Strategies to address inequity of uncorrected refractive error in the Western Pacific: A modified Delphi process.

PURPOSE: Uncorrected refractive error is the leading cause of vision impairment globally; however, little attention has been given to equity and access to services. This study aimed to identify and prioritise: (1) strategies to address inequity of access to refractive error services and (2) population groups to target with these strategies in five sub-regions within the Western Pacific. METHODS: We invited eye care professionals to complete a two-round online prioritisation process. In round 1, panellists nominated population groups least able to access refractive error services, and strategies to improve access. Responses were summarised and presented in round 2, where panellists ranked the groups (by extent of difficulty and size) and strategies (in terms of reach, acceptability, sustainability, feasibility and equity). Groups and strategies were scored according to their rank within each sub-region. RESULTS: Seventy five people from 17 countries completed both rounds (55% women). Regional differences were evident. Indigenous peoples were a priority group for improving access in Australasia and Southeast Asia, while East Asia identified refugees and Oceania identified rural/remote people. Across the five sub-regions, reducing out-of-pocket costs was a commonly prioritised strategy for refraction and spectacles. Australasia prioritised improving cultural safety, East Asia prioritised strengthening school eye health programmes and Oceania and Southeast Asia prioritised outreach to rural areas. CONCLUSION: These results provide policy-makers, researchers and funders with a starting point for context-specific actions to improve access to refractive error services, particularly among underserved population groups who may be left behind in existing private sector-dominated models of care.

Building a national eye-care service in post-conflict Timor-Leste.

PROBLEM: Violent conflict left Timor-Leste with a dismantled health-care workforce and infrastructure after 2001. The absence of existing health and tertiary education sectors compounded the challenges of instituting a national eye-care system. APPROACH: From 2001, the East Timor Eye Program coordinated donations and initially provided eye care through visiting teams. From 2005, the programme reoriented to undertake concerted workforce and infrastructure development. In 2008 full-time surgical services started in a purpose-built facility in the capital city. In 2014 we developed a clinical training pipeline for local medical graduates to become ophthalmic surgeons, comprising a local postgraduate diploma, with donor funding supporting master's degree studies abroad. LOCAL SETTING: In the population of 1.26 million, an estimated 35 300 Timorese are blind and an additional 123 500 have moderate to severe visual impairment, overwhelmingly due to cataract and uncorrected refractive error. RELEVANT CHANGES: By April 2018, six Timorese doctors had completed the domestic postgraduate diploma, three of whom had enrolled in master's degree programmes. Currently, one consultant ophthalmologist, seven ophthalmic registrars, two optometrists, three refractionists and four nursing staff form a tertiary resident ophthalmic workforce, supported by an international advisor ophthalmologist and secondary eye-care workers. A recorded 12 282 ophthalmic operations and 117 590 consultations have been completed since 2001. LESSONS LEARNT: International organizations played a pivotal role in supporting the Timorese eye health system, in an initially vulnerable setting. We highlight how transition to domestic funding can be achieved through the creation of a domestic training pipeline and integration with national institutions.

An estimation of the prevalence of diabetes mellitus and diabetic retinopathy in adults in Timor-Leste.

BACKGROUND: Once considered an affliction of people in high-income countries, diabetes mellitus is increasingly seen as a global epidemic. However, for many countries very little is known about the prevalence of diabetes and its complications. This study aims to estimate the prevalence of diabetes, and diabetic retinopathy, in adults in Timor-Leste. METHODS: From March 2013 to May 2014, adult patients being assessed for cataract surgery at the Sentru Matan Nasional (National Eye Centre) in Dili, Timor-Leste had a point-of-care HbA1c measurement performed on the DCA Vantage device (Siemens Ltd) under a quality framework. A diagnostic cut-off of 6.5% (48 mmol/mol) HbA1c was used for diagnosis of diabetes. Ocular examination, blood pressure, demographic and general health data were also collected. Diabetic retinopathy assessment was carried out by ophthalmologists. RESULTS: A total of 283 people [mean age 63.6 years (range 20-90 years)] were tested and examined during the study period. Forty-three people (15.2%) were found to have diabetes, with a mean HbA1c of 9.5% (77 mmol/mol). Of these, 27 (62.9%) were newly diagnosed, with a mean HbA1c of 9.7% (83 mmol/mol) and a range of 6.6-14% (49-130 mmol/mol). Nearly half (48.1%) of people newly diagnosed with diabetes had an HbA1c over 10.0% (86 mmol/mol). Of those with known diabetes, only 68.8% were receiving any treatment. Mean HbA1c for treated patients was 9.9% (85 mmol/mol). Diabetic retinopathy was identified in 18.6% of people with diabetes, of whom half had no previous diagnosis of diabetes. CONCLUSIONS: This study estimates the prevalence of diabetes at 15% in adults in Timor-Leste, a substantial proportion of whom have evidence of diabetic retinopathy. This is consistent with regional estimates. With the majority of patients undiagnosed, and management of people known to have diabetes largely inadequate, point-of-care testing is a valuable tool to assist with diabetes case detection and management. Whilst only a preliminary estimate, our data provides important impetus for further investigation of the prevalence and impact of diabetes in Timor-Leste. It provides guidance that further investment is required in expanding testing, as well as in prevention and treatment.