Methods

Definitions of visual impairment and blindness in Israel are similar to, but not identical with, those in Western Europe, and are in accordance with the International Classification of Diseases. Blindness is defined in Israel as best-corrected visual acuity (BCVA) of less than 1/60 or central visual field not more than 10 degrees in the less impaired eye. Severe visual impairment is defined as visual acuity of less than 3/60 but of 1/60 or better, or a corresponding visual field of less than 20 degrees in the less impaired eye. Legal blindness encompasses both definitions.

A personal Certificate of Blindness is issued by the Israeli Ministry of Social Affairs to all individuals who meet the above definitions of legal blindness. The certification process begins with a complete eye examination by a senior ophthalmologist. It includes visual acuity assessment, a thorough ophthalmologic examination, and a visual field test. Patients who are considered eligible are advised to continue the registration process. The tests are then repeated by one of a select group of senior ophthalmology consultants employed by the Ministry of Welfare National Service for the Blind. If the diagnosis is confirmed, a certificate is issued. Patients denied a certificate have recourse to a national appeal committee comprising 2 senior ophthalmologists and a social worker.

All data (including demographic information, year of registration, results of visual acuity and visual field tests, and cause of blindness) are collected in a national registry, and an annual report is published. The certificate entitles the holder to consultation and rehabilitation services; a guide dog; expanded national insurance and tax benefits, including total exemption from income tax and a 90% discount on property and municipal taxes; and major discounts on public transportation, phone tax, taxes on electrical appliances purchased, and car licensing. In addition, the blind person is entitled to a monthly pension and the assistance of a part-time worker.

It can be assumed that the vast majority of blind individuals in Israel are diagnosed and registered, thanks to universal free access to widely available healthcare in Israel, including all ophthalmologic services, and the considerable advantages conferred by their registration. The application procedure for blind certification and the access to rehabilitation services are facilitated by the work of volunteers assisting blind people in 20 stations nationwide, that is, in all tertiary clinical centers, at the national insurance centers and governmental welfare offices, and in community centers and libraries for the blind.

We analyzed the aggregated data of new certificates of legal blindness issued in Israel, as well as the causes of blindness by age and gender, from 1999 through 2008. The data were derived from the annual reports of the National Registry of the Blind. Information on the sizes of the relevant population subgroups at risk during that period was obtained from the Israel Central Bureau of Statistics database. Annual age- and sex-specific rates of all-cause and disease-specific rates of legal blindness were calculated.

Annual age-standardized rates were calculated from the standard world population for the year 2000, using a direct standardization method. Poisson regression models were used to establish time trends of all-cause and disease-specific rates of blindness, according to age and gender. The dependent variable was the annual rate of all-cause or cause-specific blindness, and the independent variables were calendar year, age group, and gender. Interactions between calendar year and sex or age also were examined.

Results

Between 1999 and 2008, a total of 19 862 newly certified people were registered in the National Registry of the Blind in Israel. There was a continuous decline in the total annual age-standardized rate of blindness certification per 100 000 residents, from 33.8 in 1999 to 16.6 in 2008 ( Figure 1 ) . This represents a drop of 51% throughout that decade.

Graph showing annual age-standardized rates of certification of blindness in Israel during the decade 1999 through 2008.

The population size in Israel (in millions) and distribution of causes of blindness during the decade 1999 through 2008 is shown in Table 1 . The leading causes of blindness certification in Israel in the years 1999 and 2008 were AMD, accounting, respectively, for 20.9% (511) and 28.7% (440) of cases; diabetic retinopathy, 12.5% (306) and 13.2% (202); glaucoma, 13.9% (340) and 12.1% (185); and cataract, 9.8% (240) and 5.1% (78). The general population sex and age distribution is shown in Table 2 , whereas the age and sex distributions of the certified population in these years is shown in Tables 3 and 4 , respectively. The annual age-standardized incidence rates of blindness resulting from the leading causes are shown in Figure 2 .

TABLE 4

Sex Distributions of the Certified Blind Population in Israel during the Decade 1999 through 2008

Age Range (y)	1999	2000	2001	2002	2003	2004	2005	2006	2007	2008
Male
0 to 5	32	32	37	35	27	29	38	24	32	29
6 to 18	59	59	52	43	38	43	59	38	42	35
19 to 40	128	99	76	74	63	68	72	71	67	67
41 to 65	297	271	278	263	257	181	214	158	185	190
66 to 80	412	431	373	349	340	332	309	259	259	213
81+	260	268	274	252	241	269	266	245	254	229
Total	1188	1160	1090	1016	966	922	958	795	839	763
Total %	48.6	49.8	48.2	48.0	49.30	49.0	49.0	48.0	48.7	49.8
Female
0 to 5	27	22	37	40	23	22	26	18	25	26
6 to 18	50	59	27	35	21	40	29	28	34	29
19 to 40	87	72	76	79	60	55	70	52	62	61
41 to 65	295	272	277	251	215	179	171	161	173	155
66 to 80	527	467	462	433	384	338	358	299	309	244
81+	271	277	294	263	289	323	339	313	279	255
Total	1257	1169	1173	1101	992	957	993	871	882	770
Total %	51.4	50.2	51.8	52.0	50.70	51.0	51.0	52.0	51.3	50.2

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