The Better Operative Outcomes Software Tool (BOOST) Prospective Study: Improving the Quality of Cataract Surgery Outcomes in Low-Resource Settings.

PURPOSE: Post-operative vision impairment is common among patients who have undergone cataract surgery in low-resource settings, impacting quality of clinical outcomes and patient experience. This prospective, multisite, single-armed, pragmatic validation study aimed to assess whether receiving tailored recommendations via the free Better Operative Outcomes Software Tool (BOOST) app improved surgical outcomes, as quantified by post-operative unaided distance visual acuity (UVA) measured 1-3 days after surgery. METHODS: During the baseline data collection round, surgeons in low and middle-income countries recorded clinical characteristics of 60 consecutive cataract cases in BOOST. Additional data on the causes of poor outcomes from 20 consecutive cases with post-operative UVA of <6/60 (4-12 weeks post-surgery) were entered to automatically generate tailored recommendations for improvement, before 60 additional consecutive cases were recorded during the follow-up study round. Average UVA was compared between cases recorded in the baseline study round and those recorded during follow-up. RESULTS: Among 4,233 cataract surgeries performed by 41 surgeons in 18 countries, only 2,002 (47.3%) had post-operative UVA 6/12 or better. Among the 14 surgeons (34.1%) who completed both rounds of the study (1,680 cases total), there was no clinically significant improvement in post-operative average UVA (logMAR units ±SD) between baseline (0.50 ± 0.37) and follow-up (0.47 ± 0.36) rounds (mean improvement 0.03, p = 0.486). CONCLUSIONS: Receiving BOOST-generated recommendations did not result in improved UVA beyond what could be expected from prospective monitoring of surgical outcomes alone. Additional research is required to assess whether targeted support to implement changes could potentiate the uptake of app-generated recommendations and improve outcomes.

Assessment of Causality Between Diet-Derived Antioxidants and Primary Open-Angle Glaucoma: A Mendelian Randomization Study.

Purpose: This study aimed to investigate the genetic causal relationships among diet-derived circulating antioxidants, primary open-angle glaucoma (POAG), and glaucoma-related traits using two-sample Mendelian randomization (MR). Methods: Genetic variants associated with diet-derived circulating antioxidants (retinol, ascorbate, ß-carotene, lycopene, α-tocopherol, and γ-tocopherol) were assessed as absolute and metabolic instrumental variables. POAG and glaucoma-related traits data were derived from a large, recently published genome-wide association study database; these traits included intraocular pressure (IOP), macular retinal nerve fiber layer (mRNFL) thickness, macular ganglion cell-inner plexiform layer (mGCIPL) thickness, and vertical cup-to-disc ratio (vCDR). MR analyses were performed per outcome for each exposure. Results: We found no causal association between six diet-derived antioxidants and POAG using the International Glaucoma Genetics Consortium data. For absolute antioxidants, the odds ratios (ORs) ranged from 1.011 (95% confidence interval [CI], 0.854-1.199; P = 0.895) per natural log-transformed ß-carotene to 1.052 (95% CI, 0.911-1.215; P = 0.490) for 1 µmol/L of ascorbate. For antioxidant metabolites, the OR ranged from 0.998 (95% CI, 0.801-1.244; P = 0.989) for ascorbate to 1.210 (95% CI, 0.870-1.682; P = 0.257) for γ-tocopherol, using log-transformed levels. A similar result was obtained with the FinnGen Biobank. Furthermore, our results showed no significant genetic association between six diet-derived antioxidants and glaucoma-related traits. Conclusions: Our study did not support a causal association among six diet-derived circulating antioxidants, POAG, and glaucoma-related traits. This suggests that the intake of antioxidants may not have a preventive effect on POAG and offers no protection to retinal nerve cells. Translational Relevance: This study provides valid evidence regarding the use of diet-derived antioxidants for glaucoma patients.

Barriers to uptake of cataract surgery among elderly patients in rural China: a cross-sectional study.

OBJECTIVE: To investigate factors that differentiate elderly adults in rural China who accept free vision screening and cataract surgery from those who could benefit from vision care but refuse it when offered. DESIGN: We conducted a population-based, cross-sectional study between October and December 2016. Logistic regression models were used to examine the predictors of accepting free vision screening and cataract surgery. SETTING: Rural communities in Handan, China. PARTICIPANTS: Adults aged 50 years or older, with presenting visual acuity ≤6/18 in the better seeing eye, suspected by examining ophthalmologist to be due to cataract. RESULTS: Among 613 persons with cataract identified on a population basis, 596 (97.2%) completed the household survey (mean (SD) age, 71.5 (10.0) years; 79.8% female). A total of 214 persons (35.9%) refused participation, while 382 (64.1%) took part in the vision screening. A total of 193 (50.5%) participants were found eligible for surgery, while 189 (49.5%) were not. Among 99 randomly selected participants who were offered immediate free surgery, surgery was accepted by 77 participants (77.8%) and refused by 22 (22.2%). In the multivariate model, being engaged in income-generating activities (p<0.01), self-reported better physical capacity (p<0.001) and having had a recent physical examination (p=0.01) were significantly associated with acceptance of vision screening. The only variable significantly associated with acceptance of surgery was presenting visual acuity, with better vision inversely associated with acceptance of surgery (p<0.05) models. CONCLUSION: Our results suggest that refusal of basic eye examinations may be at least as important a determinant of low surgical rates in rural China as lack of acceptance of surgery itself.

Impact of Vision Impairment and Ocular Morbidity and Their Treatment on Quality of Life in Children: A Systematic Review.

TOPIC: This review summarizes existing evidence of the impact of vision impairment and ocular morbidity and their treatment on children's quality of life (QoL). CLINICAL RELEVANCE: Myopia and strabismus are associated with reduced QoL among children. Surgical treatment of strabismus significantly improves affected children's QoL. METHODS: We conducted a systematic review and meta-analysis by screening articles in any language in 9 databases published from inception through August 22, 2022, addressing the impact of vision impairment, ocular morbidity, and their treatment on QoL in children. We reported pooled standardized mean differences (SMDs) using random-effects meta-analysis models. Quality appraisal was performed using Joanna Briggs Institute and National Institutes of Health tools. This study was registered with the International Prospective Register of Systematic Reviews (identifier, CRD42021233323). RESULTS: Our search identified 29 118 articles, 44 studies (0.15%) of which were included for analysis that included 32 318 participants from 14 countries between 2005 and 2022. Seventeen observational and 4 interventional studies concerned vision impairment, whereas 10 observational and 13 interventional studies described strabismus and other ocular morbidities. Twenty-one studies were included in the meta-analysis. The QoL scores did not differ between children with and without vision impairment (SMD, -1.04; 95% confidence interval [CI], -2.11 to 0.03; P = 0.06; 9 studies). Myopic children demonstrated significantly lower QoL scores than those with normal vision (SMD, -0.60; 95% CI, -1.09 to -0.11; P = 0.02; 7 studies). Children with strabismus showed a significantly lower QoL score compared with those without (SMD, -1.19; 95% CI, -1.66 to -0.73; P < 0.001; 7 studies). Strabismus surgery significantly improved QoL in children (SMD, 1.36; 95% CI, 0.48-2.23; P < 0.001; 7 studies). No randomized controlled trials (RCTs) concerning refractive error and QoL were identified. Among all included studies, 35 (79.5%) were scored as low to moderate quality; the remaining met all quality appraisal tools criteria. DISCUSSION: Reduced QoL was identified in children with myopia and strabismus. Surgical correction of strabismus improves the QoL of affected children, which supports insurance coverage of strabismus surgery. Further studies, especially RCTs, investigating the impact of correction of myopia on QoL are needed. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Six-Year Change in Cataract Surgical Coverage and Postoperative Visual Outcomes in Rural Southern China: The Yangxi Eye Study.

PURPOSE: The purpose of this study was to investigate a 6-year change in cataract surgical coverage (CSC), effective cataract surgical coverage (eCSC), and visual outcomes in an elderly population in rural southern China. DESIGN: This is a prospective population-based study with a 6-year follow-up. METHODS: The study included rural residents aged 50 years and above in southern China with comprehensive eye examinations at baseline and follow-up in 2014 and 2020, respectively. RESULTS: Five thousand six hundred thirty-eight participants underwent baseline examinations (mean age 66.1±10.2 y, 50.8% women); and 3141 (64.9%) of 4841 eligible survivors attended the 6-year follow-up. Cataract surgical coverage was 41.7% and 40.6% at baseline and follow-up, respectively, while eCSC were 32.6% and 26.6%. In multivariate models, the 6-year likelihood of cataract surgery decreased with older age [odds ratio (OR)=0.97 per year, 95% confidence interval (CI): 0.94, 0.99, P =0.012] and worse baseline presenting uncorrected visual acuity (PVA) in the worse-seeing eye (OR=0.35 per unit logarithm of the minimum angle of resolution (logMAR), 95% CI: 0.25, 0.48, P <0.001), and increased with prior cataract surgical history at baseline (OR=3.88, 95% CI: 1.91, 7.09, P <0.001). The likelihood of receiving effective cataract surgery decreased with worse baseline PVA in the worse eye (OR=0.49 per unit logMAR, 95% CI: 0.24, 0.97, P =0.042) and better-seeing eye (OR=0.68 per unit logMAR, 95% CI: 0.48, 0.95, P =0.026). Posterior capsular opacification was the main reason for PVA <6/18, reporting it in logMAR (0.5) in operated eyes (38.4% at baseline; 28.1% at follow-up). CONCLUSIONS: World Health Organization has established a global target of increasing eCSC by 30% before 2030, but no increase was found in rural southern China between 2014 and 2020, let alone reaching the World Health Organization target of 56.3%. Strategies to improve surgery incidence should focus on older persons and those with worse preoperative PVA.

Impact of Cataract Surgery on Income in Rural Southern China: The SUCCESS Randomized Controlled Trial.

PURPOSE: Visual impairment from cataracts is closely associated with low income, but trial evidence regarding the impact of surgery on income is lacking. We investigated whether cataract surgery could increase personal income. DESIGN: A 2-arm, parallel-group, open-label, randomized controlled trial (ClinicalTrials.gov, NCT03020056). METHODS: Persons aged 50 years or older in rural Guangdong, China, with best-corrected visual acuity <6/19 in both eyes due to cataracts were randomly assigned (1:1) to receive surgery within 4 weeks (intervention group), or 1 year later (control group). All participants were interviewed at baseline and end-line regarding demographic characteristics, income, and quality of life. RESULTS: Among the 292 eligible persons (5.40%, mean age = 74.0 y, 61.0% women) randomly assigned to intervention (n = 146) or control (n = 146) groups, 12 participants (8.22%) in the intervention group and 1 (0.68%) in the control did not receive the allocated intervention. By study closeout, 18 participants (6.16%) were lost to follow-up. The mean 1-year income increase of the intervention group ($2469-$3588; change = $1119) was significantly larger than that of the controls ($2258-$2052; change = $-206), a between-group difference of $1325 (relative increase = 54.0%; 95% CI = $739 to $1911; P < 0.001). In multivariable modeling, intervention group membership was associated with greater income increase (ß = 1143.2; 95% CI = 582.0 to 1704.3; P < 0.001). Greater improvement in best-corrected visual acuity was associated with income increase in univariable modeling (ß = 1626.9; 95% CI = 1083.6 to 2170.1; P < 0.001). CONCLUSIONS: Cataract surgery substantially increases personal income in rural China, offering a strategy for poverty alleviation. The strong association between increased income and change in visual acuity enhances the biological plausibility of the result.

Glaucoma Treatment Patterns in Sub-Saharan Africa.

PRCIS: Physicians were most likely to recommend primary medical therapy upon diagnosis of glaucoma. Laser therapy was underutilized where they were available. Physicians were more likely to recommend surgery in severe glaucoma, laser therapy in mild glaucoma, while recommendation of medical therapy did not depend on glaucoma severity. PURPOSE: To characterize treatment patterns for newly diagnosed glaucoma in sub-Saharan Africa (SSA). METHODS: This was a multicenter cross-sectional study of adults newly diagnosed with glaucoma at 27 eye care centers in 10 African countries. In addition to demographic and clinical data, physician treatment recommendations (medication, laser, surgery, or no treatment) were recorded. Statistical analyses were performed using STATA version 14.0. RESULTS: Data from 1201 patients were analyzed. Physicians were most likely to recommend primary medical therapy upon diagnosis of glaucoma (69.4%), with laser (13.2%), surgery (14.9%), and no treatment (2.5%) recommended to the remaining patients. All sites had medical therapy available and most (25/27, 92.6%) could provide surgical treatment; only 16/27 (59.3%) sites offered laser, and at these sites, 30.8% of eyes were recommended to undergo primary laser procedures. As glaucoma severity increased, the laser was recommended less, surgery more, and medications unchanged. Patient acceptance of medical therapy was 99.1%, laser 88.3%, and surgery 69.3%. CONCLUSIONS: Medical therapy for first-line glaucoma management is preferred by most physicians in SSA (69%). Laser therapy may be underutilized at centers where it is available. These findings underscore the need for comparative studies of glaucoma treatments in SSA to inform the development of evidence-based treatment guidelines and of programs to reduce glaucoma blindness in SSA. Strategic approaches to glaucoma therapy in SSA must address the question of whether medical therapy is the most optimal first-line approach in this setting.

Patterns and determinants of incident cataract surgery in China from 2011 to 2015 using a nationally representative longitudinal database.

OBJECTIVES: To investigate incident cataract surgery and to investigate determinants of cataract surgery uptake in Chinese adults. DESIGN: This nationally representative longitudinal study recorded self-reported incident cataract surgery, and measured biological, clinical and socioeconomical characteristics at baseline and endline. SETTING: In the first stage, 150 county-level units were randomly chosen with a probability-proportional-to-size sampling technique from a sampling frame containing all county-level units. The sample was stratified by region and within region by urban district or rural county and per capita gross domestic product. The final sample of 150 counties fell within 28 provinces of China. PARTICIPANTS: Urban and rural Chinese persons aged 45 years and older. PRIMARY AND SECONDARY OUTCOME MEASURES: Incident cataract surgery (primary outcome) and the factors associated with incident cataract surgery (secondary outcome). RESULTS: Among 16 663 people enrolled in 2011, 13 705 (82.2%) attended follow-up in 2015. Among these, 167 (1.22%) reported incident cataract surgery. Those receiving surgery were significantly older (66.2±8.79 vs 58.3±9.18, p≤0.001) and more likely to report: illiteracy (44.9% vs 27.1%, p<0.001), poor baseline distance vision (49.7% vs 20.0%, p≤0.001), poor baseline near vision (37.1% vs 21.8%, p≤0.001), baseline visual impairment (15.6% vs 5.5%, p≤0.001), diabetes (12.0% vs 7.42%, p≤0.05) and higher baseline depression scores (9.7 vs 8.4 on a scale of 0-30, p≤0.05). In linear regression models, older age, worse distance vision, hypertension or diabetes, illiteracy and lower depression score were significantly associated with undergoing surgery. Results were similar in models including only persons aged ≥60 years, except that urban residence was also associated with surgery. When only those aged ≥60 years with poor vision were included, results were again the same, except that higher household expenditure was also associated with surgery. CONCLUSIONS: In China, cataract surgical rates remain low; underserved groups such as rural dwellers are less likely to receive cataract surgery.

Prevalence of self-reported chronic conditions and poor health among older adults with and without vision impairment in China: a nationally representative cross-sectional survey.

OBJECTIVE: To examine the self-reported prevalence of 13 chronic conditions and poor health among Chinese adults aged 45 years and older with and without self-reported vision impairment. DESIGN: Cross-sectional study from the China Health and Retirement Longitudinal Study 2018, a nationally representative survey of Chinese adults aged 45 years and older involving 19 374 participants. METHODS: We used logistic regression to assess the association between vision impairment and 13 common chronic conditions and between vision impairment and poor health for those with any of these chronic conditions. RESULTS: Older people with self-reported vision impairment were significantly more likely to report all 13 chronic conditions (all p<0·05). After controlling for age, gender, education, residential status (rural vs urban), smoking and BMI, the highest adjusted odds were for hearing impairment (OR=4.00 (95% CI 3·60 to 4·44]) and depression (OR=2.28 (95% CI 2.06 to 2.51)). The lowest risk, though still significant, was for diabetes (OR=1·33 (95% CI 1.11 to 2.05)) and hypertension (OR=1.20 (95% CI 1.04 to 1.38)). After controlling for these potential confounding factors, among older people with chronic conditions, those with vision impairment were 2.20 to 4.04 times more likely to have poor health, compared with those without vision impairment (all p<0.001), with the exception of cancer (p=0.595). CONCLUSIONS: Higher prevalence of chronic conditions is strongly associated with vision impairment among older Chinese adults and poor health is strongly associated with vision impairment among people with chronic conditions.

Direct selective laser trabeculoplasty in open angle glaucoma study design: a multicentre, randomised, controlled, investigator-masked trial (GLAUrious).

INTRODUCTION: Laser trabeculoplasty is an effective and widely used treatment for glaucoma. A new laser technology, the Eagle direct selective laser trabeculoplasty (DSLT) device, may provide automated, fast, simple, safe and effective laser treatment for glaucoma in a broader range of clinical settings. This trial aims to test the hypothesis that translimbal DSLT is effective and not inferior to selective laser trabeculoplasty (SLT) in reducing intraocular pressure (IOP) in open angle glaucoma (OAG). METHODS AND ANALYSIS: This is a multicentre, randomised, controlled, investigator-masked study. The primary efficacy outcome is intergroup difference in mean change from baseline IOP measured at 6 months. Secondary outcomes include mean percentage reduction in IOP at 3, 6 and 12 months; proportion of participants with at least 20% reduction in IOP from baseline at 6 months; change in ocular hypotensive medications at 12 months and evaluation of safety. Participants were aged >= 40 years with OAG, including exfoliative or pigmentary glaucoma, or ocular hypertension with untreated or washed out IOP 22-35 mm Hg. TREATMENTS: DSLT: 120 shots, 3 ns, 400 µm spot size, energy 1.4-1.8 mJ delivered at the limbus over 2 s. SLT: approximately 100 shots, 3 ns, 400 µm spot size administered 360 degrees at the limbus using any gonioscopy lens, energy 0.3-2.6 mJ. A sample size of 164 is sufficient to detect a non-inferiority margin of 1.95 mm Hg for change from baseline IOP. CLINICAL TRIAL REGISTRATION NUMBER: NCT03750201, ISRCTN14033075.

Longitudinal associations between self-reported vision impairment and all-cause mortality: a nationally representative cohort study among older Chinese adults.

OBJECTIVE: To compare the effects of pre-existing and new self-reported vision impairment (VI), and its correction, on all-cause mortality among Chinese adults aged 45 years and older. METHODS: We used four waves of data from the China Health and Retirement Longitudinal Study. Our analytical cohort consists of 15 808 participants aged 45 years and older with an average follow-up of 6.4 years. Exposures included pre-existing self-reported VI and vision correction (time-independent exposures), new self-reported VI and vision correction (time-dependent exposures). Outcomes were measured as the risk of all-cause mortality and the risk stratification for pre-specified factors. RESULTS: Compared with participants with normal vision, all-cause mortality was higher among those with pre-existing self-reported VI (crude HR (cHR)=1.29, 95% CI: 1.17 to 1.44; adjusted HR (aHR)=1.22, 95% CI: 1.09 to 1.37) and new self-reported VI (cHR=1.42, 95% CI: 1.28 to 1.58; aHR=1.36, 95% CI: 1.21 to 1.51). Mortality risk was lower among those with high school or higher education. Participants who were wearing eyeglasses/contact lenses or had cataract surgery at baseline did not have significantly higher all-cause mortality (eyeglasses: aHR=0.82, 95% CI: 0.65 to 1.02; cataract surgery: aHR=1.12, 95% CI: 0.74 to 1.69) compared with participants with normal vision. The same was true among participants with new correction of self-reported VI (glasses: aHR=1.01, 95% CI: 0.78 to 1.24; cataract surgery: aHR=0.95, 95% CI: 0.68 to 1.31). CONCLUSIONS: Both pre-existing and new self-reported VI increase all-cause mortality among Chinese adults aged 45 years and older, though visual correction reduces this risk.

Minimally Invasive Glaucoma Surgery in Primary Angle-Closure Glaucoma.

Primary angle-closure glaucoma (PACG) is responsible for half of the glaucoma-related blindness worldwide. Cataract surgery with or without trabeculectomy has been considered to be the first-line treatment in eyes with medically uncontrolled PACG. While minimally invasive glaucoma surgery has become an important surgical approach for primary open-angle glaucoma, its indications and benefits in PACG are less clear. This review summarizes the efficacy and safety profile of minimally invasive glaucoma surgery in PACG to unfold new insights into the surgical management of PACG.

Impact of Vision Impairment and Ocular Morbidity and Their Treatment on Depression and Anxiety in Children: A Systematic Review.

TOPIC: This systematic review and meta-analysis summarizes existing evidence to establish whether vision impairment, ocular morbidity, and their treatment are associated with depression and anxiety in children. CLINICAL RELEVANCE: Understanding and quantifying these associations support early detection and management of mental health symptoms in children with vision impairment and ocular morbidity. Additionally, this review provides evidence in favor of insurance coverage for timely strabismus surgery. METHODS: We searched 9 electronic databases from inception through February 18, 2021, including observational and interventional studies assessing whether vision impairment, ocular morbidity, or both and their treatment are associated with depression, anxiety, or both in children. We used narrative synthesis and meta-analysis with the residual maximum likelihood method. A protocol was registered and published on The International Prospective Register of Systematic Reviews (identifier: CRD42021233323). RESULTS: Among 28 992 studies, 28 956 studies (99.9%) were excluded as duplicates or unrelated content. Among 36 remaining studies, 21 studies (58.3%) were observational studies concerning vision impairment, 8 studies (22.2%) were observational studies concerning strabismus, and 7 studies (19.4%) were interventional studies. Vision impaired children demonstrated significantly higher scores of depression (standard mean difference [SMD], 0.57; 95% confidence interval [CI], 0.26-0.89; 11 studies) and anxiety (SMD, 0.62; 95% CI, 0.40-0.83; 14 studies) than normally sighted children. In particular, children with myopia demonstrated higher scores of depression (SMD, 0.58; 95% CI, 0.36-0.81; 6 studies) than normally sighted children. Strabismus surgery significantly improved symptoms of depression (SMD, 0.59; 95% CI, 0.12-1.06; 3 studies) and anxiety (SMD, 0.69; 95% CI, 0.25-1.14; 4 studies) in children. CONCLUSION: Among children, vision impairment is associated with greater symptoms of depression and anxiety. Surgical treatment of strabismus improved these symptoms. Further randomized controlled trials exploring the impact of public health measures for myopia correction on mental health in children are needed. Scaling up access to strabismus surgery could improve the mental health of affected children.

Outreach screening to address demographic and economic barriers to diabetic retinopathy care in rural China.

IMPORTANCE: Poor access to existing care for diabetic retinopathy (DR) limits effectiveness of proven treatments. OBJECTIVES: We examined whether outreach screening in rural China improves equity of access. DESIGN, SETTING AND PARTICIPANTS: We compared prevalence of female sex, age > = 65 years, primary education or below, and requiring referral care for DR between three cohorts with diabetes examined for DR in neighboring areas of Guangdong, China: passive case detection at secondary-level hospitals (n = 193); persons screened during primary-level DR outreach (n = 182); and individuals with newly- or previously-diagnosed diabetes in a population survey (n = 579). The latter reflected the "ideal" reach of a screening program. RESULTS: Compared to the population cohort, passive case detection reached fewer women (50·8% vs. 62·3%, p = 0·006), older adults (37·8% vs. 51·3%, p < 0·001), and less-educated persons (39·9% vs. 89·6%, p < 0·001). Outreach screening, compared to passive case detection, improved representation of the elderly (49·5% vs. 37·8%, p = 0·03) and less-educated (70·3% vs. 39·9%, p<0·001). The proportion of women (59.8% vs 62.3%, P>0.300) and persons aged > = 65 years (49.5% vs 51.3%, p = 0.723) in the outreach screening and population cohorts did not differ significantly. Prevalence of requiring referral care for DR was significantly higher in the outreach screening cohort (28·0%) than the population (14·0%) and passive case detection cohorts (7·3%, p<0·001 for both). CONCLUSIONS AND RELEVANCE: Primary-level outreach screening improves access for the poorly-educated and elderly, and removes gender inequity in access to DR care in this setting, while also identifying more severely-affected patients than case finding in hospital.

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.

Visual Impairment and Risk of Self-Reported Road Traffic Crashes Among Bus Drivers in Bangladesh.

PURPOSE: This study assesses the prevalence and the causes of visual impairment among bus drivers undergoing screening in Bangladesh and associations with self-reported crashes. METHODS: Eye health screenings including refraction and questionnaires were conducted at 10 bus terminals in 7 districts of Bangladesh from June through August 2019. Presenting near and distance visual impairment and self-reported road traffic crashes were recorded. RESULTS: Among 700 participants, nearly 1 in 5 (n = 126, 18.0%) had presented visual acuity (VA) in the better-seeing eye ≤6/9, not meeting the vision standard of Bangladesh for bus drivers. A majority of drivers (n = 492, 70.3%) had near or distance refractive error, and most who failed to reach the driving standard (88.1%, n = 111) could be improved with readily available treatment, either glasses or cataract surgery. A history of 1 or more road traffic crashes while driving a bus or minibus was reported by 62 (8.97%) participants. In multivariable models, factors significantly associated with near or distance visual impairment included older age [odds ratio (OR) per year 1.15, 95% confidence interval (CI): 1.12-1.18, P < 0.0001] and having no driver's license (OR 1.80, 95% CI: 1.04-3.13, P = 0.037). Self-reported history of a motor vehicle crash was associated with near or distance visual impairment (OR 2.45, 95% CI: 1.09-5.49, P = 0.030), even when adjusting for other factors such as age and weekly miles are driven. CONCLUSIONS: Ensuring that bus drivers are screened to meet the required visual standards for driving while referring those who do not for treatment, can contribute to safer roads in this high-risk setting.

Time trends, associations and prevalence of blindness and vision loss due to glaucoma: an analysis of observational data from the Global Burden of Disease Study 2017.

OBJECTIVE: To estimate global prevalence of blindness and vision loss caused by glaucoma, and to evaluate the impact of socioeconomic factors on it. DESIGN: A population-based observational study. SETTING: The prevalence of blindness and vision loss due to glaucoma were obtained from the Global Burden of Disease Study 2017 database. The Human Development Index (HDI), inequality-adjusted HDI and other socioeconomic data were acquired from international open databases. MAIN OUTCOME MEASURES: The prevalence of blindness and vision loss due to glaucoma by age, gender, subregion and Socio-Demographic Index (SDI) levels. Multiple linear regression analysis was performed to explore the associations between the prevalence and socioeconomic indicators. RESULTS: The overall age-standardised prevalence of blindness and vision loss due to glaucoma worldwide was 81.5 per 100 000 in 1990 and 75.6 per 100 000 in 2017. In 2017, men had a higher age-standardised prevalence than women (6.07% vs 5.42%), and the worldwide prevalence increased with age, from 0.5 per 100 000 in the 45-49 year age group to 112.9 per 100 000 among those 70+. Eastern Mediterranean and African regions had the highest prevalence during the whole period, while the Americas region had the lowest prevalence. The prevalence was highest in low-SDI and low-income regions while lowest in high-SDI and high-income regions over the past 27 years. Multiple linear regression showed cataract surgery rate (ß=-0.01, p=0.009), refractive error prevalence (ß=-0.03, p=0.024) and expected years of schooling (ß= -8.33, p=0.035) were associated with lower prevalence, while gross national income per capita (ß=0.002, p<0.001) was associated with higher prevalence. CONCLUSIONS: Lower socioeconomic levels and worse access to eyecare services are associated with higher prevalence of glaucoma-related blindness and vision loss. These findings provide evidence for policy-makers that investments in these areas may reduce the burden of the leading cause of irreversible blindness.

A Review to Populate A Proposed Cost-Effectiveness Analysis of Glaucoma Screening in Sub-Saharan Africa.

To populate a proposed cost-effectiveness analysis of glaucoma screening in Sub-Saharan Africa (SSA).A complete search was conducted on PubMed, Medline and African Journals Online (AJOL) to obtain relevant published articles, which were included in this review. All relevant articles on prevalence of glaucoma in SSA and among other African-derived populations, severity of glaucoma, cost of diagnosis and management, clinical effectiveness of glaucoma screening and treatment and the different glaucoma screening strategies in SSA were reviewed.Population screening interventions for glaucoma may be considered as follows: standalone screening for glaucoma, screening for glaucoma during cataract outreach, and screening incorporated with diabetic retinopathy image review using tele-ophthalmology. Our review suggests that cost of glaucoma treatment is relatively low with cost of medical treatment ranging from USD 273 to USD 480 per year/patient and surgical treatment cost of USD 283 per patient as with other developing countries. Compliance with medication is moderate to good in about 50% of glaucoma patients. Prevalence of glaucoma is much higher in SSA and almost 50% of glaucoma patients are blind in at least one eye at presentation in clinics (without outreach screening). Our review suggests a moderate sensitivity and specificity in identifying glaucoma with basic equipment (direct ophthalmoscope, contact tonometer and frequency doubling technology) during outreach screening although about a third or fewer take up glaucoma services in clinics.Our review provides the necessary information to conduct a cost-effective analysis of glaucoma screening in SSA using the decision Markov model.

Objective quantification of lens nuclear opacities using swept-source anterior segment optical coherence tomography.

BACKGROUND/AIMS: The primary objective is to quantify the lens nuclear opacity using swept-source anterior segment optical coherence tomography (SS-ASOCT) and to evaluate its correlations with Lens Opacities Classification System III (LOCS-III) system and surgical parameters. The secondary objective is to assess the diagnostic performance for hard nuclear cataract. METHODS: This cross-sectional study included 1222 patients eligible for cataract surgery (1222 eyes). The latest SS-ASOCT (CASIA-2) was used to obtain high-resolution lens images, and the average nuclear density (AND) and maximum nuclear density (MND) were measured by a custom ImageJ software. Spearman's correlations analysis was used to assess associations of AND/MND with LOCS-III nuclear scores, visual acuity and surgical parameters. The subjects were then split randomly (9:1) into the training dataset and validating dataset. Receiver operating characteristic curves and calibration curves were constructed for the classification on hard nuclear cataract. RESULTS: The AND and MND from SS-ASOCT images were significantly correlated with nuclear colour scores (AND: r=0.716; MND: r=0.660; p<0.001) and nuclear opalescence scores (AND: r=0.712; MND: r=0.655; p<0.001). The AND by SS-ASOCT images had the highest values of Spearman's r for preoperative corrected distance visual acuity (r=0.3131), total ultrasonic time (r=0.3481) and cumulative dissipated energy (r=0.4265). The nuclear density had good performance in classifying hard nuclear cataract, with area under the curves of 0.859 (0.831-0.886) for AND and 0.796 (0.768-0.823) for MND. CONCLUSION: Objective and quantitative evaluation of the lens nuclear density using SS-ASOCT images enable accurate diagnosis of hard nuclear cataract.

Falls and Physical Activity among Cataract Patients in Vietnam.

PURPOSE: To investigate the relationship between falls, physical activity, and other socio-demographic and visual factors among cataract patients in Ho Chi Minh City, Vietnam. METHODS: A cross-sectional study was conducted between April and November 2018. Patients presenting to two hospitals with age-related unilateral or bilateral cataract, aged ≥50 years, literate, and scheduled for a first-eye cataract surgery were recruited. The International Physical Activity Questionnaires short form was used to measure physical activity. Visual disability score was self-reported using the Catquest-9SF. The number of falls in the last 12 months prior to data collection were self-reported. Visual acuity and contrast sensitivity were measured using standard protocols. RESULTS: A total of 340 patients had complete data, the majority of whom were women (62.4%), living with a spouse (66.5%), had an education level of Grade 5 or below (68.2%), and a monthly income from medium to high (58.5%). Average age was 65.7 years. A total of 135 falls were reported in the last 12 months with 27.6% reporting ≥1 fall and 7.1% ≥2 falls. Persons with high (adjusted Prevalence Ratio (aPR) = 2.4, 95%CI = 1.2, 4.7) and low (aPR = 2.4, 95%CI = 1.2, 4.6) physical activity levels had more falls compared to those with moderate levels. Women (aPR = 1.7, 95%CI = 1.04, 2.7) and those with medium income (aPR = 2.9, 95%CI = 1.2, 6.9) were more likely to fall. Poor binocular logMAR visual acuity with habitual correction (aPR = 2.3, 95%CI = 1.1, 4.6) and poor visual disability scores (aPR = 1.4, 95%CI = 1.02, 2.0) were associated with falling. CONCLUSION: Patients with a moderate level of physical activity were less likely to fall compared to those with low or high levels although this U-shape relationship needs to be further investigated in prospective interventional trials. Men and those with high monthly income, better visual acuity and visual disability score were also less likely to fall. Cataract patients might be advised to maintain a moderate level of physical activity while waiting for surgery. Strategies to prevent falls may also prioritise cataract surgery for women and those with lower income.