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

BACKGROUND: Uncorrected refractive error is a leading cause of vision impairment which, in most cases, can be managed with the appropriate spectacle correction. In 2021, the World Health Assembly endorsed a global target of a 40-percentage-point increase in effective coverage of refractive error by 2030. To achieve this global target, equitable access to refractive and optical services within community and primary care settings needs to be strengthened. This review will inform the development of technical guidance to support improvements in the testing and correction of refractive error among World Health Organization (WHO) member states. OBJECTIVES: To determine the range of approaches for delivery of refractive and optical care services in community and primary care settings, and the methods employed for their evaluation. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase and Global Health databases, grey literature, and annual reports and websites of relevant organizations involved in eye-care delivery from January 2002 to November 2022 to identify approaches for refractive and optical service delivery. SELECTION CRITERIA: We included observational and interventional studies, reviews, and reports from relevant organizations related to delivering refractive services and optical services for preschool and school-aged children and adults in community and primary care settings published between January 2002 and November 2022. We searched for studies and reports published within the last 20 years because vision impairment due to uncorrected refractive error has only recently become a public health and eye health priority, therefore we did not expect to find much relevant literature until after 2002. DATA COLLECTION AND ANALYSIS: Two review authors screened titles, abstracts and full texts, and extracted data. We resolved any discrepancies through discussion. We synthesized data, and presented results as tables, figures, and case studies. This project was led by the World Health Organization (WHO) Vision and Eye Care Programme. MAIN RESULTS: We identified 175 studies from searches of databases and grey literature, 146 records from company reports, and 81 records from website searches of relevant organizations that matched our inclusion criteria. Delivery approaches for refractive and optical services in community care included school-based, pharmacy, and outreach models, whereas primary care approaches comprised vision centre, health centre, and a combination of vision or health centre and door-to-door delivery. In community care, school-based and outreach approaches were predominant, while in primary care, a vision-centre approach was mainly used. In the WHO African region, the school-based and outreach approaches were mainly reported while, in the Americas, the outreach approach was mostly used. Very few approaches for service delivery were reported in the WHO Eastern Mediterranean region. Prominent gaps exist in the evaluation of the approaches, and few studies attempted to evaluate the approaches for delivery of refractive and optical care services. AUTHORS' CONCLUSIONS: We comprehensively describe a range of approaches for delivery of refractive and optical services in community and primary care. Further evaluation of their effectiveness will better inform the application of these service-delivery approaches. The study outcomes will help guide WHO member states in strengthening refractive and optical services at community and primary care levels. FUNDING: This scoping review was supported by the Vision and Eye care Programme, World Health Organization and ATscale Global Partnership. REGISTRATION: The protocol of this scoping review was published in the Open Source Framework.

Real-world application of a smartphone-based visual acuity test (WHOeyes) with automatic distance calibration.

BACKGROUND: To develop and assess the usability of a smartphone-based visual acuity (VA) test with an automatic distance calibration (ADC) function, the iOS version of WHOeyes. METHODS: The WHOeyes was an upgraded version with a distinct feature of ADC of an existing validated VA testing app called V@home. Three groups of Chinese participants with different ages (≤20, 20-40, >40 years) were recruited for distance and near VA testing using both an Early Treatment Diabetic Retinopathy Study (ETDRS) chart and the WHOeyes. The ADC function would determine the testing distance. Infrared rangefinder was used to determine the testing distance for the ETDRS, and actual testing distance for the WHOeyes. A questionnaire-based interview was administered to assess the satisfaction. RESULTS: The actual testing distance determined by the WHOeyes ADC showed an overall good agreement with the desired testing distance in all three age groups (p>0.50). Regarding the distance and near VA testing, the accuracy of WHOeyes was equivalent to ETDRS. The mean difference between the WHOeyes and ETDRS ranged from -0.084 to 0.012 logMAR, and the quadratic weighted kappa (QWK) values were >0.75 across all groups. The test-retest reliability of WHOeyes was high for both near and distance VA, with a mean difference ranging from -0.040 to 0.004 logMAR and QWK all >0.85. The questionnaire revealed an excellent user experience and acceptance of WHOeyes. CONCLUSIONS: WHOeyes could provide accurate measurement of the testing distance as well as the distance and near VA when compared to the gold standard ETDRS chart.

What is the coverage of retina screening services for people with diabetes? Protocol for a systematic review and meta-analysis.

INTRODUCTION: Diabetic retinopathy is a leading cause of vision impairment globally. Vision loss from diabetic retinopathy can generally be prevented by early detection and timely treatment. The WHO included a measure of service access for diabetic retinopathy as a core indicator in the Eye Care Indicator Menu launched in 2022: retina screening coverage for people with diabetes. The aim of this review is to provide a comprehensive global and regional summary of the available information on retina screening coverage for people with diabetes. METHODS AND ANALYSIS: A search will be conducted in five databases without language restrictions for studies from any country reporting retina screening coverage for adults with any type of diabetes at the national or subnational level using data collected since 1 January 2000 until the search date. We will also seek reports and coverage statistics from government websites of all WHO member states. Two investigators will independently screen studies, extract relevant data and assess risk of bias of included studies. The results of the review will be reported using the Preferred Reporting Items for Systematic Review and Meta-Analysis guideline. We will summarise the range of coverage definitions reported across included studies and present the median retina screening coverage in WHO regions and by World Bank country income level. Depending on the availability of data, we will conduct meta-analysis to assess disparities in retina screening coverage for people with diabetes by factors in the PROGRESS framework (Place of residence, Race/ethnicity/culture/language, Occupation, Gender/sex, Religion, Education, Socioeconomic status and Social capital). ETHICS AND DISSEMINATION: This review will only include published data thus no ethical approval will be sought. The findings of this review will be published in a peer-reviewed journal and presented at relevant conferences. PROTOCOL REGISTRATION NUMBER: OSF registration 17/10/2023: https://osf.io/k5p69.

Monitoring hearing and vision functions in older adults: rationale and process.

Hearing and vision impairment are highly prevalent in ageing individuals and are significant public health concerns given their meaningful impacts on individuals and society. Yet, many cases of both visual and hearing impairment remain unidentified and thus, unaddressed. This article describes the rationale and process of monitoring for visual and hearing impairment in older adults, by summarising guidance and resources available from the World Health Organisation (WHO) that were developed based upon the best current available evidence. It is recommended that vision screening be offered at least annually to adults aged over 50 years and hearing screening be offered every 5 years to adults aged 50-64 years, and every 1-3 years to adults aged 65 years or older. Both hearing and vision screening can be conducted in community, home or clinical settings by trained health workers with simple equipment. More specifically, vision screening can be conducted with a simple eye chart. Hearing screening can be conducted without specialised equipment by using pure tones set to a fixed level, an automated mobile- or web-based digits-in-noise test, or the whispered voice test. Hearing screening can also be conducted in audiology clinics using pure-tone air conduction threshold testing. There exists WHO guidance to support the monitoring of hearing and vision impairment, which, when warranted, can facilitate referral for comprehensive assessment and prompt appropriate, person-centred interventions to mitigate the negative consequences of hearing and vision impairment.

Development of the WHO eye care competency framework.

BACKGROUND: The eye care workforce, particularly in lower resource settings, face challenges of limited integration into the health system, limited workforce capacity, mismatch of workforce to population need and poor quality of care. In recognition of these challenges, coupled with a gap in existing tools, provides a strong rationale for the development of the Eye care competency framework (ECCF). METHODS: A mixed methods approach was utilised to develop and validate the ECCF. Content was developed by extracting relevant components of existing frameworks used both within and outside of eye care. A diverse technical working group provided feedback and guidance on the structure, design, and content to create a preliminary draft. Competencies and activities were validated using a modified-Delphi study, and the framework was then piloted at four sites to understand how the tool can be implemented in different settings. RESULTS: The final version of the ECCF included eight outcomes, nine guiding principles, and content of each of the key elements, including the six domains, 22 competencies, 21 activities, 193 behaviours and 234 tasks, and the knowledge and skills that underpin them. 95/112 participants from the six WHO regions completed the modified-Delphi study, yielding an average of 96% agreement across the competencies and activities in the ECCF. The pilot showcased the versatility and flexibility of the ECCF, where each of the four sites had a different experience in implementing the ECCF. All sites found that the ECCF enabled them to identify gaps within their current workforce documentation. CONCLUSIONS: The ECCF was developed using a collaborative approach, reflecting the opinions of participants and stakeholders from all around the world. The comprehensive competencies and activities developed in the ECCF encompass the diverse roles of eye care workers, and thus encourage multi-disciplinary care and better integration into the health system. It is recommended that eye care workforce planners and developers use the ECCF, and adapt it to their context, to support workforce development and focus on the quality and scope of eye care service provision.

Systematic review of clinical practice guidelines for uveitis.

To facilitate the integration of eye care into universal health coverage, the WHO is developing a Package of Eye Care Interventions (PECI). Development of the PECI involves the identification of evidence-based interventions from relevant clinical practice guidelines (CPGs) for uveitis.A systematic review of CPGs published on uveitis between 2010 and March 2020 was conducted. CPGs passing title and abstract and full-text screening were evaluated using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool and data on recommended interventions extracted using a standard data extraction sheet.Of 56 CPGs identified as potentially relevant from the systematic literature search, 3 CPGs underwent data extraction following the screening stages and appraisal with the AGREE II tool. These CPGs covered screening for, monitoring and treating juvenile idiopathic arthritis (JIA)-associated uveitis, the use of adalimumab and dexamethasone in treating non-infectious uveitis, and a top-level summary of assessment, differential diagnosis and referral recommendations for uveitis, aimed at primary care practitioners. Many of the recommendations were based on expert opinion, though some incorporated clinical study and randomised controlled trial data.There is currently sparse coverage of the spectrum of disease caused by uveitis within CPGs. This may partially be due to the large number of conditions with diverse causes and clinical presentations covered by the umbrella term uveitis, which makes numerous sets of guidelines necessary. The limited pool of CPGs to select from has implications for clinicians seeking guidance on clinical care strategies for uveitis.

A Systematic Review of Clinical Practice Guidelines for Age-related Macular Degeneration.

BACKGROUND: In response to the recommendations of the World Health Organization (WHO) World report on vision, the WHO is developing a Package of Eye Care Interventions (PECI) to support the integration of eye care into health systems within countries. This study was done to systematically review clinical practice guidelines (CPGs) related to age-related macular degeneration (AMD) to provide evidence-based recommendations. METHODS: All AMD-related CPGs published between 2010 and 2020 were reviewed and evaluated using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool. RESULTS: Of 3778 CPGs identified, 48 underwent full-text screening and eight underwent quality appraisal. Five National Institute for Health and Care Excellence (NICE, UK) guidelines for AMD were finally selected for data extraction. Intravitreal anti-vascular endothelial growth factor (VEGF) treatment was strongly recommended for advanced, active neovascular AMD based on high-quality evidence. Photodynamic therapy and laser photocoagulation were not recommended as an adjunct to anti-VEGF therapy as first-line treatment for AMD. Recommendations on other interventions, including epiretinal brachytherapy, miniature lens system implantation, and limited macular translocation, were weak and evidence mostly came from low-quality case series studies. Hence these interventions were recommended to be used only with special arrangements or research. Existing evidence on treating geographic atrophy was limited, an implantable miniature telescope might be an effective intervention to improve vision but was still under investigation. DISCUSSION: Current CPGs recommend anti-VEGF therapy for patients with late active neovascular AMD, while other interventions should be used with caution and further researches are warranted.

Toward Universal Eye Health Coverage-Key Outcomes of the World Health Organization Package of Eye Care Interventions: A Systematic Review.

Importance: Despite persistent inequalities in access to eye care services globally, guidance on a set of recommended, evidence-based eye care interventions to support country health care planning has not been available. To overcome this barrier, the World Health Organization (WHO) Package of Eye Care Interventions (PECI) has been developed. Objective: To describe the key outcomes of the PECI development. Evidence Review: A standardized stepwise approach that included the following stages: (1) selection of priority eye conditions by an expert panel after reviewing epidemiological evidence and health facility data; (2) identification of interventions and related evidence for the selected eye conditions from a systematic review of clinical practice guidelines (CPGs); stage 2 included a systematic literature search, screening of title and abstracts (excluding articles that were not relevant CPGs), full-text review to assess disclosure of conflicts of interest and affiliations, quality appraisal, and data extraction; (3) expert review of the evidence extracted in stage 2, identification of missed interventions, and agreement on the inclusion of essential interventions suitable for implementation in low- and middle-income resource settings; and (4) peer review. Findings: Fifteen priority eye conditions were chosen. The literature search identified 3601 articles. Of these, 469 passed title and abstract screening, 151 passed full-text screening, 98 passed quality appraisal, and 87 were selected for data extraction. Little evidence (≤1 CPG identified) was available for pterygium, keratoconus, congenital eyelid disorders, vision rehabilitation, myopic macular degeneration, ptosis, entropion, and ectropion. In stage 3, domain-specific expert groups voted to include 135 interventions (57%) of a potential 235 interventions collated from stage 2. After synthesis across all interventions and eye conditions, 64 interventions (13 health promotion and education, 6 screening and prevention, 38 treatment, and 7 rehabilitation) were included in the PECI. Conclusions and Relevance: This systematic review of CPGs for priority eye conditions, followed by an expert consensus procedure, identified 64 essential, evidence-based, eye care interventions that are required to achieve universal eye health coverage. The review identified some important gaps, including a paucity of high-quality, English-language CPGs, for several eye diseases and a dearth of evidence-based recommendations on eye health promotion and prevention within existing CPGs.

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

BACKGROUND: In 2021, WHO Member States endorsed a global target of a 40-percentage-point increase in effective refractive error coverage (eREC; with a 6/12 visual acuity threshold) by 2030. This study models global and regional estimates of eREC as a baseline for the WHO initiative. METHODS: The Vision Loss Expert Group analysed data from 565 448 participants of 169 population-based eye surveys conducted since 2000 to calculate eREC (met need/[met need + undermet need + unmet need]). A binary logistic regression model was used to estimate eREC by Global Burden of Disease (GBD) Study super region among adults aged 50 years and older. FINDINGS: In 2021, distance eREC was 79·1% (95% CI 72·4-85·0) in the high-income super region; 62·1% (54·7-68·8) in north Africa and Middle East; 49·5% (45·0-54·0) in central Europe, eastern Europe, and central Asia; 40·0% (31·7-48·2) in southeast Asia, east Asia, and Oceania; 34·5% (29·4-40·0) in Latin America and the Caribbean; 9·0% (6·5-12·0) in south Asia; and 5·7% (3·1-9·0) in sub-Saharan Africa. eREC was higher in men and reduced with increasing age. Global distance eREC increased from 2000 to 2021 by 19·0%. Global near vision eREC for 2021 was 20·5% (95% CI 17·8-24·4). INTERPRETATION: Over the past 20 years, distance eREC has increased in each super region yet the WHO target will require substantial improvements in quantity and quality of refractive services in particular for near vision impairment. FUNDING: WHO, Sightsavers, The Fred Hollows Foundation, Fondation Thea, Brien Holden Vision Institute, Lions Clubs International Foundation.

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

BACKGROUND: Cataract is the leading cause of blindness globally. Effective cataract surgical coverage (eCSC) measures the number of people in a population who have been operated on for cataract, and had a good outcome, as a proportion of all people operated on or requiring surgery. Therefore, eCSC describes service access (ie, cataract surgical coverage, [CSC]) adjusted for quality. The 74th World Health Assembly endorsed a global target for eCSC of a 30-percentage point increase by 2030. To enable monitoring of progress towards this target, we analysed Rapid Assessment of Avoidable Blindness (RAAB) survey data to establish baseline estimates of eCSC and CSC. METHODS: In this secondary analysis, we used data from 148 RAAB surveys undertaken in 55 countries (2003-21) to calculate eCSC, CSC, and the relative quality gap (% difference between eCSC and CSC). Eligible studies were any version of the RAAB survey conducted since 2000 with individual participant survey data and census population data for people aged 50 years or older in the sampling area and permission from the study's principal investigator for use of data. We compared median eCSC between WHO regions and World Bank income strata and calculated the pooled risk difference and risk ratio comparing eCSC in men and women. FINDINGS: Country eCSC estimates ranged from 3·8% (95% CI 2·1-5·5) in Guinea Bissau, 2010, to 70·3% (95% CI 65·8-74·9) in Hungary, 2015, and the relative quality gap from 10·8% (CSC: 65·7%, eCSC: 58·6%) in Argentina, 2013, to 73·4% (CSC: 14·3%, eCSC: 3·8%) in Guinea Bissau, 2010. Median eCSC was highest among high-income countries (60·5% [IQR 55·6-65·4]; n=2 surveys; 2011-15) and lowest among low-income countries (14·8%; [IQR 8·3-20·7]; n=14 surveys; 2005-21). eCSC was higher in men than women (148 studies pooled risk difference 3·2% [95% CI 2·3-4·1] and pooled risk ratio of 1·20 [95% CI 1·15-1·25]). INTERPRETATION: eCSC varies widely between countries, increases with greater income level, and is higher in men. In pursuit of 2030 targets, many countries, particularly in lower-resource settings, should emphasise quality improvement before increasing access to surgery. Equity must be embedded in efforts to improve access to surgery, with a focus on underserved groups. FUNDING: Indigo Trust, Peek Vision, and Wellcome Trust.

Acceptance and Perception of Artificial Intelligence Usability in Eye Care (APPRAISE) for Ophthalmologists: A Multinational Perspective.

Background: Many artificial intelligence (AI) studies have focused on development of AI models, novel techniques, and reporting guidelines. However, little is understood about clinicians' perspectives of AI applications in medical fields including ophthalmology, particularly in light of recent regulatory guidelines. The aim for this study was to evaluate the perspectives of ophthalmologists regarding AI in 4 major eye conditions: diabetic retinopathy (DR), glaucoma, age-related macular degeneration (AMD) and cataract. Methods: This was a multi-national survey of ophthalmologists between March 1st, 2020 to February 29th, 2021 disseminated via the major global ophthalmology societies. The survey was designed based on microsystem, mesosystem and macrosystem questions, and the software as a medical device (SaMD) regulatory framework chaired by the Food and Drug Administration (FDA). Factors associated with AI adoption for ophthalmology analyzed with multivariable logistic regression random forest machine learning. Results: One thousand one hundred seventy-six ophthalmologists from 70 countries participated with a response rate ranging from 78.8 to 85.8% per question. Ophthalmologists were more willing to use AI as clinical assistive tools (88.1%, n = 890/1,010) especially those with over 20 years' experience (OR 3.70, 95% CI: 1.10-12.5, p = 0.035), as compared to clinical decision support tools (78.8%, n = 796/1,010) or diagnostic tools (64.5%, n = 651). A majority of Ophthalmologists felt that AI is most relevant to DR (78.2%), followed by glaucoma (70.7%), AMD (66.8%), and cataract (51.4%) detection. Many participants were confident their roles will not be replaced (68.2%, n = 632/927), and felt COVID-19 catalyzed willingness to adopt AI (80.9%, n = 750/927). Common barriers to implementation include medical liability from errors (72.5%, n = 672/927) whereas enablers include improving access (94.5%, n = 876/927). Machine learning modeling predicted acceptance from participant demographics with moderate to high accuracy, and area under the receiver operating curves of 0.63-0.83. Conclusion: Ophthalmologists are receptive to adopting AI as assistive tools for DR, glaucoma, and AMD. Furthermore, ML is a useful method that can be applied to evaluate predictive factors on clinical qualitative questionnaires. This study outlines actionable insights for future research and facilitation interventions to drive adoption and operationalization of AI tools for Ophthalmology.

The WHO-ITU MyopiaEd Programme: A Digital Message Programme Targeting Education on Myopia and Its Prevention.

The objective of this paper is to provide an overview of the World Health Organization - International Telecommunication Union MyopiaEd programme - a digital message programme targeting education on myopia and its prevention. The development of the MyopiaEd programme included 4 key steps: (1) Conceptualization and consultation with experts in the field of myopia, mHealth and health behavior change; (2) Creation of SMS message libraries and programme algorithm; (3) Review of the message libraries to ensure relevance to the target audience; and (4) Pre-testing amongst end-user groups to ensure that the design of the programme and the message content were understandable. After reviewing the available evidence and considering input of the experts, the aims, end users and key themes of the programme were finalized. Separate SMS-adapted message libraries were developed, reviewed and pre-tested for four target end-user groups; (1) general population involved in the care of children (2) parents or caregivers of children with myopia; (3) adolescents with myopia; and (4) adults with myopia. The message libraries are part of a comprehensive toolkit, developed through a consultative process with experts in digital health, to support implementation within countries. The development of the MyopiaEd programme aims to provide a basis for Member States and other stakeholders to develop, implement and monitor large-scale mHealth programmes. It is aimed at raising awareness of good eye care behaviors and addressing common reasons for non-compliance to spectacle wear. The next steps will involve adapting and evaluating the MyopiaEd programme in selected settings.

A Systematic Review of Clinical Practice Guidelines for Cataract: Evidence to Support the Development of the WHO Package of Eye Care Interventions.

The World Health Organization (WHO) is developing a Package of Eye Care Interventions (PECI) to facilitate the integration of eye care into Universal Health Coverage. This paper presents the results of a systematic review of clinical practice guidelines for cataract in adults, to help inform PECI development. We searched academic and guideline databases, and websites of professional associations, for guidelines published between January 2010 and April 2020. Guidelines were excluded if there was commercial funding or unmanaged conflicts of interest. Quality appraisal was conducted using the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool. We identified 3778 reports, 35 related to cataract guidelines, four of which met the inclusion criteria (United Kingdom: 2, United States: 1, Iran: 1). The recommendations across the four guidelines covered pre-operative (43%), intra-operative (37%), and post-operative interventions (20%). Most 'strong' recommendations were supported by good quality evidence. Differences in recommendations across guidelines may be attributable to time of publication or regional differences in surgical practice. Few guidelines met the quality criteria, and only three countries were represented. The results of this step of the PECI development process will inform subsequent phases for development of the WHO's package of evidence-based eye care interventions for cataract.

A systematic review of clinical practice guidelines for myopic macular degeneration.

Background: Myopic macular degeneration (MMD) is a primary cause of blindness and visual impairment in many parts of the world. A review of clinical practice guidelines (CPGs) for intervention selection are required with the increasing demand for MMD management in clinical practice as well as in national health services. Therefore, we aim to systematically review CPGs for MMD and assist the recommendations development of the Package of Eye Care Interventions (PECI) program of the World Health Organization. Methods: A systematic review of CPGs published on MMD between 2010 and April 2020 was conducted. Guidelines were evaluated using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool. Cochrane systematic reviews were also included when the evidence from included CPGs were inadequate or contradict. Results: After applying exclusion criteria and conducting the quality appraisal, two CPGs were finally included. The average of the AGREE II ratings for the identified Guidelines were 56 and 63 respectively (7 for each item). To provide further information on interventions for MMD, one Cochrane review on MMD was additionally identified and included in the study. Intravitreal anti-vascular endothelial growth factor (anti-VEGF) drugs were recommended for patients with myopic choroidal neovascularization (mCNV) as first-line therapy to improve vision and reduce central macular thickness, and ranibizumab showed significant effectiveness compared to photodynamic therapy (PDT). PDT was recommended to be performed in those resistant to the treatment by one CPG but lacked of adequate description and support. Data extracted from the Cochrane systematic reviews indicated that anti-VEGF therapy for mCNV had significant effectiveness in improving visual acuity and reducing CMT compared to PDT with moderate to low certainty of evidence. Ranibizumab and bevacizumab were considered as equally effective with moderate certainty. Conclusions: The outcomes of this review suggest that high quality clinical practice guidelines for MMD management are limited. Intravitreal injection of anti-VEGF agents was recommended as an effective intervention to treat myopic CNV as the first-line treatment, while there was inadequate guidance for the application of PDT in myopic CNV management. The use of other interventions for MMD were not recommended at this time and additional evidence is called for.

A systematic review of clinical practice guidelines for childhood glaucoma.

OBJECTIVE: To conduct a systematic review to identify and critically appraise clinical practice guidelines on the assessment, diagnosis and management of childhood glaucoma. METHODS AND ANALYSIS: A systematic literature search of databases and professional websites for clinical practice guidelines published on eye conditions between 2010 and April 2020 in English was conducted. Identified guidelines were screened for relevance to childhood glaucoma and exclusion criteria applied. Guidelines that passed the screening and quality appraisal with the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool and, if they achieved a mean score of ≥45 and ≥3 on subsets of 9 and 5 AGREE II items, respectively, were selected for inclusion and data extracted using a standardised form. RESULTS: Following screening and critical appraisal, three guidelines were included for data extraction. None of the three guidelines was specifically developed for childhood glaucoma. A consistent recommendation was that children should undergo some form of eye screening examination or a comprehensive eye assessment to detect paediatric eye disease. Children at high risk of childhood glaucoma should undergo additional screening. One clinical practice guideline recommended interventions for childhood glaucoma consisting of tube surgery and topical beta-blockers or carbonic anhydrase inhibitors. Recommended interventions for childhood glaucoma were based on low-quality to moderate-quality evidence or expert opinion. CONCLUSION: Based on our selection criteria, we did not identify any high-quality clinical practice guidelines specifically targeted at childhood glaucoma. This is compounded by the lack of high-quality evidence on childhood glaucoma.

Identification and critical appraisal of evidence for interventions for refractive error to support the development of the WHO package of eye care interventions: a systematic review of clinical practice guidelines.

PURPOSE: The World Health Organization is developing a Package of Eye Care Interventions (PECI) to support the integration of eye health care into national health programmes. Interventions included in the PECI should be based on robust evidence where available. Refractive error is a leading cause of blindness and vision impairment and is a PECI priority condition. The aim of this study was to provide high-quality evidence to support the development of the PECI by identifying and critically appraising clinical practice guidelines (CPGs), and extracting recommendations for refractive error interventions. METHODS: We searched for CPGs on refractive error published in the last 10 years. We conducted the searches initially in February and March 2019 and repeated them in March 2020. We evaluated the quality of potentially relevant guidelines using the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool. RESULTS: We identified 12 high-quality CPGs relevant to refractive error, written by six organisations from three high-income countries. Organisations used a variety of frameworks to assess the strength of recommendations based on available evidence, with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) being most common. Vision screening for children aged 3 to 5 years was recommended consistently. Evidence for screening and eye evaluations at other ages was weaker, although ophthalmic professional organisations consistently recommended regular evaluations. Recommendations on optical and laser correction of refractive error were limited and did not consider implications for low resource settings. Interventions for slowing myopia progression in children were recommended, but these will need regular updating as new evidence emerges. CONCLUSIONS: Current high-quality guidelines on refractive error have been formulated in high-income countries. Recommendations focused on prevention and treatment of refractive error in low-and middle-income countries are lacking. Regular updating of systematic reviews and CPGs is essential to ensure that robust evidence is promptly appraised and incorporated into recommendations for eye health care practitioners.

Clinical Practice Guidelines for the Detection and Treatment of Amblyopia: A Systematic Literature Review.

PURPOSE: The World Health Organization's Package of Eye Care Interventions (PECI) aims to support incorporation of amblyopia detection and treatment into health service provision. The aim of this study was to systematically review clinical practice guidelines (CPGs) for amblyopia to inform the development of this package. METHODS: MEDLINE, Embase, CINAHL and Global Index Medicus databases, guideline databases and professional body websites were searched for CPGs published in English between 2010 and 9th March 2020. Guidelines were assessed using the AGREE II tool. RESULTS: Five CPGs from North America published between 2017-2019 were identified. One CPG provided recommendations on amblyopia treatment and four focused on amblyopia detection and assessment. Non-specialist screening for amblyopic risk factors was recommended in children aged 3-5 years. At least one comprehensive eye examination was recommended for infants and children aged 0-5 years. Treatment recommendations consisted of refractive correction followed by occlusion or cycloplegic penalization. CONCLUSIONS: Additional evidence is required to compare the benefits and limitations of comprehensive eye examinations for asymptomatic children to those from screening programs. Identified CPGs were produced in high-resource countries and may not be readily applied in lower resource settings where the PECI has the greatest potential to improve service provision.

A Systematic Review of Clinical Practice Guidelines for Infectious and Non-infectious Conjunctivitis.

PURPOSE: To systematically review and critically appraise clinical practice guidelines (CPGs) and summarise the recommendations for non-infectious and infectious conjunctivitis. METHODS: CPGs published on non-infectious and infectious conjunctivitis between 2010 and March 2020 were reviewed, evaluated, and selected using nine items from the Appraisal of Guidelines for Research and Evaluation II tool (4, 7, 8, 10, 12, 13, 15, 22 and 23). CPGs with an average score for items 4, 7, 8, 12, or 22 below 3 and/or a sum of the two researchers' average score for all nine items less than 45 were excluded. Two authors independently extracted and validated the data using standardised forms. RESULTS: Fifteen CPGs from five sources remained for data extraction. CPGs consistently recommended non-pharmacological interventions (artificial tears, cold compress, avoidance or removal of allergens) for non-infectious conjunctivitis and pharmacological interventions (topical anti-histamine, mast-cell stabiliser and dual-acting agent) for allergy types. Observation without treatment was strongly recommended for non-herpetic viral and bacterial infections. Systemic and topical anti-viral was consistently recommended for herpetic viral conjunctivitis, while systemic and topical antibiotics were recommended for chlamydial and gonorrhoeal conjunctivitis. The methods used to assess the level of evidence and the strength of recommendation varied among CPGs. CONCLUSIONS: There are a number of high-quality CPGs for non-infectious and infectious conjunctivitis. While there were a number of consistencies in the recommendations provided within these CPGs, several inconsistencies were also identified. Many of which related to the scope of practise of the targeted end-user of the particular guideline.