increased IOP, with no cupping or normal pressure (low-tension glaucoma) with
cupping.
• Glaucoma occurs when there is damage to the optical nerve
• There are five main types of glaucoma
• More common after the age of 40
• Symptoms include eye ache, photophobia, blepharospasm, lacrimation, enlarged
eyeballs
GLAUCOMA
 GLAUCOMA
Angle closure or closed angle glaucoma
 Sudden onset of vision loss with intense pain and nausea
 Risk factors; female, family history, hypermetropia,
 Precipitation factors; dim illumination, emotional stress, intense concentration, trauma/illness, mydriatics
 Redness of the eye and blurred vision because of blockage of the flow of fluid from the eye
 Signs; hazy cornea, vertically oval shaped mid dilated pupils, high IOP > 60-70mmhg
 This type is considered a medical emergency as irreversible blindness can occur within a few days.
 Treatment include IV acetazolamide, mannitol, mitotics,
 Treatment is usually immediate laser surgery(laser peripheral iridotomy) to open a passageway through
the trabecular meshwork for fluid to exit the eye or to allow flow of fluid through the iris
 GLAUCOMA

Open angle glaucoma

• Mild painful insidious red eye, usually bilateral but asymmetrical in onset
• Maybe asymptomatic or incidental
• Slow progressive rise in IOP above 21mmhg
• Large cup disc ratio
• Primary pathology is a degenerative process in the trabecular meshwork
• Risk factor include myopia, disc hemorrhage, age, family history, diabetes, HTn, migraine, peripheral
vasospasm, alcohol intake, cigarette smoking
• It is often hereditary, and causes slow, sometimes unnoticed loss of peripheral vision and
loss in central vision with blind spots
 GLAUCOMA

Open angle glaucoma

• Can cause night blindness, and blurring.
• Although treatment cannot restore vision, it can usually prevent progression of the disease .without
treatment, blindness is usually inevitable
• Medication include timolol (B-blocker to decrease aqueous, production),latanoprost, sympathomimetic
e.g. epinephrine and pilocarpine-mitotics to increase aqueous outflow
• Advise patient to prevent increase in IOP to avoid tight cloth, emotional stress, heavy exertion
• Compliance with topical medical treatment is often a problem as drops cause discomfort and redness
and temporary blurring of the vision, and some people have difficulty applying them
• Argon laser trabeculoplasty or trabeculotomy as last resort
 GLAUCOMA
Congenital Glaucoma
• Some Children are born with a defect in the structure of the eye which slows the normal
drainage of fluid in the eye.
• Symptoms are cloudiness in the eye, excessive tearing, and light sensitivity.
• Treatment is usually surgical intervention as the use of eye drops is difficult in infants.
• In earlier days, some surgical interventions included holes or wedges cut from the iris which cause
increased photophobia.
Secondary Glaucoma
• Occurs most often as the result of eye surgery, eye injury or infection, steroid induced,
intraocular tumor, or from certain other eye conditions such as aniridia or severe cataract
• There is also a form that is linked to diabetes.
 GLAUCOMA
Low-Tension Glaucoma
• Occurs when the individual has intraocular pressure less than 21 Hg, but still have changes in the optic disk or
visual field.
• In some cases, intraocular pressure as low as single digits is recommended
• There are three basic treatments of glaucoma:
1.Laser trabeculoplasty- involves the use of a laser to open the trabecular meshwork and allow drainage of the fluid
of the eye
2.Conventional surgery- making a new opening for the fluid to leave the eye covered by a flap known as a blep
3.Eye medication; use of different eye drops or medications which must be taken regularly and continuously, to
either slow production of the fluid of the eye or to increase the flow by thinning the fluid
• Current research indicates that there may be some possibilities of restoring damaged optic disk tissue, but
treatment options for disk replacement are still in clinical trials
 GLAUCOMA – IMPLICATIONS FOR EMPLOYMENT

• Changes in vision may take adjustment time and a person, even with medical
compliance may have changes in vision that will need accommodation.
• If they have remaining vision, they may have difficulty with dark places, dealing with
clutter and visual awareness of their environment.
• If the have no vision, they will rely heavily on other sensory input to function.
• Orientation & mobility is important.
• Proper training and assistive technology and adaptive equipment enables
functioning
DIABETIC RETINOPATHY
• Diabetic eye disease is a group of eye problems that may be acquire as a
complication of diabetes
• Diabetic eye disease includes: cataract, glaucoma & diabetic retinopathy
• Diabetic retinopathy is the leading cause of blindness in persons under
age 45
• Diabetic retinopathy is more frequent and with less time between
diagnosis and onset of visual loss in young people with insulin-dependent
diabetes (type I) than those with age related (type II) diabetes.
• It is caused by changes in the blood vessels of the retina; either as retinal
blood vessels swelling and leaking fluid or by neo-vascularization
DIABETIC RETINOPATHY

Author’s clinical photo

DIABETIC RETINOPATHY
• Two types of diabetic retinopathy: Proliferative and Non-proliferative
• Prevalence of proliferative retinopathy in type I diabetics with 15 years of
systemic disease is 50%, while it is much less in those with type II.
• Between 40-45% of those diagnosed with diabetes have some degree of
diabetic retinopathy.
• Symptoms are sometimes very difficult to detect because until the macula is
affected there may be no obvious indication to the individual
• Regular eye exams are so important for persons who have DM, once there is
some impact on the macula, blurred vision occurs.
DIABETIC RETINOPATHY
• Major factor in preventing diabetic retinopathy and its advancement
is good blood sugar control of around 80-120mg/dl.
• Secondary vision concerns include:
• Glaucoma
• Detached retinas
• Cataracts
• Blurry vision
DIABETIC RETINOPATHY; IMPLICATIONS FOR EMPLOYMENT

• Diabetic retinopathy is spotty at times and the person’s functional vision can swing from 20/200 to totally blind.
• Depending on where the blind areas are in the central vision and how severe the vision loss is, the individual
may have difficulty making eye contact with customers, using a cash register, reading numbers on a credit
card, reading expiration dates on merchandise, keeping the area clean and pleasant looking, and organizing
and completing paperwork.
• They may also have difficulty recognizing faces, discriminating certain colors and dealing with glare.
• All of these areas can be corrected with training, low vision devices and strategies, environmental
modifications, and assistive technology.
• Assistive technology, rehabilitation program and accessible equipment are also necessary.
RETINITIS PIGMENTOSA (RP)
• A group of inherited eye diseases that affect the retina
• RP causes the degeneration of photoreceptor cells in the retina, most often starting with the
rods, as these cells degenerate and die, patients experience progressive vision loss
• Persons with RP often experience a ring of vision loss in their mid-periphery with small islands
of vision in their vary far periphery.
• Others report the sensation of tunnel vision, as though they see the world through a straw.
• Many patients with retinitis pigmentosa retain a small degree of central vision throughout their
life.
RETINITIS PIGMENTOSA (RP)
RETINITIS PIGMENTOSA (RP)
• Initial symptoms include:
• Night blindness
• Tunnel vision
• Blind spots
• Difficulty adjusting to different lighting conditions
• Photosensitivity
• Onset of symptoms usually occurs in persons between 18 and 30;d iagnosis by electroretinalgram (ERG) can be
done at any age.
• There is no treatment or cure and loss of vision varies in individuals, although recent clinical studies are
holding out some hope in the use of stem cell implantations
• Usher’s Syndrome is a syndrome which includes the loss of hearing and RP.
RETINITIS PIGMENTOSA (RP) – IMPLICATIONS FOR
EMPLOYMENT

• RP can lead to total blindness in some people, and it is not unusual for persons
with RP to have an unexpected significant change in vision.
• Since mobility is a challenge, often individuals with RP may have a guide dog or
require the use of a white cane.
• If accompanied by deafness and balance issues, communications and safety
considerations will need to be made.
• Proper training and assistive technology can make it possible for blind or
deafblind persons with RP to be effective blind entrepreneurs.
TRACHOMA

http://www.aao.orgmedialibrary
TRACHOMA TREATMENT

 The World Health Organization (WHO) recommends carrying out an initiative called ‘SAFE’. SAFE stands
for:
 Surgery to repair damage to the eye.
 Antibiotics to treat the infection.
 Face washing to reduce the spread of infection.
 Environmental changes, such as providing access to clean water and suitable sanitation.
Mass antibiotic treatment with single-dose oral azithromycin reduces the prevalence of active trachoma
and ocular infection in communities.

http://www.who.int/blindness/causes/trachoma/en/index.html
ONCHOCERCIASIS

http://www.unep.org/yearbook/2004/097.htm
ONCHOCERCIASIS

• Onchocerciasis, also known as river blindness, is caused by the filarial nematode

Onchocerca volvulus
• This worm is transmitted by the Simulium black fly, which breeds in the rivers and
streams of Africa, Brazil, Mexico, the Middle East, and parts of Central America.
• Onchocerciasis is endemic in at least 27 sub-Saharan African countries, and in Yemen
• Studies indicate that most eye clinical manifestations occur in response to
degenerating microfilariae and the release of endosymbiotic Wolbachia bacteria.

http://whqlibdoc.who.int/publications/2010/9789241500722_eng.pdf
ONCHOCERCIASIS
ONCHOCERCIASIS TREATMENT

• The treatment for onchocerciasis is ivermectin.

• A single dose of ivermectin needs to be taken annually to be effective
• Targeting endosymbiotic Wolbachia species has emerged as a new approach in the
control of onchocerciasis
• Onchocerca embryogenesis is completely dependent on the presence of Wolbachia,
studies of doxycycline therapy (100–200 mg/d for 6 wk.) have shown great promise.

http://www.who.int/entity/pbd/blindness/onchocerciasi
s/en/onchocerca_volvulus.jpg
 CAUSES BLINDNESS IN CHILDREN

 1.4 million children under age 15 are blind.

 The major causes of blindness in children vary widely from region to region and are largely
determined by socioeconomic development, the availability of primary health care and eye care
services.
 The available data suggests that, worldwide, corneal scarring is the single most important cause of
avoidable blindness in childhood, followed by cataract and ROP-Retinopathy
Of prematurity

http://www.who.int/bulletin/archives/79(3)22.pdf

http://www.vision2020kano.org/wp-content/uploads/2009/07/african-child-blind1-300x204.jpg
KEY POINTS TO NOTE IN CHILDREN

• Any child with a squint should be referred.

• Differential Diagnosis of ‘Cat’s Eye” are:
 Retinoblastoma
 Cataract
 Retinopathy of Prematurity
• Avoid prolonged cover of one eye in children. It can cause Amblyopia.
VITAMIN A DEFICIENCY

http://motherchildnutrition.org/malnutrition/images/xerophthalmia.jpg http://motherchildnutrition.org/malnutrition/images/xerophthalmia02.jpg
 VITAMIN A DEFICIENCY

• Vitamin A deficiency can result in Xerophthalmia (severe dryness and scarring of the
eye), corneal ulceration and perforation (keratomalacia) and night blindness
• Is the single most important cause of childhood blindness in developing countries.
• An estimated 2.8 million preschool-age children are at risk of blindness from VAD
• Vitamin A supplements can reduce child mortality by up to 34%

http://www.who.int/blindness/causes/priority/en/index4.html
RETINOPATHY OF PREMATURITY

http://www.aao.orgmedialibrary
RETINOPATHY OF PREMATURITY (ROP)
ftp://ftp.nei.nih.gov/eye_exam/exam13_15
0.tif
 Affects a premature infants and is an important cause of childhood blindness in developed countries.
 Results from damage to the retina due to incomplete development of retinal blood vessels prior to birth
 Risk factor is low gestational age , the smaller a baby the more likely that the baby is to develop ROP.
 Major risk factors; Low birthweight (less than 1500 grams) & Low gestational age (32 weeks or less)
 Over 80% of infants born at less than 28 weeks’ gestational age develop ROP and 60% of infants born at
28−31weeks
• Successful treatment requires early detection and timely laser therapy by skilled practitioners
• Despite improvements in detection and treatment, ROP remains a leading cause of lifelong visual
impairment among children in developed countries
Y
OTHER EYE CONDITIONS
• There are a number of congenital (from birth) and adventitious (adult onset) eye conditions.
• Other relatively common conditions include the following:
• Nystagmus – in children who are born with visual impairment it is not unusual for the eye to move
involuntarily in a rotary or pendular fashion or a combination of similar movements, etc.
• Retinoblastoma – cancer of the eye.
• Often leading to removal of one or both eyes.
• May lead to partial vision or total blindness.
• If the cancer also impacts the orbit around the eye, there may be additional facial scarring
• Albinisim
• lack of pigment in the skin, retina, and hair.
• Often leads to legal blindness, super-sensitivity to light and nystagmus.
REFERENCES

• Hosni FA. Survey of major blinding conditions in Qatar. Ophthalmologica. 1977; 175(4):215-21.
• Vision for Children. A global overview of blindness, childhood and VISION2020: the right to sight.
• World Health Organization (WHO) and the International Agency for the Prevention of Blindness (IAPB).
www.v2020.org. Accessed April 2009.
• Dr E. M. Obazee; Consultant Family Physician wacp lecture
• National Eye Institute. (2015). https://www.nei.nih.gov/health
• Alingham, R., Damji, K., Freedman, S., Moroi, S., & Shafranov, G. (2004). Shield’s Textbook of Glaucoma. New
York: Lippincott Williams & Wilkins Publishing.
• Baker, C., Lund, P., Nyathi, R., & Taylor, J. (2010). The myths surrounding people with albinism in South Africa and
Zimbabwe. Journal of African Cultural Studies, 22(2), 169-181. doi: 1080/13696815.2010.491412
• Moore, J.E., Graves, W.H., & Patterson, J.B. (1997). Foundations of rehabilitation counseling with persons who are
blind or visually impaired. New York: AFB Press.
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