Authors: Public Health Task Force for Vision and Ophthalmology
Helene Boisjoly, University of Montreal
Jean Real Brunette, Vision Health Research Council
Ralf Buhrmann, University of Ottawa [Rapporteur]
Paul Courtright, BC Centre for Epidemilogy & International Ophthalmology [Chair]
Alan Creuss, Queens University
Gerrard Grace, CNIB
Jacques Gresset, University of Montreal
Janet Hanevelt, CNIB
Bill Hodge, University of Ottawa [Rapporteur]
Carol Kauppi, CNIB
Ray LeBlanc, Dalhousie University
David Maberley, University of British Columbia [Rapporteur]
Phillip Mickelson, Health Canada
David Persaud, Dalhousie University
Barbara Robinson, University of Waterloo
Lyn Sibley, BC Centre for Epidemiology & International Ophthalmology
Martin Steinbach, Vision Health Research Council
Linda Studholme, CNIB
Greg Taylor, Health Canada

For communication :
Paul Courtright, DrPH
BC Centre for Epidemiology and International Ophthalmology
University of British Columbia
St. Paul’s Hospital
1081 Burrard Street
Vancouver, BC  Canada  V6Z 1Y6

Tel:  (604) 806-8169
Fax:  (604) 806-8058
Email:   pcourtright@providencehealth.bc.ca

Abstract
The changing demographics in Canada suggest that there will be significant increases in the demand for eye care services (treatment and rehabilitation).  It is important to document the information needs so that relevant agencies at a local, provincial, and national level can focus attention more effectively.  Population health is the key concept in the process of focusing attention to the eye care needs of the population.

In March 2000 Health Canada supported a meeting of key individuals from throughout Canada who are currently involved in aspects of population health in eye care.  The group was multi-disciplinary, including ophthalmologists, optometrists, epidemiologists, rehabilitation specialists, social scientists, and health policy planners.  The primary objective of the meeting was to generate the key information needs for eye health strategies for the coming decade. Attention was given to cataract, glaucoma, age-related macular degeneration, and diabetic retinopathy.
 
CATARACT - Information needs for the prevention of vision loss from cataracts
In US studies cataract has been found to be the second leading cause of blindness in the community and the leading cause of blindness in the nursing home population.  In Canada, the average waiting time for surgery varies considerably and it is likely that lengthy waiting times lead to a substantial burden of decreased vision and quality of life from cataract across the country. A better understanding of the burden of vision related quality of life due to cataract is needed.  Populations for whom the access to cataract are felt to be particularly difficult are nursing home residents, members of visible minorities, as well as geographically isolated First Nations peoples. Interestingly, the tremendous success of modern cataract surgery in preventing vision loss has also decreased awareness of the huge burden of visual impairment alleviated by cataract surgery. A projection of cataract surgery needs over the next 5, 10 and 20 years would allow us to strategically plan and advocate access to this effective intervention.  There are concerns regarding the escalating costs of new technology for cataract surgery which may not necessarily offer any improvement in surgical outcomes. In fact, these technologies may limit the number of surgeries that can be provided.

Cataract Summary Recommendations
Information is needed to:

1. Provide a projection of needs for cataract surgery over the next 20 years as well as develop some estimate of disability prevented and cost utility of cataract surgery.
   
2. Better understand and monitor on an ongoing basis the burden of disease from cataract experienced by Canadians waiting for cataract surgery.
   
3. Establish standards for health technology assessment in ophthalmology particularly as pertains to cataract surgery to ensure that the effectiveness and cost effectiveness of new technologies is established prior to their widespread adoption.

GLAUCOMA - Information needs for the prevention of vision loss from glaucoma
The amount of blindness from glaucoma that could be prevented by optimally applying available technology is between 40 - 70%.  In the US, Holland and Australia 50% of glaucoma was undiagnosed. Compliance is a major difficulty in comparing treatment effectiveness. Although no satisfactory method exists for screening of early glaucoma at the present time the sensitivity and specificity of current diagnostic modalities is extremely good for more advanced disease. Our current tools for measuring the progression of the disease are imprecise and improvement of the precision of techniques of monitoring glaucoma could greatly assist management of the disease. Despite difficulties with defining the disease a great deal is known about the epidemiology of open-angle glaucoma; however, the determinants of progression and the natural history of open-angle and angle-closure glaucoma, particularly blinding glaucoma, is very poorly understood.
 

Glaucoma Summary Recommendations
Information is needed to:

1. Develop a better understanding of the natural history of and risk factors for progressive glaucoma particularly “blinding” glaucoma with an aim to better target high risk groups for screening or aggressive treatment.
   
2. Characterise the reasons for under-diagnosis of glaucoma and poor compliance with treatment (population awareness, utilisation of periodic ocular examinations, patient education and health behaviour).
   
3. Develop an adequate framework for screening and improved methods for monitoring glaucoma.

AGE RELATED MACULAR DEGENERATION - Information needs for the prevention of vision loss from age related macular degeneration
The Canadian population is aging and research is needed on how this demographic shift will affect the prevalence/incidence of age-related macular degeneration (AMD). Information is also needed to determine what effect AMD will have on eye care resources over the next 10-20 years. Awareness of AMD may be different for the different forms, namely wet and dry, and impact of these two conditions on vision loss is not understood by health (non-eye) care providers of the elderly. More risk factor information is needed, including genetic work, so that high risk patients can be identified earlier.  In terms of management, the best we can offer for most patients with dry AMD is low vision aids. Access to low vision services and rehabilitation services need to be evaluated and promoted so that the potential impact of these services can be assessed. The coming treatments are ultraexpensive; drug costs nationally for photodynamic treatments may reach $100 million over the next year.

AMD Summary Recommendations
Information is needed to:

1. Improve awareness programmes: only 2% of the Canadian population knows about AMD. Programs are needed to educate family physicians, vision care workers, nurses, and the general population about AMD. Specific efforts are needed to publicize the availability of low vision services and newer treatments for AMD.
   
2. Improve access to service: Low vision services and rehabilitation are the mainstay of AMD management at present. These services need to be evaluated in terms of access and effectiveness.
   
3. Improve therapies: New therapeutic modalities will become available over the next 1 to 2 years. These therapies will likely prove to be very expensive for both patient and/or the Federal Government. These treatments may also tax the medical system from a manpower perspective. Studies are needed to evaluate the impact of these new technologies on the healthcare system in general. Recommendations are also needed about qualifications for individuals who perform angiographic interpretations and treatments for AMD.

DIABETIC RETINOPATHY - Information needs for the prevention of vision loss from diabetic retinopathy
At present there is little published information about diabetic retinopathy (DR) prevalence in Canada or Canadian ethnic populations. Moreover, there is no information about risk factors for the progression of diabetic retinopathy in Canadian peoples. In particular, how many diabetics of type 1 and 2 are there in Canada and, specifically, in Aboriginal populations (prevalence ranges from 2-17%)?  What are the standards for diagnosis, treatment of diabetic retinopathy, and are the paradigms of care changing?  Do they differ for specific populations? Most of the research in this area has been performed on Caucasian American populations.  Efforts are needed to undertake some of this research in specific Canadian populations.   Telemedicine may provide a new approach to this disorder and may be one way of answering some of these questions. Who will provide screening care and make policy decisions about screening care? Awareness and education about DR are both very important for patients and care providers. Knowledge needs to be passed on to GPs, emergency physicians and other practitioners regarding DR. There is an education gap that needs to be addressed. There is also a need to collect and utilize data, possibly in partnership with the National Diabetes Surveillance System.
 

Diabetic retinopathy summary recommendations
Information is needed to:

1. Define the magnitude of the problem: Evaluations are needed to assess the magnitude of the problem of DR, especially in Aboriginal Canadian populations where the diabetes prevalence is high. As well, broad determinants of health need to be evaluated as risk factors for DR—again, primarily in populations that are known to have a high prevalence of diabetes.
   
2. Create awareness programmes: Education is needed to alert populations at high risk for DR about known risk factors for progression?specifically, glycemic control, HTN, lipid levels, smoking, and nephropathy.
   
3. Improve access to services:  A coordinated approach should be sought for screening for DR and, at the same time, addressing risk factors for DR in high-risk populations. Telemedicine holds great promise as a means of addressing information needs about DR prevalence and risk factors. Telemedicine projects need to be developed with careful study design so that the resulting programs employ validated techniques. Evaluations, including cost-effectiveness analyses, of such programs should be carried-out simultaneously.
   

CROSSCUTTING THEMES
A number of themes are relevant to all four major diseases and should be included in considerations of prevention of vision loss from a population health perspective.  These include:

Society, culture and the eye health of populations:
Information is needed on the burden of vision-related disability among Canadians.  This should include an estimate of the cost that is attributable to vision loss in this country.

Health services and health systems:
Information is needed on the obstacles to the utilisation of vision care services by patients, particularly among high-risk groups (who have the most to gain from sight preserving interventions).  An understanding of the distribution of eye care services provided in Canada would be valuable.
Finally, paradigms of delivering care cost-effectively to remote populations and exploring new paradigms of delivering eye care more effectively in urban and rural Canada should be explored.

Applied clinical and basic biomedical research:
There is a need to foster the development of standards for health technology assessment to
 ensure that the effectiveness and cost utility of new innovations are demonstrated prior to their widespread adoption.
In the major blinding diseases of AMD and glaucoma a sizeable portion of the burden from these diseases cannot be adequately prevented or treated with existing modalities; support for basic biomedical research needs to be strengthened.  

For further information, contact one of the individuals on the Public Health Task Force for Vision and Ophthalmology listed below.

Public Health Task Force for Vision and Ophthalmology:
Helene Boisjoly, University of Montreal    
Jean Real Brunette, Vision Health Research Council   
Ralf Buhrmann, University of Ottawa [Rapporteur]   
Paul Courtright, BC Centre of Epidemiology & Int’l Ophthalmology [Chair]
Alan Creuss, Queens University   
Gerrard Grace, CNIB   
Jacques Gresset, University of Montreal   
Janet Hanevelt, CNIB    
Bill Hodge, University of Ottawa [Rapporteur]   
Carol Kauppi, CNIB   
Ray LeBlanc, Dalhousie University   
David Maberley, University of British Columbia [Rapporteur]   
Phillip Mickelson, Health Canada   
David Persaud, Dalhousie University   
Barbara Robinson, University of Waterloo    
Lyn Sibley, BC Centre for Epidemiology & Int’l Ophthalmology   
Martin Steinbach, Vision Health Research Council   
Linda Studholme, CNIB   
Greg Taylor, Health Canada