Effective refractive error coverage: an eye health indicator to measure progress towards universal health coverage

Perception of optometrists on causes of professional discordance among eye care professionals and its impact on refractive error service delivery in Kenya

PURPOSE

To evaluate the perception of optometrists on causes of professional discordance among eye care professionals and its impact on refractive error service delivery in Kenya.

METHODS

This was a prospective qualitative case study conducted between January and June 2022 among optometrists registered with the Optometrists Association of Kenya. The data was collected through telephonic interviews. Purposive sampling was used to recruit the participants. Descriptive statistics were presented using frequency, percentages and with p values. Thematic analysis was carried out for qualitative data using the NVivo Software, Version 11. It was an iterative process consisting of both deductive and inductive processes.

RESULTS

Out of the 100 respondents, 37 (37%) were female. The mean age for the participants was 30.5 years with majority being in the age group 30-34 years. There was no statistically significant difference between the ages of males and females (p = 0.132) Most participants 82 (82%) had practiced for more than 4 years. The participants reported; mistrust among eye care professionals, employment sector, specialty, undermining the potential of other cadres within the eye care ecosystem, confusion and misconception and negative attitude as the perception of optometrists on causes of professional discordance among eye care professionals on refractive error service delivery. All of the optometrists agreed that professional discordance exists among eye care professionals in Kenya which potentially impacts negatively on refractive error service delivery.

CONCLUSION

Professional discordance remains an underrated barrier which negatively impacts on refractive error service delivery. However, to achieve effective refractive error coverage, a strengthened team approach among eye care professionals is desirable in a country with limited human resource such as Kenya.

Strategies to address inequity of uncorrected refractive error in the Western Pacific: A modified Delphi process

PURPOSE

Uncorrected refractive error is the leading cause of vision impairment globally; however, little attention has been given to equity and access to services. This study aimed to identify and prioritise: (1) strategies to address inequity of access to refractive error services and (2) population groups to target with these strategies in five sub-regions within the Western Pacific.

METHODS

We invited eye care professionals to complete a two-round online prioritisation process. In round 1, panellists nominated population groups least able to access refractive error services, and strategies to improve access. Responses were summarised and presented in round 2, where panellists ranked the groups (by extent of difficulty and size) and strategies (in terms of reach, acceptability, sustainability, feasibility and equity). Groups and strategies were scored according to their rank within each sub-region.

RESULTS

Seventy five people from 17 countries completed both rounds (55% women). Regional differences were evident. Indigenous peoples were a priority group for improving access in Australasia and Southeast Asia, while East Asia identified refugees and Oceania identified rural/remote people. Across the five sub-regions, reducing out-of-pocket costs was a commonly prioritised strategy for refraction and spectacles. Australasia prioritised improving cultural safety, East Asia prioritised strengthening school eye health programmes and Oceania and Southeast Asia prioritised outreach to rural areas.

CONCLUSION

These results provide policy-makers, researchers and funders with a starting point for context-specific actions to improve access to refractive error services, particularly among underserved population groups who may be left behind in existing private sector-dominated models of care.

Near vision impairment and effective refractive error coverage for near vision in Andhra Pradesh, India - The Akividu Visual Impairment Study (AVIS)

CLINICAL RELEVANCE

Near Vision Impairment (NVI) is common in developing countries. A substantial proportion of NVI can be addressed by providing spectacles. Innovative eye care programmes are needed to address NVI. Population-based epidemiological studies can provide vital data to plan such eye care service delivery models.

BACKGROUND

To report the prevalence of NVI and effective Refractive Error Coverage (eREC) for near vision in West Godavari and Krishna districts in Andhra Pradesh, south India.

METHODS

A population-based cross-sectional study was carried out using a Rapid Assessment of Visual Impairment methodology. Presenting and pinhole distance visual acuity were assessed followed by near vision assessment using a N notation chart at a fixed distance of 40 cm. If the presenting near vision was worse than N8, the best corrected near visual acuity was recorded with age appropriate near vision correction. NVI was defined as presenting near vision worse than N8 among those without distance vision impairment (6/18 or better in the better eye). Effective Refractive Error Coverage for near was calculated as the proportion of individuals with an adequate correction to the total participants, including those with inadequate, adequate, and no correction for near vision.

RESULTS

Data of 2,228 participants aged ≥40 years were analysed. The mean age of these participants was 54.0 ± 10.4 years; 53.8% were women; 44.5% had no formal education. The prevalence of NVI was 27.1% (95% CI: 25.2-29.0%). NVI significantly associated with 70 and above age group (adjusted OR: 1.97; 95% CI: 1.45-3.70). Participants with formal education had lower odds for NVI (adjusted OR: 0.75; 95 % CI: 0.68-0.83). The eREC for near vision was 48.0%.

CONCLUSION

NVI affects over a quarter of people aged ≥40 years in the West Godavari and Krishna districts of Andhra Pradesh. However, eREC is under 50% and there is scope for improving this by establishing eye care services to achieve universal eye health for all.

BCLA CLEAR Presbyopia: Epidemiology and impact

The global all-ages prevalence of epidemiologically-measured 'functional' presbyopia was estimated at 24.9% in 2015, affecting 1.8 billion people. This prevalence was projected to stabilise at 24.1% in 2030 due to increasing myopia, but to affect more people (2.1 billion) due to population dynamics. Factors affecting the prevalence of presbyopia include age, geographic location, urban versus rural location, sex, and, to a lesser extent, socioeconomic status, literacy and education, health literacy and inequality. Risk factors for early onset of presbyopia included environmental factors, nutrition, near demands, refractive error, accommodative dysfunction, medications, certain health conditions and sleep. Presbyopia was found to impact on quality-of-life, in particular quality of vision, labour force participation, work productivity and financial burden, mental health, social wellbeing and physical health. Current understanding makes it clear that presbyopia is a very common age-related condition that has significant impacts on both patient-reported outcome measures and economics. However, there are complexities in defining presbyopia for epidemiological and impact studies. Standardisation of definitions will assist future synthesis, pattern analysis and sense-making between studies.

The Rapid Assessment of Avoidable Blindness survey: Review of the methodology and protocol for the seventh version (RAAB7)

The Rapid Assessment of Avoidable Blindness (RAAB) is a population-based cross-sectional survey methodology used to collect data on the prevalence of vision impairment and its causes and eye care service indicators among the population 50 years and older. RAAB has been used for over 20 years with modifications to the protocol over time reflected in changing version numbers; this paper describes the latest version of the methodology-RAAB7. RAAB7 is a collaborative project between the International Centre for Eye Health and Peek Vision with guidance from a steering group of global eye health stakeholders. We have fully digitised RAAB, allowing for fast, accurate and secure data collection. A bespoke Android mobile application automatically synchronises data to a secure Amazon Web Services virtual private cloud when devices are online so users can monitor data collection in real-time. Vision is screened using Peek Vision's digital visual acuity test for mobile devices and uncorrected, corrected and pinhole visual acuity are collected. An optional module on Disability is available. We have rebuilt the RAAB data repository as the end point of RAAB7's digital data workflow, including a front-end website to access the past 20 years of RAAB surveys worldwide. This website ( https://www.raab.world) hosts open access RAAB data to support the advocacy and research efforts of the global eye health community. Active research sub-projects are finalising three new components in 2024-2025: 1) Near vision screening to address data gaps on near vision impairment and effective refractive error coverage; 2) an optional Health Economics module to assess the affordability of eye care services and productivity losses associated with vision impairment; 3) an optional Health Systems data collection module to support RAAB's primary aim to inform eye health service planning by supporting users to integrate eye care facility data with population data.

Effective refractive error coverage and spectacle coverage among school children in Telangana, South India

BACKGROUND

Uncorrected refractive error (URE) is one of the leading causes of childhood vision impairment. Increasing effective refractive error coverage (e-REC) is one of the main indicators of WHO's 2030 global eye health targets. The aim of this study is to estimate the e-REC and spectacle coverage among school children in Telangana, South India.

METHODS

School children aged 4-15 years in the study locations underwent vision screening using 6/12 tumbling E optotype by trained community eye health workers in the schools. Those failing the initial vision screening and/or found to be having eye conditions were referred to a nearby referral centre appropriately, where they underwent detailed eye examination.

RESULTS

A total of 774,184 children were screened in schools of which 51.49% were boys. The mean age was 9.40 ± 3.27 years. The prevalence of URE was 1.44% (95%CI:1.41-1.46) of which myopia was 1.38% (95%CI: 1.35-1.41). In multivariate analysis, the risk of myopia was higher among older children (Adj.OR: 17.04; 95%CI: 14.64-19.85), those residing in urban areas (Adj.OR:3.05, 95%CI:2.60-3.57), those with disabilities (Adj.OR:2.61, 95%CI:2.00-3.39) and among girls (Adj.OR:1.30, 95%CI:1.25-1.35) (P < 0.001). The overall e-REC was 56.97% and the spectacle coverage was 62.83%.

CONCLUSION

The need for interventions to improve e-REC to achieve 2030 global eye health target is eminent among children in this region. Improving refractive services through school eye health programs could aid in accelerating this process to achieve the target. Myopia being the most common type of RE, the risk factors included increasing age, urban location, and presence of disability.

[Global ophthalmology : Update]

The aim of global ophthalmology is to maximize vision, ocular health and functional ability, thereby contributing to overall health and well-being, social inclusion and quality of life of every individual worldwide. Currently, an estimated 1.1 billion people live with visual impairment, 90% of which can be prevented or cured through largely cost-effective interventions. At the same time, 90% of people affected live in regions with insufficient eye health coverage. This challenge drove the World Health Organization (WHO) and a group of nongovernmental organizations to launch "VISION 2020: the Right to Sight", a global campaign which recently concluded after 20 years. The achievements, challenges and lessons learned were identified and incorporated into the current campaign "2030 IN SIGHT".

Prevalence of visual impairment, uncorrected refractive errors and effective refractive error coverage in Koshi Province, Nepal - Rapid Assessment of Refractive Errors

BACKGROUND/OBJECTIVE

To determine the prevalence of visual impairment (VI), uncorrected refractive errors (URE), and effective refractive error coverage among individuals aged 15-50 years in Koshi Province, Nepal.

METHODS

A population-based cross-sectional study was conducted in Koshi Province in which 4800 participants were selected from 80 clusters. The study teams visited the selected households and conducted eye examinations. This included monocular unaided (and aided) visual acuity assessment using a Snellen chart with tumbling E optotypes at a distance of 6 meters. Near vision was assessed binocularly using the N notation chart at a fixed distance of 40 cm for each individual. Torchlight examination and distance direct ophthalmoscopy was done. VI was defined as presenting visual acuity worse than 6/12 in the better eye. URE was defined as presenting visual acuity worse than 6/12 and improving to 6/12 or better on using a pinhole. Near Vision Impairment was defined as binocular presenting near vision worse than N8 among those age 35 years and older.

RESULTS

In total, 4057 were examined (84.5% response rate). The prevalence of VI was 3.52% (95% CI:2.89-4.13; n = 143). The prevalence of URE in the better eye was 1.95% (95% CI:1.54-2.42; n = 79). The Refractive Error Coverage and Effective Refractive Error Coverage were 34.8% and 31.3% respectively. The prevalence of NVI was 34.24% (95% CI: 32.1-36.40; n = 666).

CONCLUSION

The prevalence of VI and  URE was low, attributed to the availability and uptake of services in Koshi province in Nepal.

Evaluation of the better operative outcome software tool to predict cataract surgical outcome in the early postoperative follow-up

BACKGROUND

Cataracts are the world's leading cause of avoidable blindness. In low-income countries, there are high rates of poor follow-up, which makes it very difficult to monitor surgical outcomes. To address this issue, the Better Operative Outcome Software Tool (BOOST Cataract app) predicts outcome on the first postoperative day and provides specific advice to improve outcomes. The aim of the study is to evaluate the ability of the BOOST Cataract app to categorise surgical outcomes and to analyse the possible factors that contribute to its performance. This was a prospective observational study performed at the General Hospital of Hospitalet of Llobregat.

RESULTS

A total of 126 cataracts were included. Patients had a mean [SD] age of 75.8 [12.19] years, and 52% were females. Manual small-incision cataract surgery was involved in 57% and phacoemulsification in 43%. Thirty-eight percent of eyes presented significant corneal oedema on day 1. The BOOST Cataract app succeeded in categorising the final outcome in 65.6% of the eyes and in 93,4% of the eyes with good outcome.The agreement between the BOOST and UDVA outcomes was 0.353 (p< .000). The level of agreement improved to 0.619 (p< .000) in eyes with clear corneas. Success obtained by BOOST for both types of surgery was not statistically different. Eyes that obtained a good outcome on day one after surgery and eyes with clear cornea had 37 times higher odds (95% CI 6.66, 212.83) and 12 times higher odds (95% CI 3.13, 47.66) of being correctly categorised by the BOOST Cataract app than eyes that obtained a suboptimal (moderate and poor) outcome and eyes with corneal oedema on day 1.

CONCLUSIONS

The BOOST Cataract app is an e-Health tool designed to address issues of measuring quality in low- and middle-income settings. Although its reliability is limited to eyes that obtain a good outcome and with clear corneas on day 1, the use of the tool on a regular basis facilitates monitoring and reporting outcomes when clinical data collection is challenging due to low postoperative follow-up rates.

Retrospective diagnosis of naked eye visual acuity (UCVA) variations in patients with refractive errors treated with SMILE, LASIK, and WF-LASIK refractive surgery

A retrospective assessment of the visual acuity (UCVA) variations in bare eyes of the refractive error cases treated with SMILE, LASIK and WF-LASIK. A retrospective selection of 126 patients with refractive error treated by refractive surgery admitted to our hospital between January 2019 and December 2021 were divided into three separate sets of patients according to their surgical methods: the SMILE cohort, the LASIK cohort, and the WF-LASIK cohort, and the three sets of patients were analyzed for bare eye visual acuity, refraction, higher-order aberration, BUT, SIt index, and complications, and the recovery effects of patients with the three surgical procedures. All three types of refractive surgery, SMILE, LASIK and WF-LASIK, can yield good surgical results in the reduction of refractive error, and patients with SMILE have better postoperative tear film stability, while patients with WF-LASIK have the best postoperative visual quality.

Indigenous Eye Health in the Americas: The Burden of Vision Impairment and Ocular Diseases

Review of the burden of vision impairment and blindness and ocular disease occurrence in Indigenous Peoples of the Americas. We systematically reviewed findings of the frequency of vision impairment and blindness and/or frequency of ocular findings in Indigenous groups. The database search yielded 2829 citations, of which 2747 were excluded. We screened the full texts of 82 records for relevance and excluded 16. The remaining 66 articles were examined thoroughly, and 25 presented sufficient data to be included. Another 7 articles derived from references were included, summing a total of 32 studies selected. When considering adults over 40 years old, the highest frequencies of vision impairment and blindness in Indigenous Peoples varied from 11.1% in high-income North America to 28.5% in tropical Latin America, whose rates are considerably higher than those in the general population. Most of the ocular diseases reported were preventable and/or treatable, so blindness prevention programs should focus on accessibility to eye examinations, cataract surgeries, control of infectious diseases, and spectacles distribution. Finally, we recommend actions in six areas of attention towards improving the eye health in Indigenous Peoples: access and integration of eye services with primary care; telemedicine; customized propaedeutics; education on eye health; and quality of data.

Prevalence and Risk Factors of Refractive Errors and Effective Spectacle Coverage in Emiratis and Non-Emiratis Aged 40 Years or Older: the Dubai Eye Health Survey

PURPOSE

The aim was to investigate the prevalence and risk factors of refractive errors (REs) and the effective spectacle coverage in Emiratis and non-Emiratis in Dubai.

DESIGN

The Dubai Eye Health Survey was a population-based cross-sectional study of participants aged 40 years or older.

METHODS

Distance and near visual acuity (VA), and noncycloplegic automated refraction were tested according to a standardized protocol. Distance VA was tested using the Early Treatment Diabetic Retinopathy Study (ETDRS) logMAR chart at 3 m and near VA was measured using the near vision logMAR chart at 40 cm under ambient lighting. Myopia was defined as spherical equivalent of refraction of less than -0.50 diopters (D), and hypermetropia as spherical equivalent of more than +0.50 D. Astigmatism was defined as cylinder power of 0.5 D or greater. Effective spectacle coverage for distance vision was computed as met need/(met need+unmet need+under-met need)×100%. Multivariable logistic regression models were used to examine associations between sociodemographic factors and RE.

RESULTS

The authors included 892 participants (446 Emiratis and 446 non-Emiratis) in the analysis. The prevalence of hypermetropia was 20.4% [95% confidence interval (CI): 16.8%-24.4%] in Emiratis and 20.6% (95% CI: 20.0%-24.7%) in non-Emiratis. The prevalence of myopia and high myopia was 27.4% (95% CI: 23.3%-31.7%) and 1.8% (95% CI: 0.8%-3.5%) in Emiratis, and 19.5% (95% CI: 15.9%-23.5%) and 0.9% (95% CI: 0.2%-2.3%) in non-Emiratis, respectively. High education (P=0.02) and not currently working (P=0.002) were risk factors of myopia in non-Emiratis only. The prevalence of astigmatism was 7.4% (95% CI: 5.1%-10.2%) in Emiratis and 1.6% (95% CI: 0.6%-3.2%) in non-Emiratis. This prevalence was higher in individuals aged over 60 years (P<0.001) and men (P=0.014) among Emiratis. The prevalence of anisometropia and uncorrected presbyopia was 11.4% (95% CI: 8.6%-14.8%) and 0.7% (95% CI: 0.1%-2.0%) in Emiratis, and 9.2% (95% CI: 6.7%-12.3%) and 0.4% (95% CI: 0.05%-1.6%) in non-Emiratis, respectively. The effective spectacle coverage was 62.3% (95% CI: 54.0%-70.6%) and 69% (95% CI: 60.5%-77.5%) in Emiratis and non-Emiratis, respectively.

CONCLUSIONS

A high proportion of Emiratis and non-Emiratis was affected by RE without optimal effective spectacle coverage, highlighting the imperativeness of intervention to alleviate the burden. The findings may help facilitate evidence-based policymaking concerning the delivery of eye care services and allocation of medical resources in Dubai.

Prevalence, pattern, and compliance with spectacles use among the elderly in homes for the aged in South India: The Hyderabad Ocular Morbidity in Elderly Study (HOMES)

Purpose

This study was conducted to report on the pattern of spectacles use and compliance among the elderly (aged ≥60 years) in homes for the aged in Hyderabad region in Telangana State, India.

Methods

Participants were recruited from 41 homes for the aged centres for comprehensive eye health assessments. A questionnaire was used to collect information on current and past use of spectacles, type of spectacles, spectacles provider and amount paid for the spectacles. For those that reported using spectacles in the past, information was collected on the reasons for their discontinuation. Compliance with spectacles use was assessed after eight months of provision of the spectacles.

Results

A total of 1182/1513 participants were examined from 41 homes for the aged in Hyderabad, India. The mean age of the participants examined was 75 years (standard deviation (SD): 8.8 years; range: 60-108 years); 764 (64.6%) of them were women and 240 participants (20.3%) had no formal education. The prevalence of spectacles use was 69.9% (95% confidence interval [CI]: 67.1-72.4; n = 825). Bifocals were the most commonly used type of spectacles (86.7%) followed by single vision glasses for distance vision (7.4%). Private eye clinics were the largest service provider (85.5%) followed by local optical outlets (6.9%) and other service providers (7.7%). The prevalence of spectacles compliance was 81.5% (211/259).

Conclusion

Use of spectacles and compliance are high among the elderly living in residential care homes in the Hyderabad region. Spectacles use can be further improved by periodic eye assessments along the lines similar to school eye programs, which can immensely benefit this vulnerable, aged population.

Effective cataract surgical coverage in adults aged 50 years and older: estimates from population-based surveys in 55 countries

BACKGROUND

Cataract is the leading cause of blindness globally. Effective cataract surgical coverage (eCSC) measures the number of people in a population who have been operated on for cataract, and had a good outcome, as a proportion of all people operated on or requiring surgery. Therefore, eCSC describes service access (ie, cataract surgical coverage, [CSC]) adjusted for quality. The 74th World Health Assembly endorsed a global target for eCSC of a 30-percentage point increase by 2030. To enable monitoring of progress towards this target, we analysed Rapid Assessment of Avoidable Blindness (RAAB) survey data to establish baseline estimates of eCSC and CSC.

METHODS

In this secondary analysis, we used data from 148 RAAB surveys undertaken in 55 countries (2003-21) to calculate eCSC, CSC, and the relative quality gap (% difference between eCSC and CSC). Eligible studies were any version of the RAAB survey conducted since 2000 with individual participant survey data and census population data for people aged 50 years or older in the sampling area and permission from the study's principal investigator for use of data. We compared median eCSC between WHO regions and World Bank income strata and calculated the pooled risk difference and risk ratio comparing eCSC in men and women.

FINDINGS

Country eCSC estimates ranged from 3·8% (95% CI 2·1-5·5) in Guinea Bissau, 2010, to 70·3% (95% CI 65·8-74·9) in Hungary, 2015, and the relative quality gap from 10·8% (CSC: 65·7%, eCSC: 58·6%) in Argentina, 2013, to 73·4% (CSC: 14·3%, eCSC: 3·8%) in Guinea Bissau, 2010. Median eCSC was highest among high-income countries (60·5% [IQR 55·6-65·4]; n=2 surveys; 2011-15) and lowest among low-income countries (14·8%; [IQR 8·3-20·7]; n=14 surveys; 2005-21). eCSC was higher in men than women (148 studies pooled risk difference 3·2% [95% CI 2·3-4·1] and pooled risk ratio of 1·20 [95% CI 1·15-1·25]).

INTERPRETATION

eCSC varies widely between countries, increases with greater income level, and is higher in men. In pursuit of 2030 targets, many countries, particularly in lower-resource settings, should emphasise quality improvement before increasing access to surgery. Equity must be embedded in efforts to improve access to surgery, with a focus on underserved groups.

FUNDING

Indigo Trust, Peek Vision, and Wellcome Trust.

Effective refractive error coverage in adults aged 50 years and older: estimates from population-based surveys in 61 countries

BACKGROUND

In 2021, WHO Member States endorsed a global target of a 40-percentage-point increase in effective refractive error coverage (eREC; with a 6/12 visual acuity threshold) by 2030. This study models global and regional estimates of eREC as a baseline for the WHO initiative.

METHODS

The Vision Loss Expert Group analysed data from 565 448 participants of 169 population-based eye surveys conducted since 2000 to calculate eREC (met need/[met need + undermet need + unmet need]). A binary logistic regression model was used to estimate eREC by Global Burden of Disease (GBD) Study super region among adults aged 50 years and older.

FINDINGS

In 2021, distance eREC was 79·1% (95% CI 72·4-85·0) in the high-income super region; 62·1% (54·7-68·8) in north Africa and Middle East; 49·5% (45·0-54·0) in central Europe, eastern Europe, and central Asia; 40·0% (31·7-48·2) in southeast Asia, east Asia, and Oceania; 34·5% (29·4-40·0) in Latin America and the Caribbean; 9·0% (6·5-12·0) in south Asia; and 5·7% (3·1-9·0) in sub-Saharan Africa. eREC was higher in men and reduced with increasing age. Global distance eREC increased from 2000 to 2021 by 19·0%. Global near vision eREC for 2021 was 20·5% (95% CI 17·8-24·4).

INTERPRETATION

Over the past 20 years, distance eREC has increased in each super region yet the WHO target will require substantial improvements in quantity and quality of refractive services in particular for near vision impairment.

FUNDING

WHO, Sightsavers, The Fred Hollows Foundation, Fondation Thea, Brien Holden Vision Institute, Lions Clubs International Foundation.

Exploring the Use of Washington Group Questions to Identify People with Clinical Impairments Who Need Services including Assistive Products: Results from Five Population-Based Surveys

This study analyses the use of the self-reported Washington Group (WG) question sets as a first stage screening to identify people with clinical impairments, service and assistive product (AP) referral needs using different cut-off levels in four functional domains (vision, hearing, mobility and cognition). Secondary data analysis was undertaken using population-based survey data from five countries, including one national survey (The Gambia) and four regional/district surveys (Cameroon, Chile, India and Turkey). In total 19,951 participants were sampled (range 538–9188 in individual studies). The WG question sets on functioning were completed for all participants alongside clinical impairment assessments/questionnaires. Using the WG “some/worse difficulty” cut-off identified people with mild/worse impairments with variable sensitivity (44–79%) and specificity (73–92%) in three of the domains. At least 64% and 60% of people with mild/worse impairments who required referral for surgical/medical and rehabilitation/AP services, respectively, self-reported “some/worse difficulty”, and much fewer reported “a lot/worse difficulty.” For moderate/worse impairment, both screening cut-offs improved identification of service/AP need, but a smaller proportion of people with need were identified. In conclusion, WG questions could be used as a first-stage screening option to identify people with impairment and referral needs, but only with moderate sensitivity and specificity.

Grand Challenges in global eye health: a global prioritisation process using Delphi method

BACKGROUND

We undertook a Grand Challenges in Global Eye Health prioritisation exercise to identify the key issues that must be addressed to improve eye health in the context of an ageing population, to eliminate persistent inequities in health-care access, and to mitigate widespread resource limitations.

METHODS

Drawing on methods used in previous Grand Challenges studies, we used a multi-step recruitment strategy to assemble a diverse panel of individuals from a range of disciplines relevant to global eye health from all regions globally to participate in a three-round, online, Delphi-like, prioritisation process to nominate and rank challenges in global eye health. Through this process, we developed both global and regional priority lists.

FINDINGS

Between Sept 1 and Dec 12, 2019, 470 individuals complete round 1 of the process, of whom 336 completed all three rounds (round 2 between Feb 26 and March 18, 2020, and round 3 between April 2 and April 25, 2020) 156 (46%) of 336 were women, 180 (54%) were men. The proportion of participants who worked in each region ranged from 104 (31%) in sub-Saharan Africa to 21 (6%) in central Europe, eastern Europe, and in central Asia. Of 85 unique challenges identified after round 1, 16 challenges were prioritised at the global level; six focused on detection and treatment of conditions (cataract, refractive error, glaucoma, diabetic retinopathy, services for children and screening for early detection), two focused on addressing shortages in human resource capacity, five on other health service and policy factors (including strengthening policies, integration, health information systems, and budget allocation), and three on improving access to care and promoting equity.

INTERPRETATION

This list of Grand Challenges serves as a starting point for immediate action by funders to guide investment in research and innovation in eye health. It challenges researchers, clinicians, and policy makers to build collaborations to address specific challenges.

FUNDING

The Queen Elizabeth Diamond Jubilee Trust, Moorfields Eye Charity, National Institute for Health Research Moorfields Biomedical Research Centre, Wellcome Trust, Sightsavers, The Fred Hollows Foundation, The Seva Foundation, British Council for the Prevention of Blindness, and Christian Blind Mission.

TRANSLATIONS

For the French, Spanish, Chinese, Portuguese, Arabic and Persian translations of the abstract see Supplementary Materials section.

Population-based assessment of prevalence of spectacle use and effective spectacle coverage for distance vision in Andhra Pradesh, India - Akividu Visual Impairment Study

CLINICAL RELEVANCE

Effective spectacle coverage is a useful indicator to assess the coverage of refraction services in a given region. We found a low coverage in the Akividu region suggesting a need to develop effective refraction services.

BACKGROUND

To assess the prevalence of spectacle use and effective spectacle coverage for distance vision among people aged 40 years and older in the Indian state of Andhra Pradesh.

METHODS

A population-based cross-sectional survey was carried out in the Akividu region in West Godavari and Krishna districts. The study teams visited selected households and conducted eye examinations in the selected clusters. A structured questionnaire was used to collect information on spectacle use. 'Met Need' was defined as unaided VA worse than 6/12 but improved to 6/12 or better with their current spectacles. 'Unmet Need' was defined as unaided VA worse than 6/12 but improved to 6/12 with pinhole, among those not using spectacles. The 'Under-met Need' was defined as aided VA worse than 6/12 but improving with pinhole to 6/12 or better. Based on these definitions, Effective Refractive Error Coverage (e-REC) is calculated as: e-REC (%) s = ((met need)/(met need + under-met need + unmet need)) X100.

RESULTS

Of 3,000 enumerated from 60 clusters, 2,587 (86.2%) participants were examined. The prevalence of current spectacle use was 43.1% (95% CI:41.2-45.0). The e-REC was 37.4%. It was also lower in men compared to women and among those without any education. Participants who had cataract surgery in either eye had similar e-REC compared to those who were not operated.

CONCLUSION

Though spectacle use was found to be high, there is a still large unmet need for refractive correction for distance. Effective service delivery models to provide refraction and spectacle dispensing services are needed to achieve universal eye health coverage in the region.

Estimating Need for Glasses and Hearing Aids in The Gambia: Results from a National Survey and Comparison of Clinical Impairment and Self-Report Assessment Approaches

Few estimates are available of the need for assistive devices (ADs) in African settings. This study aimed to estimate population-level need for glasses and hearing aids in The Gambia based on (1) clinical impairment assessment, and (2) self-reported AD awareness, and explore the relationship between the two methods. The Gambia 2019 National Eye Health Survey is a nationally representative population-based sample of 9188 adults aged 35+ years. Participants underwent standardised clinical vision assessments including the need for glasses (distance and near). Approximately 25% of the sample underwent clinical assessment of hearing and hearing aid need. Data were also collected on self-reported awareness, need and access barriers to vision and hearing ADs. Overall, 5.6% of the study population needed distance glasses (95% CI 5.0-6.3), 45.9% (95% CI 44.2-47.5) needed near glasses and 25.5% (95% CI 22.2-29.2) needed hearing aids. Coverage for each AD was very low (<4%). The agreement between self-report and clinical impairment assessment for AD need was poor. In conclusion, there is high prevalence and very low coverage for distance glasses, near glasses and hearing aids in The Gambia. Self-report measures alone will not provide an accurate estimate of AD need.

Near-vision impairment and effective near-vision spectacle coverage in two districts in Telangana, India: a population-based cross-sectional study

OBJECTIVES

To investigate the prevalence of near-vision impairment (NVI) and effective spectacle coverage for near vision in those aged ≥40 years in Khammam and Warangal district in Telangana, India.

DESIGN

A population-based cross-sectional study.

SETTING

Khammam and Warangal district in Telangana, India.

PARTICIPANTS

Of 6000 people enumerated, 5357 were examined (89%). 4526 participants without distance vision impairment were included in the analysis.

MAIN OUTCOME MEASURES

The study teams visited selected households and conducted eye examinations. NVI was defined as binocular presenting near vision worse than N6. 'Unmet need' was deemed to be present if the unaided near vision was worse than N6 and improved to N6 with near correction among the participants who did not have spectacles for near vision. 'Met need' was deemed to be present when unaided near vision was worse than N6 but improving to N6 with their spectacles. The 'undermet need' was deemed to be present when aided near vision was worse than N6 but improved to N6 with correction. Based on these definitions, e-near-vision coverage (%) is calculated as follows: e-NVC (%)=met need/(met need+undermet need+unmet need) × 100.

RESULTS

The mean age was 53.5 years (SD: 10.8 years), 2534/4526 (55.8%) were women, 1819/4526 (41.8%) had at least primary school education and 2368/4526 (52.3%) were from the Khammam district. The prevalence of NVI was 55.8% (95% CI 72.5 to 75.1; n=3343). Overall, the e-NVC (%) was 31.8%. It was 40.0% in Khammam and 23.2% in Warangal.

CONCLUSION

NVI is common in Khammam and Warangal districts in Telangana with inadequate effective near-vision coverage. Effective service delivery models are needed to reach out and provide services to address NVI to achieve universal eye health coverage in the region.

Changes in Eye Health and Service Coverage in Nampula, Mozambique between 2011 and 2018

Purpose: Globally, there are few examples of repeated eye health surveys to assess changes in prevalence and causes of visual impairment, and service coverage over time. Two separate, unlinked rapid assessments of avoidable blindness (RAAB) were conducted in Nampula province, Mozambique in 2011 and 2018. This paper reports the observed changes and examines how the trends differ for males and females.Methods: Standard RAAB methodology was used in both studies. Two-stage cluster sampling was used to generate random samples of adults aged over 50 years. Participants underwent a simplified visual acuity (VA) exam, a lens exam and posterior segment exam using a direct ophthalmoscope for all subjects with presenting VA<6/18. Data were analysed using Stata and logistic regression models were developed to assess changes.Results: The 2011 study enrolled 3,050 people and examined 96.9% (2,954 people). The 2018 survey enrolled 4,191 people and examined 95.8% (4,015 people). Age- and sex-adjusted estimates of blindness decreased from 6.2% in 2011 to 4.5% in 2018 (z = -2.21, p = .028). Cataract surgical coverage was higher among males in both surveys (13.4% among males vs 7.7% among females in 2011, and 40.0% among males vs 19.4% among females in 2018) and the gender disparity grew between surveys.Conclusion: Significant changes were observed in the eye health and service coverage between 2011 and 2018. Further improvements to services are required to improve access for women and people with moderate visual impairment.

Eye health indicators for universal health coverage: results of a global expert prioritisation process

Introduction

In its recent World Report on Vision, the WHO called for an updated approach to monitor eye health as part of universal health coverage (UHC). This project sought to develop a consensus among eye health experts from all world regions to produce a menu of indicators for countries to monitor eye health within UHC.

Methods

We reviewed the literature to create a long-list of indicators aligned to the conceptual framework for monitoring outlined in WHO’s World Report on Vision. We recruited a panel of 72 global eye health experts (40% women) to participate in a two-round, online prioritisation exercise. Two-hundred indicators were presented in Round 1 and participants prioritised each on a 4-point Likert scale. The highest-ranked 95 were presented in Round 2 and were (1) scored against four criteria (feasible, actionable, reliable and internationally comparable) and (2) ranked according to their suitability as a ‘core’ indicator for collection by all countries. The top 30 indicators ranked by these two parameters were then used as the basis for the steering group to develop a final menu.

Results

The menu consists of 22 indicators, including 7 core indicators, that represent important concepts in eye health for 2020 and beyond, and are considered feasible, actionable, reliable and internationally comparable.

Conclusion

We believe this list can inform the development of new national eye health monitoring frameworks, monitor progress on key challenges to eye health and be considered in broader UHC monitoring indices at national and international levels.

Men perspectives on attending antenatal care visits with their pregnant partners in Misungwi district, rural Tanzania: a qualitative study

Background

Mens’attendance with their pregnant partners at facility-based antenatal care (ANC) visits is important for maternal and child health and gender equality yet remains uncommon in parts of rural Tanzania. This study examined men’s perspectives on attending ANC with their pregnant partners in Misungwi District, Tanzania.

Methods

Twelve individual interviews and five focus group discussions were conducted using semi-structured questionnaires with fathers, expectant fathers, and in-depth interviews were done to health providers, volunteer community health workers, and village leaders. Interviews were recorded and transcribed in Swahili and later translated to English. The research team conducted thematic analysis to identify common themes among interviews.

Results

We identified two broad themes on the barriers to male attendance at facility-based ANC visits: (1) Perceived exclusion during ANC visits among men (2) Traditional gender norms resulting to low attendance among men.

Conclusion

Attendance at health facility for ANC visits by men with their pregnant partners in the study areas were challenged by structural and local cultural norms. At the facility men were uncomfortable to sit with women due to lack of specific waiting area for men and that they perceived to be neglected. Local cultural norms demanded women to have secrecy in pregnancy while men perceived not to have a role of being with their partners during ANC visits.

The Gambia National Eye Health Survey 2019: survey protocol

Two national surveys of vision impairment and blindness were undertaken in The Gambia in 1986 and 1996. These provided data for the inception of The Gambia's National Eye Health Programme (NEHP) within the Ministry of Health and Social Welfare. There have been important developments in the eye health services provided by the NEHP in the last 20 years. At the same time, the population has also undergone major demographic changes that may have led to substantial changes in the burden of eye disease. We conducted a National Eye Health Survey of vision impairment, blindness and its comorbidities in adults in The Gambia in 2019. We examined a nationally representative population-based sample of adults 35 years and above to permit direct comparison with the data available from the previous surveys. Alongside a comprehensive vision and eye examination, the survey provides nationally representative data on important comorbidities in this population: diabetes, hypertension, obesity, hearing impairment, disability and mental health. Secondly, it estimates access to assistive technologies and eye health services. Thirdly, it is powered to allow a five-year follow up cohort study to measure the incidence and progression of eye disease.

Prevalence and causes of visual impairment among hearing impaired students in Lagos, Nigeria

OBJECTIVES

To determine the prevalence and causes of visual impairment in hearing-impaired students in Lagos, Nigeria and to assess their level of ophthalmic care utilization.

METHODS

Descriptive cross sectional study carried out in a primary school for hearing impaired students in Lagos, Nigeria. Socio-demographic characteristics, medical and ocular history were obtained. Ocular examination comprised of distance and near visual acuity assessment; cover tests; anterior segment examination and direct fundoscopy. Visually impaired students had cycloplegic refraction, dilated fundoscopy and subjective refraction. In-depth interviews were carried out for parents of students requiring referral for further eye care.

RESULTS

One hundred and nine students participated in the study. The prevalence of visual impairment was 19%. The causes of visual impairment were refractive error (11%), amblyopia (6%), cataract (1%) and macular scarring (1%). A lower mean age (p = 0.020) and ocular misalignment (p = 0.037) were associated with visual impairment on multivariate analysis. The spectacle correction coverage was 11% and only 8% of the students had prior ophthalmic care utilization. Ignorance of ocular morbidity and perceived inaccessibility of eye care were cited by parents/guardians as reasons for poor utilization of eye-care services.

CONCLUSION

A high prevalence of visual impairment was found among the hearing impaired students; uncorrected refractive error and refractive amblyopia were the most prevalent causes. The level of prior ophthalmic service utilization was found to be low. It was recommended that ophthalmic services especially refractive services should be made available in schools for the hearing impaired.