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Current Health Issues in the Caribbean BLINDNESS in THE Current Health Issues in the Caribbean BLINDNESS IN THE CARIBBEAN Alfred L. Anduze, M.D. St. Croix Vision Center St. Croix Hospital St. Croix U.S. Virgin Islands Caribbean Studies Association Merida, Mexico May 26, 1994 Abstract: Blindness in the Caribbean Background: The prevailing of blindness in the Caribbean region are reviewed in the context of world blindness statistics to identify differences and similarities that might exist. Method: A review of the status of blindness in the U.S. Virgin Islands, Barbados, Jamaica, Puerto Rico, Trinidad, and Mexico; individually with regard to causal etiology, epidemiology, treatment and possible future research. Results: Blindness in the Caribbean is the result of genetics, tropical environment and cultural habits of the inhabitants and consist of Age-related macular disease, Infectious diseases, Diabetes mellitus, Glaucoma, Congenital defects, Xerophthalmia, Trachoma, Trauma and Cataracts. Conclusion: There are almost 50 million people who are legally blind worldwide (i.e. with a vision of 20/200 or less) 2-3 million in the Caribbean region. The social and economic consequences are serious additional deterrents in developing countries. Outline: Causes of Blindness in the Caribbean I. Age-related macular disease a. Vascular insufficiency b. Senile macular degeneration II. Cataracts III. Glaucoma IV. Diabetes mellitus V. Infectious diseases a. Trachoma b. Onchocerciasis c. Leprosy d. Toxoplasmosis e. Toxocariasis f. AIDS VI. Trauma a. industrial/work-related b. sports c. home accidents VII. Nutritional a. Xerophthalmia/keratomalacia b. Iron-deficiency anemia c. Tobacco/Alcohol Retinopathy VIII. Congenital defects a. genetic syndromes b. strabismus Legal blindness is acceptably defined as vision 20/200 (6/60) or less. An individual with this level of vision has difficulty carrying out normal activities of daily living (ADL) without some kind of low vision aid or appliance. In developing countries this often involves dependency on another individual thereby reducing or removing two people from the ranks of productivity. The reduced quality of life, social stigmatization, and psychological withdrawal that accompanies most individuals with subnormal vision can often lead to reduced life expectancy. In the Caribbean region, there is hardly a single family without at least one member who is or has been afflicted with blindness. A review of the principal causes of blindness in the Caribbean islands of Barbados, Jamaica, Puerto Rico, Trinidad, the U.S. Virgin Islands (1), and the nation of Mexico (2), reveals that 1. Cataract 2. Glaucoma 3. Diabetes mellitus 4. Age-related macula* disease 5. Trauma 6. Infections/diseases 7. Nutritional Deficiencies 8. Congenital Defects are the most prevalent. These are presented in outline form for purposes of clarity: Underlying etiologies include genetic make-up, environment and cultural habits. In decreasing order of frequency: VIII. CONGENITAL DEFECTS such as Down's Syndrome, Tay-Sach's disease, Stargardt's disease, and Retinitis pigmentation are generally less in the developed countries, since the gene pool is more hybridized and varied. Strabismus leading to amblyopia is slightly less than the 2.5% quoted worldwide. (2) The incidence of incapacitating blindness has been reduced somewhat due to surgical innovations and medical implementation in the more developed countries, but remains a significant detriment in the poorer areas. NUTRITIONAL DEFICIENCIES in reference to blindness specifically targets Vitamin A as the most prevalent cause. There are various factors that impair Vitamin A status: hot dry seasons lead to a short supply of source food; peak age is 3-6 years old, males are at greater risk than females; precipitating illnesses include gastroenteritis and respiratory tract infections. The pattern of disease includes night blindness, Bitot's spot and conjunctival xerosis (drying), hence the inclusive term "xerophthalmia". Treatment involves the consumption of foods containing Vitamin A and carotene, and/or massive amounts of vitamin A (100,000 IU/daily). It can be noted that 100 grams of mango provide all the daily needs of vitamin A as well as all the fructose needed to precipitate diabetes mellitus. Many areas of Mexico and Central America have a high incidence of vitamin A deficiency. Iron deficiency anemia is quite common in the Caribbean islands among pre-teens and teenagers due to inappropriate diet, as well as in areas where the diet is high in starch and low in protein. The well-known term "blind drunk" is not a misnomer as the effect has come to be known as tobacco/alcohol retinopathy. This, coupled with the fact that many inhabitants fail to eat a balanced diet, can lead to extensive nerve degeneration in the retina. VI. TRAUMA to the eyes with loss of vision is increasing in frequency along with industrial development and social sophistication. Cataract, retinal detachment and irreparable scars are the main results of chemical injuries, pressure injuries (explosions), and misapplied mechanical implements. Sports and recreation injuries are also increasing despite better equipment and higher awareness. Accidents in and around the home coincide with "modern" implements such as barbed wire and handguns. V. INFECTIOUS DISEASES as a major cause of blindness have been on the decline until recently with the advent of increased bacterial and parasitical resistance to antibiotics. Trachoma has long held first place as a cause of blindness in hot, dry areas. Most of the cases in the Caribbean, however, are from elsewhere (South America, Northern Africa and the Middle East). Caused by Chlamydia trachomatis, it consists of acute conjunctivitis developing into extensive lid and corneal scarring. Treatment is with the timely topical and systemic application of antibiotics (sulfacetamide, tetracycline, erythromycin). Onchocerciasis (African River Blindness) is caused by the worm, onchocerca volvulus, found in rural areas with rapidly running streams, flies and crabs, mainly central America and Mexico. Blindness occurring as the result of Keratitis, optic atrophy and chorioretinitis, destruction of the layers of the eye, is usually bilateral and total. Treatment is difficult and consists of surgical removal of nodules containing the worm and antihelminthic medications with variable effect. Toxocariasis is the infection in man with the eggs of the roundworm, Toxocara canis, via ingestion (pica), through the alimentary system to the blood circulation and hence to the eye. It is usually unilateral and causes complete blindness. It is still prevalent on all Caribbean islands where dogs and cats abound. Filariasis is the infection of the body by the roundworm (loa loa) which is ingested and matures in the tissues of the eye thus leading to retinal and choroidal damage. This is the same nematode responsible for Elephantiasis, (gross edematous swelling of the lower extremities-"big foot", which on the more developed islands, is on the decline. Leprosy, resulting from infection by mycobacterium leprae, is still present throughout the Caribbean and is especially high in Mexico and Central America. A hot, dry climate, inadequate health care, and low socioeconomics contribute to maintaining its prevalence. Early detection and Dapsone tablets are the treatment of choice. Toxoplasmosis is caused by the protozoan T-Gondii, which affects both eyes and is characterized by recurrences and remissions and can be transmitted from mother to fetus. There is extensive chorioretinal scarring and generalized resistance to treatment, with blindness occurring early. There can be extensive brain damage from calcification. The blindness resulting from Auto Immune Deficiency Syndrome (AIDS) can be rapid and total - is often accompanied by concomitant infections such as the Toxoplasmosis and Cytomegalo virus, which are highly resistant to treatment. Of the common causes of blindness on the mainland U.S.A., senile macular degeneration has long been the chief concern. Known more recently as ARMD (age-related macular disease) it occurs predominantly in aging individuals of Caucasian lineage. As non-Caucasians ascend on the socio- economic scheme and extend their life expectancy, the incidence of ARMD also rises. Cataracts appear to be more prevalent in the Caribbean but actually occur with equal frequency when compared to other regions- though they appear at an earlier age, it takes longer to become incapaciting. (4) Glaucoma is eight (8) times more prevalent in non- whites than in whites and four (4) times more likely to lead to blindness. Diabetes mellitus has an incidence of 11.1% in the USA and 30% in the ophthalmic population over the age of 40 in the U.S. Virgin Islands. A diet high in starches and sugars, the cultural habit of festive overeating, and basic genetics all play decisive roles in leading to this exceptionally high rate. As the population ages, the incidences of all four conditions increase and appear in combination. Fifty (50%) of the diabetics in the Virgin Islands have glaucoma, 66% will develop debilitating cataracts by the age of 70, and all will have developed ARMD by the age of 80. DIABETES MELLITUS (inability to metabolize sugar correctly in the body tissues) affects females twice as much as males. It affects non-whites twice as often as whites; 5% of all West Indian diabetics are blind, and 80% of these die within 5 years of the onset of blindness. The typical diabetic patient tends to be obese, has glaucoma, significant cataracts, hypertension, hypercholesterolemia
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