VISION 2020: what remains to be done after the COVID-19 pandemic?
Authors: Scott R Lambert
Journal: The Lancet Child & Adolescent Health (2021)

In 1999, WHO and the International Agency for the Prevention of Blindness launched VISION 2020. The goal of this programme was to eliminate avoidable blindness (preventable or treatable) globally by 2020. Some of the targets for ending avoidable childhood blindness included eliminating corneal scarring from vitamin A deficiency and measles, eradicating new cases of congenital rubella syndrome, providing appropriate surgery for all children with congenital cataracts coupled with immediate optical correction, and retinal examinations for all infants at risk of retinopathy of prematurity.1Gilbert C Foster A Childhood blindness in the context of VISION 2020—the right to sight.Bull World Health Organ. 2001; 79: 227-232PubMed Google Scholar Ophthalmologists worked diligently to achieve these goals and it was anticipated that 2020 would be a celebratory year, but alas the COVID-19 pandemic redirected the focus of the world from eliminating avoidable childhood blindness to fighting a lethal virus. However, it remains important to assess how close we came to achieving the goals of VISION 2020 and what further actions are needed. In The Lancet Child & Adolescent Health, the study by Lucinda Teoh and colleagues2Teoh LJ Solebo AL Rahi JS Visual impairment, severe visual impairment, and blindness in children in Britain (BCVIS2): a national observational study.Lancet Child Adolesc Health. 2021; (published online Jan 29.)https://doi.org/10.1016/S2352-4642(20)30366-7Summary Full Text Full Text PDF PubMed Scopus (33) Google Scholar helps us to understand the causes and incidence of visual impairment among children in the UK. Using a network of British ophthalmologists and paediatricians, Teoh and colleagues identified children newly diagnosed as visually impaired over a 12-month period beginning on Nov 1, 2015. The cumulative incidence of childhood visual impairment by age 18 years was 10 per 10 000 children (95% CI 9·35–10·76).2Teoh LJ Solebo AL Rahi JS Visual impairment, severe visual impairment, and blindness in children in Britain (BCVIS2): a national observational study.Lancet Child Adolesc Health. 2021; (published online Jan 29.)https://doi.org/10.1016/S2352-4642(20)30366-7Summary Full Text Full Text PDF PubMed Scopus (33) Google Scholar The most common causes of visual impairment were cerebral visual impairment, retinal disorders, and optic nerve disorders. Almost three-quarters of children also had other disabilities. Most of these other disabilities arose from hypoxic or ischaemic encephalopathy or other structural problems of the brain. Many children with isolated visual impairment had genetic disorders such as retinal dystrophies, albinism, and aniridia. Only a small percentage of children had preventable or treatable causes of visual impairment, emphasising the success of current strategies for preventing or treating these conditions in the UK. For example, only 4% of children were visually impaired from retinopathy of prematurity, presumably because of the effectiveness of current programmes in the UK to regulate oxygen administration to premature infants, screen them for retinopathy of prematurity, and treat them when warranted with laser photocoagulation or intravitreal injections of anti-VEGF drugs.3Stahl A Lepore D Fielder A et al.Ranibizumab versus laser therapy for the treatment of very low birthweight infants with retinopathy of prematurity (RAINBOW): an open-label randomised controlled trial.Lancet. 2019; 394: 1551-1559Summary Full Text Full Text PDF PubMed Scopus (260) Google Scholar Similarly, although cataracts were previously a leading cause of blindness among children, they only accounted for 7% of the causes of visual impairment in Teoh and colleagues' study.2Teoh LJ Solebo AL Rahi JS Visual impairment, severe visual impairment, and blindness in children in Britain (BCVIS2): a national observational study.Lancet Child Adolesc Health. 2021; (published online Jan 29.)https://doi.org/10.1016/S2352-4642(20)30366-7Summary Full Text Full Text PDF PubMed Scopus (33) Google Scholar Consistent red reflex screening of newborns by paediatricians, an improved understanding of the importance of early treatment, improved surgical techniques, and more options for optically correcting these children after cataract surgery have made cataracts largely an avoidable cause of childhood visual impairment in high-income countries.4Bothun ED Wilson ME Yen KG et al.Outcomes of bilateral cataract surgery in infants 7 to 24 months of age using the toddler aphakia and pseudophakia treatment study registry.Ophthalmology. 2020; (published online July 15.)https://doi.org/10.1016/j.ophtha.2020.07.020Summary Full Text Full Text PDF Scopus (4) Google Scholar, 5Bothun ED Wilson ME Vanderveen DK et al.Outcomes of bilateral cataracts removed in infants 1 to 7 months of age using the toddler aphakia and pseudophakia treatment study registry.Ophthalmology. 2020; 127: 501-510Summary Full Text Full Text PDF PubMed Scopus (40) Google Scholar Likewise, improved treatment of glaucoma has made this a relatively uncommon cause of visual impairment in the UK.6Jayaram H Scawn R Pooley F et al.Long-term outcomes of trabeculectomy augmented with mitomycin C undertaken within the first 2 years of life.Ophthalmology. 2015; 122: 2216-2222Summary Full Text Full Text PDF PubMed Scopus (44) Google Scholar In the future, more genetic diseases such as retinal dystrophies could be treatable using gene therapy.7Ku CA Pennesi ME The new landscape of retinal gene therapy.Am J Med Genet C Semin Med Genet. 2020; 184: 846-859Crossref PubMed Scopus (19) Google Scholar The findings of the study by Teoh and colleagues2Teoh LJ Solebo AL Rahi JS Visual impairment, severe visual impairment, and blindness in children in Britain (BCVIS2): a national observational study.Lancet Child Adolesc Health. 2021; (published online Jan 29.)https://doi.org/10.1016/S2352-4642(20)30366-7Summary Full Text Full Text PDF PubMed Scopus (33) Google Scholar are similar to those of a 2019 study of childhood visual impairment in New Zealand.8Chong C McGhee CNJ Dai SH Causes of childhood low vision and blindness in New Zealand.Clin Exp Ophthalmol. 2019; 47: 165-170Crossref PubMed Scopus (28) Google Scholar However, the New Zealand study gathered data from a childhood visual impairment registry rather than an active surveillance programme. The three leading causes of visual impairment in New Zealand were cerebral visual impairment, optic nerve atrophy, and optic nerve hypoplasia. The leading causes of preventable visual impairment were neonatal trauma, retinopathy of prematurity, and non-accidental injuries. Although there were differences in the proportion of disorders causing visual impairment, a low rate of visual impairment from retinopathy of prematurity, cataracts, and glaucoma was observed. Unfortunately, children in low-income and middle-income countries continue to become blind from avoidable causes. For example, in sub-Saharan Africa, cataracts continue to be one of the leading causes of childhood blindness and retinopathy of prematurity is becoming an increasingly more common cause of childhood blindness with the advent of more neonatal intensive care units (NICUs), which have increased the survival rate of premature infants. Unfortunately, oxygen administration is not properly regulated in many of these NICUs, putting these infants at increased risk of developing retinopathy of prematurity.9Lloyd T Isenberg S Lambert SR Current management of retinopathy of prematurity in sub-Saharan Africa.J AAPOS. 2020; 24: 151Summary Full Text Full Text PDF PubMed Scopus (7) Google Scholar Organisations such as the International Pediatric Ophthalmology and Strabismus Council are working hard to provide training and supplies to NICUs in sub-Saharan Africa in an attempt to reduce the incidence of blindness from retinopathy of prematurity. Although much still needs to be done to meet the goal of VISION 2020 to eliminate avoidable childhood blindness, particularly in low-income and middle-income countries, there are hopeful signs that meaningful steps are being taken to achieve this end. Every child deserves the right to sight and by uniting our efforts this aspiration can be realised. I declare no competing interests. Visual impairment, severe visual impairment, and blindness in children in Britain (BCVIS2): a national observational studyBCVIS2 provides a contemporary snapshot of the heterogeneity, multi-morbidity, and vulnerability associated with childhood visual disability in a high-income country. These findings could facilitate developing and delivering health care and planning of interventional research. Our findings highlight the importance of including childhood visual disability as a sentinel event and metric in global child health initiatives. Full-Text PDF