1.16 Eye health
Why is it important?
The partial or full loss of vision is the loss of a critical sensory function that has impacts across all dimensions of life. Vision loss and/or eye disease can lead to linguistic, social and learning difficulties and behavioural problems during schooling years, which can then lead to poor education outcomes and employment prospects. Visual impairment can affect health related quality of life and independent living (West et al. 2002).
Cataract is a degenerative condition in which the lens of the eye clouds over, obstructing the passage of light. Blindness from cataract is now rare due to a highly effective surgical procedure but remains a major cause of vision loss among Aboriginal and Torres Strait Islander peoples (Taylor et al. 2014).
Diabetic retinopathy is damage to the blood vessels in the retina caused by complications of diabetes. Without treatment, diabetic retinopathy can progress to blindness. Although diabetic retinopathy often has no early symptoms, early diagnosis and treatment can prevent up to 98% of vision loss (Taylor et al. 2014). The NHMRC recommends that Indigenous Australians with diabetes should have an eye examination every year (NHMRC 2008).
Trachoma is an eye infection that can result in scarring, in-turned eyelashes (trichiasis) and blindness. Trachoma in Australia is found almost exclusively in remote and very remote Indigenous populations. Trachoma is associated with living in an arid dusty environment; poor waste disposal and high number of flies; lack of hand and face washing; overcrowding and low socio-economic status (NTSRU 2012).
The 2008 National Indigenous Eye Health Survey was based on a sample of 2,883 Indigenous Australians. This survey's strength was that it was based on actual eye examinations and therefore avoided the problem of under-reporting due to undiagnosed conditions. Note: 62% of the sample was in remote areas. In 2008, 9% of Indigenous adults had vision impairment and 2% blindness; while 1.5% of Indigenous children had low vision and 0.2% blindness. Of those adults with vision impairment, the most common causes were refractive error (54%), cataract (27%), diabetic retinopathy (12%) and trachoma (2%). Vision loss associated with trachoma was only found in very remote areas, with higher rates inland (1.3%) than in coastal areas (0.4%). The leading causes of blindness for Indigenous adults found in this study were cataract, optic atrophy, refractive error, diabetic retinopathy and trachoma. Approximately 65% of Indigenous Australians who needed cataract surgery had been operated on, and a further 35% still required treatment. Of those who had diabetes, 20% reported having had an eye examination within the last year and 13% had visual impairment. Comparisons with studies of non-Indigenous Australians found that Indigenous adults had higher rates of vision impairment and blindness from cataract, diabetic retinopathy and trachoma; and Indigenous children had better vision than non-Indigenous children, especially in remote areas (Taylor, H et al. 2009).
The most recent self-reported data on eye health comes from the 2012–13 Health Survey based on a representative sample of 9,300 Indigenous Australians. In 2012–13, one-third (33%) of Indigenous Australians reported eye or sight problems. Long-sightedness (19%) and short-sightedness (13%) were the most common problems reported followed by partial/complete blindness (3%) and cataract (1%). After adjusting for differences in the age structure of the two populations, Indigenous Australians reported higher rates of partial/complete blindness (7 times) and cataract (1.4 times) than non-Indigenous Australians. Indigenous rates were slightly higher for long sightedness (1.1 times) and lower for short sightedness (0.8 times). Half (52%) of non-Indigenous Australians reported some form of eye problems with the most common being long sightedness (27%), followed by short sightedness (23%). A higher proportion of Indigenous females (38%) reported eye problems compared with Indigenous males (29%). In 2012–13, 9% of Indigenous children aged 0–14 years had eye or sight problems. Eye problems increased with age. Those with diabetes were twice as likely to report eye problems (82%) as those without diabetes (43%). In 2012–13, 29% of Indigenous Australians with diabetes reported they had sight problems due to diabetes and 49% had consulted an eye specialist within the last 12 months. In 2012–13, 79% of Indigenous Australians with eyesight problems wore glasses/ contact lenses.
A study from the Eastern Goldfields of WA found that 25% of Indigenous Australians with diabetes showed signs of diabetic retinopathy and 75% of Indigenous Australians with vision loss also had diabetes. Having diabetes increased the risk of vision loss from any cause by 8.5 times (Clark et al. 2010). In 2012, the National Trachoma Surveillance and Reporting Unit reported the prevalence of trachoma in children aged 5–9 years in 204 at-risk communities in the NT, SA, WA and Qld combined as 4%. Prevalence was 4% in NT, 4% in WA and 1% in SA. None of the children screened in Qld had active trachoma. One quarter of communities screened (48 out of 193) had endemic trachoma (over 5% of children with active trachoma) and 63% of communities (121) had no trachoma detected (NTSRU 2012). Of the cases detected, 95% had received treatment and 81% of the estimated household and other contacts had received treatment. Health promotion activities were reported in 133 of the 204 communities screened. The study also screened for clean faces, with 79% of children overall having clean faces. The proportion of communities reaching the target of 80% of children with clean faces ranged from 33% in Qld to 89% in SA.
Based on a survey of GPs, eye problems accounted for 1% of all problems managed by GPs at encounters with Indigenous patients during 2008–13. Overall rates were similar to other Australians except for cataracts, where Indigenous rates were significantly higher (3.5 times).In 2013–14, 47,414 Medicare health assessments (which included eye checks) were undertaken with Indigenous children aged 0–14 years, representing around 19% of children in this age group. In 2012–13, 62% of Australian Government-funded Indigenous primary health services provided access to optometrists on site and 41% off site, while 32% provided access to ophthalmologists onsite and 64% off-site.
In the two years to June 2013, there were 5,674 hospitalisations of Indigenous Australians for diseases of the eye (mainly cataracts). The hospitalisation rate was lower for Indigenous Australians than non-Indigenous Australians (ratio of 0.8). In the 9 years between 2004–05 and 2012–13, there has been a doubling of hospitalisations for eye disease among Indigenous Australians in NSW, Vic, Qld, WA, SA and the NT combined. These rates reflect hospitalisations rather than the extent of the problem in the community. In 2012–13, the cataract surgery rate for Indigenous Australians was 8.7 per 1,000 population, similar to other Australians (8.9 per 1,000) (AIHW 2014f). In 2013–14, the public hospital median wait time for cataract surgery was 107 days for Indigenous patients compared with 78 days for other patients (AIHW 2014g).
Eye health can be affected by diseases such as diabetes (see measure 1.09) as well as environmental factors linked to higher rates of infection and cross-infection, geographic isolation, economic disadvantage and barriers to health care, which can limit the opportunities for detection and treatment. It has been estimated that 94% of vision loss in the Indigenous population is preventable or treatable but 35% of Indigenous adults have never had an eye exam (Taylor et al. 2014).
The WHO SAFE strategy to eliminate trachoma includes surgery (to correct trichiasis), antibiotic treatment, facial cleanliness and environmental improvements (such as fly control, sewerage/rubbish removal, house maintenance). This strategy is based on a primary care model tailored to local situations and building community capacity (NTSRU 2012).
The Australian Government will provide $22 million over four years from 2013–14 to improve the eye health of Indigenous Australians. $16.5 million dollars of this has been allocated to continue national efforts to eliminate trachoma by 2020. The screening and treatment of trachoma is conducted in line with the 2013 National Trachoma Guidelines. The remaining funding will be used to undertake trachoma surveillance and reporting activity, purchase eye health equipment for use in remote areas, perform cataract surgeries in remote areas and fund the Indigenous Eye Health Unit at the University of Melbourne to undertake a range of activities to improve eye health for Indigenous Australians. In addition, approximately $25.4 million is being provided from 2013–14 to 2016–17 to support the Visiting Optometrists Scheme (VOS), which improves access to optometry services for people living in rural and remote locations. In 2013–14, around 19,000 Indigenous patients (out of 39,000 total) were seen through the VOS. The Rural Health Outreach Fund (RHOF) provides outreach initiatives aimed at supporting people living in rural and remote locations to access health care including eye health. In 2013–14, 4,224 Indigenous patients (out of 20,364) were seen by ophthalmologists through the RHOF and a further 1,696 Indigenous patients (out of 4,064) were seen by other eye health professionals. In Qld an Indigenous Diabetes Eye and Screening van provides screening and eye procedures to regional areas.
Figure 1.16.1 shows the proportion of vision loss amongst Aboriginal and Torres Strait Islander adults attributable to the following causes: refractive error; cataract; diabetes; glaucoma; and trachoma in 2008. Data is presented separately for major cities; inner regional areas; outer regional areas; remote areas; and very remote areas. In 2008, 9% of Indigenous adults had vision impairment and 2% blindness; while 1.5% of Indigenous children had low vision and 0.2% blindness. Of those adults with vision impairment, the most common causes were refractive error (54%), cataract (27%), diabetic retinopathy (12%) and trachoma (2%). Vision loss associated with trachoma was only found in very remote areas.
Source: National Indigenous Eye Health Survey, 2008 (Taylor, H et al. 2009)
Figure 1.16.2 shows prevalence of trachoma in children aged 5–9 years in 204 at-risk communities in the NT, SA, WA and Qld. Prevalence was 4% in NT, 4% in the WA and 2% in SA. None of the children screened in Qld had active trachoma. One quarter (25%) of communities screened had endemic trachoma (over 5% of children with active trachoma) and 63% had no trachoma detected.
Source: National Trachoma Surveillance and Reporting Unit