Experts had a hunch that rates of blindness in the Southeast Asian country of Burma were high.

But it wasn't until a team led by South Australian-based non-governmental organisation 'Sight For All' completed a large survey of avoidable blindness in late 2005 that the extent of the problem became undeniable.

Eight per cent of adults over 40 who were sampled in a regional area of the country were blind. That's the highest rate reported in the world.

The results astonished everyone, including Burma's health minister, who immediately vowed to increase efforts to tackle the problem.

South Australian ophthalmologist and Sight For All founder James Muecke was part of the research team and discussed the findings with the country's health minister.

"He was visibly distressed. What he said to me was, 'I thought we were doing better than that,' " Muecke recounts.

The government pledged to open more eye centres in rural areas and train more eye surgeons to staff them, and it has. Two eye centres have since opened in the delta region and two more are set to open near Rangoon.

Blindness affects the developing world disproportionately. Of the estimated 45 million people in the world who are blind, and the 250 million more who are severely vision-impaired, 90 per cent live in low-income countries, according to the World Health Organisation. Moreover, blindness contributes to the cycle of poverty in those countries, disrupting everything from education to employment. That's partly why in 1999 the WHO launched Vision 2020, with an agenda to eliminate avoidable blindness by that year.

An estimated 80 per cent of cases of blindness are classified as avoidable, meaning they could be treated or prevented by known, cost-effective means. But how best to combat the problem?

Muecke is adamant that the answer lies not in short-term service provision trips where skilled individuals or groups fly in to perform surgeries, however well-intentioned or rewarding those experiences may be.

"From a purely mathematical viewpoint, such trips make no sense," Muecke says. "Doctors enjoy these trips as they feel they're doing some good. Individual patients benefit. But ultimately they have no impact at a population level as the blindness rate continues to soar."

In fact, according to Brian Doolan, chief executive of the Fred Hollows Foundation, the fly-in, fly-out model can be downright dangerous.

"It's really harmful and it undermines the systems in the countries where we are working," Doolan says. "There was a distressing study done in India that found the second leading cause of blindness was bad surgery. You have to do about 100 cataract operations to get a good understanding of the nuances involved in this kind of surgery."

Cataract is the single biggest cause of blindness globally, causing the lens of the eye to become cloudy. Surgery to replace the affected lens with a plastic one called an intraocular lens is highly cost-effective. However, Western surgeons use techniques and equipment that are inappropriate in much of Asia and the Pacific.

"Most Australian ophthalmologists use lasers, but you can't do that in developing countries because of the expense of that kind of equipment and the remote nature of a lot of the work we do," Doolan says.

"In countries such as Nepal, where a large proportion of the population lives in remote locations, we still need to literally take surgery to the people, using whatever infrastructure is available. You have to do manual, small-incision cataract surgery with a scalpel. And you have to do high volumes to be good at that."

Doctors flying in and offering free services are also making it more difficult for local doctors trying to earn a living. There are other problems: they don't always leave patient information behind, ongoing training is limited and they often don't do the necessary follow-up at two weeks and three months, Doolan says. "The quality is questionable."

So that's what not to do. Muecke and Doolan agree it's much more effective to use a development approach, rather than a charity approach, and both advocate working with a given country's government to improve local systems.

"There is an enormous backlog of cataract blindness -- in the tens of millions -- and one million newly blind every year adding to this," Muecke says. "No amount of short-term operating trips by visiting Aussie teams or the opening of the occasional eye centre can surmount this problem. The whole country needs to be geared up to address the issue."

Sight For All was launched about 15 years ago under a different name and has grown organically. Muecke and his colleague associate professor Henry Newland saw many of their co-workers volunteering in various parts of Asia and wanted to maximise their influence in a sustainable way. They decided to choose one country and focus their efforts there. First up was Burma.

The doctors set up a fellowship in South Australia to train Burmese doctors in specific sub-specialty areas lacking in their homeland, sending them back home to pass on the skills to others. Past recipients have focused on everything from eyelids and retinas to pediatric surgery.

"We still do short-term trips, though these are aimed more at teaching than doing. We're up-skilling the local eye surgeons rather than doing the surgery ourselves," Muecke says.

Sight For All now works in several Southeast Asian countries and continues to do epidemiological research to identify key problems and look for long-term solutions. For example, a survey of Burma's schools for the blind revealed measles was the No 1 cause of childhood blindness. It is hoped the data will encourage the government to expand its vaccination program.

The NGO's work involves training, health promotion, upgrading existing facilities and providing appropriate equipment.

But Sight For All is far from alone. The Fred Hollows Foundation follows a similar model, meeting the ministry of health to develop a plan in each country where it works.

"There are now more than 121 countries that have a national blindness prevention plan. What we need now is to be resourcing and monitoring those plans," Doolan says.

For its part the Fred Hollows Foundation helped screen 1.7 million people, perform more than 195,000 surgeries and train more than 5000 people last year.

In 2008 the Australian government dedicated $45 million to the first phase of an Avoidable Blindness Initiative, funding eye health and vision care programs throughout the Asia-Pacific region. The Fred Hollows Foundation is the primary agent of the Vision 2020 Australia consortium that distributes AusAid money to a range of partners, including the International Centre for Eyecare Education, the Royal Australian and New Zealand College of Ophthalmologists, the Royal Australasian College of Surgeons, CBM Australia, the Centre for Eye Research Australia, Foresight Australia, and the Royal Institute for Deaf and Blind Children.

Meanwhile, other countries are stepping up their efforts.

India has pledged more than $US250m to set up vision centres with screening equipment, eye banks and eye donation centres and other initiatives to expand eye care services to rural areas.

Last year China launched its unimaginatively titled Million Cataract Surgeries Initiative, whereby each operation is subsidised by 800 yuan ($124). So far 19 provinces have signed up.

Doolan believes such initiatives make sense on multiple levels. "This is a development issue and there is a huge economic impact," he says. "We will never have universal primary education if children can't see the blackboard because their sight is not being tested or if little girls are bring forced to stay home to take care of a blind relative."

There's a lot to do, but progress is being made. Sight For All has taken its model elsewhere, too.

Muecke was recently in Sri Lanka, equipping that country's first two pediatric eye units. And in Burma, the country of 55 million has its first pediatric eye surgeon, one who trained at South Australian Institute of Ophthalmology in Adelaide on a Sight For All fellowship.

If these trends continue and grow, Doolan believes Vision 2020's goal is achievable.

"It's possible we can eliminate avoidable blindness in the next 10 years with a concerted push," he says enthusiastically. "The only thing stopping us is political will. It's absolutely doable."

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