Research Agenda for Global Blindness Prevention:

Appendix 2: Research Goals: Prioritization and the Means to Move Forward

On this page:

1. Evaluative Research
   
   
2. Operational Research
   
   
3. Discovery Research

"Research," by definition, is the systematic discovery of new knowledge.

While major, fundamental insights often arise from the unfettered search for new knowledge, the ICO's more urgent and achievable goals of reducing global visual impairment and blindness will be best served by focusing global action in poorer countries on:

1. the systematic elucidation of their major causes of needless visual impairment, and
   
   
2. a shared, coordinated, energetic and innovative approach toward understanding and overcoming obstacles to their resolution.

A. Evaluative Research

1. Burden of visual impairment

Knowing the primary causes of visual impairment is critical to prioritizing the interests of the eye care community, mobilizing resources, and influencing policy.

Given the large number of "blindness" surveys conducted during the past two decades, few countries need to carry additional ones out. Countries that have can serve as reasonably valid indices for those with similar characteristics that haven't.

2. Quantifying the "Burden" of pathology

However, in this day and age, mere "prevalence" of disease is inadequate to move policymakers or even affect research or programmatic allocations.

Health priorities are now established on the basis of "burden of disease," a concept that more dynamically captures visual impairment.

To be meaningful for ophthalmic conditions, one needs to know:

1. The distribution of visual impairment (for most practical purposes, in the better eye) by severity and age.
   
   

   The younger the onset, and the more severe the impairment, the greater its "burden."

   Permanently impaired vision in a young child will cause a greater "burden of disease" because this burden will be born for more years than when the impairment had its onset in old age.

   Hence senile cataract, which may appear to be the overwhelming cause of visual impairment, can become less important, relatively, to childhood causes like injuries or xerophthalmia, or mid-adult causes like trachoma.

2. The impact of different levels of visual impairment, at different ages, on "quality of life."

   Very little work has been done in this regard, though a start had begun over the past decade and a half.

   Almost all of the (meager) correlations between vision, impairment, and quality of life come from studies on older individuals (primarily with cataract) in wealthier countries.

   A better delineation of these relationships is critical to establishing "burden of disease" estimates.

Action Item: Regional consortia, composed of countries with similar characteristics, should pool resources and opportunities for developing data needed to estimate "burden of disease" created by their common ocular ailments.

B. Operational Research

At least two major issues are critical to dealing with "avoidable" visual impairment:

1. Generating the capacity to meet the population's need for interventions, whether cataract surgery or treatment for trachoma.

   In most developing countries, unoperated cataract remains the single most common cause of visual impairment and blindness (more sophisticated data is still needed to determine its relative "burden of disease").

   Enormous progress has been made in reducing the time, cost, and complexity of cataract surgery, for example, and in ways to motivate populations to seek care.

   But the gap between needed care and available care remains, for most poor countries of Asia and Africa, enormous.

   For most of the rural, poor countryside, there will never be adequate access to fully qualified ophthalmic expertise if one relies on the procedures and techniques employed in wealthy countries.

Action Item: There is a continuing need to refine approaches to cataract surgery (trichiasis remediation, etc.) to simplify the procedure; reduce the need for sophisticated equipment, facilities, and supplies; and minimize the training and experience required by the operating "surgeon" but remain compatible with high-quality outcomes.

2. Capacity and quantity of activity is not itself adequate. Outcomes, whether of cataract surgery or trachoma intervention, must be successful and approach "international" standards and expectations

   These improvements must address both short- and long-term results, and "quality of life" indicators of the recipient populations

Action Item: There is still a paucity of data on the outcome of ophthalmic interventions in developed and developing countries alike. But the limited resources of developing countries make it imperative that resources are not wasted.

Every country needs to monitor outcomes of its interventions, primarily to identify where and why these might fall short, and thereby prompt remedial intervention.

It makes sense for countries with similar characteristics to jointly develop, test, and refine common protocols, as a spur to action and as a means for sharing "lessons."

C. Discovery Research

Nearly every ocular condition would benefit from basic discoveries related to etiology, treatment, and prevention: from macular degeneration, for which little can presently be done, to cataract, where prevention might well prove far more cost-effective and reduce dependence on readily accessible care.

All countries can participate in discovery research, though most such work will be funded and conducted by investigators in wealthy nations (where appropriate, in collaboration with colleagues from poorer countries).

"Discovery research," while critically important, is probably of tertiary relevance to the funding priorities of poorer countries: Investments in evaluative and operational research are likely to provide more immediate returns.

However, developments or discoveries in wealthy countries that impact on ocular conditions in poorer countries are important: Azithromycin for trachoma and Ivermectin for onchocerciasis are two examples.

Action Item: A consortium of ophthalmic scientists from wealthy and poor countries should systematically monitor new drugs, discoveries, and technologies for potential testing and application in the developing world.

Next: For the Public

Also see: Table of Contents of the Research Agenda for Global Blindness Prevention