The role and functions of national institutes of ophthalmology: report on a WHO meeting, Brussels, 11–14 December 1978

kp ,a EURO Reports and Studies 5 Ih OI OI '7/ E [ole aril turulior$ tlaliorill lnstitutB$ 0nIl[almolouu Report on a WHO Meeting Arch. I ( RB o t 1 Ul 79Julf{ ls REGIONAL OFFICE FOR EUROPE World Health Organization COPENHAGEN @ EURO Reports and Studies 5 Ihe Iole ilnil [unrlir]ts ol ilalioral lnstilulg$ ol 0u[lhillmulnuu Report on a WHO Meeting Brussels 11 -14 December 1978 REGIONAL OFFICE FOR EUROPE World Health Organization COPENHAGEN @ ISBN 92 9020 t44 4 @ World Health Organization 1979 Publications of the World Health Organization enjoy copyright pro- tection in accordance with the provisions of Protocol 2 of the Universal Copyright Convention. For rights of reproduction or translation, in part or in toto, of publications issued by the WHO Regional Office for Europe application should be made to the Regional Office for Europe, Scherfigsvej 8, DK-2100 Copenhagen @, Denmark. The Regional Office welcomes such applications. 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I'RIN I I,D IN I)I N[IARK Reissued under ISBN: 9789289024334 (print) in 2025. Originally published under ISBN-10: 9290201444. ISBN 0250-8710 (print) CONTENTS 1. Introduction. 2. Existinginstitutesof ophthalmology. . . . 3. The extent and causes ofblindness and visual handicap 4. The role of epidemiological studies 5. The organization and provision of eye health care 6. Rehabilitation of the visually handicapped 7 . Manpower and training. 8. Research and other functions in relation to health care administration 9. Conclusions and recommendations . Annex I List of working papers and background material Annex II List of participants . Page I J 5 6 7 8 9 l0 ll l4 l6 WHO MEETING ON TITE ROLE AND FI.JNCTIONS OF NATIONAL INSTITUTES OF OPITTHALMOIJOGY Brussels, I I - I 4 December I 978 I. INTRODUCTION A meeting on the role and functions of national institutes of ophthalmo- logy was convened in Brussels from I I to 14 December 1978 by the Regional Office for Europe of the World Health Organization.lts purpose was to review the knowledge and experience gained so far by existing national institutes of ophthalmology, to define the optimal role and functions of such institutes in a public health context, to outline recommendations to national authorities concerning the possible establishment of such institutes where they did not already exist, and to make suggestions for research and other measures to be undertaken in professional fields relevant to eye care (ophthalmology, epidemiology, health services research, health economics, teaching, etc.). The participants came from l0 countries of the WHO European Region (Belgium, Bulgaria, France, Federal Republic of Germany, Hungary, the Netherlands, Spain, Sweden, the United Kingdom and the USSR) and from the United States of America. They included ophthalmologists, epidemio- logists, an educationalist and an economist. (For list of participants see Annex II.) An address of welcome was given by Professor S. Halter, Secretary- General, Ministry of Public Health and Family Welfare of Belgium, and the meeting was opened by Dr B. Nizetic, Regional Officer for Research Promotion and Development, WHO Regional Office for Europe. Professor J. Frangois was elected Chairman and Professor M. Radnot Vice-Chairmanl Professor E.S. Perkins acted as Rapporteur. In his introductory statement Professor Franqois recalled the resolution on public health ophthalmology approved by the International Council of Ophthalmology on 25 May 1974 in Paris, which read as follows: "As society turns from its past interest, which has been almost exclusively that of curing diseases in individuals, towards concern for preserving and promoting the health of populations, the science of ophthalmolory must also increasingly direct its interest towards the public health aspects of eye health. The field of public health ophthalmolory, as a newly emerging concept, offers many opportunities for research and practice of comprehensive eye health care which includes, in a continuum, prevention, treatment and re- habilitation. It is not, it should not and it can not be considered as a sub- specialty. It is a new dimension of ophthalmolory as a science and a service. I It is considered necessary to develop this aspect of ophthalmology at the national and international level by: (l) issuing national policy statements for the field of ophthalmolory; (2) strengthening the professional dialogue with thc_ disciplines which are reteuant to this approach (epidemiolory, health administration, biostatistics, etc.); (3) promoting the inclusion of public health aspects in ophthalmo- logical curricula; (4) including public health ophthalmology in the agenda of national, regional and international societies' meetings." The situation in Europe is completely different from that in the developing countries, where infective conditions such as trachoma and onchocerciasis, dietary conditions such as xerophthalmia, and cataract are the major problems. In Euiope, the prevention of blindness strould form part of a comprehensive continuous prograflrme of eye health care covering not only prevention but also diagrosis, treatrnent and rehabilitation' SuJn a programme could be achieved by establistring better communica- tion between optrthut nological institutes on the one hand and public health authorities on the other. There are three main ways in which the eye health of a population could be improved: (1) Public health eduution. It is the duty of society and the states io'.nrrr. more effective communication with people in order to increase their awareness of what they must do to protect their vision. Information about vision, eye diseases, eye injuries, available treatments and the importance of early detection of impairment is essential and should be ptouia.O through the mas media (radio, television and the press)' (2\ vision-screening proiects. These projects should te educational as'well as bringing direct benefit to individuals. Efforts should be made to detect diabetes and diabetic retinopathy, glaucoma in elderly people' and eye problems in young children. All sections of the public, and particulariy those in the medical and educational professions' should ieceive appropriate instruction by means of educational brochures, Iilms, exhibitions, etc. (3) Resurch. Research,especially on glaucoma,diabetic-retinopathy, ieiinat dystrophies and degenerations, vir{l diseases and strabismus, should be promoted. 2 2. EKSTING INSTITUTES OF OPIITHALMOITOGY It is apparent that existing institutes of ophthalmology vary widely in their scope, organization and funding, and particularly in the extent to which they are asociated with national or governmental bodies such as ministries of health. Some institutes, such as the Institute of Experimental Ophthalmolory in Bonn and the Netherlands Research Institute in Amsterdam, are primarily research institutes concentrating on basic scientific studies in the fields of biochemistry, physiolory, electrophysiolory, medical physics and genetics. Others, like the Institute of Ophthalmology in London, have a large teaching commitment and are concerned particularly with postgraduate training in ophthalmology and courses in special aspects of ophthalmolory. The London institute also has extensive research departments dealing with basic sciences and clinical research. It is, however, in the process of setting up a department of public health ophthalmology. It is financed by university and other sources and has no official relationship with the Department of Health and Social Security. In some countries the institutes are responsible for teaching and research and act additionally as consultative bodies for national ministries of health, as in the USSR and Bulgaria. They are thus involved in planning eye health services and can collect the data necessary for such planning by the use of surveys; further, they are able to organize large-scale screenhg programmes for specific ocular conditions such as amblyopia and glaucoma. Genetic conditions are now becoming increasingly important as causes of blindness and the need for genetic research is therefore being emphasized. The Institute of Ophthalmolory in Ghent has a large Medical Genetics Depart- ment which is partly supported by the Ministry of Public Health and is one of seven such centres in Belgium. Each centre is affiliated to a university and provides diagnostic facilities, genetic counselling, registration of cases, genetic research and genetic education for scientific and technical personnel, doctors and other health personnel; in addition, it arranges lectures for the general public. Genetic research also plays a prominent part in the work of the Netherlands Ophthalmic Research Institute and genetic centres are now being set up throughout the Netherlands. Major problems in genetic research concern the lack of uniformity in terminolory, diagnostic criteria and the registration of patients. Some form of record linkage is essential in order to avoid duplication of case reports, and a cooperative study could usefully be initiated by the nine countries of the EEC to compare the coverage of registration, terminolory and diag- nostic criteria. Confidentiality in the storage of data in computer systems is also a problem which merits attention. The National Eye Institute in Bethesda, Maryland, is one of l2 institutes which form part of the United States Department of Health and Welfare. The primary function of this institute has been to carry out research on ocular 3 conditions and to train research workers, but it is now extending its activities to the practical application of research results, first by applying them in a controlled clinical situation and then by disseminating the results more widely through lectures and papers presented at meetings. In this way it is possible to build up a reliable consensus of opinion on the value of a new treatntent or diagnostic technique. Some new diagnostic and therapeutic techniques are very expensive and have not yet been thorougtrly investigated from a cost/benefit point of view. In these days of escalating health care costs the important economic reasons for medical research must be made clear to governments. Financial support for research would be easier to obtain if it could be shown how research can reduce the cost of care forthe blind and help to maintain the earning capacity of visually disabled people. Little has been done so far in this direction and the economists who have to attempt to estimate the cost of health services are often unable to obtain the necessary information from physicians. In some countries a large amount of information is collected by different organ- izations but too few people are able to gah access to it. The possibility of using a census for the collection of health statistics was discussed, but it was concluded that unless a specific test (e.g.,of visual acuity) was used the results from a simple questionnaire would be too unre- liable to be of value. The meeting recognized that the rather wide differences in the structure and organization of existing institutes made it difficult for some to undertake all the ideal functions in relation to public health ophthalmology; however, it was agreed that the institute should act as a bridge between, on the one hand, the scientific communities concerned not only with ophthalmology but also with related fields such as paediatrics and genetics, and, on the other, the health services in a given country.It should also act as a centre for the collec- tion and disemination of data on which health care planning depends. Other functions include the training of research workers, the education of eye health policy-makers, the monitoring of eye health trends, the evaluation of existing systems of eye health care delivery, cost/benefit analysis of alternative methods of eye care, health education of the community and advice on man- power requirements and the financing of services. Where no national institute exists, members of professional societies and heads of university eye departments should form a small advisory committee together with other experts such as epidemiologists and health economists, in order to stimulate interest in public health ophthalmolory irmong ophthal- mologists, to suggest requirements for research in this field and to advise and asist governments on problems of eye health care. 4 3. THE EXTENT AND CAUSES OF BLINDNESS AND VISUAL HANDICAP With the decline in infectious diseases such as trachoma, the major causes of blindness in Europe are now congenital defects in the younger age goups and degenerative conditions in the older age groups. Although the total population of Europe is likely to increase by only about SVo in the next 50 years, the number of people over the age of 55 will double. Already most visually disabled people in England and Wales, for example, are above retire- ment age and often tend to accept a slow failure of sight as one of the inev- itable consequences of growing old. Many of them never seek help and apart from family doctors there is no one in regular contact with them who has been taught to look for or recognize visual handicap. Household surveys in England and Wales have shown that there are approximately 520 visually disabled adults per 100 000, using the WHO definition of visual impairment - a vision in the better eye of less than 6/18 Snellen. Almost 8U/o of the visually disabled were over the age of retirement and 5Vo were aged 75 years or more. About one-third of them would qualify for registration as blind or partially sighted by current statutory definition,but only two-thirds of these were actually registered;the remainder all complained of difficulty in seeing to read or to get about, or both. As might be expected in this age group, many had other disabilities and less than one-half considered poor sight their only disability. The principal diseases causing visual disability, assessed by an ophthalmo- logist, were cataract (28%), senile macular degeneration (lWo), glaucoma (8%), diabetic retinopathy, myopia, aphakia, congenital blindness, retinal detachment (each 6%), optic atrophy, keratitis, corneal ulcer, pan-uveitis, injury, choroiditis, stroke, herpes zoster and other (each2%). The high incidence of cataract confirms figures from blind registration statistics that much loss of vision remains undetected or untreated. Some of the reasons for this are the over-ready acceptance of failing sight by elderly people, with consequent failure to seek help, and a lack of apprecia- tion among those in regular contact with elderly people that visual assessment is easy and simple and that elderly people cannot be relied upon to indicate the need for help themselves. The results of this survey differ from blind registration statistics as far as causes of blindness are concerned. In Belgium, for example, even in adults genetic causes are the major factor (29%),the other main causes being trauma (16%), cataract (13%),glaucoma OATI), systemic disease (ll%), and infection (8%). Part of the difficulty in comparing figures from different areas arises from variations in terminolory and definitions. It is essential that the terms used in reporting the results of surveys be clearly defined. 5 In the evaluation of visual impairment it would be desirable to develop a visual capacity table in percentage terms such as that used in Belgium. Even so, it is difficult to estimate the effect of visual impairment on the function of the individual, including the wider aspects such as the increased risk of accident, and loss of education and earning capacity. This is particularly difficult when other physical disabilities are also present. The participants agreed that there is a need for each country to conduct prevalence studies on the causes of visual impairment as this is the only way in which the magnitude of the problem can be determined and changing trends in causation evaluated. Cros-sectional studies are required to determine the priorities for action, together with case control studies for diseases the causes of which are not understood; longitudinal studies would then be required to determine whether intervention is really useful. With regard to the problem of visual impairment from unoperated cataract, it seems that the reasons for such impairment are complex and stem partly from lack of follow-up of early cases and partly from long waiting lists for surgery. New methods of surgery such as phakoemulsification reduce the length of stay in hospital but do not alleviate the problem of longoperating lists and the time required for outpatient follow-up after surgery. In the long term, basic research into the causation of cataract offers the best hope of delaying the onset of visual impairment, even if prevention proves impossible. 4. THE ROLE OF EPIDEMIOLOGICAL STUDIES The role of the epidemiologist was outlined under the following headings: ( 1 ) Measurement of the problem. This involves defining the magnitude and importance of the causes of visual impairment so that priorities can be determined and plans made to provide the necessary resources and meet manpower and training requirements. In order to do this a population-based data capture system has to be evolved and zupplemented by ad hoc surveys. It is important to define criteria, norms, and standards, the major requirement being that of data compatibility. It is also necessary to agree on indices such as the number of years of visual loss, visual capacity and educational problems. The indices selected will depend on the objective of the study. (2) Identification of the cause of diseose. Primary prevention depends on discovering the etiology, and epidemiological methods can help in this respect. (3) Identification of vulnerable groups. If this can be done, early detection and extra surveillance of high-risk groups can be undertaken. 6 (4) Strategic planning. This entails proposing alternative strategies and comparing their cost/effectiveness. (5) Evaluation. This is an important part of any epidemiological study and necessitates clinical trials and the assessment of the value of any intervention. It must be linked with health services research. In all epidemiological studies it is necessary to think in terms of popula- tions, using the facilities of the entire health system. This implies a need for the training of staff at all levels. Screening methods for the early detection of ocular disease were discussed and experiments with the use of television to detect reduced visual acuity and visual field defects were mentioned. At the present time the number of condi- tions in which early detection can be shown to be of value is rather limited and in view of the high cost of screening programmes it is important to give priority to conditions in which early treatment has been proved to be worth- while; amblyopia in preschool children is one such condition. In spite of the successful results of glaucoma screening reported from some countries, a num- ber of participants expressed doubts as to the value of population screening for this condition, holding the view that no entirely satisfactory screening methods were yet available. Other conditions discussed included myopia (which seems to be increasing in prevalence), cataract, diabetes and retinoblastoma; prevalence studies for these and other conditions are valuable, as even if they are not preventable at present they may become so in the future. If high-risk groups can be defined (the relatives of known glaucoma cases, for example), screening should start with these groups. Vision screening at school has proved very valuable, and it was also suggested that as so much visual disability occurs in post-retirement years, screening for glaucoma, early cataract, etc., should be done at the time of retirement from work. Other subjects discussed were the side effects of medication, the epide- miology of infectious diseases such as toxoplasmosis and ctrlamydial infections and the possibility of an epidemiological approach to such conditions as senile macular degeneration. 5. THE ORGAMZATION AND PROVISION OF EYE HEALTH CAR.E From a discussion on the provision of eye health care two main points emerged: first, eye care involves more than the mere treatment of disease and concerns staff other than ophthalmologists; secondly, eye care delivery must be considered in an economic framework. 7 The organization of eye health care can be expressed as a pyramid. The lowest level is self-care, which depends on the cultural level and health education of the population. The next level consists of trained auxiliaries and nurses, followed by general practitioners, then ophthalmic specialists and hospital services, culminating in the university hospitals and institutes of ophthalmology at the apex of the pyramid. The place of ophthalmic opticians and other ancillary workers was discussed at some length and it was agreed that they had a useful part to play provided they were under the supervision of an ophthalmologist. In Sweden some nurses are given a two-year training which includes orthoptics and are then employed in screening children for squint and amblyopia. In the Netherlands orthoptists screen children at nine months of age for amblyopia and test for deafness at the same time. The rising costs of health care make it imperative that the economics of eye care delivery be taken into account. New and costly procedures are often introduced widely before they have been carefully evaluated and there should be a critical examination of the appropriateness, effectiveness and extent of utilization of existing methods of treatment and health care deliv- ery. It was suggested that health departments should be urged to allocate l7o of their total health care budget to finance research on these lines. The cost of such research is likely to be more than offset by savings on the cost of medical care and by savings achieved in the rationalization of services. After further discussion of current problems of public health aspects of ophthalmolory, the Meeting considered that many of these problems could be solved by the existing personnel provided that suitable training was available. Education of the general public in elementary eye care should be encouraged, using the media of radio, television and the press. Preventive prograflrmes in Belgium, Bulgaria, the Netherlands and the USSR were then discussed. The organization of health services h Bulgaria, Hungary and the USSR provides opportunities for preventive care from the postnatal period to adult life, including screening for glaucoma for all persons over the age of40 years. The role of general practitioners was also discussed and it was agreed that they should be encouraged to include an eye examination in the routine physical examination of patients and be trained to recognize ocular conditions such as glaucoma. 6. REHABILTTATION OF THE YISUALLY HANDICAPPED Ophthalmologists tend to leave the problems of the visually handicapped to the well established rehabilitation services available in most countries, 8 but there are still areas of research in which they could be involved. There has been little critical evaluation of the many elaborate and expensive devices developed as aids to mobility for the blind. Aids for reading should have a high priority as, although many low-vision aids are provided, few of them are used successfully. Social, economic and educational rehabilitation is important in addition to medical rehabilitation,but even when it is successful there is still the major problem of finding zuitable employment. It was suggested that all the partici- pants should list suitable types of employment for visually handicapped persons and encourage government departments to employ more people with visual handicaps. The education of blind and partially sighted children, with particular reference to special schools, was also discussed at some lengh. In Sweden there is a new scheme for educating such children in normal schools with the aid of specially trained teachers and extra equipment. If successful, such a scheme might be less expensive than running special schools and would aid the integration of visually handicapped children in the community. It would also encourage the normally sighted to accept the handicapped more readily and ease their integration in society. Many blind people are reluctant to enter the system of rehabilitation because they still hope to recover their vision. It is the duty of the ophthalmo- logist to promote the registration of the blind, and he must also be concerned with the preservation of remaining vision. 7. MANFOWER AND TRAINING It takes a long time to asemble a satisfactory health care team and it is essential that the best use should be made of each member of the team. The educational goal for each level of staff must be enumerated and these goals must be relevant and capable of being tested and achieved. Financial consid- erations may make it impossible to introduce new levels of staff, but a start can be made by educating existing staff to undertake additional tasks. The methods required for training adults are not the same as those required for children and much can be achieved by self-teaching using taped or video- taped instruction. Health education of the general public is also of considerable value. Giving additional tasks to ancillary staff raises the problem of incentives, and although the satisfaction of learning a new skill is often sufficient motiva- tion, additional remuneration may sometimes be necessary to provide an incentive. Even so, the cost would be much less than training more ophthal- mologists, since it costs 20-100 times more to train an ophthalmologist 9 than to train an ophthalmic technician. With advances in automation it is quite possible that the greater part of a routine examination will be automated in 20 years' time and will not require an ophthalmologist to perform it. In some countries nurses are trained to take the patient's history and make a routine examination; this allows the ophthalmologist more time to discuss problems with the patient. Manpower planning should also be concerned with deciding how many ophthalmologists are required in a country and this necessitates a careful asessment of the objectives of their training. Epidemiological methods could help in deciding which tasks can be performed by ancillary personnel and which require a trained ophthalmologist, particularly as it is likely that their respective functions will change with time. National eye institutes could play an active part in such studies. This is a global problem and offers an oppor- tunity for cooperation between national institutes of different countries in defining research problems in this field and making known the requirements. 8. RESEARCH AND OTHER FI.JNCTIONS IN RELATION TO HEALTH CARE ADMINISTRATION Following a discussion of the research role of national institutes in rela- tion to health care administration, the Meeting concluded that the following activities should be considered: (l) the provision of reliable data, using epidemiological techniques, so that planning can be soundly based; (2) the evaluation of new and existing techniques; (3) the investigation of the best ways of utilizing manpower in health care delivery; (4) the standardization of instruments and methods. In order to obtain the maximum practical benefit from such research it is essential for eye institutes to cooperate with epidemiologists and institutes of public health. In addition, eye institutes should have access to the govern- ment departments responsible for health care. This system is well established in the countries of eastem Europe, but in some other countries advisers appointed by government departments may not be sufficiently experienced in the wider aspects of public health ophthalmology. The problem of financing this type of research was discussed and the possibility of WHO supporting such research was considered. It was pointed l0 out, however, that WHO can only support specific projects if the request comes in the form of a recommendation by the minister of health of the country concerned. Government departments are more likely to provide finance if the results of the research can be shown to improve the cost/ effectiveness of the health care services. An attempt was made to compile a list of diseases particularly amenable to epidemiological studies and of major importance from the public health point of view. These were (in alphabetic order) amblyopia, cataract, congen- ital anomalies, diabetic retinopathy, glaucoma, myopia, retinal degenerations and retinal vascular disease. 9. CONCLUSIONS AND RECOMMENDATIONS l. Although many national eye institutes, particularly those in eastern Europe, already play a major role in public health ophthalmology and have a close relationship with the relevant government departments, others are engaged primarily in research and teaching and have not so far entered the field of public health. All institutes of ophthalmology should play an active part in this field, particularly in the collection of adequate data on the prevalence and incidence of eye diseases leading to visual handicap. They should also cooperate with epidemiologists and institutes of public health to provide statistics for the planning of eye health care by the respective national health services. 2. Where no national institute of ophthalmology or equivalent body exists, a srnall advisory committee should be formed, comprising representatives of ophthalmological research institutes and eye departments and other experts such as epidemiologists and health economists. Such a committee would encourage interest in public health ophthalmology among ophthalmo- logists, determine research requirements in this field and advise and assist governments on problems of eye care. 3. Institutes or their equivalents should initiate clinical trials to assess the value of new techniques of investigation and treatment and reassess current methods to ensure the cost/effectiveness of these procedures. The education of all levels of staff and the general population in the public health aqpects of eye care should also be the concern of institutes. 4. In order to carry out this progamme, close collaboration with epidemio- logists is essential. The contribution of epidemiology to the development of public health ophthalmolory may take various forms, including the following: l1 (a) studies of the prevalence and incidence of eye affections causing visual handicap; (c) longitudinal studies to verify the value of new techniques of treat- ment, including surgical treatnlent; (d) evaluation of present methods of diagnosis, treatment and rehabil- itation; (e) measurement of the reliability, sensitivity and specificity of the various indicators used to judge visual capacity; (0 identification of the tasks to be performed by various categories of health personnel with a view to ensuring their optimal use in preven- tion, treatment and rehabilitation work. 5. To achieve the above aims, improvements in the training and organization of the various categories of staff are required. Hence it is necessary: (a) to define the educational objectives for each category, bearing in mind that these objectives must be validated in respect of their relevance; (b) to identify those strategies and methods of teaching which are already available and have proved effective, emphasis being placed on self-education and active methods of apprenticeship; (c) to ensure continuing objective evaluation of educational prog rammes; (d) to support teaching facilities at national and/or regional level so that specialists and others can acquire a knowledge of the methodology recommended. 6. With regard to the economics of eye health care, further research is required into the impact on the national economy of biomedical research prograrnmes in terms of employment opportunities, economic stability and potential improvements in the quality of life. Cost/benefit ratios for preven- tion, treatment and rehabilitation in relation to visually disabled individuals should also be developed. t2 (b) case control studies of specific conditions, in particular to establistr etiological factors with a view to primary prevention, and to identify high-risk groups requiring extra surveillance or eady diagnosis; 7. Institutes or equivalent bodies should be involved in the guidance and coordination of activities concerned with the rehabilitation of the visually handicapped. New ideas, for example the education of visually handicapped children in normal schools with the aid of specially trained teachers and extra equipment, should be further explored. Efforts should also be made to extend employment opportunities for the blind and the visually handicapped. 8. Institutes or equivalent bodies have an important role to play in moni- toring eye health trends so as to predict future requirements with regard to manpower, resources and research. The changing age structure of the popula- tion is likely to lead to more visual disability caused by degenerative condi- tions. Some attempt should be made to measure trends in prevalence rates so that the effect of interventions can be evaluated. 9. Technical advances, particularly in the field of automation, may produce radical changes in the provision of eye care in the next 20 years and the posible impact of such advances should be taken into account in the economic aspects of eye health care delivery systems. 10. It would be helpful if WHO were to undertake a systematic analysis of problems in the delivery of care and health economics in this field. This could be followed by the convening of ad hoc meetings of experts to review and evaluate specific topics in order to support the national institutes or equivalent bodies in planning and action. I I . The WHO Regional Office for Europe could usefully continue monitoring the existing efforts in various countries and might envisage convening a similar meeting, in the not too distant future,to assess the results obtained and deter- mine additional objectives with greater precision. 12. Many of the activities proposed above are already being undertaken by existing services and institutions and all collaborative efforts in this field are to be encouraged. 13 Annex I LIST OF WORKING PAPERS AND BACKGROI.JND MATERIAL rcP/oND 004/6 rcP/oND 004/7 rcP/oND 004/8 Role and functions of national institutes of ophthal' molory - Dr B. Nizetic Institute of Ophthalmolory, University of London - Professor E.S. Perkins Role and function of the national institutes, in- cluding that of ophthalmology in Hungary - Professor M. Radnot The National Institute of Ophthalmolory, Madrid - Professor A. Dominguez The Institute of Experimental Ophthalmolory of the University of Bonn - Professor E. Weigelin The Netherlands Ophthalmic Research Institute, Amsterdam - Dr G.M. Bleeker All-Union Research Institute of Eye Diseases, Ministry of Health of the USSR - Professor M.M. Krasnov Role and functions of the Institute of Ophthalmolory in the Bulgarian People's Republic - Professor S.B. Dabov rcP/oND 004/e rcP/oND oo4/lo rcP/oND 004/11 rcP/oND oult2 rcP/oND oo4/13 kckgtomd nwterial Cnllinan, T.R. Visual disability in Enghnd and l4tales (unpublished document) (English only) Hogarth, l. Glossary of health core terminologt Copenhagen, WHO Regional Office for Europe, 1975 (fublic health in Eutope, No.4) Eye health care (clearing-up terminolog). Revue intemationole du Trachome et de tt Pathologie oculaire nopiule et sub-topicole, l-2: 16l-17l (1976) (reprint: in En$ish and French only) Eye health care and national health programming. WHO Regional Office for South-East Asia (unpublished document SEA/Ophthalm. Meet./3) (English only) Public heatth ophthalmolory. In: Hobson, 1{., ed. The theory and practice of public health. London, Oxford University Press, 1975 (Englistr only) l4 Introduction to epidemiolory. In: Perkins, E.S. & Hill, D.W., ed. Scientific fomdations of ophthalmologt. London, Heinemann, 1978 (English only) WHO Regional Office for Europe. Research promotion and developmcnt programne: llHO Regiorul Office for Etope: progress report, September 1977 - August 1978 (unpublished document EUR/RC28/8) 15 Annex II LIST OF PARTICIPANTS Temprary Advisers Dr G.M. Bleeker, Professor of Ophthalmology, Director, NetJrerlands Ophthalmic Research Institute ( I 0 I ), Amsterdam, Netherlands Dr T.R. Cullinan, Senior lrcturer, Department of Environmental and Preventive Medicine, St Bartholomew's Medical College, london, United Kingdom hofessor S. Dabov, Chief, Department of Ophthalmology, Academy of Medicine, Sofia, Bulgaria Professor A. Dominguez, Director, National Institute of Ophthalmology, Madrid, Spain Professor J. Frangois, hesident, European Ophthalmological Society, Ghent, Belgium (Chairrrwn) Dr J.F. d'Ivernois, Director, Department of Health Sciences Teaching, Experimental Teaching and Research Unit for Medicine and Human Biolory, University of Paris XIII, Bobigny, France Professor C. Kupfer,a Director, National Eye Institute, National Ins- titute of Health, Bethesda, Maryland, USA Dr K. Troutneva, Director, Helmholtz Institute of Ophthalmolory, Moscow, USSR Professor M.F. kchat, School of Pr-rblic Health, Epidemiology Unit, University of louvain, Brusels, Belgium Professor E.S. Perkins, Sembal hofessor of Experimental Ophthalmology, Institute of Ophthalmology, University of london, United Kingdom (Rtpporteur) l6 a Participation expenses not paid by WHO Professor M. Radnot, Director, Department of Ophthalmolory No l, University Medical School, Bud apest, Hungary (Vi ce -Clwirrnan) Professor B. Tengroth, Professor in Ophthalmolory, Karolinska Hospital, Stockhokn, Sweden I\& H.H. von Stackelberg,a Deutsches Gnines Kreuz, Marburg/lahn, Federal Republic of Germany Professor E. Weigelin, Director, Institute for Experimental Ophthal- molory, University of Bonn, Bonn-Venusberg, Federal Republic of Germany llorld Heal th Organization Regional Office for Eurupe Dr B.Z. Nizetic, Regional Oflicer for Research Promotion and Devel- opment a Participation expenses not paid by WHO t7 WHO crrbllcdon. rny b. obt ln d. dlrrct orlhrcueh boofirlbn, ftom: ALOEnlA AEOErtNNA AUSTI/IIIA DBM()CR/TTIC X,EPUELIC AUIITRIA EANOLIDETIII BEIl}ruM ARA'ZIL EURMA, CANAI'A CHINA C{)IPMEIA cz8clil>$ov.rl(IA DANM'' T ACUADOR EOY?T BL SALVAI'OR FUI FINLA!ID PRANCE OBNM]I'}{ S-fut d N. c.o*t ol ardrt&rl &etln (bt t,,tr,DtloB) .' C.[rdLD h&Uc llotrb Arod.dc, t3!t Crrtht AtloB. Sulr.2t0. (rlTAwa. O!t. KtZ tNl. SrArdrrroir.'Sptr fur, a&rt, ccoafud by chqu ,rrd. ott ,o ,1, Rorrl l.[l ol CrDrdr. Ottltr! 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