Andrea Zin, MD, PhD
Fernandes Figueira Institute-FIOCRUZ
The control of childhood blindness is one of the priorities of the VISION 2020 programme -“The Right to Sight”. The causes of childhood blindness will vary from region to region, but half of the 50,000 blind children due to retinopathy of prematurity (ROP) in the world live in Latin America.
Blindness from ROP can be prevented by prevention of premature birth, improvement in neonatal care and early detection and treatment of established sight threatening retinopathy. In addition, early identification of child with low vision and adequate management is crucial to warrant appropriate development.
Since 1997, ophthalmic community in Latin America (LA) and later the LA IAPB childhood blindness subcommittee recognized the importance of the prevention of ROP blindness. Although the focus was initially in early detection and treatment of retinopathy of prematurity, the successful partnership with neonatologists brought important concepts: ROP is an indicator of the level of neonatal care and that the control of blindness can be achieved by improvement of neonatal care to reduce risk factors (e.g. improved management of oxygen administration; infection, temperature and pain control). Since 2006, ROP prevention strategies in LA have a more comprehensive and multidisciplinary approach: prevention of preterm birth (obstetricians), improvement of neonatal care (neonatologists and nurses), detection and treatment (ophthalmologists and anesthetists) and visual habilitation (low vision and occupational therapist). Neonatologists and nurses now play a key role in the prevention of ROP blindness.
Since 2001, there were organized more than 30 national and 2 Latin American workshops and in partnership with non governmental organizations working in the region, as CBM and ORBIS, the Panamerican Health Organization, national societies of Ophthalmology and Pediatrics, as well as the Sociedad Iberoamericana de Neonatologia (Siben) and the Panamerican Association of Ophthalmology (PAAO). Lately, Ministries of Health are also taking part of the effort.
Regional guidelines were developed in 2006 by neonatologists and ophthalmologists, under the auspices of the IAPB, PAHO, PAAO (Panamerican Association of Ophthalmology) and SIBEN (Sociedad Latinoamericana de Neonatología), and were revised in 2007 and 2008. It can be used not only for program implementation, but also for advocacy and to mobilize resources.
There are many challenges to increase coverage of ROP programs as pointed out by Zuluaga, Zepeda and Gordillo. Support from Ministries of Health is essential to both neonatal and eye care. In 2009, Ministries of Health of LA countries approved the Plan for Retinopathy of Prematurity in the 49th PAHO-WHO Directive Council. Several countries in the region have approved Ministerial Resolutions that support strategies for the prevention of ROP blindness (e.g. Argentina, Chile, Mexico, Peru).
As a result of a coordinated effort, a lot has been achieved in Latin America. With support from ministries of health and international and local non-government organizations ROP programs are expanding in many countries. National ROP Committees have been formed and management information systems developed (e.g. ROP-21 and ROP database PAAO funded and hosted by IFF-FIOCRUZ). Most countries are following similar policies and practices for screening and treatment. The Latin American Examination and Treatment Guidelines were revised with emphasis on the utilisation of broader screening criteria. Guidelines were also developed for the use of oxygen and treatment management by neonatologists and nurses. Detection of cases is improving in many countries; however, access to treatment services is complicated in several countries. There is a high number of “unusual cases” (babies with BW > 1500g and severe ROP) and missing opportunities implying that much could be done to reduce the incidence of ROP. Neonatal care in Latin America is still critical in several countries with gaps in technical and human resources. There are few opportunities for education and training of nurses and neonatologists in the region. Gordillo describes the innovative neonatal training programme on oxygen management developed in Peru.
Although there are approximately 26,000 ophthalmologists in the region, there is still a need to train professionals to perform the diagnosis and treatment. Lack of financial reimbursement for time spent by ophthalmologists on the program is a major factor contributing to the lack of interest. Almeida describes the situation in Ecuador.
Laser photocoagulation of the peripheral avascular retina is the gold standard treatment for severe ROP. Nevertheless, treatment facilities and professionals to deliver laser treatment are not widely available in LA as Zepeda and Gordillo pointed out. Anti-angiogenic drugs are a tempting and seem to be a promising alternative. However, Graham et al warned against the widespread use of anti-angiogenic drugs to treat serious ROP and the possible adverse and long term effects.
Parents, governmental agencies and health care providers must be advised of the serious of the ROP issue in Latin America. This can be achieved through publications, public service announcements and other means. Extensive educational material is available in several countries and it should be more widely dispersed.
Support from Ministries of Health to implement ROP programs is essential, as well as support by non-government organizations. Advocacy to gain support for programs is vital.
National Societies (Pediatrics and Ophthalmology) and government need to work together aiming the same goal: improvement of neonatal care and implementation of screening and treatment of ROP in neonatal units in the Latin America.
Andrea is an Attending Pediatric Ophthalmologist/Researcher at the Neonatology Department of Fernandes Figueira Institute-FIOCRUZ, Rio de Janeiro, Brazil, where she coordinates the PAHO/WHO Collaborating Centre on Childhood Blindness.
She is also professor at the IFF/FIOCRUZ Public Health Postgraduate programme. Dr Zin received her medical degree from Federal University of Rio de Janeiro. She completed her Ophthalmology residency and received her Master degree in Visual Sciences at the same University. At FIOCRUZ she received her PhD degree on Maternal and Child Health.
Dr Zin works as a CBM medical advisor since 2004 and supported the implementation of several ROP screening and treatment programmes in several Latin American countries.