The long term impact of cataract surgery on quality of life, activities and poverty: results from a six year longitudinal study in Bangladesh and the Philippines

The effect on income of providing near vision correction to workers in Bangladesh: The THRIVE (Tradespeople and Hand-workers Rural Initiative for a Vision-enhanced Economy) randomized controlled trial

INTRODUCTION

Presbyopia, the leading cause of vision impairment globally, is common during working years. However, no trials have assessed presbyopia's impact on income.

METHODS

In April 2017, we conducted a census among 59 Bangladesh villages to identify persons aged 35 to 65 years with presbyopia (presenting distance vision > = 6/12 bilaterally and correctable inability to see 6/13 at 40 cm with both eyes), who never had owned glasses. Participants were randomized (1:1) to receive immediate free reading glasses (intervention) or glasses delivered 8 months later (control). Visual demand of different jobs was stratified into three levels. Outcomes were between-group differences in the 8 month change in: self-reported monthly income (primary) and Near Vision Related Quality of Life (NVRQOL, secondary).

RESULTS

Among 10,884 census participants, 3,655 (33.6%) met vision criteria and 863 (23.6%) comprised a sample enriched for near vision-intensive jobs, but 39 (4.52%) could not be reached. All participants allocated to intervention (n = 423, 51.3%) and control (n = 401, 48.7%) received the appropriate intervention, and follow-up was available for 93.4% and 96.8% respectively. Groups were similar at baseline in all characteristics: mean age was 47 years, 50% were male, 35% literate, and about half engaged in "most near vision-intensive" occupations. Glasses wear at 8-month follow-up was 88.3% and 7.81% in intervention and control respectively. At baseline, both the intervention and control groups had a self-reported median monthly income of US$35.3. At endline, the median income for the intervention group was US$47.1 compared with US$35.3 for control, a difference of 33.4%. Predictors of greater income increase in multivariate models included intervention group allocation (OR 1.45, 95% CI 1.12, 1.88, P = 0.005), male sex (OR 2.41, 95% CI 1.84, 3.16, P <0.001), and not engaging in income-producing work at baseline (OR 2.35, 95% CI 1.69, 3.26, P<0.001).

CONCLUSION

Provision of reading glasses increases income in near vision-intensive occupations, and may facilitate return to work for those currently unemployed.

[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".

Barriers to uptake of cataract surgery among elderly patients in rural China: a cross-sectional study

OBJECTIVE

To investigate factors that differentiate elderly adults in rural China who accept free vision screening and cataract surgery from those who could benefit from vision care but refuse it when offered.

DESIGN

We conducted a population-based, cross-sectional study between October and December 2016. Logistic regression models were used to examine the predictors of accepting free vision screening and cataract surgery.

SETTING

Rural communities in Handan, China.

PARTICIPANTS

Adults aged 50 years or older, with presenting visual acuity ≤6/18 in the better seeing eye, suspected by examining ophthalmologist to be due to cataract.

RESULTS

Among 613 persons with cataract identified on a population basis, 596 (97.2%) completed the household survey (mean (SD) age, 71.5 (10.0) years; 79.8% female). A total of 214 persons (35.9%) refused participation, while 382 (64.1%) took part in the vision screening. A total of 193 (50.5%) participants were found eligible for surgery, while 189 (49.5%) were not. Among 99 randomly selected participants who were offered immediate free surgery, surgery was accepted by 77 participants (77.8%) and refused by 22 (22.2%). In the multivariate model, being engaged in income-generating activities (p<0.01), self-reported better physical capacity (p<0.001) and having had a recent physical examination (p=0.01) were significantly associated with acceptance of vision screening. The only variable significantly associated with acceptance of surgery was presenting visual acuity, with better vision inversely associated with acceptance of surgery (p<0.05) models.

CONCLUSION

Our results suggest that refusal of basic eye examinations may be at least as important a determinant of low surgical rates in rural China as lack of acceptance of surgery itself.

The case for investment in eye health: systematic review and economic modelling analysis

Objective

To assess how the returns on investment from correcting refractive errors and cataracts in low- and middle-income countries compare with the returns from other global development interventions.

Methods

We adopted two complementary approaches to estimate benefit-cost ratios from eye health investment. First, we systematically searched PubMed® and Web of Science™ on 14 August 2023 for studies conducted in low-and-middle-income countries, which have measured welfare impacts associated with correcting refractive errors and cataracts. Using benefit-cost analysis, we compared these impacts to costs. Second, we employed an economic modelling analysis to estimate benefit-cost ratios from eye health investments in India. We compared the returns from eye health to returns in other domains across global health and development.

Findings

We identified 21 studies from 10 countries. Thirteen outcomes highlighted impacts from refractive error correction for school students. From the systematic review, we used 17 out of 33 outcomes for benefit-cost analyses, with the median benefit-cost ratio being 36. The economic modelling approach for India generated benefit-cost ratios ranging from 28 for vision centres to 42 for school eye screening, with an aggregate ratio of 31. Comparing our findings to the typical investment in global development shows that eye health investment returns six times more benefits (median benefit-cost ratio: 36 vs 6).

Conclusion

Eye health investments provide economic benefits with varying degrees based on the intervention type and location. Our findings underline the importance of incorporating eye health initiatives into broader development strategies for substantial societal returns.

Impact of Cataract Surgery on Income in Rural Southern China: The SUCCESS Randomized Controlled Trial

PURPOSE

Visual impairment from cataracts is closely associated with low income, but trial evidence regarding the impact of surgery on income is lacking. We investigated whether cataract surgery could increase personal income.

DESIGN

A 2-arm, parallel-group, open-label, randomized controlled trial (ClinicalTrials.gov, NCT03020056).

METHODS

Persons aged 50 years or older in rural Guangdong, China, with best-corrected visual acuity <6/19 in both eyes due to cataracts were randomly assigned (1:1) to receive surgery within 4 weeks (intervention group), or 1 year later (control group). All participants were interviewed at baseline and end-line regarding demographic characteristics, income, and quality of life.

RESULTS

Among the 292 eligible persons (5.40%, mean age = 74.0 y, 61.0% women) randomly assigned to intervention (n = 146) or control (n = 146) groups, 12 participants (8.22%) in the intervention group and 1 (0.68%) in the control did not receive the allocated intervention. By study closeout, 18 participants (6.16%) were lost to follow-up. The mean 1-year income increase of the intervention group ($2469-$3588; change = $1119) was significantly larger than that of the controls ($2258-$2052; change = $-206), a between-group difference of $1325 (relative increase = 54.0%; 95% CI = $739 to $1911; P < 0.001). In multivariable modeling, intervention group membership was associated with greater income increase (β = 1143.2; 95% CI = 582.0 to 1704.3; P < 0.001). Greater improvement in best-corrected visual acuity was associated with income increase in univariable modeling (β = 1626.9; 95% CI = 1083.6 to 2170.1; P < 0.001).

CONCLUSIONS

Cataract surgery substantially increases personal income in rural China, offering a strategy for poverty alleviation. The strong association between increased income and change in visual acuity enhances the biological plausibility of the result.

Prevalence and impact of combined vision and hearing (dual sensory) impairment: A scoping review

Hearing and vision impairments are common globally. They are often considered separately in research, and in planning and delivering services. However, they can occur concurrently, termed dual sensory impairment (DSI). The prevalence and impact of hearing and vision impairment have been well-examined, but there has been much less consideration of DSI. The aim of this scoping review was to determine the nature and extent of the evidence on prevalence and impact of DSI. Three databases were searched: MEDLINE, Embase and Global Health (April 2022). We included primary studies and systematic reviews reporting the prevalence or impact of DSI. No limits were placed on age, publication dates, or country. Only studies where the full text was available in English were included. Two reviewers independently screened titles, abstract, full texts. Data were charted by two reviewers independently using a pre-piloted form. The review identified 183 reports of 153 unique primary studies and 14 review articles. Most evidence came from high-income countries (86% of reports). Prevalence varied across reports, as did age groups of participants and definitions used. The prevalence of DSI increased with age. Impact was examined across three broad groups of outcomes-psychosocial, participation, and physical health. There was a strong trend towards poorer outcomes for people with DSI across all categories compared to people with one or neither impairment, including activities of daily living (worse for people with DSI in 78% of reports) and depression (68%). This scoping review highlights that DSI is a relatively common condition with substantial impact, particularly among older adults. There is a gap in evidence from low and middle-income countries. There is a pressing need for a consensus position on the definition(s) of DSI and standardisation of reporting age groups to enable reliable estimates to be ascertained and compared and responsive services developed.

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.

Association of Visual Health With Depressive Symptoms and Brain Imaging Phenotypes Among Middle-Aged and Older Adults

IMPORTANCE

Vision loss and depression are common conditions with major health implications. However, mechanisms of the association of visual health (across the full acuity spectrum) with depression remain unclear.

OBJECTIVE

To characterize the association between visual health and depression and investigate the association between depression and brain microstructure and macrostructure in subgroups divided by visual acuity.

DESIGN, SETTING, AND PARTICIPANTS

In the UK Biobank Study cohort, 114 583 volunteers were included at baseline from March to June 2006 to July 2010. Habitual distance visual acuity was examined using the logarithm of the minimum angle of resolution (LogMAR) characters. Depression was identified based on Patient Health Questionnaire (PHQ) or through an interview-based psychiatric diagnosis. Subgroup participants completed multimodal magnetic resonance imaging (MRI) of the brain and PHQ evaluation during the imaging visit after 2014. Data were analyzed from May 5 to August 9, 2022.

MAIN OUTCOMES AND MEASURES

Depression, depressive symptoms, and imaging-derived phenotypes from T1-weighted and diffusion MRI.

RESULTS

Of the 114 583 participants from the UK Biobank Study, 62 401 (54.5%) were women, and the mean (SD) age was 56.8 (8.1) years (range, 39-72 years). A 1-line worse visual acuity (0.1 LogMAR increase) was associated with 5% higher odds of depression (odds ratio, 1.05 [95% CI, 1.04-1.07]) after adjustment for age, sex, race and ethnicity, Townsend index, educational qualifications, smoking, alcohol consumption, obesity, physical activity, history of hypertension, diabetes, hyperlipidemia, and family history of depression. Of the 7844 participants eligible for MRI analysis, there were linear associations between PHQ score and the left volume of gray matter in supracalcarine cortex (coefficient, 7.61 [95% CI, 3.90-11.31]) and mean isotropic volume fraction (ISOVF) in the right fornix (cres) and/or stria terminalis (coefficient, 0.003 [95% CI, 0.001-0.004]) after correction for multiple comparison. In addition, their association could be moderated by visual acuity, whereby increased PHQ score was associated with higher ISOVF levels only among those with poorer visual acuity (P = .02 for interaction).

CONCLUSIONS AND RELEVANCE

This study suggests an association between visual health and depression and that the diffusion characteristic of ISOVF in the fornix (cres) and/or stria terminalis is associated with depressive symptoms in participants with poorer visual acuity.

Lens Epithelial Cell Removal in Routine Phacoemulsification: Is It Worth the Bother?

PURPOSE

To review the literature on crystalline lens epithelial cell (LEC) removal in routine phacoemulsification and determine whether it should be incorporated as part of a surgeon's standard technique.

DESIGN

Perspective.

METHODS

Expert commentary with video demonstrations on techniques of removal of LECs and associated potential complications. Discussion incorporates the importance of LEC removal, a review of techniques to prevent posterior capsular opacification (PCO), and the effects of intraocular lens design on LEC proliferation and PCO.

RESULTS

The evidence suggests that LEC removal should be routinely performed as it can be carried out safely and with considerable short- and long-term benefits for patients. With effective cleanup, there is reduced anterior capsule opacification, fibrosis, and decentration of the capsular bag as well as reduced rates of posterior capsular opacification. Techniques for removal are easy to learn, with very low complication rates, and can reduce the risk of the long-term need for technically complex procedures such as intraocular lens explantation.

CONCLUSIONS

LEC removal from both the anterior and posterior capsule is part of a continuous, incremental improvement of cataract surgery and should be introduced to ophthalmology trainees during their formative years as part of their regular cataract surgery armamentarium.

Vision impairment and self-reported anxiety and depression in older adults in Nigeria: evidence from a cross-sectional survey in Kogi State

BACKGROUND

More than 2 billion people are thought to be living with some form of vision impairment worldwide. Yet relatively little is known about the wider impacts of vision loss on individual health and well-being, particularly in low- and middle-income countries (LMICs). This study estimated the associations between all-cause vision impairment and self-reported symptoms of anxiety and depression among older adults in Kogi State, Nigeria.

METHODS

Individual eyes were examined according to the standard Rapid Assessment of Avoidable Blindness methodology, and anxiety and depression were assessed using the Washington Group Short Set on Functioning-Enhanced. The associations were estimated using multivariable logistic regression models, adding two- and three-way interaction terms to test whether these differed for gender subgroups and with age.

RESULTS

Overall, symptoms of either anxiety or depression, or both, were worse among people with severe visual impairment or blindness compared with those with no impairment (OR=2.72, 95% CI 1.86 to 3.99). Higher levels of anxiety and/or depression were observed among men with severe visual impairment and blindness compared with women, and this gender gap appeared to widen as people got older.

CONCLUSIONS

These findings suggest a substantial mental health burden among people with vision impairment in LMICs, particularly older men, underscoring the importance of targeted policies and programmes addressing the preventable causes of vision impairment and blindness.

Advancing the Sustainable Development Goals through improving eye health: a scoping review

UN member states have committed to achieving the Sustainable Development Goals (SDGs) by 2030. This Review examines the published evidence on how improving eye health can contribute to advancing the SDGs (beyond SDG 3). We identified 29 studies that showed direct benefits from providing eye health services on SDGs related to one or more of poverty (SDGs 1, 2, and 8), education (SDG 4), equality (SDGs 5 and 10), and sustainable cities (SDG 11). The eye health services included cataract surgery, free cataract screening, provision of spectacles, trichiasis surgery, rehabilitation services, and rural community eye health volunteers. These findings provide a comprehensive perspective on the direct links between eye health services and advancing the SDGs. In addition, eye health services likely have indirect effects on multiple SDGs, mediated through one of the direct effects. Finally, there are additional plausible links to other SDGs, for which evidence has not yet been established.

Andersen's utilization model for cataract surgical rate and empirical evidence from economically-developing areas

Background

Un-operated cataract is the leading cause of vision loss worldwide, responsible for 33% of visual impairment, and half of global blindness. The study aimed to build a fast evaluation method utilizing Andersen’s utilization framework and identify predictors of cataract surgical rate in sub-Saharan Africa and China.

Methods

The study was a cross-over ecological epidemiology study with a total of 19 countries in sub-Saharan Africa, and 31 provinces in China. Information was extracted from public data and published studies. Linear regression and structural equation modeling with Bootstrap were used to analyze predictors of CSR and their pathways to impact in sub-Saharan Africa and China separately.

Results

Cataract surgical resources in sub-Saharan Africa were linearly correlated with CSR (β = 0.74, 95% CI: 0.09, 0.91), while GDP/P didn’t impact cataract surgical resources (β = 0.29, 95% CI: − 0.12, 0.75). In China, residents’ average ability to pay was confirmed as the mediator between GDP/P and CSR (p = 0.32, RMSEA = 0.07; β_CSR-paying = 0.77, 95% CI: 0.25, 0.90; β_paying-GDP/P = 0.89, 95% CI: 0.82, 0.93).

Conclusions

In sub-Saharan Africa, CSR is determined by health care provision. Local economic development may not directly influence CSR. Therefore, international assistance aimed to providing free cataract surgery directly is crucial. In China, CSR is determined principally by health care demand (ability to pay). To increase CSR in underserved areas of China, ability to pay must be enhanced through social insurance, and reduced surgical fees.

Impact of Hearing Aids on Poverty, Quality of Life and Mental Health in Guatemala: Results of a before and after Study

There are 466 million people globally with disabling hearing loss, many of whom can benefit from hearing aids. The aim of the study was to assess the impact of providing hearing aids on poverty, mental health, quality of life, and activities, among adults in Guatemala. A nonrandomised before and after study was conducted, with a comparison group to assess for secular trends. Adult cases with bilateral hearing impairment were identified within 150 km of Guatemala City, as well as age- and sex-matched comparison subjects without disabling hearing loss. All participants were interviewed with a semistructured questionnaire, and cases were offered hearing aids. Participants were reinterviewed 6–9 months later. We interviewed 135 cases and 89 comparison subjects at baseline and follow-up. At baseline, cases were poorer than comparison subjects with respect to individual income (p = 0.01), household income (p = 0.02), and per capita expenditure (PCE) (p = 0.003). After provision of hearing aids, median household income improved among cases (p = 0.03). In the comparison group, median individual income (p = 0.01) and PCE (p = 0.03) fell between baseline at follow-up. At follow-up, there were also improvements in productive time use, quality of life, and depressive symptoms among cases, but these were less apparent in the comparison group. In conclusion, this study has demonstrated a positive effect of hearing aids in improving quality of life, economic circumstances and mental health among Guatemalan adults.

Blindness above and below the Poverty Line: Reflections form Sofala, Mozambique

Although the correlation between visual impairment and poverty has been established, economic assessment is not a standard component of blindness surveys. The purpose of this study was to determine the prevalence of avoidable blindness and its association with poverty in Sofala province of Mozambique. As part of a Rapid Assessment of Avoidable Blindness, 94% of a random sample of 3600 people >50 years responded to questions regarding daily per capita expenditure. The WHO definition of blindness (presenting visual acuity <3/60) was used to determine the visual status of participants, and the World Bank's threshold of living on <$1.25 International Dollar a day demarcated the poverty line. The prevalence of blindness was 3.2% [95% Confidence Interval (CI): 2.6, 3.8]. People living below the poverty line had significantly greater odds of being blind [Odds Ratio (OR): 2.6 (CI: 1.6 to 4.5)]. Age above 60 [OR: 7.0 [CI: 4.6 to 10.80] predicted blindness but the association with illiteracy, gender or rural residence was not significant. Blindness disproportionately affects people living below the poverty line. Development initiatives could augment the impact of blindness prevention programs. Measuring poverty should become a standard component of visual impairment surveys.

Audomni: Super-Scale Sensory Supplementation to Increase the Mobility of Blind and Low-Vision Individuals-A Pilot Study

OBJECTIVE

Blindness and low vision have severe effects on individuals' quality of life and socioeconomic cost; a main contributor of which is a prevalent and acutely decreased mobility level. To alleviate this, numerous technological solutions have been proposed in the last 70 years; however, none has become widespread.

METHOD

In this paper, we introduce the vision-to-audio, super-scale sensory substitution/supplementation device Audomni; we address the field-encompassing issues of ill-motivated and overabundant test methodologies and metrics; and we utilize our proposed Desire of Use model to evaluate proposed pilot user tests, their results, and Audomni itself.

RESULTS

Audomni holds a spatial resolution of 80 x 60 pixels at ~1.2° angular resolution and close to real-time temporal resolution, outdoor-viable technology, and several novel differentiation methods. The tests indicated that Audomni has a low learning curve, and several key mobility subtasks were accomplished; however, the tests would benefit from higher real-life motivation and data collection affordability.

CONCLUSION

Audomni shows promise to be a viable mobility device - with some addressable issues. Employing Desire of Use to design future tests should provide both high real-life motivation and relevance to them.

SIGNIFICANCE

As far as we know, Audomni features the greatest information conveyance rate in the field, yet seems to offer comprehensible and fairly intuitive sonification; this work is also the first to utilize Desire of Use as a tool to evaluate user tests, a device, and to lay out an overarching project aim.

Desire of Use: A Hierarchical Decomposition of Activities and its Application on Mobility of Blind and Low-Vision Individuals

OBJECTIVE

Blind and low-vision individuals often have severely reduced mobility, affecting their quality of life and associated socioeconomic cost. Despite numerous efforts and great technological progress, the only used primary mobility aids are still white canes and seeing-eye dogs. Furthermore, there is a permeating tendency in the field to ignore knowledge of both mobility and the target group, as well as constantly design new metrics and tests that makes comparisons between solutions markedly more difficult.

METHOD

The Desire of Use model is introduced in an effort to promote a more holistic approach; it should be generalizable for any activity by any user, but is here applied on mobility of blind and low-vision individuals by a proposal and integration of parameters.

RESULTS

An embodiment of the model is presented and with it we show why popular mobility metrics of today are insufficient to guide design; what tasks and metrics that should provide better understanding; as well as which fundamental properties determine them and are critical to discuss.

CONCLUSION

Desire of Use has been introduced as a tool and a theoretical framework, and a realization has been proposed.

SIGNIFICANCE

Desire of Use offers both a structured perspective of pertinent design challenges facing a given solution, as well as a platform from which to compare test results and properties of existing solutions; in for example the field of electronic travel aids it should prove valuable for designing and evaluating new tests and devices.

Burden of eye disease and demand for care in the Bangladesh Rohingya displaced population and host community: A cohort study

BACKGROUND

There is a growing awareness that addressing chronic as well as acute health conditions may contribute importantly to the well-being of displaced populations, but eye care service has generally not been prioritized in crisis situations. We describe a replicable model of eye care provision as delivered by Orbis International and local partners to the Rohingya and host population in Cox's Bazar, Bangladesh, and characterize the burden of vision impairment and demand for sight-restoring services in this setting.

METHODS AND FINDINGS

Orbis International and local secondary facility Cox's Bazar Baitush Sharaf Hospital (CBBSH) provide eye care support to the Rohingya population and the host community of all ages in Cox's Bazar, Bangladesh, with fixed vision screening locations established in Camps 4 and 11 of the Kutupalong refugee settlement. Structured outreach targets these camps and four surrounding local subdistricts, with referrals made as needed for refraction (glasses measurement) and cataract surgery to CBBSH. Between February 2018 and March 2019, 48,105 displaced Rohingya (70.3%, among whom 71.6% were children and 46.5% women) and 20,357 local residents (29.7%, 88.5% children, 54.4% women) underwent vision screening. Displaced Rohingya sought services from a total of 12 surrounding camps, within which coverage was 17.3%, including 43.3% (27,027/62,424) of children aged 5-11 years and 60.0% (5,315/8,857) of adults ≥ 60 years old. The prevalence of blindness (presenting acuity < 3/60) among Rohingya patients exceeded that among local residents by 3- to 6-fold in each 10-year age group between 18 and 59 years (P < 0.001 comparing vision between the two groups in this age range), and the prevalence of cataract requiring surgery was also higher in Rohingya patients (18-29 years: 4.67% versus 1.80%, P = 0.0019; 30-39: 7.61% versus 2.39%, P < 0.001; and 40-49 years: 7.91% versus 3.77%, P = 0.0014). A limitation of the study is lack of data on population prevalence of eye disease.

CONCLUSIONS

The burden of untreated eye disease is very high among the Rohingya, particularly those in their peak working years who could contribute most to the resiliency of their community. Demand for eye care service is also great among children and adults in this population with many competing healthcare priorities. Research is needed, building on strong evidence of benefit in settled populations, to explore the specific impact of vision care on the well-being of displaced populations.

Barbosa RT, Valenti VE, Oliveira FR, Roque AL, Júnior HMFES, Garner DM, Raimundo RD, de Abreu LC. The effects of cataract surgery on autonomic heart rate control: a prospective cross-sectional and analytical study

OBJECTIVES

We aimed to evaluate the effects of cataract surgery on cardiac autonomic modulation.

METHODS

A cross-sectional and analytical study was conducted at the Hospital Maria Braido in the city of São Caetano do Sul, São Paulo, between 2015 and 2016. We investigated 19 patients of both sexes who were all over 50 years old; all patients had a diagnosis of senile or bilateral cataracts and were recommended to undergo implantation of the intraocular lens. Heart rate variability (HRV) was evaluated before, during and after cataract surgery.

RESULTS

There were no significant changes in the time and geometric domains of HRV before, during or after surgery. The high-frequency (HF) band in normalized units (nu) on the spectral analysis significantly increased (p=0.02, Cohen's d=0.9, large effect size). However, the low-frequency (LF) band in nu significantly decreased during surgery (p=0.02, Cohen's d=0.9, large effect size).

CONCLUSION

Throughout the intraocular lens implantation cataract surgery, there was an increase in parasympathetic modulation and a decrease in the sympathetic component of the heart rate (HR). We propose that this result is attributable to the supine position of the patients during surgery and the trigeminal reflex.

Estimates of visual impairment and its causes from the National Eye Survey in Malaysia (NESII)

BACKGROUND

Population-based data on prevalence, causes of blindness and extent of ophthalmological coverage is required for efficient implementation and evaluation of ocular health programs. In view of the scarcity of prevalence data for visual impairment and blindness in Malaysia, this study aims to estimate the prevalence and causes of visual impairment (VI) in the elderly, using Rapid Assessment of Avoidable Blindness (RAAB) survey technique.

METHODS

Malaysia was divided into six regions, with each region consisting of 50 clusters. Multistage cluster sampling method was used and each cluster contained 50 residents aged 50 years and above. Eligible subjects were interviewed and pertinent demographic details, barriers to cataract surgery, medical and ocular history was noted. Subjects had visual acuity assessment with tumbling 'E' Snellen optotypes and ocular examination with direct ophthalmoscope. The primary cause of VI was documented. Results were calculated for individual zones and weighted average was used to obtain overall prevalence for the country. Inter-regional and overall prevalence for blindness, severe VI and moderate VI were determined. Causes of VI, cataract surgical coverage and barriers to cataract surgery were assessed.

RESULTS

A total of 15,000 subjects were examined with a response rate of 95.3%. The age and gender-adjusted prevalence of blindness, severe visual impairment and moderate visual impairment were 1.2% (95% Confidence Interval: 1.0-1.4%), 1.0% (95%CI: 0.8-1.2%) and 5.9% (5.3-6.5%) respectively. Untreated cataract (58.6%), diabetic retinopathy (10.4%) and glaucoma (6.6%) were the commonest causes of blindness. Overall, 86.3% of the causes of blindness were avoidable. Cataract surgical coverage (CSC) in persons for blindness, severe visual impairment and moderate visual impairment was 90%, 86% and 66% respectively.

CONCLUSION

Increased patient education and further expansion of ophthalmological services are required to reduce avoidable blindness even further in Malaysia.

The effect of cataract surgery on sleep quality: a systematic review and Meta-analysis

AIM

To evaluate the effect of cataract surgery on sleep quality and to compare the difference between ultraviolet-blocking clear intraocular lens (UVB-IOL) and blue-filtering intraocular lens (BF-IOL) implantation.

METHODS

Electronic search was performed of PubMed, MEDLINE, Embase and the Cochrane Library up to January 2016. Studies were eligible when they evaluated the sleep quality before and after cataract surgery by Pittsburgh sleep quality index (PSQI). A random/fixed-effects Meta-analysis was used for the pooled estimate. Heterogeneity was assessed with the I² test.

RESULTS

Six studies were selected from 5623 references. Cataract surgery significantly reduced the PSQI scores at postoperative 0-3mo [mean difference (MD) =-0.62, 95%CI: -1.14 to -0.11, P=0.02, I²=66%] and 3-12mo (MD=-0.32, 95%CI: -0.62 to -0.02, P=0.04, I²=0), respectively. Considering different intraocular lens (IOL) implantations, relative post-operative PSQI reduction was found for both UVB-IOL and BF-IOL, but a significant reduction was detected only for UVB-IOL. No significant difference was found with the effect of BF-IOL vs UVB-IOL on sleep quality.

CONCLUSION

This study found that cataract surgery significantly improved the PSQI score-derived subjective sleep quality irrespective of the IOL type implanted. These findings highlight a substantial benefit of cataract surgery on systemic health with photoreceptive restoration in addition to visual acuity improvements.

Multiple deprivation, vision loss, and ophthalmic disease in adults: global perspectives

The association between socioeconomic position and morbidity and mortality has long been recognized. We evaluate the evidence for an association between multiple aspects of deprivation and ocular health in a global context. This is a systematic review of studies that evaluated deprivation in the adult population in the context of the major acquired causes of visual loss such as cataract, diabetic eye disease, glaucoma, age-related macular degeneration, and ocular trauma. The search strategy identified relevant studies reported between 1946 and August 2016, with randomized control trials, case-control, cohort, and cross-sectional study designs being selected for inclusion. The studies identified in this review from across the world demonstrate the extent to which the common themes such as low educational attainment and low income may be associated with increased incidence of various sight-threatening conditions and may adversely affect access to specialist assessment and delivery of treatment. Health inequality may always persist, but an increased recognition of the importance of the various impacts of deprivation may empower policy makers to target limited resources to the most vulnerable groups in order to deliver the greatest benefit.

Effective cataract surgical coverage: An indicator for measuring quality-of-care in the context of Universal Health Coverage

OBJECTIVE

To define and demonstrate effective cataract surgical coverage (eCSC), a candidate UHC indicator that combines a coverage measure (cataract surgical coverage, CSC) with quality (post-operative visual outcome).

METHODS

All Rapid Assessment of Avoidable Blindness (RAAB) surveys with datasets on the online RAAB Repository on April 1 2016 were downloaded. The most recent study from each country was included. By country, cataract surgical outcome (CSOGood, 6/18 or better; CSOPoor, worse than 6/60), CSC (operated cataract as a proportion of operable plus operated cataract) and eCSC (operated cataract and a good outcome as a proportion of operable plus operated cataract) were calculated. The association between CSC and CSO was assessed by linear regression. Gender inequality in CSC and eCSC was calculated.

FINDINGS

Datasets from 20 countries were included (2005-2013; 67,337 participants; 5,474 cataract surgeries). Median CSC was 53.7% (inter-quartile range[IQR] 46.1-66.6%), CSOGood was 58.9% (IQR 53.7-67.6%) and CSOPoor was 17.7% (IQR 11.3-21.1%). Coverage and quality of cataract surgery were moderately associated-every 1% CSC increase was associated with a 0.46% CSOGood increase and 0.28% CSOPoor decrease. Median eCSC was 36.7% (IQR 30.2-50.6%), approximately one-third lower than the median CSC. Women tended to fare worse than men, and gender inequality was slightly higher for eCSC (4.6% IQR 0.5-7.1%) than for CSC (median 2.3% IQR -1.5-11.6%).

CONCLUSION

eCSC allows monitoring of quality in conjunction with coverage of cataract surgery. In the surveys analysed, on average 36.7% of people who could benefit from cataract surgery had undergone surgery and obtained a good visual outcome.

Poverty and Blindness in Nigeria: Results from the National Survey of Blindness and Visual Impairment

PURPOSE

Poverty can be a cause and consequence of blindness. Some causes only affect the poorest communities (e.g. trachoma), and poor individuals are less likely to access services. In low income countries, cataract blind adults have been shown to be less economically active, indicating that blindness can exacerbate poverty. This study aims to explore associations between poverty and blindness using national survey data from Nigeria.

METHODS

Participants ≥40 years were examined in 305 clusters (2005-2007). Sociodemographic information, including literacy and occupation, was obtained by interview. Presenting visual acuity (PVA) was assessed using a reduced tumbling E LogMAR chart. Full ocular examination was undertaken by experienced ophthalmologists on all with PVA <6/12 in either eye. Causes of vision loss were determined using World Health Organization guidelines. Households were categorized into three levels of poverty based on literacy and occupation at household level.

RESULTS

A total of 569/13,591 participants were blind (PVA <3/60, better eye; prevalence 4.2%, 95% confidence interval [CI] 3.8-4.6%). Prevalences of blindness were 8.5% (95% CI 7.7-9.5%), 2.5% (95% CI 2.0-3.1%), and 1.5% (95% CI 1.2-2.0%) in poorest, medium and affluent households, respectively (p = 0.001). Cause-specific prevalences of blindness from cataract, glaucoma, uncorrected aphakia and corneal opacities were significantly higher in poorer households. Cataract surgical coverage was low (37.2%), being lowest in females in poor households (25.3%). Spectacle coverage was 3 times lower in poor than affluent households (2.4% vs. 7.5%).

CONCLUSION

In Nigeria, blindness is associated with poverty, in part reflecting lower access to services. Reducing avoidable causes will not be achieved unless access to services improves, particularly for the poor and women.

Recovery after cataract surgery

Cataract surgery is the most common ophthalmological surgical procedure, and it is predicted that the number of surgeries will increase significantly in the future. However, little is known about the recovery after surgery. The first aim of this study was to evaluate the prevalence, severity and duration of pain and other ocular discomfort symptoms experienced after cataract surgery. The other objectives were to identify the factors associated with lower postoperative patient satisfaction and to measure the effect of cataract surgery on patients' health-related quality of life (HRQoL) and visual function in everyday life. The study design was a prospective follow-up study. The course of the recovery and the presence of ocular symptoms were evaluated by interviewing the patients via a questionnaire at 1 day, 1 week, 6 weeks and one year after surgery The visual functioning in everyday life was measured with Visual Functioning Index VF-7 and Catquest-9SF-questionnaires and furthermore the HRQoL was measured with the 15D-instrument before surgery and at 12 months after surgery. The patients returned the questionnaires by mail and were interviewed in the hospital on the day of the surgery. The same patients filled-in all the questionnaires. The patient reports were used to collect the data on medical history. A total of 303 patients were approached at Kuopio University Hospital in 2010-2011 and of these 196 patients were eligible and willing to participate, with postoperative data being available from 186 (95%) patients. A systematic review article was included in the study procedure and it revealed the wide range in the reported incidence of postoperative ocular pain. Some of the identified randomized controlled studies reported no or only minor pain whereas in some studies significant pain or pain lasting for several weeks has been described in more than 50% of the study patients. In the present study setting, pain was reported by 34% during the first postoperative hours and by approximately 10% of patients during the first six weeks after surgery. During the early recovery in the hospital, only a minority of the patients reporting pain were provided with pain medication. The ocular discomfort symptoms such as itchiness, burning, foreign-body sensation and tearing were common both before (54%) and after surgery (38-52%). These symptoms can also be described as painful symptoms and are often difficult to distinguish from ocular pain. The symptoms are also typical of ocular surface disease, and some patients may benefit from the postoperative administration of tear substitutes. The patients reporting postoperative ocular symptoms were less satisfied with the treatment outcome at 12 months after surgery (p = 0.001) compared to the patients who experienced no symptoms. Those patients reporting less disability in visual functioning before surgery were more satisfied than patients with more reported disability. The HRQoL improved significantly after cataract surgery (p = 0.002). However, when compared to an age-and gender-standardized control population, in cataract subjects the HRQoL remained slightly worse both before and at 12 months after surgery.

Health-related quality of life after cataract surgery with the phacoemulsification technique and intraocular lens implantation

PURPOSE

Disease-specific instruments have shown significant gains in measuring health-related quality of life (HRQoL) in subjects having cataract surgery. However, the usage of generic instruments has resulted in conflicting evidence.

METHODS

In this prospective study, we have evaluated the impact of cataract surgery on subjects' HRQoL measured with a 15-dimension generic instrument, the 15D. The HRQoL of cataract subjects was compared with that of an age- and gender-standardized sample of the general population in Finland. A total of 152 subjects (mean age 74 years, 66% females) with a first-eye cataract surgery completed the 15D questionnaire both before and 12 months after cataract surgery.

RESULTS

When compared with the general population, cataract subjects had much lower HRQoL at baseline (mean difference 0.037 (95% CI: 0.020, 0.054), p < 0.001). At 12 months after cataract surgery, the overall utility index improved from the mean of 0.837 to 0.855 (mean difference 0.018 (95% CI: 0.007, 0.029), p = 0.002). Significant improvement was observed on the following five dimensions: seeing, moving, hearing, usual activities and discomfort/symptoms in the 15D questionnaire.

CONCLUSION

Our data indicate that at 12 months after first-eye cataract surgery, patients' HRQoL is slightly better than that before surgery. However, patients' postoperative HRQoL may remain lower than that of an age-and gender-standardized control population.

Patient considerations in cataract surgery - the role of combined therapy using phenylephrine and ketorolac

Cataract, a degradation of the optical quality of the crystalline lens, progressive and age-related, is the leading cause of treatable blindness worldwide. Cataract surgery is the most common surgical procedure performed by ophthalmologists and is the only effective treatment for cataracts. Advances in the surgical techniques and better postoperative visual outcomes have progressively changed the primary concern of cataract surgery to become a procedure refined to yield the best possible refractive results. Sufficient mydriasis during cataract removal is critical to a successful surgical outcome. Poor pupil dilation can lead to serious sight-threatening complications that significantly increase the cost of surgery and decrease patients comfort. Mydriasis is obtained using anticholinergic and sympathomimetic drugs. Phenylephrine, an α1-adrenergic receptor agonist, can efficiently dilate the pupil when administered by intracameral injection. Additionally, nonsteroidal anti-inflammatory drugs (NSAIDs) like ketorolac, which inhibit the synthesis of prostaglandins, are used to decrease intraoperative miosis, control pain and inflammation associated with cataract surgery, and to prevent the development of cystoid macular edema following surgery. Recently, a new combination of phenylephrine and ketorolac (Omidria^®) has been approved by United States Food and Drug Administration for use during cataract surgery to maintain intraoperative mydriasis, prevent miosis, and reduce postoperative pain and inflammation. Clinical trials have shown that this new combination is effective, combining the positive effects of both drugs with a good safety profile and patient tolerability. Moreover, recent reports suggest that this combination is also effective in patients with high risk of poor pupil dilation. In conclusion, cataract is a global problem that significantly affects patients' quality of life. However, they can be managed with a safe and minimally invasive surgery. Advances in surgical techniques and newer pharmacological agents such as the combination of phenylephrine and ketorolac, together with better intraocular lenses, have greatly improved visual outcomes and thus patients' expectations regarding visual recovery are also increasing.

The demographics of patients affected by surgical disease in district hospitals in two sub-Saharan African countries: a retrospective descriptive analysis

BACKGROUND

There is a growing awareness of the importance of surgical disease within global health. We hypothesised that surgical disease in low income countries predominantly affects young adults and may therefore have a significant economic impact.

METHODS

We retrospectively reviewed all surgical admission data from two rural government district hospitals in two different sub-Saharan African countries over a 6-month period. We analysed all surgical admissions with respect to patient demographics (age and gender), diagnosis, and procedure performed.

RESULTS

Surgical admissions accounted for 12.9 and 19.8 % of all hospital admissions in Malawi and Sierra Leone respectively. 18.5 and 6.2 % of all hospital patients required a surgical procedure in Malawi and Sierra Leone respectively, with the low number in Sierra Leone accounted for in that many of the obstetric admissions were referred to a nearby Medicins Sans Frontiers (MSF) hospital for treatment. 17.9 and 10.5 % of surgical admissions were under the age of 16 in Malawi and Sierra Leone respectively, with 16-35 year olds accounting for 57.3 % of surgical admissions in Sierra Leone and 53.5 % in Malawi. Men accounted for 53.7 and 46.0 % of surgical admissions in Sierra Leone and Malawi respectively. An unexpected finding was the high level of patients who absconded from hospital in Sierra Leone after diagnosis but before treatment. This involved 11.8 % of all surgical patients, including 38 % with a bowel obstruction, 39 % with peritonitis and 20 % with ectopic pregnancy.

CONCLUSIONS

Most people affected by disease requiring surgery are young adults and this may have significant economic implications.

Cataract

Cataract is the leading cause of reversible blindness and visual impairment globally. Blindness from cataract is more common in populations with low socioeconomic status and in developing countries than in developed countries. The only treatment for cataract is surgery. Phacoemulsification is the gold standard for cataract surgery in the developed world, whereas manual small incision cataract surgery is used frequently in developing countries. In general, the outcomes of surgery are good and complications, such as endophthalmitis, often can be prevented or have good ouctomes if properly managed. Femtosecond laser-assisted cataract surgery, an advanced technology, can automate several steps; initial data show no superiority of this approach over current techniques, but the results of many large clinical trials are pending. The greatest challenge remains the growing 'backlog' of patients with cataract blindness in the developing world because of lack of access to affordable surgery. Efforts aimed at training additional cataract surgeons in these countries do not keep pace with the increasing demand associated with ageing population demographics. In the absence of strategie that can prevent or delay cataract formation, it is important to focus efforts and resources on developing models for efficient delivery of cataract surgical services in underserved regions. For an illustrated summary of this Primer, visit: http://go.nature.com/eQkKll.

The effect of blue-blocking intraocular lenses on circadian biological rhythm: protocol for a randomised controlled trial (CLOCK-IOL colour study)

INTRODUCTION

Blue light information plays an important role in synchronising internal biological rhythm within the external environment. Circadian misalignment is associated with the increased risk of sleep disturbance, obesity, diabetes mellitus, depression, ischaemic heart disease, stroke and cancer. Meanwhile, blue light causes photochemical damage to the retina, and may be associated with age-related macular degeneration (AMD). At present, clear intraocular lenses (IOLs) and blue-blocking IOLs are both widely used for cataract surgery; there is currently a lack of randomised controlled trials to determine whether clear or blue-blocking IOLs should be used.

METHODS AND ANALYSIS

This randomised controlled trial will recruit 1000 cataract patients and randomly allocate them to receive clear IOLs or blue-blocking IOLs in a ratio of 1:1. The primary outcomes are mortality and the incidence of cardiovascular disease, cancer and AMD. Secondary outcomes are fasting plasma glucose, triglycerides, cholesterol, glycated haemoglobin, sleep quality, daytime sleepiness depressive symptoms, light sensitivity, the circadian rhythm of physical activity, wrist skin temperature and urinary melatonin metabolite. Primary outcomes will be followed until 20 years after surgery, and secondary outcomes will be assessed at baseline and 1 year after surgery.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Institutional Review Board of Nara Medical University (No. 13-032). The findings of this study will be communicated to healthcare professionals, participants and the public through peer-reviewed publications, scientific conferences and the University Hospital Medical Information Network Clinical Trials Registry (UMIN-CTR) home page.

TRIAL REGISTRATION NUMBER

UMIN000014680.