Access to eye care during the COVID-19 pandemic, India

Diagnostic Performance of the Offline Medios Artificial Intelligence for Glaucoma Detection in a Rural Tele-Ophthalmology Setting

PURPOSE

This study assesses the diagnostic efficacy of offline Medios Artificial Intelligence (AI) glaucoma software in a primary eye care setting, using nonmydriatic fundus images from Remidio's Fundus-on-Phone (FOP NM-10). Artificial intelligence results were compared with tele-ophthalmologists' diagnoses and with a glaucoma specialist's assessment for those participants referred to a tertiary eye care hospital.

DESIGN

Prospective cross-sectional study PARTICIPANTS: Three hundred three participants from 6 satellite vision centers of a tertiary eye hospital.

METHODS

At the vision center, participants underwent comprehensive eye evaluations, including clinical history, visual acuity measurement, slit lamp examination, intraocular pressure measurement, and fundus photography using the FOP NM-10 camera. Medios AI-Glaucoma software analyzed 42-degree disc-centric fundus images, categorizing them as normal, glaucoma, or suspect. Tele-ophthalmologists who were glaucoma fellows with a minimum of 3 years of ophthalmology and 1 year of glaucoma fellowship training, masked to artificial intelligence (AI) results, remotely diagnosed subjects based on the history and disc appearance. All participants labeled as disc suspects or glaucoma by AI or tele-ophthalmologists underwent further comprehensive glaucoma evaluation at the base hospital, including clinical examination, Humphrey visual field analysis, and OCT. Artificial intelligence and tele-ophthalmologist diagnoses were then compared with a glaucoma specialist's diagnosis.

MAIN OUTCOME MEASURES

Sensitivity and specificity of Medios AI.

RESULTS

Out of 303 participants, 299 with at least one eye of sufficient image quality were included in the study. The remaining 4 participants did not have sufficient image quality in both eyes. Medios AI identified 39 participants (13%) with referable glaucoma. The AI exhibited a sensitivity of 0.91 (95% confidence interval [CI]: 0.71-0.99) and specificity of 0.93 (95% CI: 0.89-0.96) in detecting referable glaucoma (definite perimetric glaucoma) when compared to tele-ophthalmologist. The agreement between AI and the glaucoma specialist was 80.3%, surpassing the 55.3% agreement between the tele-ophthalmologist and the glaucoma specialist amongst those participants who were referred to the base hospital. Both AI and the tele-ophthalmologist relied on fundus photos for diagnoses, whereas the glaucoma specialist's assessments at the base hospital were aided by additional tools such as Humphrey visual field analysis and OCT. Furthermore, AI had fewer false positive referrals (2 out of 10) compared to the tele-ophthalmologist (9 out of 10).

CONCLUSIONS

Medios offline AI exhibited promising sensitivity and specificity in detecting referable glaucoma from remote vision centers in southern India when compared with teleophthalmologists. It also demonstrated better agreement with glaucoma specialist's diagnosis for referable glaucoma participants.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Utilisation of eye health services and compliance with spectacles wear among community school adolescents: a mixed-methods study from Bagmati province of Nepal

OBJECTIVES

This study aims to determine the factors influencing eye care service utilisation and compliance with spectacles wear among school students.

DESIGN

Mixed-methods study.

SETTING

27 community schools from 6 districts of Bagmati province of Nepal.

PARTICIPANTS

Adolescents with mild vision impairment who were screened at schools by their trained peers for visual acuity measurement and subsequently received subsidised spectacles for refractive error correction. For the quantitative study, 317 students from 21 schools completed the survey. For qualitative study, 62 students from 6 schools participated in 6 focus group discussions.

PRIMARY OUTCOME MEASURES

Utilisation of eye care services and compliance with spectacles wear.

RESULTS

Among 317 students, 53.31% were aged 15-19, and 35.96% were male. More than half (52.68%, n=167) did not use eye health services. Among students who did not go, 51.50% reported eye health facilities being far away. Thematic analysis showed that distance, COVID-19 and awareness were influential in the utilisation of eye care. The multivariate analysis showed urban residents were likelier (adjusted OR (AOR) 4.347, 95% CI 2.399 to 7.877, p<0.001) to use eye care services. During an unannounced visit to schools after 3-4 months of spectacles distribution, 188 (59.31%) students were wearing spectacles. 20.16% of students not wearing spectacles reported they did not feel the need. Thematic analysis showed the influence of family and peers, affordability, aesthetic appearance, comfortability and symptomatic relief in spectacles compliance. The multivariate analysis showed that urban residents (AOR 2.552, 95% CI 1.469 to 4.433, p<0.001), older adolescents (AOR 1.758, 95% CI 1.086 to 2.848, p=0.022), mothers with paid jobs (AOR 2.440, 95% CI 1.162 to 5.125, p=0.018) and students visiting eye care centres (AOR 1.662, 95% CI 1.006 to 2.746, p=0.047) were more likely to be compliant with spectacles wear.

CONCLUSIONS

There are multiple barriers for students to use eye care services and stay compliant with spectacles wear. Eye health programmes should include eye health promotion and be accessible, affordable and equitable.

Global estimates on the number of people blind or visually impaired by age-related macular degeneration: a meta-analysis from 2000 to 2020

BACKGROUND

We aimed to update estimates of global vision loss due to age-related macular degeneration (AMD).

METHODS

We did a systematic review and meta-analysis of population-based surveys of eye diseases from January, 1980, to October, 2018. We fitted hierarchical models to estimate the prevalence of moderate and severe vision impairment (MSVI; presenting visual acuity from <6/18 to 3/60) and blindness ( < 3/60) caused by AMD, stratified by age, region, and year.

RESULTS

In 2020, 1.85 million (95%UI: 1.35 to 2.43 million) people were estimated to be blind due to AMD, and another 6.23 million (95%UI: 5.04 to 7.58) with MSVI globally. High-income countries had the highest number of individuals with AMD-related blindness (0.60 million people; 0.46 to 0.77). The crude prevalence of AMD-related blindness in 2020 (among those aged ≥ 50 years) was 0.10% (0.07 to 0.12) globally, and the region with the highest prevalence of AMD-related blindness was North Africa/Middle East (0.22%; 0.16 to 0.30). Age-standardized prevalence (using the GBD 2019 data) of AMD-related MSVI in people aged ≥ 50 years in 2020 was 0.34% (0.27 to 0.41) globally, and the region with the highest prevalence of AMD-related MSVI was also North Africa/Middle East (0.55%; 0.44 to 0.68). From 2000 to 2020, the estimated crude prevalence of AMD-related blindness decreased globally by 19.29%, while the prevalence of MSVI increased by 10.08%.

CONCLUSIONS

The estimated increase in the number of individuals with AMD-related blindness and MSVI globally urges the creation of novel treatment modalities and the expansion of rehabilitation services.

Approaches for delivery of refractive and optical care services in community and primary care settings

BACKGROUND

Uncorrected refractive error is a leading cause of vision impairment which, in most cases, can be managed with the appropriate spectacle correction. In 2021, the World Health Assembly endorsed a global target of a 40-percentage-point increase in effective coverage of refractive error by 2030. To achieve this global target, equitable access to refractive and optical services within community and primary care settings needs to be strengthened. This review will inform the development of technical guidance to support improvements in the testing and correction of refractive error among World Health Organization (WHO) member states.

OBJECTIVES

To determine the range of approaches for delivery of refractive and optical care services in community and primary care settings, and the methods employed for their evaluation.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and Global Health databases, grey literature, and annual reports and websites of relevant organizations involved in eye-care delivery from January 2002 to November 2022 to identify approaches for refractive and optical service delivery.

SELECTION CRITERIA

We included observational and interventional studies, reviews, and reports from relevant organizations related to delivering refractive services and optical services for preschool and school-aged children and adults in community and primary care settings published between January 2002 and November 2022. We searched for studies and reports published within the last 20 years because vision impairment due to uncorrected refractive error has only recently become a public health and eye health priority, therefore we did not expect to find much relevant literature until after 2002.

DATA COLLECTION AND ANALYSIS

Two review authors screened titles, abstracts and full texts, and extracted data. We resolved any discrepancies through discussion. We synthesized data, and presented results as tables, figures, and case studies. This project was led by the World Health Organization (WHO) Vision and Eye Care Programme.

MAIN RESULTS

We identified 175 studies from searches of databases and grey literature, 146 records from company reports, and 81 records from website searches of relevant organizations that matched our inclusion criteria. Delivery approaches for refractive and optical services in community care included school-based, pharmacy, and outreach models, whereas primary care approaches comprised vision centre, health centre, and a combination of vision or health centre and door-to-door delivery. In community care, school-based and outreach approaches were predominant, while in primary care, a vision-centre approach was mainly used. In the WHO African region, the school-based and outreach approaches were mainly reported while, in the Americas, the outreach approach was mostly used. Very few approaches for service delivery were reported in the WHO Eastern Mediterranean region. Prominent gaps exist in the evaluation of the approaches, and few studies attempted to evaluate the approaches for delivery of refractive and optical care services.

AUTHORS' CONCLUSIONS

We comprehensively describe a range of approaches for delivery of refractive and optical services in community and primary care. Further evaluation of their effectiveness will better inform the application of these service-delivery approaches. The study outcomes will help guide WHO member states in strengthening refractive and optical services at community and primary care levels.

FUNDING

This scoping review was supported by the Vision and Eye care Programme, World Health Organization and ATscale Global Partnership.

REGISTRATION

The protocol of this scoping review was published in the Open Source Framework.

Strategies for successful management of moderate and severe Mooren's ulcer at a rural center during the COVID-19 pandemic: Lessons learnt

PURPOSE

This study aimed to report the strategies that evolved in managing Mooren's ulcer (MU) at a resource-limited center in rural India during the coronavirus disease 2019 (COVID-19) pandemic.

METHODS

This study includes a retrospective analysis of clinically diagnosed MU cases from January 2021 to August 2021 wherein strategies for management were developed. The demographic profile, ulcer clinical features, treatment algorithms (medical and surgical), complications encountered, referral to a higher center, and compliance with medication and follow-up were studied.

RESULTS

The mean age of presentation was 68.1 years (range, 62-73 years), and 90% were men. The median best-corrected visual acuity (BCVA) was 1.26 logarithm of the Minimum Angle of Resolution (LogMAR) (interquartile range (IQR), 0.00-5 logMAR) in the affected eye on presentation, which improved to 0.69 logMAR (IQR, 0.00-3 logMAR) at resolution ( P = 0.442). The first-line management was conjunctival resection and tissue adhesive application (90%). 70% of cases were unilateral, 50% of cases had less than 2 clock hours of involvement, and 50% had less than 50% stromal involvement. Confounding factors included infectious keratitis (2) and corneal perforation (3). The mean duration of follow-up was 96 (1-240) days. The average follow-up visits per patient were 8.8 (1-22). 90% of cases could be managed successfully at the secondary center level with two cases needing a tertiary care referral.

CONCLUSION

MU can be managed effectively by following a systemic strategy of early diagnosis, surgical therapy, and rapid institution of systemic immunosuppression in a remote location-based secondary center. The strategies developed can be a guide for ophthalmologists at remote centers managing patients or who are unable to travel to tertiary institutes.

Impact of Covid-19 on Pediatric Ophthalmology Care: Lessons Learned

The COVID-19 pandemic came with many new challenges that forced personal and professional lifestyle modifications. Medical facilities were in scarcity against this new unknown enemy and were challenged with the overloaded patient flow, scarcity of healthcare staff, and evolving treatment modalities with a better understanding of the virus each day. Ophthalmology as a "branch of medicine" suffered challenges initially because of a lack of guidelines for patient management, close working distance during routine examinations, and halt of major surgeries, including cataracts. Pediatric ophthalmology had major implications, as reduced outpatient visits would mean deeper amblyopia, and changed lifestyles, including online classes and home refinement, predisposing children to myopia, digital eye strain, and worsening of strabismus. COVID-19 also unveiled underlying accommodation and convergence anomalies that predisposed pediatric and adolescent patients to an increased prevalence of headache and acute onset esotropia. Teleophthalmology and other innovative solutions, including the use of prism glasses, safe slit-lamp shields, alternative ways of school screening with the use of photoscreeners, performing retinoscopy only when needed, and using autorefractors were among the few guidelines or modifications adopted which helped in the efficient and safe management of pediatric patients. Many pediatric ophthalmologists also suffered in terms of financial constraints due to loss of salary or even closure of private practices. School screening and retinopathy of prematurity screening suffered a great setback and costed a lot of vision years, data of which remains under-reported. Important implications and learnings from the pandemic to mitigate future similar situations include using teleophthalmology and virtual platforms for the triage of patients, managing non-emergency conditions without physical consultations, and utilizing home-based vision assessment techniques customized for different age groups. Though this pandemic had a lot of negative implications, the innovations, modifications, and other important learnings helped pediatric ophthalmologists in navigating safely.

Year One of COVID-19 Pandemic: Effect on Presentation of Patients With Glaucoma in a Multi-Tier Ophthalmology Network in India

Objective

To describe the demographics and clinical profile of patients with glaucoma presenting during the novel coronavirus (COVID-19) lockdown and unlock phases in India.

Methods

This retrospective hospital-based comparative study included patients presenting between March 25, 2017, and March 31, 2021. All patients who presented with glaucoma disorders were included as cases. The demographic and clinical data of these glaucoma patients were collected using an electronic medical record system.

Results

Overall, 34,419 patients (mean 47 per day) diagnosed with glaucoma diseases presented to the network and were included for analysis. The mean age of the patients was 54.16 ± 18.74 years and most were male (n=21,140; 61.42%) from the urban region (n=12,871;37.4%). On categorizing based on the timeline of the COVID-19 pandemic, most of the patients presented pre-COVID-19 (n=29,122; 84.61%), followed by a minority (n=175; 0.51%) during the lockdown and the rest (n=5,122; 14.88%) during unlock phase. An increasing number of patients with secondary glaucoma (n=82; 46.86%) and presenting from the local intra-city (n=82; 46.86%) was seen during the lockdown. There was a 6.6-fold increase in neovascular glaucoma and a 2.7-fold increase in lens induced glaucoma during the lockdown phase ((p<0.001) for both). There was a significant increase in subjects in 4th decade (p<0.03) and a decrease in subjects in 7th decade (p<0.008) during the lockdown period.

Conclusion

The presentation of patients with glaucoma disorders to the hospital is evolving due to the COVID-19 pandemic. The footfalls of patients during the unlock regained to two-thirds of the pre COVID-19 level. During the lockdown, the older patients were less, there was an increase in younger patients and those with secondary glaucoma, and the majority presenting from within the city.