ministry of health , the republic of myanmar report of

Ministry of Health , The Republic of Myanmar

Report of Rapid Assessment of Avoidable Blindness

Survey – 2018

Technical Support : International Agency for Prevention of Blindness, IAPB-SEA Financial Support: Fred Hollows Foundation/Australia WHO Country Office Myanmar Seva Foundation USA/Canada

Rapid Assessment of Avoidable Blindness in Myanmar 2018

RAAB Survey Report 2018 1

Acronyms and Abbreviations

ARMD Age Related Macular Degeneration

BCVA Best Corrected Visual Acuity

CI Confidence Interval

CSR Cataract Surgical Rate

CSC Cataract Surgical Coverage

CRS Cluster Random Sampling

DR Diabetic Retinopathy

IAPB International Agency for Prevention of Blindness

IOL Intra Ocular Lens

IOV Inter-observer variation

MVI Moderate Visual Impairment

ON Ophthalmic Nurse

PCO Posterior capsular opacification

PH VA Visual Acuity with pinhole

PVA Presenting Visual Acuity

RAAB Rapid Assessment of Avoidable Blindness,

SVI Severe Visual Impairment

URE Uncorrected Refractive Error

VA Visual Acuity

WHO World Health Organisation



Executive Summary

Background

The previous national representative survey was carried out in Myanmar was in 1997, which

shows overall blindness (all ages) as 0.58%.

As there is no other national representative data on blindness and visual impairment were

available for Myanmar to date. Therefore, the national representative population based

prevalence survey on blindness and visual impairment was been considered as urgent need of

the country which enables evidence based planning for the Eye Care Services in Myanmar.

WHO Global Action Plan endorsed by all member state in 2013 also indicated to have objective

oriented planning with feasible target as 25% reduction on the prevalence of blindness rate with

the base line of 2010. As there is no national blindness data in Myanmar in recent past so no

base line data were available to set the target and make strategic plan to achieve the same in

eye care services of the country.

Therefore, with financial support from Fred Hollows Foundation, WHO Country office Myanmar

and Seva foundation and technical collaboration with IAPB, a national representative blindness

survey using RAAB survey methodology was carried out in Myanmar in 2017-2018.

Objective

The overall objective of this survey is to assess the magnitude of blindness and visual

impairment, its causes and the impact of existing eye care service in Union of Myanmar by using

epidemiologically valid survey methodology

Methodology

The survey was carried out by formation of sampling frame according to state/provinces/region of

the country. Each state/province had adequate sample size and study cluster were taken which

is powered to generalize the findings at provincial as well as at the national level. A total of

37,350 people age 50 and over were enrolled in 747 clusters in 11 state/region/province of the

country in this survey.

The survey teams were trained by certified RAAB trainer and Intra observer variation test was

carried out before starting of survey data collection.

The survey teams led by an ophthalmologist were mobilized for data collection. Visual acuity

assessment, medial and fundus examination with direct ophthalmoscope was performed for

clinical examination and data collection in this study.



RAAB6 survey methodology was used for survey design and data collection in this survey.

Smart phone with mRAAB peek application was used in data collection of all eligible survey

participants in the selected study clusters. The collected data was sent to server

computer/Principal investigator by email in regular basis. The survey data collection was

paperless and no separate data entry was necessary in this survey.The server computer

installed with RAAB6 software used for data analysis and report generation.

Results:

Prevalence of blindness and visual impairment:

The study achieved over all 99.7% response rate. It is unusually high compare to similar survey

carried out in other part of the world. The survey found weighted sample prevalence of blindness

among the people age 50 and over was 2.9% (95% CI 2.4 to 3.3). As there are differences in

census population data and survey sample data, Therefore this difference are adjusted and

showed as age sex adjusted prevalence was calculated. The age and sex adjusted prevalence in

Myanmar was found to be 2.7% (95% CI 2.2-3.2) in the population of age 50 and over. A total of

170,478 people age 50 and over are estimated as bilateral blind in survey area of Myanmar.

Based on this finding prevalence of blindness for all ages, is extrapolated as 0.58% for all

Myanmar population.

Similarly age sex adjusted prevalence for severe visual impairment (VA<6/60 to 3/60) was 3.4 %

(95% CI 3.0 to 3.8%) and Moderate Visual impairment was 12.8% (95% CI 10.3-15.3). The

survey estimates there are 816,515 people have visual impairment and 220,304 people have

severe visual impairment in survey area of Myanmar.

The prevalence of cataract blindness in this survey was found to be 1.6%. A total of 101,836

people are estimated to be bilateral blind (pin hole VA <3/60) in Myanmar. Similarly, severe

visual impairment and moderate visual impairment was found to be 1.9% (95% CI 1.4 to 2.3) and

6.0 (95% CI 4.9 to 7.1) due to cataract respectively.

The prevalence of operable cataract (pin hole visual acuity <6/60) was found 3.5%, There are

estimated to be 222,671 operable bilateral cataract blind in Myanmar. Similarly total visual

impairment due to cataract (pin hole VA <6/18 due to cataract is found as 9.5%. Total number of

visual impairment due to cataract blind person is estimated to be 608,366.

The prevalence of blind (<3/60), severe visual impaired (<6/60) and vision impaired (<6/18) eyes

due to cataract was found to be 3.8% (95% CI 3.1 -4.5), 6.4 (95% CI5.9 to 7.3) and 13.8% (95%

CI 12.1 – 14.5) in this survey. The survey shows a total of 1,760,891 eyes are having vision

impaired due to cataract in survey area of Myanmar.



Causes of blindness and visual impairment:

Cataract is overall leading cause of blindness (72.9%) found in this survey. Other major causes

are Glaucoma 11.7%, Corneal Opacity other than Trachoma 2.9%, Surgical complication 2.3%,

Trachoma 1.6% and Diabetic Retinopathy 0.9%. A total of posterior segment causes were

responsible for 4.5% of overall blindness in the country.

Cataract is still found to be leading cause of severe visual impairment 86.4% and vision

impairment 67.4%. Uncorrected refractive error found to be second leading cause if vision

impairment as 21.1%). A total of 94.3% of cause of blindness are found to avoidable either

treatable or preventable.

Refractive error and Low vision:

Prevalence of Refractive error in age 50 and older was found to be 27.3%. Out of these 53.7%

were wearing refractive correction (distance glass coverage (53.7%).

We assumed all people over 50 years and over need near vision correction. Based on this

assumption the survey found that only 31% (male 37% female 27%) of them were having near

correction.

Prevalence of functional low vision (VA <6/18 not due to cataract or refractive error) found to be

1.5% in this survey.

Cataract Surgical coverage:

Cataract surgical coverage in person (bilateral cataract blind) VA<3/60 was found to be74.7%.

Similarly, the coverage was found 60.5% and 40.5% in vision category of better eye <6/60 and

6/18 due to cataract.

Among the cataract eyes the coverage was 61.9%, 49.1% and 31.5% in the vision category of <3/60,

6/60 and 6/18 category respectively.

Visual Outcome of cataract surgery:

Over all good visual outcome was found to be 70.9% among cataract operated eyes. Poor

outcome (PVA <6/60) was found in 10.2% and borderline outcome (PVA<6/18 to 6/60) was in

17.6%.

Barriers to cataract surgery:

The major barrier do not felt the need of surgery 25.8% and fear to surgery 24.2% were found to

be main reason for cataract blind not seeking surgical services. The financial reason was for

16.2% and 9.7% were due to accessibility issues. A total of 16.1% was found to be unaware of

the fact that cataract is treatable.



Conclusion:

The result shows that Myanmar has still high prevalence of blindness in this age group. There is

big back log of cataract with bilateral blind and visual impairment in the country. The cataract

surgical coverage and visual outcome of cataract needs further improvement. Along with cataract

there are other problem such as glaucoma, diabetic retinopathy and corneal lesion are either

emerging or persistent issues to be resolved in the country. The survey also shows that there are

evidences of trachoma or has been trachoma in some specific pockets of the country. It strongly

suggests further investigation in Trachoma endemicity in the country. The survey found that

unaware and fear for surgery are prominent barriers for not up taking available cataract surgical

services in addition to service accessibility in the country. These findings suggest promoting

awareness activities along with other services not adequate and requires further expansion in

the country.



1. Introduction

1. Background

Universal Eye Health: a Global Action Plan (GAP) 2014–2019 was endorsed by by WHO

and adopted by its member states at the World Health Assembly in 2013 (WHA 66.4).

Myanmar was one of the signatories in the World Health Assembly in 2013 who endorsed

to operationalize the goal and target of GAP by reducing prevalence of visual impairment

by 25% in from 2010 to 2019. To achieve this, international partners together with

member states and the WHO secretariat are strategic actions in line with key objectives,

“need for generating evidence on the magnitude and causes of visual impairment and eye

care services using it to advocate greater political and financial commitment by Member

States to eye health” (WHA 66.4). It recommends conducting population based surveys to

provide an evidence-base for planning and evaluating eye health programs. This survey in

Myanmar was planned and executed in line with the mandates of the WHO Global Action

Plan 2014-2019.

1.1 Global Scenario of Visual Impairment

Visual impairment (VI) is emerging as a major public health challenge. Vision

impairment and age-related eye diseases affect economic and educational

opportunities, [1] reduce quality of life,[2] and increase the risk of death [3,4].

Globally, in 2015, it was estimated that 36·0 million (crude prevalence 0·48%) were blind,

216·6 million (2·95%) people had moderate to severe visual impairment (MSVI), and

188·5 million (2·57%) had mild visual impairment [5]. The leading causes blindness were

cataract (35%), uncorrected refractive error (21%) and glaucoma (8%). Similarly, major

causes of MSVI were uncorrected refractive error (53%) followed by un-operated cataract

(25%), age-related macular degeneration (4%), glaucoma (2%) and diabetic retinopathy

(1%).

Visual impairment is more frequent amongst the older groups, 82% of those blind and

65% of those with moderate or severe blindness were older than 50 years of age, while

this age group comprises about 20 % of the world's population [7]. With an increasing

elderly population in many countries, more people will be at risk of visual impairment due

to chronic eye diseases and ageing.

Populations most affected by blindness and visual impairment are in low income countries

in Asia and Africa, mostly in rural areas with few or under-utilized eye care facilities. The

Prevalence of blindness and MSVI in South Asia is still three times higher than in Central

Asia and globally, with women generally more often affected than women [5]. Fortunately,

if adequate interventions are taken, 80% of all visual impairment are avoidable

(preventable or curable) [8].

2. Eye-Health Care Service Infrastructure in Myanmar

Health care is a pluralistic mix of public and private systems, both in financing and provision. The

private, for-profit sector is mainly providing ambulatory care except for some providing

institutional care in Yangon, Mandalay and some larger cities. They are regulated in conformity



with the provision of law relating to Private Health Care Services. Apart from this, there are

private, non-profit, Community Based Organization (CBOs) and Faith Based Organizations

providing ambulatory care, though some provide institutional care. Apart from this, there is an

existing system of traditional medicine too. Major sources of finance for health care services are

the government, private, households, social security system, community contribution and

external aid. Almost 70% of health care finance is from government and 15-20% is private

financing.

The Ministry of Health is the major organization responsible for the health status of the people of

Myanmar. Health care is provided in both rural and urban areas through a tiered system. In the

rural area, the first point of contact are the basic health staff (BHS) (Midwives, Lady Health

Visitors and Health Assistants) who provide promotive, preventive, curative and rehabilitative

services at sub-rural and rural level for a population of 20,000-30,000. The next level is the

Township Health Department that forms the backbone of primary and secondary health care

covering 100,000-200,000 population and is headed by a Township Medical Officer. Each

Township hospital is 16/25-50 bedded (depending upon the size of the population of the

township). Each township hospital has one to two station hospitals and 4-7 rural health centres

(RHC) to provide health services to rural population. Each RHC has 4 sub-centres covered by

mid-wife and a public health supervisor grade 2 at the village level. In addition, there are

voluntary health workers (community health workers and auxiliary midwives) in outreach

providing Primary Health Care (PHC) to the community. The next level is the district hospital

for a population of 0.5-1 million. It is at this level that a specialist is posted (including an

ophthalmologist) and at the top level is the regional/state health department for the entire

region.

Eye Care Services System

Tertiary Eye Care services

At present a total of five eye care institution in Myanmar are considered as tertiary level eye care

services. These hospitals provide regular cataract surgical services with some sub-specialty

services such as Glaucoma, Pediatric and Cornea. They are:

(1) Yangon Eye Hospital

(2) North Okkalapa General Hospital

(3) Mandalay Eye, ENT Hospital

(4) Magway Teaching Hospital

(5) Nay Pi Taw Eye ENT Hospital

Secondary Eye care services

The secondary eye care institution are manned by ophthalmologist, based in general hospital

provides ambulatory eye care and cataract surgical services.

Table 1: Eye Care Services provision in the country

S.

No

State/Region Medical services

(Hospitals)

Prevention of

blindness

1 Kachin State 2

2 Sagaing Region 5 3

3 Shan State 5 -

4 Kayah State 1 -

5 Bago Region 3 2



6 Mandalay

Region

5 4

7 Magway Region 3 7

8 Chin State 2 -

9 Ayeyarwady

Region

6 2

10 Mon State 1 -

11 Kayin State 1 -

12 Tanintharyi

Region

3 -

13 Yangon Region 6 -

14 Rakhine State 2

15 NayPyiTaw

(Union Territory)

3

Total 48 18

3. 0 Prevalence of Blindness and Visual Impairment (VI) in Myanmar

The Meiktila Eye Study (MES) which was conducted in 2005 in the Mandalay Region The survey

shows the Prevalence of Blindness based on Presenting Visual Acuity is 8.1% (6.5 – 9.9%) and

Visual Impairment as 32.9% (27.7 – 38.1%) among the population of age 40 and over. The

prevalence of blindness is associated with increasing age. Cataract was the main cause of

blindness responsible for 40.39% and is associated with increasing age, lower level of education

and lower body mass index.

Another study conducted in rural Myanmar on 2009: Mount Popa Taung-Kalat Blindness

Prevention Project shows that five hundred thirty-one eyes of the total 1,300 eyes (39.5%) had

VI/SVI/BL, and 40 eyes of the children (38.1%) (average age 15.3 ± 13.3) had VI/SVI/BL. The

leading causes of VI/SVI/BL were cataract with 288 cases (54.2%), glaucoma with 84 cases

(15.8%), and corneal pathology with 78 cases (14.7%). Of all the VI/SVI/BL cases, 8.4% were

preventable, 81.9% were treatable, and total of 90.5% were avoidable.

The Ocular morbidity survey conducted in 1997 which shows the overall blindness as 0.58% and

Cataract the leading cause of blindness cataract as 63% and Glaucoma 16% is only national

representative blindness data available in the country. In the national planning still this data is

been used which is more than 15 years old.

The recent district based RAAB survey in the population of age 50 and overs shows following

results*.

Table 2: Finding of recent RAAB survey conducted at district level

No Region District Year completed Prevalence

1. Mandalay Meiktila 2011 1.40

2. Sagaing Sagaing 2011 2.66

3. Sagaing Shwebo 2011 3.78

4. Mandalay Myingyan 2013 3.70

5. Mandalay Pyinmana 2013 2.66

https://en.wikipedia.org/wiki/Ayeyarwady_Region

https://en.wikipedia.org/wiki/Ayeyarwady_Region



Data Source TC and PBL, Public health Department, MoH

As there is no national level data available for Myanmar till now, the national representative

prevalence survey is been considered as urgent need of the time for evidence based planning for

the Eye Care Services in Myanmar.

WHO Global Action Plan endorsed by all member state in 2013 also indicated to have objective

oriented planning with feasible target as 25% reduction on the prevalence of blindness rate with

the base line of 2010. As there is no national blindness data in Myanmar in recent past so no

base line data are available to set the target and make strategic plan to achieve the same in eye

care services of the country.

The information revealed from the this national representative RAAB survey will clearly

demonstrate the situation of existing eye care service in terms of cataract surgical coverage,

visual outcome of cataract surgery and need and priority to align, promote and deliver high-

quality, sustainable eye care services by developing adequate infrastructure, human resource

and quality assurance system in eye care. Evidences of surgical outcomes will inform the need

for surgical training skills of eye health professionals and need to adapt the recent scientific

advancement of eye care services in the country. Ultimately it is aimed that the finding of the

survey will also help the country as advocacy document for resource mobilization in eye health.

4.0 Overall Objective:

The overall objective of this survey is to assess the magnitude of blindness; its causes and the

impact of existing eye care service in Union of Myanmar by using epidemiologically valid survey

methodology.

4.1 Specific Objective:

: overall prevalence of blindness, severe visual impairment and visual impairment;

: prevalence of blindness, severe visual impairment and visual impairment from avoidable

causes;

: prevalence of blindness, severe visual impairment and visual impairment from cataract;

: main causes of blindness, severe visual impairment and visual impairment;

:

: prevalence of aphakia and/or pseudophakia;

: cataract surgical coverage;

: visual outcome of cataract surgery;

: barriers to cataract surgery;

: uncorrected refractive errors and uncorrected presbyopia;

: cataract surgery service indicators (age at time of surgery, place, costs and type of surgery,

cause of visual impairment after cataract surgery).

5.0 Survey Design:

The Survey methodology planned to use in this study is RAAB – 6 survey methodology. This

6. Sagaing Monywa 2013 2.60

7. Bago Bago 2015 4.70

8. Bago Taungoo 2015 1.50

9. Magway Pakokku 2015 10.0



survey methodology is one of preferred method of blindness survey and used in more than 70

countries globally. It is been planned that the survey team in this survey will use mobile phone

installed with Peek mRAAB application for data collection. This will enable more precision of data

entry as it is been carried out by the ophthalmologist when study participants is still present. The

data can be transferred to server computer through email at the end of cluster or when internet

connection for field team is available.

The survey protocol and manual of procedure is already been approved by Health Research

Committee, Ministry of Health, Union of Myanmar and been carried out in some districts in

previous years.

The Union of Myanmar is politically divided in to 15 states and regions (1 union territory, 7 region

and 7 states). It consists of 69 districts, 330 townships, 82 sub-townships, 396 towns, 3045

wards, 13267 village tracts and 67285 villages. The eye care services up to the district level are

provided with dedicated ophthalmic personnel or ophthalmologist and in sub-district level are

provided by the general health worker trained in primary eye care. The hospital and health

service are divided in to the region and district.

Therefore, it is thought to be more appropriate that findings of the survey are able to generalize

at region/state level as well as at National level. This will also demonstrate magnitude of problem

and the impact of ongoing eye care service both at region/state level and at national level. For

this purpose the sampling frame of the study will designed for state-region based with

consideration of homogeneity of geographical area, rural urban setting, ethnic population and

accessibility to the eye care services. Smaller and identical state/region will be merged to have

one sampling frame.

For this purpose the country is stratified into following 11 geographical area for the survey

purpose. Each stratum will be considered as one sampling frame and ample size will be chosen

to generalized the findings of each strata and consolidation of the 11 strata will be the findings at

national level.

To cover all country a total of 37350 people with age 50 and over were enrolled in the study in

randomly chosen 747 clusters in 11 provinces or state of the country (Table 4).

The recent census data of Myanmar 2014 will be used to create the sampling frame for this

study. Mainly two category of data age, five years age group according to gender and smallest

population unit if possible village track - ward-wise data will be used to create the sampling unit

for this purpose.

A list of all population units/clusters/sampling units in the survey area, which will be used as the

sampling frame (list), from which study clusters, will be selected. People in one cluster (50

residents of that area aged 50 years or older) will be selected from one population unit (village

ward). This is usually a list of all enumeration areas in the survey area from the national census.

In a rural/remote area, several small villages may be combined in one enumeration area,

while a larger town is usually sub-divided in a number of enumeration areas (clusters).

The recent census 2014 data shows that almost 18% of the Myanmar population are of age 50



year and older. In this case we would require population of approximately 300 people of all ages

in one cluster. The population of village-track in the study area was the most suitable population

unit for the sampling frame. The complete list of these population unit/clusters/sampling units

comprises the sampling frame.

A table with the composition of the over aged 50 population of the entire survey area by sex and

by 5-year age groups. This second list is to compare the age and sex composition of the sample

that is enumerated in the survey with that of the actual population in the survey area. In case of

any differences, the survey data will be adjusted automatically in result and will be presented as

age sex adjusted prevalence in blindness.

To create the sampling frame the code number, name (location) and number of people per

population unit will be obtained and entered into a standard file, which is generated automatically

in RAAB Software. The total list of all population units in the survey area is called the sampling

frame. From this sampling frame, the required number of population units was selected by

systematic sampling with a probability proportional to size.

5.1 Sample size calculation

The multi stage cluster sampling with first stage is to select the required number of cluster by

random and systematic sampling and the second stage is to select at random 50 eligible persons

in the selected population unit.

As mentioned earlier we intend to generalize the survey findings at provincial level and weighed

prevalence at national level. For these purpose there was 11 sampling frame created to cover

entire Union of Myanmar. The approximate sample size for these studies was calculated in the

basis of followings:

The expected/assumed prevalence of bilateral blindness (VA<3/60 presenting visual

acuity) in the area.

a. The finding of recent RAAB survey conducted at district level varies prevalence of

blindness as 1.5 % to 10 % at district. Based on these findings each province was

categorized as prevalence of blindness as high 5% medium 4.5 % and low as 4%

blindness for the purpose of sample size calculation.

b. A precision of 20% around the likely prevalence is considered as tolerable error. Thus

it will be ±20% of 5 % (4 to 6), 4.5% (3.6 to 5.4) 4% (3 to 5) for high medium and low

of assumed prevalence of blindness respectively.

Confidence Level to calculate the sample for both of survey will be used as 95% (1-

ɑ) =95%.

Tolerable non-compliance rate is considered as 10 %, with the assumption of that we

will have at least 90% response rate in each cluster.

The epidemiologically valid method of cluster sampling was used to identify the

required number of sample population on these surveys. For this purpose the

appropriate number of clusters with population of 50 people age 50 and over was

selected for the study. Based on the previous survey experience of the design effect

likely to occur as expected DEFF are 1.4 for cluster-size 40, 1.5 for cluster-size 50

and 1.6 for cluster-size 60. So in our case here for the cluster size of 50 the DEFF as

1.5 was adjusted for the sample size.

Based on these assumption and formulas used for the calculation of sample size, the total

number of cluster per region required was between 60 to 80 clusters with people age 50 years

and older per region with adjustment of design effect 1.5 for the cluster sampling.



Adequate number of cluster from the sampling frame, first study cluster will be selected by

random number and subsequent cluster are selected with systematic sampling probability

proportionate to size till we get required number of cluster for the study. For all this procedure

there is built in program in RAAB6 software was used.

In the selected study clusters the clinical team headed by ophthalmologist visited door to door of

for enrollment and clinical examination of selected eligible survey participants. The clinical

protocol and examination procedure was as per RAAB6 manual.

In each sampling frame at least two teams with desirable KAPPA agreement in IOV test was

mobilized for data collection. So in total the project, we trained and mobilize 22 study teams in 11

sampling frame to cover all parts of Union of Myanmar.

Table 3 : Sample size calculation according to survey area / sampling frame

6.0 Rational for RAAB Survey

This national study to assess the prevalence and causes of blindness and visual impairment in

Myanmar carried out at national level after 1998 ocular morbidly survey The result of present

survey will be important to gauge the trend of blindness in the country and the impact of current

ongoing eye care services. The findings were considered as important to revise the current

strategy for prevention and control of avoidable blindness for the Ministry of Health to improve

eye health status Myanmar.

The RAAB survey was carried out by the Ministry of Health, Myanmar and will be important to

Estimated Sample Size, Study clusters and working days for RAAB 2017

S. No Survey Area Sampling frame

Population 50+ Pop. Enrolment/ Sample size

No of study Clusters

1 Nay Pi Taw 11,60,242 2,08,844 3,400 68

2 Magway 39,17,055 7,05,070 3,400 68

3 Sagaing 53,25,347 9,58,562 3,250 65

4 Ayeyarwaddy 61,84,829 11,13,269 3,400 68

5 Tanintharyi 14,08,401 2,53,512 3,350 67

6 Kachin 16,89,441 3,04,099 3,250 65

7 Kayin 1574079 2,83,334 3400 68

8 Chin 4,78,801 86,184 3,350 67

9 Mon 20,54,393 3,69,791 3,350 67

10 Yangon 73,60,703 13,34,747 3850 77

11 Shan 58,24,432 524199 3,350 67

Total 29617020 4806864 37350 747



influence the national eye health plan in line with the WHO global action plan. This venture was

close partnership working between the Ministry of Health, Fred Hollows Foundation, Australia

and IAPB South East Asia.

7.0 Training and Quality Assurance

There were 22 teams each led by an Ophthalmologist with three other ophthalmic professionals

(optometrist and ophthalmic assistants) were mobilized for data collection in 11 survey area.

The teams were trained for five days by two ICEH certified RAAB Trainers; Yuddha D Sapkota

from Nepal and Dr. BR Shamana from India. The training was conducted one week prior to the

commencement of the survey. The five days training included the purpose of study, study

design, data collection procedures and clinical examination procedures. The last day was

practiced in the field as practical procedure for the compact segment sampling, selection of

cluster and household and clinical examination as pilot cluster. All field staffs were thoroughly

trained according to the protocol described in the RAAB manual so that they uniformly follow

the same procedure to identify eligible subjects, to assess visual acuity and examine the

anterior segment, and to record the data.

The inter-observer variation (IOV) was tested using the standard format and Kappa ≥ 0.60 was

considered acceptable [Figure 4]. It was measured through repeated examination of 50 subjects

by each team at non study cluster. The most experienced team was considered the ‘Gold

standard’ team and the measurement of VA, examination of the lens and assignment of cause

of visual impairment were compared between teams and the with the ‘Gold standard team to

ensure that their standards were acceptable ( i.e Kappa ≥ 0.60). During the IOV, the teams

obtained acceptable agreement with a minimum kappa score of 0.67 for all parameters. Each

team was given standardised instructions on use of mRAAB application in mobile phone,

definitions, methods of selection of the subjects, examination protocol, method to obtain and

record the data, etc. A pilot study was conducted in one of the non-selected clusters and data

analysis done to compare findings of each team and group discussion done to minimise

discrepancies. After that, the national RAAB trainer accompanied the teams at least once a

week during the study to check the reliability and validity of data collection.



Figure 1: Format for IOV test

8.0 Ophthalmic clinical examination and data collection

The ophthalmic examination was conducted using the standardized RAAB Protocol and the

data collection was paperless. A survey record was completed for each eligible person directly

into the smartphone based mRAAB data collection application. It included participant’s name,

age, sex, history regarding use of spectacle for distance and near vision, presenting visual

acuity, pinhole visual acuity, history of visual impairment, previous cataract surgery and barriers

to cataract surgery. Visual acuity was measured with available correction in daylight illumination

for each eye using the Snellen Tumbling ‘E’ letter with opto sizes 6/12, 6/18 and 6/60 at 6m, 3m

and 1m.

If the VA with available correction was <6/18 in either eye, then the pinhole vision was

measured following the same procedure. For assessment of lens status, distant direct

ophthalmoscope was used in a shaded or semi-dark environment without pupillary dilatation.

Relative afferent pupillary defect (RAPD) was checked with a swinging flashlight test and the

fundus was examined using a direct ophthalmoscope by the ophthalmologist in all participants

with VA<6/18 in either eye. The pupils were dilated with a short-acting 1% tropicamide eye

drops when the pinhole VA was <6/18 unless there were obvious media opacities due to

cataract or corneal opacities to confirm the cause of visual impairment. The principal cause of

blindness or VI was recorded by the ophthalmologists. When there were co-existing primary

disorders in the same or different eyes, the disorder which is most readily curable was marked

the principal cause. The following is a recommended ranking of the disorders with respect to

these criteria by RAAB protocol 6.0: refractive error, cataract, uncorrected aphakia, surgery

related complications, preventable corneal opacities and phthisis, glaucoma, and other posterior

segment disorders.

Those who were operated for cataract, surgery history and related information such as date of

surgery, place of surgery, and cost of the surgery were recorded. In cases when the subject

was not available, was not able to communicate, or refused the examination, he/she was

enrolled in the study and the possible details of vision and cause of blindness (cataract, causes

other than cataract, or operated for cataract) were obtained from a relative or neighbor. The

participant was considered “absent for clinical examination” if not available on two repeat visits.

All participants received feedback about their eyes and were advised to seek ophthalmic

attention if they had any concerns. People who were discovered to have eye problems were

given relevant counseling and advice. Those whom it was thought would benefit from further

management, including those with operable cataracts, were referred to the nearest regional

referral hospital or the national referral hospital. Appropriate medications, prescriptions and

referral were done after the examination; rates of follow-up were not measured.

9.0 Ethical Approval

The study was approved by the Research and Ethics Board of Health, Ministry of Health,) and

conformed to the tenets of the Declaration of Helsinki. The research information sheet and

Informed Consent form was reviewed and approved by the Ethical Review Board, Minitry of

Health, Union of Myanmar. Administrative approval was obtained from the Ministry of Health,

Myanmar for the use of human resource to use in RAAB survey.

A local guide, well-known in the locality was asked for assistance for the day in informing the

eligible population for the survey and providing necessary support. Before enrollment and

examination, all the study procedures were explained in detail to each participant and their

family in local dialect by the enumeration team.

Verbal informed consent was obtained after explanation about the study, its benefits and risks.

The participants were told that the participation was voluntary and that they were free to

withdraw at any point and non-participation would not affect them in any way. It was always

explained that the name and identification of the study participant would not appear in any form

of report generated from this study. No monetary incentive was offered for participation in this

study.

10.0 Statistical Analysis

The mRAAB, a data entry application (Android) for RAAB surveys for smartphones was

developed by the PEEK Vision Project in collaboration with International Centre for Eye Health,

UK) was used for data entry. The software program developed for the Rapid Assessment of

Avoidable Blindness (RAAB Version 6, 2017 developed by IECH) was used. The software

package has an inbuilt standardized format for data analysis and display of results. The data

collected by each team were sent via application supported emails to three survey coordinators

after completion of each cluster for backup. Consistency checks were performed by the co-

ordinator based in the centre and inconsistencies were adjusted on the same day.

The prevalence estimates took account of the DEFF (design effect) while estimating the

confidence intervals. The results were recorded by person (bilateral blindness or VI) and by eye

(unilateral blindness or VI). Age and gender adjusted prevalence were calculated with reference

to the population projection for 2014. The visual outcome of cataract surgery was reported

among all the pseudophakic or aphakic eyes. Cataract surgery coverage (CSC) was calculated

by eye and person. Since the visual acuity prior to the surgery was not known, assumptions

were made that only patients with visual acuity below a certain threshold (<3/60,

<6/60 and <6/18, respectively), underwent surgery for cataract.

11.0 Outcome Measures

The following are the main outcome measures presented in this report:

The prevalence of blindness and visual impairment, causes, cataract services (CSC and

Visual outcomes) and barriers to uptake of cataract surgery.

Comparison of the prevalence of blindness and visual impairment, causes, cataract

services (CSC and Visual outcomes) and barriers to uptake of cataract surgery.

Comparison of the prevalence of blindness and visual impairment, causes, cataract

services (CSC and Visual outcomes) and barriers to uptake of cataract surgery.

12. Results

12.1 Study Population

Table : 4, Response rate and refusals

Province/ State

Enrolled Examined

Male Female Total Male Female Total

Ayeyarwaddy 1463 43.0% 1937 57.0% 3400 1448 99.0% 1925 99.4% 3373 99.2%

Chin 1358 40.5% 1991 59.5% 3349 1358 100.0% 1991 100.0% 3349 100.0%

Kachin 1401 43.0% 1858 57.0% 3259 1400 99.9% 1858 100.0% 3258 100.0%

Kayin 1439 42.3% 1960 57.7% 3399 1439 100.0% 1960 100.0% 3399 100.0%

Magway 1219 35.9% 2181 64.1% 3400 1207 99.0% 2170 99.5% 3377 99.3%

Mon 1276 38.1% 2076 61.9% 3352 1266 99.2% 2074 99.9% 3340 99.6%

Nay Pyi Taw 1301 38.3% 2099 61.7% 3400 1287 98.9% 2093 99.7% 3380 99.4%

Sagaing 1308 40.2% 1942 59.8% 3250 1308 100.0% 1940 99.9% 3248 99.9%

Shan 1046 31.2% 2304 68.8% 3350 1046 100.0% 2304 100.0% 3350 100.0%

Tanintharyi 1321 39.4% 2029 60.6% 3350 1320 99.9% 2029 100.0% 3349 100.0%

Yangon 1660 43.1% 2190 56.9% 3850 1646 99.2% 2177 99.4% 3823 99.3%

Weighted Average 14792 39.6% 22567 60.4% 37359 14725 99.5% 22521 99.8% 37246 99.7%

Overall response rate in these survey were very high. In five sampling frame there is hundred percent

enrolled were undergone clinical examination. This is exception in other surveys. In the sample

population 60% were female and 40 % were male enrolled in almost all survey area. Census data

shows male and female ratios are 45% and 55%. These differences in census population and sample

population are adjusted in age sex adjusted results of the survey.

12.2 Prevalence of Blindness and Visual Impairment

Table 5: Prevalence of blindness in sample (presenting VA<3/60 in the better eye)

Province/State

Males Females Total

% (95%CI) % (95%CI) % (95%CI)

Ayeyarwaddy 6.9% (5.4-8.5) 5.9% (4.7-7.1) 6.3% (5.2-7.4)

Chin 0.7% (0.2-1.2) 0.7% (0.2-1.1) 0.7% (0.3-1.0)

Kachin 0.1% (-0.1-0.3) 0.5% (0.2-0.8) 0.3% (0.1-0.5)

Kayin 0.6% (0.2-0.9) 1.2% (0.7-1.8) 0.9% (0.6-1.3)

Magway 4.9% (3.4-6.4) 5.6% (4.3-6.8) 5.3% (4.2-6.4)

Mon 1.8% (0.9-2.7) 2.0% (1.3-2.6) 1.9% (1.3-2.5)

Nay Pyi Taw 2.3% (1.3-3.2) 2.9% (2.1-3.7) 2.6% (2.0-3.3)

Sagaing 1.5% (0.8-2.3) 3.3% (2.4-4.1) 2.6% (1.9-3.2)

Shan 2.2% (1.2-3.2) 2.8% (1.9-3.7) 2.6% (1.9-3.3)

Tanintharyi 1.7% (1.0-2.4) 2.9% (1.9-3.8) 2.4% (1.7-3.1)

Yangon 0.2% (0.0-0.5) 0.4% (0.1-0.7) 0.3% (0.1-0.5)

Weighted average 2.7% (2.0 - 3.3) 3.1% (2.6 – 3.6) 2.9% (2.4 – 3.3)

Overall weighted sample prevalence of blindness presenting visual acuity <3/60 in survey area of

Myanmar shows 2.9%. The prevalence of blindness in Kachin is exceptionally low as 0.3%. The

prevalence of blindness in Ayeyarwaddy is found to be 6.3%. The detail of report of each survey area

is in Annex 1.

Table 6: Age and sex adjusted prevalence of all blindness PVA<3/60

State Province

Males Females Total

n % 95%CI n % 95%CI n % 95%CI

Ayeyarwaddy 26287 5.0% (3.4 - 6.5) 35610 5.7% (4.4 - 6.9) 61897 5.3% (4.2 - 6.4)

Chin 266 0.8% (0.3 - 1.3) 284 0.7% (0.3 - 1.1) 550 0.8% (0.4 - 1.1)

Kachin 100 0.1% (-0.1 - 0.3) 823 0.7% (0.4 - 1.0) 923 0.5% (0.3 - 0.7)

Kayin 711 0.6% (0.3 - 1.0) 2449 1.8% (1.3 - 2.4) 3160 1.3% (0.9 - 1.7)

Magway 12925 3.9% (2.4 - 5.3) 25339 5.6% (4.3 - 6.8) 38264 4.8% (3.7 - 6.0)

Mon 2486 1.5% (0.6 - 2.4) 4356 2.0% (1.3 - 2.7) 6842 1.8% (1.2 - 2.4)

Nay Pyi Taw 1503 2.0% (1.0 - 2.9) 2649 2.7% (1.9 - 3.5) 4152 2.4% (1.7 - 3.0)

Sagaing 5575 1.4% (0.6 - 2.1) 16299 3.0% (2.1 - 3.8) 21874 2.3% (1.7 - 2.9)

Shan 7227 1.8% (0.8 - 2.8) 14389 3.1% (2.2 - 4.0) 21616 2.5% (1.8 - 3.2)

Tanintharyi 1707 1.7% (1.0 - 2.4) 4181 3.5% (2.5 - 4.5) 5888 2.7% (2.0 - 3.4)

Yangon 1220 0.2% (-0.1 - 0.5) 4092 0.5% (0.3 - 0.8) 5312 0.4% (0.2 - 0.6)

Weighted average 60007 2.1% (1.5 - 2.6) 110471 3.1% (2.5- 3.7) 170478 2.7% (2.2 - 3.2 )

As mentioned earlier there was big difference in sample population and census population in this

survey. Therefore it is important to adjusted this difference in results as well. Age Sex adjusted

prevalence of blindness in Myanmar is found to be 2.7%. This also has big range starting from 0.4%

and 0.5% in Yangon and Kachin to 5.3% in Ayeyarwaddy and 4.8% in Magway survey area. The

extrapolation shows there are 170, 478 people with age 50 and over are bilateral blind in these survey

areas. The prevalence of blindness rate in female gender found to be high 3.1% compare to male

2.1%.

Table 7: Age and sex adjusted prevalence of all blindness BCVA <3/60

State/Province

Male Female Total

N % 95% CI N % 95% CI N % 95% CI

Ayeyarwaddy 23960 4.5% 3.1 - 6.0 31763 5.0% 4.0-6.1 55723 4.8% 3.8-5.8

Chin 214 0.6% 0.2 - 1.1 245 0.6% 0.3-1.1 459 0.6% 0.4-0.9

Kachin 100 0.1% -0.1-0.3 823 0.7% 0.4-0.1 923 0.5% 0.3-0.7

Kayin 711 0.6% 0.3-1.0 2038 1.5% 1.0 – 2.0 2749 1.1% 0.8-1.5

Magway 6883 2.1% 1.1 – 3.0 13691 3.0% 2.2 – 3.8 20574 2.6% 1.9 – 3.3

Mon 2370 1.4% 0.5- 2.3 4356 2.0% 1.3 – 2.7 6726 1.7% 1.2 – 2.3

Nay Pyi Taw 1286 1.7% 0.9-2.5 2081 2.1% 1.3 – 2.9 3367 1.9% 1.3 – 2.6

Sagaing 4823 1.2% 0.5 -1.9 15290 2.8% 1.9 – 3.6 20113 2.1% 1.5 – 2.7

Shan 6637 1.7% 0.7 – 2.6 12940 2.8% 1.9 – 3.6 19577 2.3% 1.7 – 2.9

Tanintharyi 1567 1.6% 0.9 – 2.3 3280 2.7% 1.9 – 3.5 4847 2.2% 1.6 – 2.8

Yangon 1220 0.2% -0.1-0.5 4092 0.5% 0.3 – 0.8 5312 0.4% 0.2-0.6

Weighted average 49771 1.8% (1.2-2.4) 90599 2.5% (2.0-3.0) 140370 2.2% (1.7-2.7)

Uncorrected refractive error is found to be important factor in blindness and visual impairment, the

prevalence of blindness reduced to 2.2% from 2.7% in pinhole vision. It has significant impact in

survey area, the blindness rate reduced from 5.3% to 4.8% in Ayeyraddy, 4.8 to 2.6 %in Magway

survey area .

Table 8: Adjusted prevalence of visual impairments

Presenting VA<6/60 – 3/60 (SVI) Presenting VA<6/18 – 6/60 (VI)

Province N Prev. 95% CI n Prev. 95% CI

Ayeyarwaddy 63857 5.5% (4.6 - 6.4) 153975 13.3% (11.6 - 14.9)

Chin 954 1.3% (1.0 - 1.7) 6212 8.7% (7.4 - 10.0)

Kachin 2951 1.4% (1.1 - 1.8) 19674 9.7% (8.5 - 10.8)

Kayin 3997 1.6% (1.2 - 2.1) 40943 16.7% (14.9 - 18.5)

Magway 43175 5.5% (4.5 - 6.5) 161139 20.4% (18.6 - 22.3)

Mon 9358 2.4% (1.6 - 3.3) 86839 22.5% (19.5 - 25.5)

Nay Pyi Taw 6988 4.0% (3.0 - 4.9) 25923 14.8% (13.0 - 16.6)

Sagaing 38733 4.1% (3.3 - 4.9) 95528 10.1% (8.4 - 11.8)

Shan 24088 2.8% (2.0 - 3.6) 82583 9.6% (7.9 - 11.3)

Tanintharyi 5976 2.7% (2.0 - 3.4) 27096 12.4% (10.9 - 13.9)

Yangon 20227 1.5% (1.0 - 2.0) 116603 8.7% (7.1 - 10.4)

Weighted average 220304 3.4% (3.0 – 3.8) 816515 12.8% (10.3-15.3)

The survey shows prevalence of severe visual impairment 1.3% in lowest Chin to 5.5% highest in

Ayeyarwaddy. Moderate visual impairment ranges is 8.7% in Yangon and Chin to 22.5% and 20.4% in

Mon and Magway respectively. The weighted average for all survey area of Myanmar shows 3.4% of

severe visual impairment and 12.8% vision impairment. The survey shows there are 816,515 people

have visual impairment and 220,304 people have severe visual impairment in survey area of

Myanmar.

12.3 Blindness and Visual Impairment due to cataract

Table 9: Adjusted prevalence of bilateral cataract blindness (BCVA<3/60 in the better eye) and estimated

number of cases in people aged 50+

Province/ State

Males

Females

Total

No % No % No % 95% CI

Ayeyarwaddy 21108 4.0% 25301 4.0% 46409 4.0% (3.1 - 4.9)

Chin 38 0.1% 93 0.2% 131 0.2% (0.0 - 0.3)

Kachin 52 0.1% 377 0.3% 429 0.2% (0.1 - 0.4)

Kayin 617 0.6% 1969 1.5% 2586 1.1% (0.7 - 1.4)

Magway 4229 1.3% 8071 1.8% 12300 1.6% (1.1 - 2.1)

Mon 2370 1.4% 2876 1.3% 5246 1.4% (0.9 - 1.9)

Nay Pyi Taw 573 0.8% 1421 1.4% 1994 1.1% (0.6 - 1.6)

Sagaing 3085 0.8% 8290 1.5% 11375 1.2% (0.8 - 1.6)

Shan 4897 1.2% 9184 2.0% 14081 1.6% (1.1 - 2.1)

Tanintharyi 1054 1.1% 2891 2.4% 3945 1.8% (1.3 - 2.3)

Yangon 850 0.1% 2490 0.3% 3340 0.3% (0.1 - 0.4)

Weighted average 38873 1.4% 62963 1.8% 101836 1.6% (1.3-1.9)

The prevalence of bilateral cataract blindness is found to be 0.2% in in Chin and Kachin state to 4.0%

in Ayeyarwaddy state. The survey shows high prevalence of cataract blindness in female compare to

male gender. A total of 101,836 people are bilateral cataract blind (presenting visual acuity <3/60) in

survey area of Myanmar.

Table 10: Adjusted prevalence of bilateral SVI and VI due to cataract and estimated number of cases in people aged 50+ .

Province/State

BCVA<6/60 – 3/60 (SVI) BCVA<6/18 – 6/60 (VI)

No % 95 % CI No % 95 % CI

Ayeyarwaddy 36210 3.1 (2.5 - 3.8) 58982 5.1 (4.2 - 5.9)

Chin 632 0.9 (0.6 - 1.2) 1469 2.0 (1.5 - 2.6)

Kachin 1826 0.9 (0.6 - 1.2) 12129 6.0 (5.0 - 6.9)

Kayin 3687 1.5 (1.1 - 1.9) 34845 14.2 (12.7 - 15.7)

Magway 15818 2.0 (1.4 - 2.7) 80627 10.2 (8.8 - 11.7)

Mon 7507 1.9 (1.1 - 2.8) 36598 9.5 (8.0 - 11.0)

Nay Pyi Taw 2401 1.4 (0.8 - 1.9) 12773 7.3 (6.0 - 8.5)

Sagaing 24093 2.5 (1.9 - 3.2) 57076 6.0 (4.8 - 7.2)

Shan 14487 1.7 (1.2 - 2.2) 39984 4.6 (3.4 - 5.9)

Tanintharyi 3208 1.5 (1.1 - 1.9) 9286 4.3 (3.3 - 5.2)

Yangon 10966 0.8 (0.5 - 1.2) 41926 3.1 (2.3 - 4.0)

Weighted average for all survey area 120835 1.9 (1.4 – 2.3) 385695 6.0 (4.9 -7.1)

The prevalence of cataract found to be 1.9 for severe visual impairment and 6.0% in vision impairment

category. Based on this prevalence there are estimated to be additional bilateral cataract 120,835 and

385,695 severe vision impairment and moderate vision impairment category respectively.

Table 11: Adjusted prevalence of bilateral cataract blindness (pinhole VA<6/60 in the better eye) and

estimated number of cases in people aged 50+

Males Females Total

Province/State n % n % n % 95% CI

Ayeyarwaddy 36114 6.8% 46505 7.4% 82619 7.1% (5.8 - 8.4)

Chin 372 1.1% 391 1.0% 763 1.1% (0.7 - 1.5)

Kachin 449 0.5% 1806 1.5% 2255 1.1% (0.8 - 1.4)

Kayin 2111 1.9% 4162 3.1% 6273 2.6% (2.0 - 3.1)

Magway 9765 2.9% 18353 4.0% 28118 3.6% (2.6 - 4.5)

Mon 4276 2.5% 8477 3.9% 12753 3.3% (2.1 - 4.5)

Nay Pyi Taw 1910 2.5% 2485 2.5% 4395 2.5% (1.7 - 3.3)

Sagaing 11176 2.8% 24292 4.4% 35468 3.7% (2.9 - 4.5)

Shan 10978 2.8% 17590 3.8% 28568 3.3% (2.6 - 4.0)

Tanintharyi 2118 2.2% 5035 4.2% 7153 3.3% (2.5 - 4.0)

Yangon 4029 0.7% 10277 1.4% 14306 1.1% (0.7 - 1.5)

Weighted average 83298 3.0% 139373 3.9% 222671 3.5% (2.8 – 4.2)

Best corrected visual acuity of less than 6/60 usually taken as visual acuity cut off for advising cataract

surgery. Cataract surgical burden also calculated based on this visual acuity cut off of <6/60. In this

survey overall prevalence of bilateral cataract blindness was found to be 3.5% (male 3.0% and female

3.9%). The highest prevalence of bilateral cataract blindness 7.1 was found in Ayeyarwaddy and

lowest in Yangon, Chin and Kachin as 1.1%.

Table 12: Adjusted prevalence of bilateral cataract blindness BC VA<6/18 in the better eye) and estimated number of cases in people aged 50+

Province/State

Males Females Total

n % n % n % 95% CI

Ayeyarwaddy 56822 10.7% 84779 13.5% 141601 12.2% (10.6 - 13.8)

Chin 1016 3.1% 1216 3.2% 2232 3.1% (2.4 - 3.9)

Kachin 4482 5.3% 9902 8.4% 14384 7.1% (6.1 - 8.1)

Kayin 16665 15.2% 24453 18.0% 41118 16.8% (15.2 - 18.3)

Magway 42544 12.7% 66201 14.6% 108745 13.8% (11.8 - 15.7)

Mon 18224 10.9% 31127 14.3% 49351 12.8% (10.7 - 14.9)

Nay Pyi Taw 6290 8.3% 10878 11.0% 17168 9.8% (8.2 - 11.4)

Sagaing 30862 7.7% 61682 11.2% 92544 9.7% (8.2 - 11.3)

Shan 28011 7.0% 40541 8.7% 68552 8.0% (6.3 - 9.6)

Tanintharyi 4962 5.1% 11477 9.5% 16439 7.5% (6.1 - 8.9)

Yangon 22035 3.8% 34197 4.6% 56232 4.2% (3.2 - 5.3)

Weighted average 231913 8.2% 376453 10.5% 608366 9.5% (8.4 – 11.0)

Overall prevalence of visual impairment better eye visual acuity less than 6/18 due to cataract was

found to be 9.5%. The lowest prevalence found in Chin as 3.1% and highest found in Kayin 16.8%.

With this prevalence rate it is estimated that a total of 608,366 people are visual impaired in survey

area due to cataract.

Table 13: Adjusted prevalence of eyes with cataract and estimated number of eyes in people aged 50+

Province/State

BCVA<3/60 BCVA<6/60 BCVA<6/18

n % 95%CI n % 95%CI n % CI95%

Ayeyarwaddy 183164 7.9 (6.7 - 9.1) 255948 11.0 (9.6 - 12.5) 412408 17.8 (16.0 - 19.6)

Chin 1469 1.0 (0.7 - 1.4) 3503 2.4 (1.9 - 3.0) 8483 5.9 (5.1 - 6.7)

Kachin 3145 0.8 (0.5 - 1.0) 13231 3.3 (2.7 - 3.8) 36370 8.9 (8.0 - 9.9)

Kayin 10497 2.1 (1.6 - 2.7) 22170 4.5 (3.8 - 5.3) 98690 20.1 (18.5 - 21.8)

Magway 81047 5.1 (4.3 - 6.0) 127149 8.1 (6.7 - 9.4) 320973 20.3 (18.2 - 22.5)

Mon 20041 2.6 (1.8 - 3.4) 43497 5.6 (3.9 - 7.4) 125760 16.3 (13.8 - 18.8)

Nay Pyi Taw 10962 3.1 (2.3 - 3.9) 18824 5.4 (4.3 - 6.5) 50527 14.4 (12.5 - 16.3)

Sagaing 66208 3.5 (2.9 - 4.1) 131390 6.9 (6.0 - 7.8) 265267 14.0 (12.2 - 15.7)

Shan 54141 3.1 (2.6 - 3.7) 97465 5.7 (4.8 - 6.6) 194033 11.3 (9.4 - 13.1)

Tanintharyi 15632 3.6 (3.0 - 4.2) 26919 6.2 (5.1 - 7.2) 51752 11.8 (10.2 - 13.5)

Yangon 40156 1.5 (1.1 - 1.9) 73095 2.7 (2.0 - 3.5) 196628 7.4 (6.0 - 8.7)

Weighted average 486462 3.8 (3.1 -4.5) 813191 6.4 (5.9 -7.3) 1760891 13.8 (12.1 -14.5)

Table # shows prevalence of cataract blind or visual impaired eyes in survey population. This includes

both eye of bilateral cataract and one eye of unilateral cataract blind and visual impaired. While

including unilateral cataract blind and visual impairment

12.4 Causes of Blindness and visual impairment

Table 14: Bilateral blindness - main cause in person

Province/ State URE Cat. Surg. Trach

Corneal Scar

Phthis Glau DR AMD PSD

Globe CNS

Ayeyarwaddy 0% 85.0% 1.4% 0% 0.9% 2.8% 5.2% 0.5% 1.4% 2.8% 0%

Chin 0% 21.7% 4.3% 4.3% 0.0% 0.0% 17.4% 8.7% 4.3% 39.1% 0%

Kachin 0% 45.5% 9.1% 0% 0% 0% 27.3% 0% 0% 9.1% 9.1%

Kayin 0% 100% 0% 0% 0% 0% 0% 0% 0% 0% 0%

Magway 1.1% 78.9% 1.1% 2.8% 7.2% 0.6% 2.8% 0.6% 2.2% 2.2% 0.6%

Mon 0% 79.7% 1.6% 1.6% 1.6% 1.6% 12.5% 0.0% 0.0% 1.6% 0%

Nay Pyi Taw 1.1% 74.2% 2.2% 0% 3.4% 1.1% 5.6% 0.0% 2.2% 10.1% 0%

Sagaing 0% 56.6% 6.0% 7.2% 9.6% 0.0% 16.9% 1.2% 1.2% 1.2% 0%

Shan 2.3% 72.7% 3.4% 0% 1.1% 1.1% 8.0% 3.4% 0% 4.5% 3.4%

Tanintharyi 1.3% 81.3% 2.5% 0% 1.3% 1.3% 2.5% 0.0% 0% 5.0% 5.0%

Yangon 0% 69.2% 0% 0% 0% 0% 23.1% 0.0% 0% 7.7% 0%

Weighted average 0.5% 72.9% 2.3% 1.6% 2.9% 0.9% 11.7% 0.9% 0.8% 4.5% 1.0%

Cataract is found to be leading cause of blindness found in this survey. It accounts for 72.9% of overall

cause of blindness in Myanmar. It was surprising that 100% cause of blindness was cataract in Kayin

survey area. Blindness due to Trachoma is also found as second leading cause 7.2% in Sagaing

survey area. Other area with Trachoma blindness was reveled in Chin 4.3%, Magway 2.8% and Mon

1.6%.Blindness due to Glaucoma 17.4% and Diabetic Retinopathy 8.7% was found in Chin survey

area. This state shows avoidable causes as 30% and unavoidable causes close to 70%.

Table 15: Bilateral Severe Visual Impairment (<6/60-3/60) - main cause in person

Province /State URE Cat Surg

Trach

Cornea Scar

Phthisis Glauc DR AMD PSD

Globe /CNS

Ayeyarwaddy 1.4% 87.9% 0.5% 0.0% 1.4% 1.4% 4.2% 2.3% 0.0% 0.9% 0.0%

Chin 0.0% 73.7% 2.6% 0.0% 0.0% 0.0% 13.2

% 2.6% 0.0% 7.9% 0.0%

Kachin 0.0% 78.4% 0.0% 0.0% 0.0% 0.0% 10.8

% 0.0% 10.8

% 0.0% 0.0%

Kayin 0.0% 97.8% 0.0% 0.0% 2.2% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

Magway 2.6% 90.7% 2.1% 0.0% 0.0% 0.0% 1.0% 0.0% 1.5% 2.1% 0.0%

Mon 1.1% 88.9% 1.1% 0.0% 0.0% 0.0% 3.3% 1.1% 1.1% 3.3% 0.0%

Nay Pyi Taw 2.0% 85.1% 3.4% 0.0% 2.7% 0.0% 1.4% 0.0% 2.7% 2.0% 0.7%

Sagaing 0.0% 85.8% 4.7% 0.7% 1.4% 0.0% 5.4% 0.7% 0.7% 0.7% 0.0%

Shan 4.1% 87.8% 0.0% 0.0% 1.0% 0.0% 2.0% 1.0% 1.0% 3.1% 0.0%

Tanintharyi 1.2% 88.4% 2.3% 0.0% 2.3% 0.0% 1.2% 2.3% 0.0% 1.2% 1.2%

Yangon 5.2% 79.3% 1.7% 0.0% 0.0% 0.0% 10.3

% 0.0% 3.4% 0.0% 0.0%

Weighted average

2.4% 86.0% 1.7% 0.1% 0.8% 0.3% 4.9% 0.8% 1.6% 1.3% 0.1%

Cataract was found to be still leading cause in the severe vision impairment category. The second cause here appears to be Glaucoma and 4.9%. Trachoma as 0,7% found only in Sagaing state.

Table 16: Bilateral Visual Impairment (<6/18-6/60) - main cause in person

Province/State URE Cat Surg Trach Corn scar Phth Pterygium Glau DR AMD PSD

Globe /CNS

Ayeyarwaddy 16.1% 74.8% 2.0% 0.0% 0.8% 0.0% 0.0% 3.0% 1.2% 1.6% 0.6% 0.0%

Chin 53.3% 40.9% 1.1% 0.4% 0.7% 0.0% 0.7% 0.4% 0.0% 0.4% 2.2% 0.0%

Kachin 16.6% 66.8% 1.3% 0.0% 1.0% 0.7% 0.0% 6.6% 3.7% 1.3% 2.0% 0.0%

Kayin 10.7% 88.7% 0.2% 0.0% 0.2% 0.0% 0.0% 0.0% 0.0% 0.0% 0.2% 0.0%

Magway 16.4% 68.7% 2.7% 2.3% 3.3% 0.0% 0.1% 3.1% 0.0% 1.8% 1.6% 0.0%

Mon 28.1% 66.2% 1.5% 0.1% 0.1% 0.0% 0.0% 0.4% 0.6% 1.4% 1.6% 0.0%

Nay Pyi Taw 30.2% 61.0% 2.1% 0.0% 0.4% 0.0% 0.0% 1.2% 0.9% 1.4% 2.8% 0.0%

Sagaing 15.5% 74.0% 4.1% 0.6% 1.9% 0.0% 0.0% 2.8% 0.6% 0.0% 0.6% 0.0%

Shan 25.8% 65.2% 0.6% 0.6% 0.9% 0.0% 0.0% 2.1% 1.2% 1.8% 1.8% 0.0%

Tanintharyi 51.0% 42.3% 3.3% 0.0% 0.3% 0.0% 0.0% 1.0% 0.5% 0.3% 1.0% 0.5%

Yangon 22.1% 59.8% 1.8% 0.3% 0.6% 0.0% 0.0% 4.5% 5.1% 2.1% 3.3% 0.3%

Weighted average 21.1% 67.4% 2.1% 0.5% 1.2% 0.0% 0.0% 2.9% 1.7% 1.4% 1.6% 0.1%

In moderate vision impairment category cataract still accounts for 67.4% followed by uncorrected

refractive error as 21.1%. Trachoma as cause of vision impairment is found in sate Magway, Sagaing,

Shan Taninthary and Yangon.

Table 17: Avoidable Blindness

State/Province Treatable PHC-PEC Ophthal Avoidable PSD

Ayeyarwaddy 91.0% 1.5% 3.9% 96.4% 6.9%

Chin 94.2% 1.8% 1.5% 97.4% 3.6%

Kachin 83.4% 1.7% 11.6% 96.7% 13.6%

Kayin 99.4% 0.2% 0.2% 99.8% 0.2%

Magway 85.1% 5.7% 5.8% 96.6% 6.6%

Mon 94.3% 0.2% 2.5% 97.0% 4.0%

Nay Pyi Taw 91.2% 0.4% 4.2% 95.8% 6.3%

Sagaing 89.5% 2.5% 7.5% 99.4% 3.9%

Shan 91.0% 1.5% 3.9% 96.4% 6.9%

Tanintharyi 93.3% 0.3% 4.8% 98.3% 2.8%

Yangon 81.9% 0.9% 11.5% 94.3% 15.1%

The data shows more than 90% of eye problem in Myanmar are avoidable either preventable or

curable. As most of the blinding conditions are cataracts and with addition of refractive error 80 to 90

% of blinding conditions are treatable with simple surgery or with pair of glasses.

Table 18: Prevalence of Refractive Error

Spectacle coverage (distant vision)

State Province

Prevalence or Refractive Error (DV) Prevalence of URE (DV) Spectacle coverage (DV)

Male Female Total Male Female Total Male Female Total

Ayeyarwaddy 45.7% 39.9% 42.4% 15.4% 13.8% 14.5% 66.3% 65.4% 65.8%

Chin 34.5% 33.5% 33.9% 18.7% 21.2% 20.2% 45.8% 36.7% 40.4%

Kachin 39.9% 33.5% 36.2% 11.3% 10.4% 10.8% 71.7% 69.0% 70.2%

Kayin 12.3% 13.9% 13.2% 10.1% 11.5% 10.9% 17.9% 17.3% 17.4%

Magway 20.7% 18.1% 19.0% 10.1% 9.4% 9.7% 51.2% 48.1% 48.9%

Mon 39.9% 34.5% 36.6% 25.4% 21.0% 22.7% 36.3% 39.1% 38.0%

Nay Pyi Taw 37.8% 28.7% 32.1% 16.7% 16.0% 16.2% 55.8% 44.3% 49.5%

Sagaing 16.4% 14.3% 15.1% 9.4% 9.1% 9.2% 42.7% 36.4% 39.1%

Shan 18.0% 14.5% 15.6% 10.0% 8.9% 9.3% 44.4% 38.6% 40.4%

Tanintharyi 28.9% 31.6% 30.6% 12.5% 15.2% 14.2% 56.7% 51.9% 53.6%

Yangon 34.6% 30.6% 32.3% 8.1% 8.0% 8.1% 76.6% 73.9% 74.9%

Weighted Average 29.6% 25.8% 27.3% 11.9% 11.1% 11.4% 55.8% 52.4% 53.7%

The survey found that overall prevalence of 27.3% refractive error among the people age 50 and over.

Among those glasses coverage for distance vision was 53.7%. In total 11.4% of people having vision

impairment due to refractive error not wearing any distance correction. The prevalence of uncorrected

refractive error was found highest in Mon state 22.7% and lowest in Yangon 8.1%. The spectacle

coverage among those visual impaired due to refractive was found highest in Yangon as 74.9% and

lowest 17.4% in Kayin state.

Table 19: Uncorrected Presbyopia and Spectacle coverage (near vision)

State/Province

Uncorrected NVI Spectacle coverage (NV)

Male Female Total Male Female Total

Ayeyarwaddy 50% 58% 55% 50% 42% 45%

Chin 60% 69% 65% 40% 31% 35%

Kachin 51% 56% 54% 49% 44% 46%

Kayin 93% 94% 94% 7% 6% 6%

Magway 75% 82% 80% 25% 18% 20%

Mon 54% 65% 61% 46% 35% 39%

Nay Pyi Taw 63% 76% 71% 37% 24% 29%

Sagaing 70% 90% 82% 30% 10% 18%

Shan 77% 86% 83% 24% 14% 17%

Taninthary 66% 68% 67% 34% 32% 33%

Yangon 50% 60% 56% 50% 40% 45%

Weighted Average 63% 73% 69% 37% 27% 31%

As shown in Table # 19 , overall 69% of people age 50 and over are not wearing any near corrections.

The near vision spectacle coverage was highest in Ayeyarwady and Yangon as 45% and lowest in

Kayin state 6%.

Table 20: Prevalence of Functional Low Vision in age 50+

State/Province Male Female Total

Ayeyarwaddy 1.5% 1.8% 1.6%

Chin 1.1% 1.0% 1.0%

Kachin 1.6% 1.3% 1.5%

Kayin 0.1% 0.1% 0.1%

Magway 2.5% 2.7% 2.6%

Mon 1.0% 1.5% 1.3%

Nay Pyi Taw 2.1% 1.1% 1.4%

Sagaing 1.1% 1.9% 1.6%

Shan 1.1% 1.2% 1.2%

Tanintharyi 0.7% 0.7% 0.7%

Yangon 1.3% 1.0% 1.1%

Weighted Average 1.4% 1.5% 1.5%

The functional low vision is the condition where vision impaired is not due to uncorrected refractive

error and cataract. The prevalence of functional low vision in this survey was found to be 1.5%. There

is no significant difference observe among the gender. The prevalence is lowest in Kayin as 0.1% and

highest in Magway as 2.6%.

12.5 Cataract surgical services in Myanmar

Table 21: Cataract Surgical Coverage (CSC) in cataract eyes

State/Province

CSC (eyes) <3/60 CSC (eyes) <6/60 CSC (eyes) <6/18


Ayeyarwaddy 42.0% 44.5% 43.4% 34.4% 36.3% 35.5% 25.9% 25.5% 25.6%

Chin 75.7% 79.7% 78.1% 56.6% 63.0% 60.3% 35.5% 40.3% 38.3%

Kachin 87.0% 83.2% 85.1% 61.2% 51.6% 56.1% 32.6% 29.0% 30.7%

Kayin 58.6% 51.9% 54.2% 35.4% 35.1% 35.2% 9.7% 10.9% 10.4%

Magway 55.8% 61.7% 59.9% 44.9% 50.8% 49.1% 22.8% 30.3% 27.8%

Mon 63.2% 63.2% 63.2% 45.8% 43.2% 44.0% 21.0% 21.7% 21.5%

Nay Pyi Taw 68.1% 64.3% 65.7% 53.1% 52.7% 52.8% 30.8% 28.0% 29.1%

Sagaing 60.1% 61.4% 61.0% 43.4% 44.0% 43.8% 26.8% 28.3% 27.8%

Shan 52.1% 41.2% 45.2% 35.7% 28.8% 31.3% 21.1% 16.9% 18.5%

Tanintharyi 64.5% 53.5% 57.5% 49.8% 40.2% 43.6% 33.9% 25.6% 28.4%

Yangon 88.3% 86.8% 87.5% 80.2% 77.6% 78.8% 57.2% 57.6% 57.4%


Overall cataract surgical coverage among cataract eyes was found 61.9%, 49.1% and 31.5% in in

visual acuity category of 3/60, 6/60 and 6/18 respectively. The highest surgical coverage was found in

Yangon as 87.5% and lowest in Ayeyarwaddy 43.4% in VA 3/60 category.

Table 22: Cataract Surgical Coverage (CSC) in cataract blind persons

State/Province

CSC (persons) <3/60 CSC (persons) <6/60 CSC (persons) <6/18


Ayeyarwaddy 53.5% 60.5% 57.3% 43.2% 47.2% 45.3% 35.6% 33.8% 34.6%

Chin 96.3% 92.1% 93.8% 67.5% 72.2% 70.2% 50.0% 54.2% 52.5%

Kachin 98.0% 92.3% 95.0% 84.5% 73.9% 78.7% 40.0% 33.5% 36.6%

Kayin 65.0% 61.2% 62.3% 47.8% 45.6% 46.4% 14.7% 16.2% 15.6%

Magway 73.4% 81.6% 79.3% 58.7% 66.8% 64.5% 29.7% 40.3% 36.9%

Mon 65.1% 75.9% 72.0% 51.9% 52.6% 52.4% 25.0% 28.1% 27.0%

Nay Pyi Taw 85.5% 76.5% 79.9% 67.2% 66.9% 67.0% 40.8% 35.8% 37.6%

Sagaing 81.4% 75.8% 77.5% 58.9% 54.0% 55.6% 35.4% 36.4% 36.1%

Shan 61.9% 51.2% 54.8% 47.0% 38.6% 41.4% 28.1% 24.3% 25.6%

Tanintharyi 74.5% 63.9% 67.3% 61.4% 51.4% 54.7% 45.5% 36.5% 39.4%

Yangon 97.8% 97.3% 97.5% 91.3% 87.4% 89.0% 68.9% 69.8% 69.4%


Among the cataract bilateral blind person overall coverage were found to be 74.7%, 60.5% and

40.5% in the vision category of <3/60, <6/60 and <6/18. The coverage is highest 97.5% in Yangon,

this shows there are almost no cataract bilateral blind in Yangon state. The coverage is relative

lower in Shan state and Ayeyrawaddy state survey area.

Table 23: Visual Outcome after cataract surgery( Presenting VA)

Presenting VA

State/Province

IOL Non-IOL All

good borderline poor good borderline poor good borderline poor

Ayeyarwaddy 69.0% 19.0% 12.0% 0.0% 0.0% (22)100.0% 69.0% 19.0% 12.0%

Chin 63.0% 29.0% 8.0% 0.0% 0.0% 0.0% 63.0% 29.0% 8.0%

Kachin 84.0% 12.0% 4.0% 0.0% 0.0% 100.0% 84.0% 12.0% 4.0%

Kayin 90.0% 7.0% 3.0% 0.0% 0.0% 0.0% 90.0% 7.0% 3.0%

Magway 59.0% 26.0% 15.0% 0.0% 12.0% 88.0% 57.2% 25.4% 17.4%

Mon 63.0% 30.0% 7.0% 0.0% 0.0% 100.0% 63.0% 29.0% 8.0%

Nay Pyi Taw 59.0% 23.0% 18.0% 0.0% 0.0% 100.0% 59.0% 23.0% 18.0%

Sagaing 76.0% 13.0% 11.0% 0.0% 33.0% 67.0% 76.0% 13.0% 11.0%

Shan 71.2% 16.0% 13.0% 67.0% 0.0% 33.0% 71.0% 16.0% 13.0%

Tanintharyi 68.0% 22.0% 10.0% 0.0% 0.0% 100.0% 66.0% 22.0% 12.0%

Yangon 84.0% 13.0% 3.0% 46.0% 18.0% 36.0% 82.0% 14.0% 4.0%

Weighted average 73.5% 17.6% 8.9% 18.6% 10.1% 66.3% 70.9% 17.6% 10.2%

The visual outcome of cataract surgery for all Myanmar survey area is 70.9%. The poor outcome was

found in 10.2% of cataract operated eyes. Among the IOL cases good visual outcome was found to be

90% in Kayin and 84% in Yangon State. The highest poor outcome was found in 17.4% in Nay Pi Taw

and 17.4% in Magway state.

Table 24: Visual outcome based on Best Corrected VA

IOL Non-IOL All

State/Province good borderline poor good borderline poor good borderline poor

Ayeyarwaddy 86% 7% 7% 0% 0% 100% 82% 7% 11%

Chin 82% 10% 8% 0% 0% 0% 82% 10% 8%

Kachin 92% 4% 4% 0% 0% 100% 82% 4% 4%

Kayin 96% 2% 2% 0% 0% 0% 96% 2% 2%

Magway 70% 19% 11% 0% 0% 100% 68% 19% 13%

Mon 80% 14% 6% 0% 0% 100% 79% 13% 8%

Nay Pyi Taw 71% 14% 15% 0% 0% 100% 71% 14% 15%

Sagaing 81% 10% 9% 0% 33% 67% 80% 11% 9%

Shan 80% 7% 13% 67% 0% 33% 80% 7% 13%

Tanintharyi 79% 12% 9% 50% 0% 50% 78% 12% 10%

Yangon 92% 6% 2% 46% 18% 36% 91% 6% 3%

Weighted average 83% 9% 8% 0% 0% 0% 82% 9% 9%

While measuring best corrected visual acuity, pin hole VA, overall good outcome was found in 82% of operated eyes and 83 % among the IOL implant eyes.

12.6 Barriers to Cataract Surgery

Table 25: Barriers for bilateral cataract and pinhole VA<6/60

State/Province No need Fear Cost Denied Unaware No access

Ayeyarwaddy 6.3 30.7 31.3 5.3 4.4 21.9

Chin 3.4 34.5 0.0 0.0 3.4 58.6

Kachin 21.2 9.1 21.2 0.0 27.3 21.2

Kayin 50.0 33.8 2.7 0.0 0.0 13.5

Magway 74.2 0.6 6.5 0.6 16.1 1.9

Mon 66.1 4.6 9.8 0.0 5.7 13.8

Nay Pyi Taw 41.3 23.0 7.9 6.3 19.0 2.4

Sagaing 29.4 33.2 18.2 0.5 12.8 5.9

Shan 8.0 40.9 10.2 27.0 7.3 6.6

Tanintharyi 8.2 59.8 6.2 0.0 3.1 22.7

Yangon 12.0 14.0 18.0 14.0 42.0 0.0

Weighted Average 25.8% 24.2% 16.2% 8.0% 16.1% 9.7%

Among the Cataract blind eyes pinhole VA <6/60 barrier question were administered. Overall result as

not felt necessary of better vision was the answered by 25.8% of cataract blind person, followed by

fear to surgery 24.2%, cost 16.2% and unaware of treatment were 16.1%. In Chin State accessibility to

services issues was the main barrier 58.6%. In Yangon state 42% of cataract blind answered as

unware of treatment for cataract followed by Kachin 27.3% and nay Pi Taw 19.0%.

ministry of health , the republic of myanmar report of

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