Comprehensive eye care - Issues, challenges, and way forward

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.

A practical model for effective eye care delivery in Southeast Asian rural communities: A proposal built based on experts' recommendations

PURPOSE

To evaluate rural community-based eye care models from the perspective of community ophthalmology experts and suggest sustainable technological solutions for enhancing rural eye care delivery.

METHODS

A semi-structured descriptive survey, using close-ended and open-ended questions, was administered to the experts in community ophthalmology sourced through purposive sampling. The survey was self-administered and was facilitated through online platforms or in-person meetings. Uniform questions were presented to all participants, irrespective of their roles.

RESULTS

Surveyed participants (n = 22 with 15 from India and 7 from Nepal) in high-volume tertiary eye hospitals faced challenges with resources and rural outreach. Participants had mixed satisfaction with pre-operative screening and theatre resources. Delayed presentations and inexperienced surgeons contributed to the surgery complications. Barriers to rural eye care included resource scarcity, funding disparities, and limited infrastructure. In rural/peri-urban areas 87% of participants agreed with providing primary eye care services, with more than 60% of the experts not in agreement with the makeshift center model of eye care delivery. Key components for an effective eye care model are sustainability, accessibility, affordability, and quality. These can be bolstered through a healthcare management platform and a human-chain supply distribution system.

CONCLUSION

Tailored interventions are crucial for rural eye care, emphasizing the need for stronger human resources, optimized funding, and community awareness. Addressing challenges pertinent to delayed presentation and surgical training is vital to minimizing complications, especially with advanced cataracts. Enhancements in rural eye care demand a comprehensive approach prioritizing accessibility, affordability, and consistent quality.

Barriers and Facilitators to Teledermatology and Tele-Eye Care in Department of Veterans Affairs Provider Settings: Qualitative Content Analysis

BACKGROUND

Veterans Affairs health care systems have been early adopters of asynchronous telemedicine to provide access to timely and high-quality specialty care services in primary care settings for veterans living in rural areas. Scant research has examined how to expand primary care team members' engagement in telespecialty care.

OBJECTIVE

This qualitative study aimed to explore implementation process barriers and facilitators to using asynchronous telespecialty care (teledermatology and tele-eye care services).

METHODS

In total, 30 participants including primary care providers, nurses, telehealth clinical technicians, medical and program support assistants, and administrators from 2 community-based outpatient clinics were interviewed. Semistructured interviews were conducted using an interview guide, digitally recorded, and transcribed. Interview transcripts were analyzed using a qualitative content analysis summative approach. Two coders reviewed transcripts independently. Discrepancies were resolved by consensus discussion.

RESULTS

In total, 3 themes were identified from participants' experiences: positive perception of telespecialty care, concerns and challenges of implementation, and suggestions for service refinement. Participants voiced that the telemedicine visits saved commute and waiting times and provided veterans in rural areas more access to timely medical care. The mentioned concerns were technical challenges and equipment failure, staffing shortages to cover both in-person and telehealth visit needs, overbooked schedules leading to delayed referrals, the need for a more standardized operation protocol, and more hands-on training with formative feedback among supporting staff. Participants also faced challenges with appointment cancellations and struggled to find ways to efficiently manage both telehealth and in-person visits to streamline patient flow. Nonetheless, most participants feel motivated and confident in implementing telespecialty care going forward.

CONCLUSIONS

This study provided important insights into the positive perceptions and ongoing challenges in telespecialty care implementation. Feedback from primary care teams is needed to improve telespecialty care service delivery for rural veterans.

Effect of self-instructional module towards the prevention of cataract among elderly people in India

The leading cause of blindness in the world is cataracts, which are dangerous and curable with proper eye care. Eye care service is thought to play significant role in prevention. Nonetheless, not much research has been done to gauge older persons' in rural India's level of cataract awareness and how it relates to their use of eye care services. Therefore, in order to prevent cataracts in the elderly, we described a self-instruction model for cataract knowledge and looked into the variations between pre- and post-test self-instruction models. Their demographic characteristics showed that the higher age group female had highest prevalence of cataracts. The study population's understanding of cataracts is incredibly low: only 2% of participants have adequate knowledge, 52% have somewhat adequate information, and 46% have inadequate knowledge. However, after completing the self-instructional module, 54% of participants felt they knew enough to prevent cataracts. The results of the study showed that the self-instructional module was very helpful in helping the senior population learn about cataract prevention. More interventional research with a larger sample size should be carried out to gain a better understanding of cataract prevention in older adults,.

Effect of comprehensive nursing on patients with chalazion undergoing intense pulsed light and its influence on postoperative recurrence

OBJECTIVE

To explore the effect of comprehensive nursing on patients with chalazion undergoing intense pulsed light (IPL) and its influence on postoperative recurrence.

METHODS

In this retrospective study, the medical records of 72 patients who received IPL treatment for chalazion from October 2021 to February 2023 were analyzed. Among them, 33 patients treated with comprehensive nursing were included in the research group (RG) and 39 patients treated with routine nursing were included in the control group (CG). The treatment effect, complications and recurrence were compared between the two groups. The psychological state of patients and their satisfaction about the nursing were recorded and compared between the two groups.

RESULTS

After nursing, the severity of unhealthy emotion in the RG was obviously better than that in the CG (P=0.033); The overall response rate in the RG was obviously higher than that in the CG (P=0.035). The nursing satisfaction in RG was significantly higher than that in the CG (P=0.035). The incidence of complications in RG was obviously lower than that in the CG (P=0.045).

CONCLUSION

Comprehensive nursing is effective in improving the therapeutic effect and reducing the postoperative recurrence rate for patients with chalazion.

Is Artificial Intelligence the Cost-Saving Lens to Diabetic Retinopathy Screening in Low- and Middle-Income Countries?

Diabetes is a rapidly growing global health crisis disproportionately affecting low- and middle-income countries (LMICs). The emergence of diabetes as a global pandemic is one of the major challenges to human health, as long-term microvascular complications such as diabetic retinopathy (DR) can lead to irreversible blindness. Leveraging artificial intelligence (AI) technology may improve the diagnostic accuracy, efficiency, and accessibility of DR screenings across LMICs. However, there is a gap between the potential of AI technology and its implementation in clinical practice. The main objective of this systematic review is to summarize the currently available literature on the health economic assessments of AI implementation for DR screening in LMICs. The review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. We conducted an extensive systematic search of PubMed/MEDLINE, Scopus, and the Web of Science on July 15, 2023. Our review included full-text English-language articles from any publication year. The Joanna Briggs Institute's (JBI) critical appraisal checklist for economic evaluations was used to rate the quality and rigor of the selected articles. The initial search generated 1,423 records and was narrowed to five full-text articles through comprehensive inclusion and exclusion criteria. Of the five articles included in our systematic review, two used a cost-effectiveness analysis, two used a cost-utility analysis, and one used both a cost-effectiveness analysis and a cost-utility analysis. Across the five articles, LMICs such as China, Thailand, and Brazil were represented in the economic evaluations and models. Overall, three out of the five articles concluded that AI-based DR screening was more cost-effective in comparison to standard-of-care screening methods. Our systematic review highlights the need for more primary health economic analyses that carefully evaluate the economic implications of adopting AI technology for DR screening in LMICs. We hope this systematic review will offer valuable guidance to healthcare providers, scientists, and legislators to support appropriate decision-making regarding the implementation of AI algorithms for DR screening in healthcare workflows.

Eyedrop Instillation Techniques, Difficulties, and Currently Available Solutions: A Literature Review

Purpose

To review current eyedrop instillation techniques, common difficulties faced by patients instilling eyedrops, available eyedrop assistive devices, and patient education regarding eyedrop instillation.

Methods

PubMed, Embase, and Google Scholar were searched from conception until June 2022 for articles on eyedrop instillation difficulties, techniques, tools, and patient education.

Results

Instillation involves pulling down the lower eyelids and placing drops on the corneal surface or conjunctival fornix, followed by closing of the eyelids for about 1 min. Examples of techniques include eyelid closure and nasolacrimal obstruction techniques. Patients encounter many difficulties when administering eyedrops, including but not limited to poor visibility, squeezing the dropper bottle, aiming the bottle, and accidentally blinking. However, devices are available that assist with aim and dropper compression-force reduction in eyedrop instillation. These can be particularly useful in patient demographics with diminished manual dexterity or the ability to generate force from their fingers. Furthermore, despite patient education in eyedrop instillation not being a common practice, it has been found that adequate patient education can lead to significant improvement in eyedrop instillation technique.

Conclusions

While many factors are associated with poor eyedrop instillation technique, there are many solutions available including assistive devices and proper instillation education.

The social construction of genomics and genetic analysis in ocular diseases in Ibadan, South-western Nigeria

Genomics, an emerging field to improve public health practice, has potential benefits to understanding ocular diseases. This study explored the social construction of genomics in ocular diseases in the blind community in Ibadan, Nigeria, through two focus group discussions and twelve in-depth interview sessions conducted among people living with ocular disorders. The data were thematic and content-analysed. Although the participants had limited knowledge about ocular diseases, genomics, and their nexus, they maintained a positive attitude toward its potential benefits. This informed their willingness to participate in genomics testing for ocular diseases. The participants preferred saliva-based sample collection over blood-based, and expressed concern for the procedure and accrued benefits of genomics studies. Thus, public sensitisation about ocular diseases and client-centred genomics testing procedures should be engendered.

Characteristics Associated with Barriers to Eye Care: A Cross-Sectional Survey at a Free Vision Screening Event

INTRODUCTION

Social determinants of health can limit access to regular eye care, but their role in ophthalmology is underexamined. The purpose of this study is to assess the relationship between patient characteristics and self-reported barriers to eye care.

METHODS

This anonymous, cross-sectional survey was conducted at a 2-day free eye clinic event in Pittsburgh, Pennsylvania. Adult patients presenting for vision screening were eligible to participate. Patient characteristics (demographics, health status) and self-reported barriers to eye care were collected. Predictors of barriers to eye care were analyzed using binary logistic regression.

RESULTS

Of 269 eligible, consecutive patients approached for survey completion, 183 comprised the volunteer sample. The 183 participants (105 female patients [59%]) had a mean (standard deviation) age of 53 (15) years and generally self-identified as Black (74, 46%) or White (67, 41%). While a third reported having no health insurance (60, 34%), the remaining two-thirds of participants had public (84, 48%) or private coverage (34, 19%). Three-quarters of respondents reported at least one barrier to receiving regular eye care (136, 76%), most commonly medical costs (89, 50%) and insurance issues (73, 41%). Not having health insurance or vision insurance was strongly associated with reporting at least one barrier to care (OR: 5.00, p = 0.002, and OR: 7.46, p < 0.001, respectively). Those with self-reported eye disease were more likely to report transportation difficulties (OR: 4.45, p = 0.013), and employed participants reported difficulty getting time off work to attend eye exams (OR: 7.73, p = 0.002). Finally, compared to Black race, White race was associated with a higher likelihood of reporting any barrier to care (OR: 2.79, p = 0.013).

CONCLUSION

Three-quarters of vision screening attendees reported at least one barrier to regular eye care, most commonly medical costs and insurance.

Can we scale up a comprehensive school-based eye health programme in Zambia?

BACKGROUND

Globally, 19 million children have preventable vision impairment simply because refractive and eye health services are inaccessible to most of them. In Zambia, approximately 50,000 school children need spectacle provision. The School-based Eye Health Programme (SEHP) has been identified worldwide as a proven strategy to address childhood blindness. Given its great benefits, the Zambian government intends to scale up the programme. This scalability assessment aims to identify and evaluate the essential components of an effective SEHP, determine roles, assess existing capacities within user organisations, identify environmental facilitating and inhibiting factors, and estimate the minimum resources necessary for the scaling up and their proposed scale-up strategies.

METHODS

Five elements (innovation, user organisation, resource team, environment, and strategies for horizontal and vertical scaling-up) were assessed guided by the ExpandNet-WHO Nine Steps for Developing a Scaling-Up Strategy. Literature review on proven strategies to reduce childhood blindness and the credibility of SEHP implemented in resource-limited settings, document review on the pilot project, questionnaires, and stakeholders' interviews were conducted to collect data for this assessment. Subsequently, twenty questions in the Worksheets for Developing a Scaling-up Strategy were used to report the assessment outcome systematically.

RESULTS

Additional components of SEHP incorporated in Zambia's model enhanced the innovation's credibility and relevance. The resource team was relatively competent in the pilot project, and the same team will be employed during the scaling-up. Potential change in political parties, the lack of supply chain, and unstable financial support were identified as inhibiting factors. The objectives of SEHP were aligned with the National Eye Health Strategic Plan 2017-2021, which supports the institutionalisation of the SEHP into the existing School Health and Nutrition Programme. For the pace of expansion, replicating SEHP to another district rather than a province will be more realistic.

CONCLUSION

Scaling up a comprehensive SEHP in Zambia is feasible if sufficient funding is available. Additionally, the pace must be adapted to the local context to ensure that every component within the SEHP is intact.

A Latent Class Analysis of Student Eye Care Behavior: Evidence From a Sample of 6–17 Years Old in China

Purpose

To understand the latent classes and distribution of an adolescent eye care behavior, and to provide a basis for the formulation of appropriate adolescent vision health management interventions.

Methods

Information on eye behavior and eye health of primary and secondary school students in Wuhan was collected by multistage stratified cluster sampling. The latent class analysis (LCA) method was used to analyze the students' eye care behavior, and the latent class model (LCM) was built.

Results

A total of 6,130 students were enrolled in this study, of which 53.56% were males, aged from 6 to 17 years old, with an average age of 10.33 ± 2.60. The latent class results classified the adolescents' eye care behaviors into bad behaviors, moderate behaviors, and healthy behaviors. The model fitting results were as follows: Akaike Information Criterion (AIC) was 36,698.216, Bayesian Information Criterion (BIC) was 36,906.565, Adjusted Bayesian Information Criterion (aBIC) was 36,808.056, and entropy was 0.838.Compared with the healthy behaviors class, the bad behaviors class was more prevalent in high schools (p = 0.003), non-demonstration schools (p = 0.001), and most of this group had astigmatism (p = 0.002). The moderate behaviors class predominately consisted of females (p = 0.001), 15–17 years old (p = 0.005, 6~8 years old as the reference), from non-demonstration schools (p < 0.001), and most had myopia (p = 0.009).

Conclusion

There were differences in basic demographic characteristics, visual acuity development level, and family visual environment among different classes. In the management and intervention of an adolescent vision health, we should continue to promote the visual health management of adolescents based on visual monitoring and realize the early intervention and guidance of individuals in bad behaviors class.

Interventions to promote access to eyecare for non-dominant ethnic groups in high-income countries: a scoping review

PURPOSE

People who are distinct from the dominant ethnic group within a country can experience a variety of barriers to accessing eyecare services. We conducted a scoping review to map published interventions aimed at improving access to eyecare for non-Indigenous, non-dominant ethnic groups residing in high-income countries.

METHODS

We searched MEDLINE, Embase and Global Health for studies that described an intervention to promote access to eyecare for the target population. Two authors independently screened titles and abstracts followed by review of the full text of potentially relevant sources. For included studies, data extraction was carried out independently by two authors. Findings were summarised using a combination of descriptive statistics and thematic analysis.

RESULTS

We screened 5220 titles/abstracts, of which 82 reports describing 67 studies met the inclusion criteria. Most studies were conducted in the USA (90%), attempted to improve access for Black (48%) or Latinx (28%) communities at-risk for diabetic retinopathy (42%) and glaucoma (18%). Only 30% included the target population in the design of the intervention; those that did tended to be larger, collaborative initiatives, which addressed both patient and provider components of access. Forty-eight studies (72%) evaluated whether an intervention changed an outcome measure. Among these, attendance at a follow-up eye examination after screening was the most common (n=20/48, 42%), and directly supporting patients to overcome barriers to attendance was reported as the most effective approach. Building relationships between patients and providers, running coordinated, longitudinal initiatives and supporting reduction of root causes for inequity (education and economic) were key themes highlighted for success.

CONCLUSION

Although research evaluating interventions for non-dominant, non-Indigenous ethnic groups exist, key gaps remain. In particular, the paucity of relevant studies outside the USA needs to be addressed, and target communities need to be involved in the design and implementation of interventions more frequently.

The Rising Burden of Diabetes-Related Blindness: A Case for Integration of Primary Eye Care into Primary Health Care in Eswatini

There is a rampant increase in diabetes prevalence globally. Sub-Saharan Africa (SSA) is projected to carry the largest burden of diabetes (34.2 million) by 2030. This will inevitably cause a parallel increase in diabetes-associated complications; with the predominant complications being blindness due to diabetic retinopathy and diabetic cataracts. Eye programs in developing countries remain inadequate, existing as stand-alone programs, focused on the provision of acute symptomatic care at secondary and tertiary health levels. Over 60% of people with undiagnosed diabetes report to eye care facilities with already advanced retinopathy. While vision loss due to cataracts is reversible, loss of vision from diabetic retinopathy is irreversible. Developing countries have in the last two decades been significantly impacted by infectious pandemics; with SSA countries committing over 80% of their health budgets towards infectious diseases. Consequently, non-communicable diseases and eye health have been neglected. This paper aimed to highlight the importance of strengthening primary health care services to prevent diabetes-related blindness. In SSA, where economies are strained by infectious disease, the projected rise in diabetes prevalence calls for an urgent need to reorganize health systems to focus on life-long preventative and integrated measures. However, research is critical in determining how best to integrate these without further weakening health systems.

COVID-19 impact on research and publication ethics

Editorial, No Abstract KEY WORDS: COVID-19, research, publication ethics, retraction, biomedicine, ethics

Socioeconomic Status and Decreasing Incidence of Ocular Injuries in Bosnia and Herzegovina

Purpose: To examine the epidemiologic and clinical characteristics of ocular injuries and their association with socioeconomic status (SES).Material and Methods: All cases of ocular injuries hospitalized in Department of Ophthalmology of University Clinical Center Tuzla, Bosnia and Herzegovina, from January 2009 to December 2012 and January 2017 and December 2019 were prospectively followed. The injuries were classified according to Ocular Trauma Classification System (OTCS) and Birmingham Eye Trauma Terminology (BETT).Results: This study included a total of 420 eyes from 396 patients. There were 162 (38.57%; 95%CI: 32.86-44.99) open globe injuries (OGI) and 258 (61.43%; 95%CI: 54.16-69.4) closed globe injuries (CGI). The decrease in incidence of ocular trauma requiring hospitalization was noted from 16.7 per 100 000 (95%CI: 13.11-20.97) in 2009 to 9.25 per 100 000 (95%CI: 6.64-12.55) in 2019 (p=0.006). Most injuries occurred in males 341 (81.19%; 95%CI: 72.8-90.28), active working patients 258 (61.43%, 95%CI:54.16-69.4), and patients with rural residence 285 (67.86%; 95%CI: 60.21-76.21). Almost all ocular injuries 418 (99.52%; 95%CI: 90.21-109.54) occurred in patients with middle and lower SES categories, and home was the most prevalent place of injury in 258 (61.43%, 95%CI: 54.16-69.4) patients. The total of 289 (70.49%; 95%CI: 62.59-79.1) patients had good final best corrected visual acuity (BCVA). Poor final BCVA was associated with lower ocular trauma score (OTS) (p=0.000), poor initial BCVA (p=0.000), penetrating injuries of cornea (p=0.004) and sclera (p=0.001), Zone III injuries (p=0.000), intraocular foreign body presence (p=0.000), cataract (p=0.002), retinal detachment (p=0.001), endophthalmitis (p=0.000) and vitreous hemorrhage (p=0.010).Conclusion: This study provides a detailed insight into epidemiology and socio-economic characteristics of patients hospitalized for ocular injuries.

Glaucoma blindness-A rapidly emerging non-communicable ocular disease in India: Addressing the issue with advocacy

Glaucoma, a leading cause of irreversible blindness, can be prevented or stabilized the progression if identified early and managed it appropriately. In India, around 12 million people suffer from glaucoma, and 1.5 million are blind due to it, so making the third most common cause of blindness. More than 75% of glaucoma are undiagnosed, which perhaps represent the submerged portion of the iceberg phenomenon of the traditional disease explanations. Though glaucoma per se does not lead to mortality, glaucoma blindness is categorized as a severe form of disability (category VI) out of seven World Health Organization (WHO) classification on the global burden of diseases. Indeed, there is a large gap between the prevailing burden of glaucoma and service being delivered about its prevention compared to other leading causes of blindness in India. Considering the magnitude of the problem as well as the severity of disability, a strong and effective advocacy is an urgent call to deal glaucoma problem in the country. For a resource-limited country, where mass population based-screening programs are not feasible, alternative methods like facility-based opportunistic screening and referring the high-risk groups for early detection and treatment should be aimed. However, glaucoma should not be screened in isolation from other eye problems. In fact, screening of any potential blinding ocular problems, including glaucoma, should be a clear mandate under comprehensive eye program of the WHO to achieve Universal Eye Health Coverages. This paper highlights the strategy inclusive of advocacy to curtail the increasing burden of glaucoma blindness in India.