Social inequalities in blindness and visual impairment: a review of social determinants

A descriptive epidemiological study of the prevalence of self-reported sensory difficulties by age group, sex, education, disability, and migration status in Sweden in 2020

BACKGROUND

The objective of this study is to estimate the prevalence of self-reported hearing difficulties, vision difficulties and combined vision and hearing difficulties in a Swedish adult population that varies according to migration status, sex, age, disability measured by ADL and IADL and educational attainment level.

METHODS

The study utilised data from the Survey of Health, Ageing and Retirement in Europe, which consisted of 2257 individuals aged 60 and above that were interviewed in Sweden in the 2019/2020, SHARE wave 8. To determine the prevalence of sensory difficulties (hearing, vision and dual-sensory difficulties) among various subgroups of the population, a multinomial logistic regression was used. The results of these analyses are presented in terms of predicted probabilities.

RESULTS

The study findings indicate that foreign-born older adults experience a lower prevalence of visual difficulties (6.2% [3.3-11.5] in comparison to their Swedish-born counterparts. Moreover, older adults with higher levels of education tend to report a lower prevalence of sensory difficulties overall. Furthermore, sex differences are apparent, with males reporting a higher prevalence of hearing difficulties (18.9% [15.5-22.8] vs. 12.8% [10.7-15.3]) and females reporting a higher prevalence of vision difficulties (12.7% [10.7-15.1] vs. 8.5%[6.8-10.5]).

CONCLUSION

The findings highlight disparities in the prevalence and type of perceived sensory difficulties experienced by older adults, by factors such as age, sex, education and migration status. It is important to consider these demographic factors in healthcare planning and interventions aimed at mitigating sensory difficulties in the older population.

Risk factors affecting the utilization of eye care services evaluated by the CDC's behavior risk factor surveillance system from 2018 to 2021

When thinking about major health concerns in the U.S. and around the world, eye care ranks lower compared to cardiovascular disease, cancer, and diabetes. However, people do not think about the direct connection between diabetes and eye health. Untreated diabetes can lead to visual impairments such as blindness or difficulty seeing. Studies have found that eye health associated with nutrition, occupational exposure, diabetes, high blood pressure, and heart disease are some of the known risk factors. This study aimed to identify the potential risk factors that are associated with visual impairment (VI). The data used for this analysis were obtained from the Centers for Disease Control and Prevention (CDC) - Behavioral Risk Factor Surveillance System (BRFSS) from 2018 to 2021. We found important characteristics, such as the U.S. region, general health perception, employment status, income status, age, and health insurance source, that are associated with VI. Our study confirmed that the common demographical factors including age, race/ethnicity, the U.S. region, and gender are associated with VI. The study also highlights associations with additional risk factors such as health insurance source, general health perceptions, employment status, and income status. Using this information, we can reach out to communities with large numbers of individuals experiencing vision challenges and help educate them on prevention and treatment protocols, thereby effectively addressing VI and blindness challenges within our communities, neighborhoods, and finally, the broader society.

Vision impairment and food insecurity in the national health and aging trends study

Introduction

Vision impairment (VI) may further exacerbate older adults' vulnerability to experiencing food insecurity and may be a unique and important target for policies addressing access to nutritional food. The purpose of this study is to determine the association of VI in older adults with food insecurity.

Methods

This is a cross-sectional analysis of round 11 (2021) of the National Health and Aging Trends Study (NHATS), a nationally representative survey of U.S. Medicare beneficiaries ages 65 and older. Participants include 2,815 older adults with complete data on at least one objective measure of vision (distance, near or contrast sensitivity) and food insecurity. Food insecurity was assessed using a previously developed indicator of food insecurity in NHATS. VI was defined as binocular visual acuity (VA) worse than 0.3 logMAR (Snellen equivalent 20/40) at distance or its near equivalent, or contrast sensitivity (CS) worse than 1.55 logUnits. Continuous VI measures included distance and near VA (per 0.1 logMAR), and CS (per 0.1 logCS).

Results

Participants were majority White (82%) and female (55%), and 3% had food insecurity. Older adults with any VI had a greater prevalence of food insecurity than adults without VI (5.0% vs. 2.0%, p < 0.05). In fully adjusted regression analyses, individuals with any VI experienced double the odds of food insecurity than individuals without VI (OR: 2.1, 95% CI: 1.2-3.6). Distance VI (measured continuously) was associated with 1.2 times the odds of food insecurity (OR = 1.2; 95% CI: 1.0-1.3, per 0.1 logMAR). All other vision measures trended towards higher odds of food insecurity, though not statistically significant.

Discussion

Older adults with VI experience higher rates of food insecurity than their peers. Interventions to improve food security should be targeted towards addressing the specific barriers faced by visually impaired older adults.

Best Practices for Treating Blind and Visually Impaired Patients in the Emergency Department: A Scoping Review

Introduction

Blind and visually impaired individuals, an under-represented population of the emergency department (ED), possess comorbidities and have a higher chance of in-hospital sequelae, including falls. This potentially vulnerable population, if not treated mindfully, can be subject to decreased quality of care, recurrent and/or longer hospitalizations, persistence of health issues, increased incidence of falls, and higher healthcare costs. For these reasons, it is crucial to implement holistic practices and train clinicians to treat blind and visually impaired patients in the ED setting.

Methods

We identified and used a comprehensive article describing best practices for the care of blind and visually impaired patients to establish the ED-specific recommendations presented in this paper. A scoping review of the literature was then performed using PubMed to identify additional articles to support each recommendation. To ensure that recommendations could be implemented in a representative, scalable, and sustainable manner, we consulted an advocate for the blind to help refine and provide additional suggestions.

Results

We identified 14 recommendations that focus on communication strategies, ED resource access, and continuity of care. The main recommendation is for the clinician to support the unique healthcare needs of the visually impaired individual and maintain the patient's autonomy. Another recommendation is the consistent use of assistive devices (eg, canes, guide dogs) to aid patients to safely ambulate in the ED. Also identified as best practices were discharge education with the use of a screen reader and timely follow-up with a primary care physician.

Conclusion

While we summarize a variety of recommendations in this article, it is important to implement only the strategies that work best for the patients, personnel, and environment specific to your ED. After implementation, it is vital to refine (as frequently as needed) the interventions to optimize the strategies. This will enable the provision of exceptional and equal care to blind and visually impaired patients in the ED.

Association Between Area Temperature and Severe Vision Impairment in a Nationally Representative Sample of Older Americans

PURPOSE

Several small studies have associated exposure to elevated average temperature with specific vision problems. However, no large-scale studies have examined the relationship between vision impairment and average area temperature in the general population. We conducted a cross-sectional analysis of a large nationally representative sample of older adults to further explore this relationship.

METHODS

Secondary analysis of the American Community Survey (ACS). The survey was conducted through mail, telephone and in-person interviews. Data from six consecutive years of the cross-sectional survey were analysed (2012-2017). The subsample analysed included community-dwelling and institutionalized older adults aged 65 and older in the coterminous US who lived in the same state in which they were born (n = 1,707,333). The question on severe vision impairment was "Is this person blind or does he/she have serious difficulty seeing even when wearing glasses?". Average annual temperature data from the National Oceanic and Atmospheric Administration was combined into a 100-year average and mapped to corresponding US Census Bureau's public use microdata areas from the ACS.

RESULTS

Higher average temperature is consistently associated with increased odds of severe vision impairment across all cohorts (i.e. age, sex, race, income, and educational attainment cohorts) with the exception of Hispanic older adults. Compared to those who lived in counties with average temperature of < 50 °F (< 10 °C) , the odds of severe vision impairment were 44% higher in counties with average temperature of 60 °F (15.5 °C) or above (OR 1.44; 95% CI 1.42-1.46).

CONCLUSION

If the association is found to be causal, the predicted rise in global temperatures could impact the number of older Americans affected by severe vision impairment and the associated health and economic burden.

The association between adverse childhood experiences and sensory impairment in middle-aged and older adults: Evidence from a nationwide cohort study in China

BACKGROUND

Sensory impairment (SI), as prevalent condition among the elderly, presents a substantial public health burden.

OBJECTIVES

To investigate the association of cumulative and individual adverse childhood experiences (ACEs) with SI.

METHODS

Chinese residents aged 45 years and above were recruited from the China Health and Retirement Longitudinal Study 2011-2018, using stratified random sampling. The number of ACEs was classified into "0 ACE", "1 to 3 ACEs", and "≥4 ACEs". SI was assessed with self-rated visual or hearing status. SI categories included single sensory impairment (SSI), which can be divided into single vision impairment and single hearing impairment. Possessing both vision impairment and hearing impairment was considered as dual sensory impairment (DSI). Longitudinal SI progression encompassed "maintained no SI", "no SI to SSI", "no SI to DSI", "maintained SSI", "SSI to DSI", and "maintained DSI". Logistic regression and restricted cubic splines models were used for analysis.

RESULTS

A total of 6812 participants entered the cross-sectional analysis and 5299 entered the longitudinal analysis. Compared to 0 ACE, ≥4 ACEs had a positive association with DSI (OR = 1.57, 95 % CI = 1.20-2.06) but not with single vision impairment (OR = 1.17, 95 % CI: 0.88-1.55) or single hearing impairment (OR = 1.10, 95 % CI: 0.71-1.70), and this association was observed only in females (OR = 1.73, 95 % CI = 1.20-2.51). A linear association was found between cumulative ACEs and both single vision impairment (p = 0.044) and DSI (p < 0.001). Compared to 0 ACE, ≥4 ACEs was associated with a higher risk of progression from SSI to DSI (OR = 1.71, 95 % CI = 1.03-2.84), and the maintained DSI (OR = 2.23, 95 % CI =1.37-3.65).

CONCLUSION

ACEs were found to be associated with an increased risk and more severe progression of SI later in life. It is imperative to address different types of ACE and incorporate sex-specific measures to mitigate the enduring sensory impact of ACEs.

Trends in the long-term impact of childhood visual impairment on health and social outcomes in the UK: a cross-cohort study across three decades of disability-related legislation and policy implementation

BACKGROUND

Childhood vision impairment (VI) can adversely impact health and social outcomes and limit life chances. We investigated whether its adverse impacts into adult life changed during a period in which legislation, policy and services to address inequalities relating to disability were implemented.

METHODS

Cross-cohort study comprising 14 247 participants from the 1946, 1958 and 1970 British birth cohorts (BC). Participants dichotomized as VI at age 15/16 (distance visual acuity was 6/12 or worse in the better-seeing eye) or normally sighted. Associations of childhood VI with health, well-being, socioeconomic and social participation outcomes in mid-adult life were investigated using regression models adjusted for participants' early life socioeconomic markers and sex. Change in adjusted odds ratios of >10% in the same direction in successive cohorts, or a > 20% difference between 1970BC and one older cohort were considered meaningful.

RESULTS

Trends over time in impacts of childhood onset VI into mid-adult life were complex. This included worsening of odds of poorer physical health (odds ratio 1.47; 95% confidence interval 1.02-2.14), living in unsatisfactory (1.54; 1.03-2.29) or overcrowded (2.34; 1.26-4.06) households, being unemployed (2.19; 1.19-3.97) and not gaining additional educational qualifications during mid-adult life (1.61; 1.08-2.47). By contrast the odds of not participating in some social activities (e.g. seeing friends) improved over time. Associations with other outcomes were unchanged.

CONCLUSIONS

Many adverse impacts of childhood VI do not appear ameliorated over time by legislation, policies and provision that would have been expected to reduce inequalities. Moreover, some were increased. Childhood VI continues to cast a life-long shadow.

United States Population Disparities in Ophthalmic Care: Blindness and Visual Impairment in the IRIS® Registry (Intelligent Research in Sight)

PURPOSE

To evaluate associations of patient characteristics with United States eye care use and likelihood of blindness.

DESIGN

Retrospective observational study.

PARTICIPANTS

Patients (19 546 016) with 2018 visual acuity (VA) records in the American Academy of Ophthalmology's IRIS® Registry (Intelligent Research in Sight).

METHODS

Legal blindness (20/200 or worse) and visual impairment (VI; worse than 20/40) were identified from corrected distance acuity in the better-seeing eye and stratified by patient characteristics. Multivariable logistic regressions evaluated associations with blindness and VI. Blindness was mapped by state and compared with population characteristics. Eye care use was analyzed by comparing population demographics with United States Census estimates and proportional demographic representation among blind patients versus a nationally representative US population sample (National Health and Nutritional Examination Survey [NHANES]).

MAIN OUTCOME MEASURES

Prevalence and odds ratios for VI and blindness; proportional representation in the IRIS® Registry, Census, and NHANES by patient demographics.

RESULTS

Visual impairment was present in 6.98% (n = 1 364 935) and blindness in 0.98% (n = 190 817) of IRIS patients. Adjusted odds of blindness were highest among patients ≥ 85 years old (odds ratio [OR], 11.85; 95% confidence interval [CI], 10.33-13.59 vs. those 0-17 years old). Blindness also was associated positively with rural location and Medicaid, Medicare, or no insurance vs. commercial insurance. Hispanic (OR, 1.59; 95% CI, 1.46-1.74) and Black (OR, 1.73; 95% CI, 1.63-1.84) patients showed a higher odds of blindness versus White non-Hispanic patients. Proportional representation in IRIS Registry relative to the Census was higher for White than Hispanic (2- to 4-fold) or Black (11%-85%) patients (P < 0.001). Blindness overall was less prevalent in NHANES than IRIS Registry; however, prevalence in adults aged 60+ was lowest among Black participants in the NHANES (0.54%) and second highest among comparable Black adults in IRIS (1.57%).

CONCLUSIONS

Legal blindness from low VA was present in 0.98% of IRIS patients and associated with rural location, public or no insurance, and older age. Compared with US Census estimates, minorities may be underrepresented among ophthalmology patients, and compared with NHANES population estimates, Black individuals may be overrepresented among blind IRIS Registry patients. These findings provide a snapshot of US ophthalmic care and highlight the need for initiatives to address disparities in use and blindness.

FINANCIAL DISCLOSURE(S)

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

Underrepresentation of blind and deaf participants in the All of Us Research Program

Blind and deaf individuals comprise large populations that often experience health disparities, with those from marginalized gender, racial, ethnic and low-socioeconomic communities commonly experiencing compounded health inequities. Including these populations in precision medicine research is critical for scientific benefits to accrue to them. We assessed representation of blind and deaf people in the All of Us Research Program (AoURP) 2018-2023 cohort of participants who provided electronic health records and compared it with the Centers for Disease Control and Prevention 2018 national estimates by key demographic characteristics and intersections thereof. Blind and deaf AoURP participants are considerably underrepresented in the cohort, especially among working-age adults (younger than age 65 years), as well as Asian and multi-racial participants. Analyses show compounded underrepresentation at the intersection of multiple marginalization (that is, racial or ethnic minoritized group, female sex, low education and low income), most substantively for working-age blind participants identifying as Black or African American female with education levels lower than high school (representing one-fifth of their national prevalence). Underrepresentation raises concerns about the generalizability of findings in studies that use these data and limited benefits for the already underserved blind and deaf populations.

The burden of vision loss in the Middle East and North Africa region, 1990-2019

BACKGROUND

The loss of vision is a substantial public health concern that has important implications for an individual's quality of life. The primary objective of this research was to document the burden of vision loss in the Middle East and North Africa (MENA) region, spanning the years 1990-2019, by age group, sex, underlying cause and sociodemographic index (SDI).

METHODS

Publicly available data concerning the burden of vision loss were acquired from the Global Burden of Disease study 2019. The data encompassed all 21 countries within the MENA region for the period spanning 1990 to 2019. The estimates were reported as raw counts and age-standardised rates per 100,000, accompanied by their corresponding 95% uncertainty intervals (UIs).

RESULTS

In 2019, MENA had an age-standardised point prevalence of 7040.0 (95% UI: 6195.0, 8002.7) and an YLD rate of 314.5 (222.1, 427.6) per 100,000 for vision loss, which were 11.1% (-12.5, -9.7) and 24.3% (-27.6, -20.8) lower, respectively, than in 1990. In 2019, Afghanistan [469.6 (333.0, 632.8)] had the largest age-standardised YLD rate and Turkey [210.7 (145.3, 290.9)] had the lowest. All countries showed a decrease in the age-standardised point prevalence and YLD rate between 1990 and 2019, except for Oman, Afghanistan, and Yemen. Furthermore, in 2019 the largest number of prevalent cases and YLDs were found in the 65-69 age group. Also in 2019, the age-standardised YLD rates in MENA exceeded the global averages for most age groups, for both males and females. In 2019, refractive disorders were the most common types of vision loss among children, adolescents, and middle-age adults in MENA, while near vision loss and cataracts were the most common among older adults. Finally, the burden of vision loss had a slightly negatively association with SDI over the period 1990-2019.

CONCLUSION

Although the burden of vision loss has decreased over the last three decades, the prevalence remains high. These results underscore the importance of healthcare policymakers taking action to implement preventive measures, especially among the elderly and those living in low socioeconomic countries, to decrease the attributable burden in MENA.

What do eye care workers do when their patients go blind?

Sometimes even with the best efforts by the eye care worker (ECW), patients cannot be stopped from losing vision even in the best of centers anywhere in the world. However, in developing countries, most vision loss happens in rural and suburban areas away from where ECWs are majorly located due to poor facilities, adverse living conditions, and poverty. Once irreversible blindness happens, rehabilitation should follow. However, the numbers of those who are not referred for rehabilitation by far outstrips those who are, for various reasons. To find out why this is so, 150 ECWs with 1:2 M:F ratio were contacted through Google links sent through WhatsApp groups. Glaucoma was statistically the commonest cause of irreversible blindness (χ2 = 66.17, p-value < .0001) mostly from late presentation ( n = 146 of 150 responses, 97.7%). When patients go blind, most ( n = 132, 87.4%) of the ECW advise them to go to a blind school (81.2%). Only about a quarter of the respondents properly ensure that they go. A third admitted ( n = 78, 39%) that knowing the patients personally improved their willingness to refer. Many do not think the government is doing enough to help the blind ( n = 118, 78.7%). Even though many ECWs have given sensitization talks on blindness (124 of 164 responses), very few focus on what happens after blindness occurs (42.4% of respondents). A third of the ECW admitted to not doing enough for the blind in their practice ( n = 51, 34%). Majority have, however, heard about The Lens Eye Clinic (TLEC) rehab center, one of the foremost rehabilitation centers for the blind in Nigeria ( n = 103, 68.7%). ECW should ensure those who live in rural areas have poor socioeconomic background, less educated, female, elderly, or born blind should have regular screening and awareness programs in the areas of practice to catch the condition on time with provision made for early counseling and support services.

Learning to see after early and extended blindness: A scoping review

Purpose

If an individual has been blind since birth due to a treatable eye condition, ocular treatment is urgent. Even a brief period of visual deprivation can alter the development of the visual system. The goal of our structured scoping review was to understand how we might better support children with delayed access to ocular treatment for blinding conditions.

Method

We searched MEDLINE, Embase and Global Health for peer-reviewed publications that described the impact of early (within the first year) and extended (lasting at least 2 years) bilateral visual deprivation.

Results

Of 551 reports independently screened by two authors, 42 studies met our inclusion criteria. Synthesizing extracted data revealed several trends. The data suggests persistent deficits in visual acuity, contrast sensitivity, global motion, and visual-motor integration, and suspected concerns for understanding complex objects and faces. There is evidence for resilience in color perception, understanding of simple shapes, discriminating between a face and non-face, and the perception of biological motion. There is currently insufficient data about specific (re)habilitation strategies to update low vision services, but there are several insights to guide future research in this domain.

Conclusion

This summary will help guide the research and services provision to help children learn to see after early and extended blindness.

Improving Access to Eye Care: A Systematic Review of the Literature

PURPOSE

The goals were to develop a working and inclusive definition of access to eye care, identify gaps in the current system that preclude access, and highlight recommendations that have been identified in prior studies. This manuscript serves as a narrative summary of the literature.

CLINICAL RELEVANCE

Health care disparities continue to plague the nation's well-being, and eye care is no exception. Inequities in eye care negatively affect disease processes (i.e., glaucoma, cataracts, diabetic retinopathy), interventions (surgical treatment, prescription of glasses, referrals), and populations (gender, race and ethnicity, geography, age).

METHODS

A systematic review of the existing literature included all study designs, editorials, and opinion pieces and initially yielded nearly 2500 reports. To be included in full-text review, an article had to be US-based, be written in English, and address 1 or more of the key terms "barriers and facilitators to health care," "access," and "disparities in general and sub-specialty eye care." Both patient and health care professional perspectives were included. One hundred ninety-six reports met the inclusion criteria.

RESULTS

Four key themes regarding access to eye care from both patient and eye care professional perspectives emerged in the literature: (1) barriers and facilitators to access, (2) utilization, (3) compliance and adherence, and (4) recommendations to improve access. Common barriers and facilitators included many factors identified as social determinants of health (i.e., transportation, insurance, language, education). Utilization of eye care was largely attributable to having coverage for eye care, recommendations from primary care professionals, and improved health status. Geographic proximity, age, and lack of transportation surfaced as factors for compliance and adherence. There were a variety of recommendations to improve access to eye care, including improving presence in community health clinics, reimbursement for physicians, and funding of community-based programs such as DRIVE and REACH.

CONCLUSIONS

The eye care profession has abundant evidence of the disparities that continue to affect marginalized communities. Improving community-based programs and clinics, addressing social determinants of health, and acknowledging the effects of discrimination and bias on eye care serve as ways to improve equity in this field.

Addressing Social Determinants of Vision Health

Social determinants of health encompass the quality of an individual’s social and physical environment and its effect on health outcomes. Disparities in these social and environmental factors have a significant role in vision health disparities and inequity in eye care. In this review, we discuss how disparities in visual impairment and eye care utilization are affected by each of the five core domains of social determinants of health, namely economic stability (income, employment, and food security), education (education level and health literacy), health care access (insurance and medical costs), neighborhood environment (housing conditions, home ownership, pollution, and crime), and social context (race and racism). Moreover, we describe a framework by which ophthalmologists can take action to address social determinants of vision health. These actionable strategies are guided by recommendations from the National Academies of Sciences, Engineering, and Medicine and have five complementary components to address social needs: awareness (screening for social needs), assistance (connecting patients with social care resources), adjustment (altering clinical care in recognition of social needs), alignment (understanding social assets and collaborating with community organizations), and advocacy (promoting policies to address social needs). Addressing social determinants of health is complex but achievable through collaborative strategies. Ophthalmologists have an important leadership role in addressing eye care disparities by taking action on underlying social determinants of vision health.

Etiología de baja visión y ceguera en siete centros de referencia en Colombia entre los años 2012 a 2017

Introducción: la baja visión y la ceguera tienen alta prevalencia mundial, siendo categorías de discapacidad frecuentes en Colombia. Se requieren estudios que caractericen la etiología de las deficiencias visuales permanentes. Objetivo: Identificar y caracterizar las diferentes causas de baja visión y ceguera en siete centros de referencia para la población con discapacidad visual en Colombia, atendida entre los años 2012 a 2017 en seis ciudades capitales. Materiales y métodos: estudio retrospectivo, serie de casos, descriptivo y multicéntrico. Resultados: Se contó con una muestra de 879 registros de pacientes con discapacidad visual. El 70% (612/879) con baja visión y 30% (267/879) con ceguera. Para todos los grupos de edad es más prevalente la baja visión. La etiología más frecuente en pacientes con baja visión fue la degeneración macular asociada a la edad (DMAE) (24%, 144/612); en pacientes con ceguera fue el glaucoma (17%, 45/267). Discusión: Posiblemente en Colombia las causas de baja visión y ceguera van más allá de las cataratas, errores de refracción no corregidos y ceguera infecciosa. Conclusiones: las etiologías más frecuentes encontradas son condiciones oculares crónicas y diversas, que requieren intervenciones específicas para disminuir su prevalencia y prevenir casos de baja visión y ceguera.

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.

Longitudinal Associations Between Vision Impairment and the Incidence of Neuropsychiatric, Musculoskeletal, and Cardiometabolic Chronic Diseases

PURPOSE

To compare the incidence and hazard of neuropsychiatric, musculoskeletal, and cardiometabolic conditions among adults with and without vision impairment (VI).

DESIGN

Retrospective cohort study.

METHODS

The sample comprised enrollees in a large private health insurance provider in the United States, including 24 657 adults aged ≥18 years with VI and age- and sex-matched controls. The exposure variable, VI, was based on low vision and blindness International Classification of Diseases, Ninth and Tenth Revision, Clinical Modification (ICD-9-CM and ICD-10-CM), diagnosis codes. Physician-diagnosed incident neuropsychiatric, musculoskeletal, and cardiometabolic diseases were identified using ICD codes. Separate Cox proportional hazards regression models were used to assess the association of VI with incidence of 30 chronic conditions, adjusting for Elixhauser Comorbidity Index. Analyses were stratified by age 18-64 years and ≥65 years.

RESULTS

In individuals with VI aged 18-64 years (n=7478), the adjusted hazard of neuropsychiatric (HR 2.1, 95% CI 1.9, 2.4), musculoskeletal (HR 1.8, 95% CI 1.7, 2.0), and cardiometabolic (HR 1.8, 95% CI 1.7, 2.0) diseases was significantly greater than in matched controls (mean 5.5 years follow-up). Similar associations were seen between patients with VI aged ≥65 years (n=17 179) for neuropsychiatric (HR 2.4, 95% CI 2.1, 2.7), musculoskeletal (HR 1.8, 95% CI 1.6, 1.9), and cardiometabolic (HR 1.7, 95% CI 1.4, 2.0) diseases. VI was associated with a higher hazard of each of the 30 conditions we assessed, with similar results in both age cohorts.

CONCLUSION

Across the life span, adults with VI had an approximately 2-fold greater adjusted hazard for common neuropsychiatric, musculoskeletal, and cardiometabolic disorders compared with matched controls without VI.

Visual functions and disability in Iranian adults: a population-based study

Background

Vision-related quality of life is related to severity of visual impairments and show the impact of eye diseases on daily activities. This study aims to assess visual functions and disability and its association with age, gender, education, marital status, and economic status in adults aged 45–69 years.

Methods

Data in this population-based study were from the second phase of the Shahroud eye cohort study and collected by using a Short-Form Visual Functioning Scale. The scores of visual function and disability were calculated based on Rasch-transformed scores of the National Eye Institute visual functioning questionnaire, where a more negative score indicates a better situation. Multiple linear regression was used to investigate the factors associated with visual functions.

Results

Among 4737 participants the visual function data for 4715 people were analyzed. The visual function of 75.3, 17.1 and 7.5% of participants were “ideal and good”, “moderate”, and “bad and very bad”, respectively, while 0.06% were unable for vision. The running mean of the visual function was calculated to be − 3.95 ± 0.02. The visual performance was worse in females than the males (β = 0.14, p = 0.005). Visual function improved with increasing levels of education (β = − 1.06, p < 0.001). It was worse in low-economic (β = 0.016, p = 0.005) and moderate-economic (β = 0.28, p < 0.001) participants than high-economic ones.

Conclusion

The visual function of Iranian adults aged 45–69 years was moderate. The male gender, higher education and the higher economic status had a better visual function.

A longitudinal study of the association between visual impairment and income change using a national health screening cohort

We evaluated the influence of visual impairment (VI) on income change using the longitudinal database of a Korean National Health Insurance Service cohort. A total of 5292 participants ≥ 40 years old and registered as visually impaired persons were selected at a 1:4 ratio with 45,081 non-VI participants matched for age, sex, and income level. The income level of both the VI and non-VI groups increased over time. In the VI group, the income levels 3, 4 and 5 years were higher than the initial value, while the income levels from 1 through 5 years were increased each year in the non-VI group. The rate of change in income between time and VI were significant. In the subgroup analysis considering age, sex, and severity of VI, the rate of change in income were significant in < 65 years old subgroups. Regarding the severity of VI, a significant interaction was found for the mild-to-moderate VI subgroup. Although both the VI and non-VI groups showed increased income levels over 5 years, the degree of income increase in the VI group was relatively lower than that in the non-VI group. This finding was prominent in the middle-age subgroup. These results strongly suggested that VI induced an income inequality.

Prevalence and sociodemographic factors associated with vision difficulties in Ghana, Gambia, and Togo: a multi-country analysis of recent multiple Indicator cluster surveys

Background

The sense of sight is one of the important human sensory abilities that is required for independent functioning and survival. The highest burden of sight-related problems is recorded in low-and middle-income countries, especially in sub-Saharan Africa. Despite the burden, nationally representative analyses to understand the prevalence and determinants of vision difficulties are hard to find. Therefore, this study addressed this knowledge gap by estimating the prevalence of vision difficulties and its correlates in gender-stratified models in three West African countries: Ghana, Gambia, and Togo.

Methods

The study used the most recent Multiple Indicator Cluster Surveys of Ghana (2017–2018), Gambia (2018), and Togo (2017). Summary statistics were used to describe the participants and logistic regression was used to perform the bivariate and multivariate analyses. The analyses were performed using Stata version 14 and the complex survey design of the datasets was accounted for using the ‘svyset’ command.

Results

Gendered differences were observed for vision difficulties. More women than men reported vision difficulties in Ghana (men: 14.67% vs women: 23.45%) and Togo (men: 14.86% vs women: 23.61%), but more men than women reported vision difficulties in Gambia (men: 11.64% vs women: 9.76%). We also observed gender differences in how age, education, marital status, and region of residence were significantly associated with reported vision difficulties. The direction and magnitude of these relationships were different among men and women across the survey data in Ghana, Gambia, and Togo.

Conclusion

The findings imply the need to tackle the existing gender inequities that are associated with vision difficulties to promote the quality of life of individuals, especially among older adults.

Economic Inequality in Visual Impairment: A Study in Deprived Rural Population of Iran

Purpose:

To determine economic inequality in visual impairment (VI) and its determinants in the rural population of Iran.

Methods:

In this population-based, cross-sectional study, 3850 individuals, aged 3–93 years were selected from the north and southwest regions of Iran using multi-staged stratified cluster random sampling. The outcome was VI, measured in 20 feet. Economic status was constructed using principal component analysis on home assets. The concentration index (C) was used to determine inequality, and the gap between low and high economic groups was decomposed to explained and unexplained portions using the Oaxaca–Blinder decomposition method.

Results:

Of the 3850 individuals that were invited, 3314 participated in the study. The data of 3095 participants were finally analyzed. The C was −0.248 (95% confidence interval [CI]: −0.347 - −0.148), indicating a pro-poor inequality (concentration of VI in low economic group). The prevalence (95% CI) of VI was 1.72% (0.92–2.52) in the high economic group and 10.66% (8.84–12.48) in the low economic group with a gap of 8.94% (6.95–10.93) between the two groups. The explained and unexplained portions comprised 67.22% and 32.77% of the gap, respectively. Among the study variables, age (13.98%) and economic status (80.70%) were significant determinants of inequality in the explained portion. The variables of education (coefficient: −4.41; P < 0.001), age (coefficient: 14.09; P < 0.001), living place (coefficient: 6.96; P: 0.006), and economic status (coefficient: −7.37; P < 0.001) had significant effects on inequality in the unexplained portion.

Conclusions:

The result showed that VI had a higher concentration in the low economic group, and the major contributor of this inequality was economic status. Therefore, policymakers should formulate appropriate interventions to improve the economic status and alleviate economic inequality.

Eye health profile of affordable eye care service users

CLINICAL RELEVANCE

Knowledge of the typical eye health profile of patients experiencing social or economic disadvantage is useful for health care modelling.

BACKGROUND

The aim of this work is to profile the ocular health and sociodemographic characteristics of Australian College of Optometry service users of all ages and to explore the relationships between key sociodemographic characteristics and eye health.

METHODS

For 3093 eye examinations, best-corrected distance visual acuity and mean spherical equivalent refractive error were tested non-parametrically by clinic category, remoteness area, number of co-morbidities, gender and indigenous status, also correlated against age and socioeconomic advantage/disadvantage. Covariates of interest were entered into linear mixed models of visual acuity and mean spherical equivalent refractive error, controlling for age. Risk estimates are reported for visual impairment (defined as ≤6/12 best-corrected distance visual acuity in one or both eyes) and ocular diagnoses.

RESULTS

Visual impairment is more prevalent amongst service users examined in domiciliary settings. Increasing co-morbidities were associated with poorer best-corrected distance visual acuity. Aboriginal and Torres Strait Islander service users had lower visual impairment prevalence overall but proportionally fewer aged ≥50 years attended for eye care, compared to non-indigenous.

CONCLUSIONS

Domiciliary eye examinations detect remediable visual impairment. Federal public health interventions delivered by the Australian College of Optometry for Aboriginal and Torres Strait Islander eye care appear effective but may not reach all aged ≥ 50 years; further research is required. Identification of multiple co-morbidities should prompt optometrists to tailor public health messages and signpost to low vision services earlier.

Impact of treatment of diabetic macular edema on visual impairment in people with diabetes mellitus in India

Purpose:

The aim of this study was to report visual and anatomical outcomes following treatment for diabetic macular edema (DME) in clinical practice in India.

Methods:

Retrospective chart review of patients with DME who were initiated on treatment and followed up for at least 1 year at 9 tertiary eye care centers during 2016–2017 was performed. Data on demographics, systemic illnesses, visual acuity and anatomical characteristics of DME, treatment history were collated and analyzed for change in visual acuity level and central macular thickness at 1 year.

Results:

A total 1853 patients were diagnosed with treatable DME during study period, 1315 patients were treated and 556 patients (1019 eyes) followed up at one year. Although patients achieved significantly better anatomical outcome (central macular thickness of <300μ in 32.3% at baseline compared to 60.7% at 1 year, P < 0.001), visual impairment due to DME did not differ from baseline (mild visual impairment in 53.2% at baseline compared to 56% at 1 year, P = 0.7). Cystoid type of DME was the most common phenotype (432/1019, 42.4%) followed by spongy type (325, 31.9%) and cystoid plus spongy type (138, 13.5%). Bevacizumab monotherapy was the most common (388/1019, 38.1%) treatment followed by combination therapy (359, 35.2%). Mean number of anti-VEGF injections received per eye in a year was 2.1 (SD ± 0.9).

Conclusion:

Only about a third of treated DME patients complete one year follow up in India. Most patients receive suboptimal number of treatments. Treated DME cases largely show better anatomical outcome but not a better functional outcome.

Procedures, Visits, and Procedure Costs in the Management of Microbial Keratitis

PURPOSE

To investigate the burden of procedures, visits, and procedure costs in the management of microbial keratitis (MK).

METHODS

Medical records of patients from an academic hospital outpatient facility between December 2013 and May 2018 were retrospectively reviewed. Patients were included if they were older than the age of 18 years, recruited for study of likely MK, and not concurrently undergoing treatment for other acute eye conditions. For procedural costs, Medicare data for billing were obtained using the Center for Medicare and Medicaid Services Physician Fee Lookup tool.

RESULTS

A total of 68 patients were included for analysis. Patients were on average 51.3 years (SD = 19.5), 55.9% women (n = 38), and 89.7% White (n = 61). Per person, the average number of procedures was 2.9 (SD = 4.2). The average number of visits was 13.9 (SD = 9.2) over an average of 26.9 weeks (SD = 24.3). Age (P < 0.0001), positive Gram stain (P = 0.03), and mixed Gram stain (P = 0.002) were positively associated with the number of procedures. Age (P = 0.0003), fungal keratitis (P = 0.02), and mixed Gram stain (P = 0.01) were positively associated with the number of visits. Race was inversely associated with the number of procedures (P = 0.045) and visits (0.03). Patients with bacterial keratitis were more likely to have amniotic membrane grafts (P = 0.01) and tarsorrhaphies (P = 0.03) than fungal patients. Across all procedures performed for the management of MK, the mean cost per patient was $1788.7 (SD = $3324.62).

CONCLUSIONS

Patients incur many procedural costs and attend many visits during the management of MK. These findings emphasize the importance of patient-provider communication for frequent follow-up care and the potential need to perform procedures for disease management.

Temporal Trends over a Decade in Serious Vision Impairment in a Large, Nationally Representative Population-based Sample of Older Americans: Gender, Cohort and Racial/Ethnic Differences

Purpose: The objectives of this study are:1)To identify temporal trends in the age-sex-race/ethnicity adjusted prevalence of vision impairment among Americans aged 65+ from 2008-2017; To determine if these temporal trends in vision impairment differ by 2)gender and age cohort, and 3)race/ethnicity, and; 4)To investigate if improvements in cohort educational attainment partially attenuate these trends.Methods: Secondary analysis of 10 years of annual nationally-representative data from the American Community Survey with 5.4 million community-dwelling and institutionalized older adults aged 65+. The question on vision impairment was "Is this person blind or does he/she have serious difficulty seeing even when wearing glasses?".Results: The prevalence of serious vision impairment in the US population aged 65+ declined from 8.3% to 6.6% between 2008 and 2017. There would have been an additional 848,000 older Americans with serious vision impairment in 2017 if rates had remained at the 2008 level. After age, sex and race/ethnicity were controlled, women had a 2.1% per year decline in the odds of vision impairment (OR = 0.979; CI = 0.977, 0.980), which represents a 21% decline over the decade, and men had a 9% decline over the decade (OR = 0.991; CI = 0.989, 0.993). Adjusting for education attenuated the decade decline among women, reducing it to 13%, and completely attenuated the decline among men. Most of the decline was among those aged 75+. Racial/ethnic disparities narrowed over the decade.Conclusion: Between 2008 and 2017, the prevalence of serious vision impairment among older Americans declined significantly, with steeper declines among African Americans and Hispanic Americans than among non-Hispanic White Americans.

Visual Impairment and Mental Health: Unmet Needs and Treatment Options

Purpose

An estimated 2.2 billion people are visually impaired worldwide. Given that age-related vision loss is a primary cause of vision impairment, this number is projected to rise with increases in average lifespan. Vision loss often results in significant disability and is associated with a substantial economic burden, reduced quality-of-life, concurrent medical issues, and mental health problems. In this review, the mental health needs of people with vision impairment are examined.

Patients and methods

A review of recent literature on mental health outcomes and current treatments in people with visual impairment was conducted.

Results

Considerable data indicate that rates of depression and anxiety are elevated among people with visual impairments. Moreover, individuals of lower socioeconomic status may be at increased risk for vision impairment and subsequent mental health problems. Existing psychosocial interventions for improving mental health in people with visual impairment show some promise, but are limited by low adherence and lack generalizability.

Conclusion

In order to improve outcomes, a better understanding of the mechanisms linking visual impairment and poor mental health is needed. It will also be essential to develop more effective interventions and expand access to services to improve the detection and treatment of mental health problems in this population.

Sociodemographic, behavioral, and medical risk factors associated with visual impairment among older adults: a community-based pilot survey in Southern District of Hong Kong

Background

The last visual survey of older adults in Hong Kong was a district-level study in 2002, with no assessment of behavioral and medical risk factors for visual impairment (VI). Our objectives were to determine the latest VI prevalence among older adults, significance of any spatial and temporal differences on the prevalence, and any associations of sociodemographic, behavioral and medical risk factors with VI from a multi-perspective analysis.

Methods

Community-based pilot survey of residents from a suburb of Hong Kong, aged ≥50, using a standardized questionnaire, was conducted in 2016.

Results

Of the 222 subjects, crude rates of bilateral and unilateral VI were 9.46 and 32.88%, respectively, or corresponding age-and-gender-adjusted rates of 6.89 and 30.5%. Older age and lower educational were associated with higher risk for unilateral VI, while older age, temporary housing, obesity and hyperlipidemia were associated with higher risk for bilateral VI. Smoking and alcohol-drinking status were not associated with unilateral or bilateral VI. Relative changes in ORs of hypertension or educational level on unilateral or bilateral VI were >  10% after adjusting for age. Interaction term between hyperlipidemia and gender or obesity was significant for unilateral VI. Gender, hypertension and cataract were not associated with unilateral or bilateral VI in general population of pooled analysis but were identified as risk factors in specific subgroups of stratified analysis. Refractive error (myopia or hyperopia) was significantly associated with VI in the eye-level analysis after adjusting the inter-eye correlation.

Conclusions

Sociodemographic and medical risk factors contributed to VI, but behavioral risk factors did not. Sociodemographic disparities of visual health existed. Age was the confounders of the VI-hypertension or VI-educational level relationships. Gender and obesity were more likely to have multiplicative effect on unilateral VI when combined with hyperlipidemia. Stratified analysis should be conducted to provide further insight into the risk factors for VI in specific populations. Uncorrected refractive error remains a significant cause of impaired vision. The spatial and temporal differences in bilateral VI prevalence from the previous local study indicates a territory-wide survey is needed to assess regional differences and overall prevalence of VI in Hong Kong.

Visual impairment and the prevalence of ocular pathology in homeless children and adults globally: a systematic review

BACKGROUND

Homelessness is a global issue in developing and developed countries. This article is the first systematic review to explore its impact on visual health globally.

METHODS

A systematic literature search was conducted on OVID MEDLINE, EMBASE, and Cochrane CENTRAL. Peer-reviewed English-language studies with a focus on homeless children or adults that reported on ocular outcomes were included. Primary outcomes and secondary endpoints were reported via weighted averages. Primary outcomes between homeless children and homeless adults were compared using the Fisher exact test.

RESULTS

There were 5774 individuals across 23 full-text articles included in the review. For studies reporting primary outcomes, 36.8% of homeless individuals self-reported dissatisfaction with their vision, 26.8% self-reported a previous ocular pathology, 26.3% had uncorrected refractive error, 25.6% were functionally visually impaired, 9.2% had at least one previous eye surgery or procedure, and 4.0% had nonrefractive visual impairment. Upon screening, 25.1% of homeless individuals had some type of ocular pathology, which included cornea and external eye diseases (13.4%), glaucoma (7.4%), cataracts (6.3%), retinal diseases (5.3%), ocular motility disorders (4.7%), trauma (2.3%), neuro-ophthalmological conditions (1.7%), and oculoplastic conditions (0.7%). Homeless adults had significantly more visual impairment (p < 0.001), uncorrected refractive error (p < 0.001), ocular pathology (p < 0.001), cataracts (p < 0.001), retinal pathology (p < 0.001), and neuro-ophthalmological conditions (p < 0.001) relative to children.

CONCLUSIONS

Visual impairment in homeless individuals is higher than the general population. Uncorrected refractive error is a leading cause of visual impairment in this population. Additionally, homeless adults have significantly more visual impairment and ocular pathology than homeless children. Future studies should also explore if these differences are consistent in developing countries and investigate ways to increase eye care access for homeless individuals.

Recent trends in vision impairment certifications in England and Wales

BACKGROUND

The Certificate of Visual Impairment (CVI) provides essential data for preventable sight loss indicators as part of the Public Health Outcomes Framework (PHOF) published annually by the Department of Health. Trends in CVI certification rates can provide information on the effectiveness of current services and treatments and may be used to guide allocation of resources, and is the only such indicator within ophthalmology. This study aimed to compare recent trends in new vision impairment certifications in 2017/18 against prior baseline data in England and document trends in new certifications in Wales.

METHODS

PHOF data from 2010/11 and 2017/18 were examined with respect to preventable sight loss indicators: age-related macular degeneration (AMD) (Indicator E12a), glaucoma (Indicator E12b), diabetic eye disease (Indicator E12c) as well as the total numbers of certifications (Indicator E12d).

RESULTS

In 2017/18, the rate of new CVI certifications was 41 per 100,000 population which has reduced from 43/100,000 in 2010/11 in England. Certifications for AMD reduced from 132/100,000 in 2010/11 to 107/100,000 in 2017-18. Certifications for glaucoma have remained stable at 13/100,000 in 2017/8. Certifications for diabetic eye disease have declined from 4/100,000 in 2010/11 to 3/ 100,000 in 2017/18. The number of vision impaired individuals that each Clinical Commissioning Group (CCG) has to support varies from 8 to 82 per 100,000 population.

CONCLUSIONS

There has been a significant decrease in the rate of all CVI certifications particularly from AMD and diabetic retinopathy. However, maintaining this will require changes in the way care is delivered as the elderly population, which is at greatest risk of preventable sight loss, is projected to increase by 50% over the next 20 years. Inherited retinal diseases are now the leading cause of sight loss in the working age population. CVI data demonstrate the need for CCGs to tailor their investment in ophthalmic services to the needs of their specific patient populations. It is important that all ophthalmologists continue to provide accurate CVI data in order to help support the future equitable allocation of adequate resources to reduce avoidable vision loss.

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.

[Refractive surgery for children with developmental delay : Indications, techniques and results]

Visual stimulation and communication with the surroundings are crucial factors for childhood development. In children with intellectual disability the developmental delay can be exacerbated by visual impairment leading to visual autism. Uncorrected refractive error is one of the leading causes of visual impairment and spectacles are the gold standard for treatment. For some children with developmental delay or intellectual disability, the fitting and wearing of spectacles can be impossible due to severe craniofacial malformations, poor neck control or involuntary head movements. In these cases, if wearing contact lenses is also impossible the refractive error remains untreated and the child visually impaired. In certain situations cornea-based laser refractive surgery or lens-based refractive surgery can treat these refractive errors to enable better unaided visual acuity and therefore enhanced stimulation and integration of these developmentally delayed children. This article describes and discusses the indications, technical aspects and results of refractive surgery for children with developmental delay and intellectual disability.

Generating evidence for planning eye care service delivery in an urban underprivileged population setting in Pune, Western India

Purpose

To estimate prevalence of blindness, diabetic retinopathy and causes of blindness through rapid assessment of avoidable blindness (RAAB) survey in Pune, India to develop an evidence base for planning urban eye care services.

Methods

‘Rapid assessment of avoidable blindness and diabetic retinopathy’ methodology was used. Compact segment sampling was used in each of the 60 selected electoral wards identified through cluster selection module of the RAAB software using probability proportionate to size method. Persons >50 years of age were enumerated from selected segments to achieve cumulative target of 60/day by two teams. Participants underwent presenting and pinhole visual acuity (VA) testing in each eye. A torch light examination and direct ophthalmoscopy established cause of visual impairment/blindness if present. Data were entered into and analysed using RAAB software.

Results

The response rate was 89.5% (3221/3600), and 55.3% were women. Results of only RAAB module are presented in this paper. Age-standardised and sex-standardised prevalence of blindness was 1.3% (95% CI 0.9 to 1.8). Cataract was the most common cause of blindness (45.7%) followed by overall posterior segment disorders (39.1%). Cataract surgical outcome was good (VA>6/18) or very good (VA>6/12) in 805/1190 (67.6%) cases. Cataract surgical coverage was 96.7%. ‘Need not felt’ (36.6%) and ‘cost’ (31.7%) were the most common barriers for cataract surgery.

Conclusion

Prevalence of blindness is showing declining trend in urban India. Cataract remains a major cause of blindness followed by posterior segment disorders. Social marketing, and referral linkages between community and service providers were planned after this survey.

Socio-economic status, visual impairment and the mediating role of lifestyles in developed rural areas of China

PURPOSE

To examine the impacts of socio-economic status (SES) on visual impairment (VI), and the mediating role of lifestyles in developed rural areas of China.

METHODS

A cross-sectional study was conducted among people living in rural districts of Tianjin, a developed municipality in China. An interviewer-administered survey along with free eye screenings was conducted with participants. The questionnaire included questions about demographic characteristics, SES, medical histories and lifestyles. Presenting visual acuity (PVA) and main causes of VI were identified by ophthalmologists. χ2 test was undertaken to determine whether significant differences (p<0.05) exist between VI and demographic, SES, medical history and lifestyle factors. A stepwise regression method was conducted to investigate whether lifestyles play mediating roles between SES and VI. Multivariable logistic and ordinal logistic regression were used contingent on different types of dependent variables in each regression, and adjusted odds ratio (OR) values were estimated.

RESULTS

Of the 12,233 participants, 6,233 were male (50.59%); the mean age was 34.61 years; 310 (2.54%) had VI. Hypertension, diabetes and cardiopathy were main medical histories, with 1,640 had hypertension (13.41%), 854 had diabetes (6.98%) and 483 had cardiopathy (3.95%). About SES factors, higher education level (Adjusted OR, 0.84; 95% CI, 0.75-0.95) and higher income level (Adjusted OR, 0.54; 95% CI, 0.39-0.76), were significantly associated with VI in a gradient across severity of VI. Lifestyles including smoking (Adjusted OR, 1.55; 95% CI, 1.31-1.83) and drinking (Adjusted OR, 1.36; 95% CI, 1.06-1.74) played mediating roles between SES and VI when considering the full sample. Besides smoking and drinking, reading every week (Adjusted OR, 2.07; 95% CI, 1.53-2.82) and exercising more than 2h every day (Adjusted OR, 0.39; 95% CI, 0.15-1.00) also played mediating roles between SES and VI when considering the subsample (age≥16).

CONCLUSION

This study revealed the crucial impacts of SES factors on VI, and the mediating role played by several lifestyles. Targeted public health interventions for reducing VI should thus be proposed in developed rural areas of China.

Regional differences in vision health: findings from Mwanza, Tanzania

Background

Visual impairment in developing countries has both social and economic impact on individuals and communities. Understanding the subjective visual functioning of populations will allow for local policymakers to identify the need for optometric or ophthalmic services in their communities.

Methods

The authors surveyed 644 adult patients in Mwanza, Tanzania at three clinics (Buzuruga, Mwananchi and Kisesa) using a modified Visual Functioning Questionnaire 25. Responses were categorized into General health, General vision, Ocular pain, Near activities, Distance activities, Social function, Mental health, Role difficulties, Color vision, Peripheral vision and Dependency.

Results

Patients at Buzuruga reported the lowest scores on most subscales. Of 100 employed patients, 37% claimed to have at least some difficulty in performing job duties due to their eyesight. At Kisesa, 146 (246/221) patients (66.1%) had never had an eye exam, compared with 134/227 (59.0%) at Buzuruga and 69/173 (39.9%) at Mwananchi (p<0.01). Common reasons for not seeing an eye doctor were the perceived expense and lack of vision problems.

Conclusions

Due to regional differences in visual functioning in Mwanza, a national effort for vision health cannot be entirely successful without addressing the individualized needs of local communities. Reducing the cost of vision care appointments may expand vision health care utilization in Mwanza.

The association between socioeconomic status and visual disability among older adults in China

AIM

To investigate the association between socioeconomic status (SES) and visual disability (VD) among older Chinese adults.

METHODS

We obtained data from the Second National Sample Survey on Disability, conducted in China in 2006. A total number of 192 375 older adults (aged≥65y) were screened for suspected VD via interviews with trained examiners. Those who screened positively for VD were referred to ophthalmologists to obtain a final diagnosis.

RESULTS

VD was prevalent among 7.29% of Chinese adults aged 65 and older, and was higher in rural areas (8.71%) than in urban areas (4.82%). After adjusting for SES indicators and covariates, we found that less-educated older adults were more likely to suffer from VD, with an odds ratio (OR) of 2.50 (95%CI: 2.26-2.82) for illiterates, compared with those who graduated from senior high school or above. Older adults who were in the lowest income quintile were more at risk of VD, with an OR of 1.81 (95%CI: 1.68-2.95), compared with adults in the highest income quintile. In urban areas, when compared with adults who graduated from senior high school or above, those who did not continue their education after junior high school, primary school, or those who were illiterate, were more likely to suffer from VD, with an OR of 1.35 (95%CI: 1.51-1.59), 1.84 (95%CI: 1.60-2.12), and 2.63 (95%CI: 2.27-3.04), respectively. Lower levels of income were statistically significant when associated with VD. In rural areas, adults who were illiterate had an OR of 2.21 (95%CI: 1.75-2.79) when compared to adults with senior high school or above education level. Per capita, household income remained significantly associated with VD. Older adults who were ≥85, female, single, and residing in rural areas were associated with higher risks of VD.

CONCLUSION

Individual-level SES among the elderly, in the form of education and income, is associated with VD among elderly Chinese adults in both urban and rural areas; however, the association is stronger in rural areas. Further studies are still required to explore the mechanism behind the relationships.

Sex, gender and blindness: a new framework for equity

Four-fifths of all blind or vision impaired people live in middle-income and low-income countries with the African region and parts of Asia and the Middle East bearing the heaviest burden. At the same time, we know that around two thirds of all blind people in the world are female. Hence, the poorest (and usually the oldest) women are most likely to have their lives limited by visual impairment. While recent strategies have focussed on international variations in eye health, very few have paid attention to the gender differences that are an inextricable element in these inequalities. This review will explore possible explanations for the advantage of men in the exercise of one of the most basic of human senses. It will show that this cannot be understood through the use of a biomedical approach alone. Broader social perspectives will also be needed in order to create an appropriate knowledge base for tackling global inequalities in blindness.

Prevalence of Blindness and Low Vision in Iran: A Systematic Review and Meta-Analysis

PURPOSE

Visual impairment is responsible for medical, mental, and socio-economic problems. Several studies have investigated the prevalence of blindness and low vision in different parts of Iran. This study aims to estimate the pooled results of these studies to estimate the total prevalence of this problem in Iran.

METHODS

National and international databases were searched using specific keywords. The selected primary studies were quality assessed using STROBE checklist. According to the results of the heterogeneity tests (Cochrane and I-squared indices), fixed- or random-effect models were applied to estimate the pooled results. The factors responsible for the heterogeneity were investigated using meta-regression models. The point and pooled estimates were presented by forest plots, and the presence of publication bias was assessed based on Egger test.

RESULTS

Considering the results of 10 eligible studies showed that the prevalence (95% confidence intervals) of blindness among men, women, urban, and rural population as well as total population was 0.96% (0.60-1.31), 1.00% (0.70-1.31), 0.81% (0.19-1.44), 0.89% (0.45-1.32), and 1.02% (0.71-1.34), respectively. Prevalence (95% confidence intervals) of low vision among men, women, urban, and rural populations and also total populations was estimated at 2.19% (1.60-2.79), 2.60% (2.08-3.12), 2.81% (1.26-4.36), 3.67% (2.17-5.17), and 2.85% (2.12-3.58), respectively.

CONCLUSION

Our meta-analyses showed that more than 3% of Iranian people are suffering from visual problems. In addition, we found that prevalence of blindness and low vision among Iranian women was more common than that of Iranian men and also was higher in rural areas than urban areas.

Financial inclusion: perceptions of visually impaired older Nigerians

Purpose

The purpose of this paper is to explore areas of challenge in managing personal finances among visually impaired older people, with critical appraisal of current structures available in financial institutions for equal access to financial services. The paper intends to create understanding of the drawbacks to financial inclusion from the perspectives and experiences of older people with vision impairment in Nigeria as well as highlighting areas where support is/are needed to tackle digital exclusion.

Design/methodology/approach

This study employed a qualitative approach, interviewing 30 visually impaired older adults, aged 60 years and over. Participants were drawn from a voluntary organisation for people living with vision impairment in Southwest Nigeria. Interview data were transcribed verbatim and analysed thematically using qualitative data analysis software – NVivo (version 11).

Findings

Results provide clear insight on the nature of the challenges faced by visually impaired older people, particularly with managing finances on computer-enabled platforms. The findings also revealed fears and hopes of this group about the rapid evolution of technologies for managing finances.

Originality/value

The study critically explored an understudied population, showing peculiar challenges and made a case for inclusive designs that are useful for digital inclusion of this population.

Social Inequality and Visual Impairment in Older People

Objectives

Visual impairment is the leading cause of age-related disability, but the social patterning of loss of vision in older people has received little attention. This study's objective was to assess the association between social position and onset of visual impairment, to empirically evidence health inequalities in later life.

Method

Visual impairment was measured in 2 ways: self-reporting fair vision or worse (moderate) and self-reporting poor vision or blindness (severe). Correspondingly, 2 samples were drawn from the English Longitudinal Study on Ageing (ELSA). First, 7,483 respondents who had good vision or better at Wave 1; second, 8,487 respondents who had fair vision or better at Wave 1. Survival techniques were used.

Results

Cox proportional hazards models showed wealth and subjective social status (SSS) were significant risk factors associated with the onset of visual impairment. The risk of onset of moderate visual impairment was significantly higher for the lowest and second lowest wealth quintiles, whereas the risk of onset of severe visual impairment was significantly higher for the lowest, second, and even middle wealth quintiles, compared with the highest wealth quintile. Independently, lower SSS was associated with increased risk of onset of visual impairment (both measures), particularly so for those placing themselves on the lowest rungs of the social ladder.

Discussion

The high costs of visual impairment are disproportionately felt by the worst off elderly. Both low wealth and low SSS significantly increase the risk of onset of visual impairment.

Beyond monetary benefits of restoring sight in Vietnam: Evaluating well-being gains from cataract surgery

A more holistic understanding of the benefits of sight-restoring cataract surgery requires a focus that goes beyond income and employment, to include a wider array of well-being measures. The objective of this study is to examine the monetary and non-monetary benefits of cataract surgery on both patients as well as their caregivers in Vietnam. Participants were randomly recruited from a Ho-Chi-Minh City Hospital. A total of 82 cataract patients and 83 caregivers participated in the survey conducted for this study. Paired t-tests, Wilcoxon Signed Rank tests, and regression analysis are used to detect any statistically significant differences in various measures of well-being for patients and caregivers before and after surgery. There are statistically significant improvements in monetary and non-monetary measures of well-being for both patients and caregivers approximately three months after undergoing cataract surgery, compared with baseline assessments collected prior to surgery. Non-monetary measures of well-being include self-assessments of overall health, mental health, hope, self-efficacy, happiness and life satisfaction. For patients, the benefits included statistically significant improvements in earnings, mobility, self-care, the ability to undertake daily activities, self-assessed health and mental health, life satisfaction, hope, and self-efficacy (p<0.01). For caregivers, attendance at work improved alongside overall health, mental health, hope, self-efficacy, happiness and life satisfaction, three months post-surgery (p<0.01). Restoring sight has positive impacts for those suffering from cataracts and their caregivers. Sometimes the benefits are almost equal in their magnitude. The study has also demonstrated that many of these impacts are non-monetary in nature. It is clear that estimates of the rate of return to restoring sight that focus only on financial gains will underestimate the true returns to society of restoring sight from cataract surgeries.

Interventions to improve access to cataract surgical services and their impact on equity in low- and middle-income countries

BACKGROUND

Cataract is the leading cause of blindness in low- and middle-income countries (LMICs), and the prevalence is inequitably distributed between and within countries. Interventions have been undertaken to improve cataract surgical services, however, the effectiveness of these interventions on promoting equity is not known.

OBJECTIVES

To assess the effects on equity of interventions to improve access to cataract services for populations with cataract blindness (and visual impairment) in LMICs.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2017, Issue 3), MEDLINE Ovid (1946 to 12 April 2017), Embase Ovid (1980 to 12 April 2017), LILACS (Latin American and Caribbean Health Sciences Literature Database) (1982 to 12 April 2017), the ISRCTN registry (www.isrctn.com/editAdvancedSearch); searched 12 April 2017, ClinicalTrials.gov (www.clinicaltrials.gov); searched 12 April 2017 and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en); searched 12 April 2017. We did not use any date or language restrictions in the electronic searches for trials.

SELECTION CRITERIA

We included studies that reported on strategies to improve access to cataract services in LMICs using the following study designs: randomised and quasi-randomised controlled trials (RCTs), controlled before-and-after studies, and interrupted time series studies. Included studies were conducted in LMICs, and were targeted at disadvantaged populations, or disaggregated outcome data by 'PROGRESS-Plus' factors (Place of residence; Race/ethnicity/ culture/ language; Occupation; Gender/sex; Religion; Education; Socio-economic status; Social capital/networks. The 'Plus' component includes disability, sexual orientation and age).

DATA COLLECTION AND ANALYSIS

Two authors (JR and JP) independently selected studies, extracted data and assessed them for risk of bias. Meta-analysis was not possible, so included studies were synthesised in table and text.

MAIN RESULTS

From a total of 2865 studies identified in the search, two met our eligibility criteria, both of which were cluster-RCTs conducted in rural China. The way in which the trials were conducted means that the risk of bias is unclear. In both studies, villages were randomised to be either an intervention or control group. Adults identified with vision-impairing cataract, following village-based vision and eye health assessment, either received an intervention to increase uptake of cataract surgery (if their village was an intervention group), or to receive 'standard care' (if their village was a control group).One study (n = 434), randomly allocated 26 villages or townships to the intervention, which involved watching an informational video and receiving counselling about cataract and cataract surgery, while the control group were advised that they had decreased vision due to cataract and it could be treated, without being shown the video or receiving counselling. There was low-certainty evidence that providing information and counselling had no effect on uptake of referral to the hospital (OR 1.03, 95% CI 0.63 to 1.67, 1 RCT, 434 participants) and little or no effect on the uptake of surgery (OR 1.11, 95% CI 0.67 to 1.84, 1 RCT, 434 participants). We assessed the level of evidence to be of low-certainty for both outcomes, due to indirectness of evidence and imprecision of results.The other study (n = 355, 24 towns randomised) included three intervention arms: free surgery; free surgery plus reimbursement of transport costs; and free surgery plus free transport to and from the hospital. These were compared to the control group, which was reminded to use the "low-cost" (˜USD 38) surgical service. There was low-certainty evidence that surgical fee waiver with/without transport provision or reimbursement increased uptake of surgery (RR 1.94, 95% CI 1.14 to 3.31, 1 RCT, 355 participants). We assessed the level of evidence to be of low-certainty due to indirectness of evidence and imprecision of results.Neither of the studies reported our primary outcome of change in prevalence of cataract blindness, or other outcomes such as cataract surgical coverage, surgical outcome, or adverse effects. Neither study disaggregated outcomes by social subgroups to enable further assessment of equity effects. We sought data from both studies and obtained data from one; the information video and counselling intervention did not have a differential effect across the PROGRESS-Plus categories with available data (place of residence, gender, education level, socioeconomic status and social capital).

AUTHORS' CONCLUSIONS

Current evidence on the effect on equity of interventions to improve access to cataract services in LMICs is limited. We identified only two studies, both conducted in rural China. Assessment of equity effects will be improved if future studies disaggregate outcomes by relevant social subgroups. To assist with assessing generalisability of findings to other settings, robust data on contextual factors are also needed.

Trends in Visual Health Inequalities in Childhood Through Associations of Visual Function With Sex and Social Position Across 3 UK Birth Cohorts

Importance

Despite the existing country-specific strategies tackling social inequalities in visual health in adults, little is known about trends in visual function in childhood and its association with social position.

Objective

To investigate the distribution of childhood visual function in the United Kingdom and associations with early-life social position between 1961 and 1986, a period of significant social change.

Design, Setting, and Participants

Longitudinal cohort study using harmonized data sets from the British 1946, 1958, and 1970 national birth cohorts. In total, 14 283 cohort members with complete data on visual acuity at age 15 or 16 years, measured in 1961, 1974, and 1986, respectively, for each cohort, and social position were assessed.

Main Outcomes and Measures

Using habitual distance visual acuity (with correction if prescribed), participants were assigned to a visual function category ranging from bilateral normal to visual impairment/severe visual impairment/blindness (International Statistical Classification of Diseases, Tenth Revision, Clinical Modification). Distribution of visual function over time and associations with social position (risk ratios [RRs] and 95% confidence intervals) were analyzed.

Results

Complete data were available for 3152 participants (aged 15 years; 53% boys [n = 1660]) in the 1946 Medical Research Council National Survey of Health and Development, 6683 participants (aged 16 years; 51% boys [n = 3420]) in the 1958 National Child Development Study, and 4448 participants (aged 16 years; 48% boys [n = 2156]) in the 1970 British Birth Cohort Study. The proportion of children with bilateral normal vision decreased by 1.3% (95% CI, -5.1% to 2.7%) in 1974 and 1.7% (95% CI, -5.9% to 2.7%) in 1986. The risk of overall impaired vision increased by 1.20 times (95% CI, 1.01-1.43) and the risk of visual impairment/severe visual impairment/blindness by 1.75 times (95% CI, 1.03-2.98) during this period. Girls were consistently at increased risk of all vision impairment categories. Higher social position at birth and in childhood was associated with reduced risk of visual impairment/severe visual impairment/blindness (RR, 0.58; 95% CI, 0.20-1.68) and unilateral impairment (RR, 0.89; 95% CI, 0.72-1.11), respectively.

Conclusions and Relevance

Our study provides evidence of temporal decline in childhood visual function between 1961 and 1986. Despite the limited power of the analysis owing to the small sample size of those with impaired vision, we found an emergence of a contribution of sociodemographic status to the cohort effect that may be the antecedent of the current picture of childhood blindness. Equally, early-life social position may also have contributed to the current social patterning in visual function in older adults in the United Kingdom. These findings highlight the potential value of targeting children in national ophthalmic public policies tackling inequalities.

Self-reported vision impairment and incident prefrailty and frailty in English community-dwelling older adults: findings from a 4-year follow-up study

Background

Little is known about vision impairment and frailty in older age. We investigated the relationship of poor vision and incident prefrailty and frailty.

Methods

Cross-sectional and longitudinal analyses with 4-year follow-up of 2836 English community-dwellers aged ≥60 years. Vision impairment was defined as poor self-reported vision. A score of 0 out of the 5 Fried phenotype components was defined as non-frail, 1–2 prefrail and ≥3 as frail. Participants non-frail at baseline were followed-up for incident prefrailty and frailty. Participants prefrail at baseline were followed-up for incident frailty.

Results

49% of participants (n=1396) were non-frail, 42% (n=1178) prefrail and 9% (n=262) frail. At follow-up, there were 367 new cases of prefrailty and frailty among those non-frail at baseline, and 133 new cases of frailty among those prefrail at baseline. In cross-sectional analysis, vision impairment was associated with frailty (age-adjustedandsex-adjusted OR 2.53, 95% CI 1.95 to 3.30). The association remained after further adjustment for wealth, education, cardiovascular disease, diabetes, falls, cognition and depression. In longitudinal analysis, compared with non-frail participants with no vision impairment, non-frail participants with vision impairment had twofold increased risks of prefrailty or frailty at follow-up (OR 2.07, 95% CI 1.32 to 3.24). The association remained after further adjustment. Prefrail participants with vision impairment did not have greater risks of becoming frail at follow-up.

Conclusion

Non-frail older adults who experience poor vision have increased risks of becoming prefrail and frail over 4 years. This is of public health importance as both vision impairment and frailty affect a large number of older adults.

The Prevalence and Causes of Vision Loss in Indigenous and Non-Indigenous Australians: The National Eye Health Survey

PURPOSE

To conduct a nationwide survey on the prevalence and causes of vision loss in Indigenous and non-Indigenous Australians.

DESIGN

Nationwide, cross-sectional, population-based survey.

PARTICIPANTS

Indigenous Australians aged 40 years or older and non-Indigenous Australians aged 50 years and older.

METHODS

Multistage random-cluster sampling was used to select 3098 non-Indigenous Australians and 1738 Indigenous Australians from 30 sites across 5 remoteness strata (response rate of 71.5%). Sociodemographic and health data were collected using an interviewer-administered questionnaire. Trained examiners conducted standardized eye examinations, including visual acuity, perimetry, slit-lamp examination, intraocular pressure, and fundus photography. The prevalence and main causes of bilateral presenting vision loss (visual acuity <6/12 in the better eye) were determined, and risk factors were identified.

MAIN OUTCOME MEASURES

Prevalence and main causes of vision loss.

RESULTS

The overall prevalence of vision loss in Australia was 6.6% (95% confidence interval [CI], 5.4-7.8). The prevalence of vision loss was 11.2% (95% CI, 9.5-13.1) in Indigenous Australians and 6.5% (95% CI, 5.3-7.9) in non-Indigenous Australians. Vision loss was 2.8 times more prevalent in Indigenous Australians than in non-Indigenous Australians after age and gender adjustment (17.7%, 95% CI, 14.5-21.0 vs. 6.4%, 95% CI, 5.2-7.6, P < 0.001). In non-Indigenous Australians, the leading causes of vision loss were uncorrected refractive error (61.3%), cataract (13.2%), and age-related macular degeneration (10.3%). In Indigenous Australians, the leading causes of vision loss were uncorrected refractive error (60.8%), cataract (20.1%), and diabetic retinopathy (5.2%). In non-Indigenous Australians, increasing age (odds ratio [OR], 1.72 per decade) and having not had an eye examination within the past year (OR, 1.61) were risk factors for vision loss. Risk factors in Indigenous Australians included older age (OR, 1.61 per decade), remoteness (OR, 2.02), gender (OR, 0.60 for men), and diabetes in combination with never having had an eye examination (OR, 14.47).

CONCLUSIONS

Vision loss is more prevalent in Indigenous Australians than in non-Indigenous Australians, highlighting that improvements in eye healthcare in Indigenous communities are required. The leading causes of vision loss were uncorrected refractive error and cataract, which are readily treatable. Other countries with Indigenous communities may benefit from conducting similar surveys of Indigenous and non-Indigenous populations.