Improved screening of retinopathy of prematurity (ROP): development of a target product profile (TPP) for resource-limited settings.

BACKGROUND: As more preterm infants survive, complications of preterm birth, including retinopathy of prematurity (ROP), become more prevalent. ROP rates and blindness from ROP are higher in low-income and middle-income countries, where exposure to risk factors can be higher and where detection and treatment of ROP are under-resourced or non-existent. Access to low-cost imaging devices would improve remote screening capabilities for ROP. METHODS: Target product profiles (TPPs) are developed early in the medical device development process to define the setting, target user and range of product requirements. A Delphi-like process, consisting of an online survey and consensus meeting, was used to develop a TPP for an ROP imaging device, collecting feedback on a proposed set of 64 product requirements. RESULTS: Thirty-six stakeholders from 17 countries provided feedback: clinicians (72%), product developers (14%), technicians (6%) and other (8%). Thirty-six per cent reported not currently screening for ROP, with cited barriers including cost (44%), no training (17%) and poor image quality (16%). Among those screening (n=23), 48% use more than one device, with the most common being an indirect ophthalmoscope (87%), followed by RetCam (26%) and smartphone with image capture (26%). Consensus was reached on 53 (83%) product requirements. The 11 remaining were discussed at the consensus meeting, and all but two achieved consensus. CONCLUSIONS: This TPP process was novel in that it successfully brought together diverse stakeholders to reach consensus on the product requirements for an ROP imaging devices. The resulting TPP provides a framework from which innovators can develop prototypes.

Cataract services for all: Strategies for equitable access from a global modified Delphi process.

Vision loss from cataract is unequally distributed, and there is very little evidence on how to overcome this inequity. This project aimed to engage multiple stakeholder groups to identify and prioritise (1) delivery strategies that improve access to cataract services for under-served groups and (2) population groups to target with these strategies across world regions. We recruited panellists knowledgeable about cataract services from eight world regions to complete a two-round online modified Delphi process. In Round 1, panellists answered open-ended questions about strategies to improve access to screening and surgery for cataract, and which population groups to target with these strategies. In Round 2, panellists ranked the strategies and groups to arrive at the final lists regionally and globally. 183 people completed both rounds (46% women). In total, 22 distinct population groups were identified. At the global level the priority groups for improving access to cataract services were people in rural/remote areas, with low socioeconomic status and low social support. South Asia and Sub-Saharan Africa were the only regions in which panellists ranked women in the top 5 priority groups. Panellists identified 16 and 19 discreet strategies to improve access to screening and surgical services, respectively. These mostly addressed health system/supply side factors, including policy, human resources, financing and service delivery. We believe these results can serve eye health decision-makers, researchers and funders as a starting point for coordinated action to improve access to cataract services, particularly among population groups who have historically been left behind.

Assessing the capacity of primary health care facilities in Nigeria to deliver eye health promotion: Results of a mixed-methods feasibility study.

Over 25 million people in sub-Saharan Africa are blind or visually impaired, the majority from avoidable causes. Health promotion and disease prevention are important strategies for eye health, through good governance, health literacy and increasing access to eye care services. To increase equity in access for eyecare services, the World Health Organization Africa Region developed a package of interventions for primary eye care, which includes health promotion. The aim of this study was to assess the capacity of the primary healthcare system to deliver health promotion for eye care in Nigeria. Mixed methods were used during a survey of 48 government-owned primary health care facilities in Anambra state, Nigeria: interviews with district health supervisors, facility staff and village health workers, and a desk review of policy documents for primary health care and eye care in Nigeria. Findings were benchmarked against the capacities needed to deliver health promotion agreed through a Delphi exercise and were analysed using the World Health Organization's health system building blocks. Eye health promotion policies exist but are fragmented across different national health policies. Health promotion activities focussed on "mobilising" community members to access care provided in facilities, particularly for women of childbearing age and young children, and health education was limited. Only one in ten facilities engaged the elderly and a fifth delivered health promotion for eye care. Health promotion activities were supervised in 43.2% of facilities and transport to remote areas was limited. A robust eye health promotion strategy needs to be included in the National Eye Health Policy. The scope of existing health promotion will need to expand to include eye conditions and different age groups. Increasing eye health literacy should be emphasized. Governance, training health workers in eye health promotion, educational materials, and transport to visit communities will also be needed.

Human resource and governance challenges in the delivery of primary eye care: a mixed methods feasibility study in Nigeria.

BACKGROUND: To increase access to eye care, the World Health Organization's Africa Region recently launched a primary eye care (PEC) package for sub-Saharan Africa. To determine the technical feasibility of implementing this package, the capacity of health systems at primary level needs to be assessed, to identify capacity gaps that would need to be addressed to deliver effective and sustainable PEC. This study reports on the human resource and governance challenges for delivering PEC in Anambra State, Nigeria. METHODS: Design: This was a mixed methods feasibility study. A desk review of relevant Nigerian national health policy documents on both eye health and primary health care was conducted, and 48 primary health care facilities in Anambra state were surveyed. Data on human resource and governance in primary health facilities were collected using structured questionnaires and through observation with checklists. In-depth interviews were conducted with district supervisors and selected heads of facilities to explore the opportunities and challenges for the delivery of PEC in their facilities/districts. Data were analysed using the World Health Organization's health system framework. RESULTS: A clear policy for PEC is lacking. Supervision was conducted at least quarterly in 54% of facilities and 56% of facilities did not use the standard clinical management guidelines. There were critical shortages of health workers with 82% of facilities working with less than 20% of the number recommended. Many facilities used volunteers and/or ad hoc workers to mitigate staff shortages. CONCLUSION: Our study highlights the policy, governance and health workforce gaps that will need to be addressed to deliver PEC in Nigeria. Developing and implementing a specific policy for PEC is recommended. Implementation of existing national health policies may help address health workforce shortages at the primary health care level.

Cost-minimisation Analysis from a Non-inferiority Trial of Ready-Made versus Custom-Made Spectacles for School Children in India.

Purpose: Uncorrected refractive error is the leading cause of visual impairment in children. Many countries, including India, implement school eye health programmes involving vision screening and provision of free spectacles. This is costly for governments/organisations involved. This analysis estimates potential cost-savings if ready-made spectacles, in addition to traditional custom-made spectacles, are available for dispensing in school eye health programmes.Methods: An economic evaluation was conducted alongside a randomised controlled trial comparing spectacle wear of ready-made spectacles versus custom-made spectacles for children aged 11-15 years in schools in India. A cost-minimisation approach was used to calculate cost-savings of a 'ready-made spectacles available' programme compared with a 'custom-made spectacles only' school programme. The analysis was from a service provider perspective. Main outcomes: cost-saving per child needing spectacles and cost-saving per 1000 children screened.Results: The prevalence of uncorrected refractive error was 2.23%, and 86% of children were eligible for ready-made spectacles. The cost per child needing spectacles in a custom-made spectacles only programme was USD$26.91, and in a ready-made spectacles available programme was $11.15, producing a 58.6% cost-saving per child needing spectacles of $15.76. Considering the total cost of the eye health programme, this equated to a 15.1% cost-saving per 1000 children screened of $361. Results were robust to multivariate sensitivity analyses.Conclusion: Our study is the first to demonstrate the significant cost-saving potential of ready-made spectacles in school eye health programmes for uncorrected refractive error compared with custom-made spectacles alone. This has substantial economic benefits for national/international programmes.

Assessment of diabetic retinopathy in type 1 diabetes in a diabetes care center in South India-Feasibility and awareness improvement study.

The prevalence of youth-onset diabetes, both type 1 diabetes (T1D) and young-onset type 2 diabetes (YT2D) are gradually increasing in India. Early and repetitive screening for diabetic retinopathy (DR) is essential to provide timely management, and thereby prevent visual impairment due to the silent sight-threatening microvascular complication of diabetes. A study was undertaken at a diabetes care center in Chennai, south India, to assess the feasibility of screening for DR in T1D in a diabetes clinic and determine the burden of sight-threatening DR (STDR) in individuals with T1D. 315 people with T1D were screened for DR (mean age at onset of diabetes 12.3 ± 6.4 years) by digital retinal color photography, at the urban diabetes center, in a semi-urban and rural diabetes clinic. Counseling about diabetes and the importance of annual screening for retinopathy was provided by diabetes educators. Participants were reviewed after 6 months/1 year based on ophthalmologist's advice. DR was detected in 37.1% (n = 117), 42 (13%) of whom had STDR.Three-quarter participants were compliant with the annual follow-up retinal examination. The peer support group was established for participants with T1D and their families to foster interactions with service providers. The peer group meetings helped to increase the awareness of retinopathy among the parents and individuals with T1D. This narrative provides details of the study that shows that screening for DR among individuals with T1D in a diabetes clinic is a feasible model, irrespective of its location.

Cataract Services are Leaving Widows Behind: Examples from National Cross-Sectional Surveys in Nigeria and Sri Lanka.

The Sustainable Development Goals aim to leave no one behind. We explored the hypothesis that women without a living spouse-including those who are widowed, divorced, separated, and never married-are a vulnerable group being left behind by cataract services. Using national cross-sectional blindness surveys from Nigeria (2005-2007; n = 13,591) and Sri Lanka (2012-2014; n = 5779) we categorized women and men by marital status (married/not-married) and place of residence (urban/rural) concurrently. For each of the eight subgroups we calculated cataract blindness, cataract surgical coverage (CSC), and effective cataract surgical coverage (eCSC). Not-married women, who were predominantly widows, experienced disproportionate cataract blindness-in Nigeria they were 19% of the population yet represented 56% of those with cataract blindness; in Sri Lanka they were 18% of the population and accounted for 54% of those with cataract blindness. Not-married rural women fared worst in access to services-in Nigeria their CSC of 25.2% (95% confidence interval, CI 17.8-33.8%) was far lower than the best-off subgroup (married urban men, CSC 80.0% 95% CI 56.3-94.3); in Sri Lanka they also lagged behind (CSC 68.5% 95% CI 56.6-78.9 compared to 100% in the best-off subgroup). Service quality was also comparably poor for rural not-married women-eCSC was 8.9% (95% CI 4.5-15.4) in Nigeria and 37.0% (95% CI 26.0-49.1) in Sri Lanka. Women who are not married are a vulnerable group who experience poor access to cataract services and high cataract blindness. To "leave no one behind", multi-faceted strategies are needed to address their needs.

Retinopathy of prematurity prevention, screening and treatment programmes: Progress in South America.

Retinopathy of prematurity (ROP) is the main cause of blindness and visual impairment in Latin America and prevention, detection and treatment have been a priority in the Region in the last two decades. There is progress in the number of eligible babies screened and treated in at least half of the countries with strong regulations on ROP, but screening is not yet available in all provinces in most. More effort is needed to increase national protocols and legislation, strengthening of services and human resources to cover all national provinces; telemedicine might be a promising strategy.

Barriers, Costs, and Attitudes Toward Pediatric Cataract Surgery at Two Large Facilities in China and India.

PURPOSE: To better understand barriers of costs and attitudes toward pediatric cataract surgery in China and India. METHODS: From January 2014 to June 2015, families of children ≤ 10 years old about to undergo or having completed surgery for bilateral, non-traumatic cataract at two tertiary centers in China and India completed questionnaires regarding their demographic characteristics, financial status, living environment, health seeking behaviors, and medical burden. RESULTS: In China, 38 children (23 boys [60.5%], mean age 3.11 ± 2.88 years) were un-operated, and 44 (26 boys [59.1%], mean age 5.09 +/- 2.17 years) had undergone surgery, while in India there were 60 (44 boys [73.3%], mean age 4.61 +/- 3.32 years) and 39 (29 boys [74.4%], mean age 6.45 +/- 2.74 years) children respectively, 181 in total. Chinese children were younger at presentation (p ≤ 0.03 for both operated and un-operated) and also when cataract was detected (median [inter quartile range] 10 [3-34] versus 24 [6-60] months [p = 0.06] for un-operated, 5 [2-12] versus 36 [8-72] months [p < 0.001] for operated). Maternal education levels were lower in India (48.3% and 51.3% with elementary education only among un-operated [p = 0.11] and operated [p = 0.006] families in India versus 27.0% and 20.5% in China), as were rates of consulting medical practitioners for illness (44.7% and 36.4% for un-operated [p < 0.001] and operated [p = 0.001] in China versus 10% and 5.13% in India). CONCLUSIONS: Socioeconomic challenges to securing cataract surgery may be greater, and delays in obtaining surgery longer, in India compared to China, if these facilities are representative.

Evidence for national universal eye health plans.

Many low- and middle-income countries use national eye-care plans to guide efforts to strengthen eye-care services. The World Health Organization recognizes that evidence is essential to inform these plans. We assessed how evidence was incorporated in a sample of 28 national eye-care plans generated since the Universal eye health: a global action plan 2014-2019 was endorsed by the World Health Assembly in 2013. Most countries (26, 93%) cited estimates of the prevalence of blindness and 18 countries (64%) had set targets for the cataract surgical rate in their plan. Other evidence was rarely cited or used to set measurable targets. No country cited evidence from systematic reviews or solution-based research. This limited use of evidence reflects its low availability, but also highlights incomplete use of existing evidence. For example, despite sex-disaggregated data and cataract surgical coverage being available from surveys in 20 countries (71%), these data were reported in the eye health plans of only nine countries (32%). Only three countries established sex-disaggregated indicators and only one country had set a target for cataract surgical coverage for future monitoring. Countries almost universally recognized the need to strengthen health information systems and almost one-third planned to undertake operational or intervention research. Realistic strategies need to be identified and supported to translate these intentions into action. To gain insights into how a country can strengthen its evidence-informed approach to eye-care planning, we reflect on the process underway to develop Kenya's seventh national plan (2019-2023).

De nombreux pays à revenu faible et intermédiaire ont recours à des plans nationaux de santé oculaire pour guider les actions visant à renforcer les services d'ophtalmologie. L'Organisation mondiale de la Santé reconnaît qu'il est essentiel de disposer de données factuelles pour orienter ces plans. Nous avons évalué la manière dont ces données factuelles ont été intégrées à un échantillon de 28 plans nationaux de santé oculaire, élaborés depuis l'adoption par l'Assemblée Mondiale de la Santé, en 2013, du document Santé oculaire universelle: plan d'action mondial 2014­2019. La plupart des pays (26, soit 93%) ont indiqué utiliser des estimations de la prévalence de la cécité et 18 pays (64%) avaient fixé des objectifs relatifs au taux de chirurgie de la cataracte dans leur plan. D'autres types de données factuelles ont rarement été mentionnés ou utilisés pour définir des objectifs mesurables. Aucun pays n'a mentionné de données issues de revues systématiques ou de recherches fondées sur des solutions. Cette utilisation limitée des données factuelles reflète leur faible accessibilité, mais aussi l'usage incomplet des données existantes. Par exemple, bien que des enquêtes menées dans 20 pays (71%) donnent accès à des données ventilées par sexe et au taux de couverture de la chirurgie de la cataracte, seuls neuf pays (32%) ont reporté ces données dans leur plan de santé oculaire. Seuls trois pays ont mis en place des indicateurs ventilés par sexe et un seul a défini un objectif de couverture de la chirurgie de la cataracte pour en suivre l'évolution. La quasi-totalité des pays a reconnu qu'il était nécessaire de renforcer les systèmes d'information sanitaire et près d'un tiers prévoyait d'entreprendre des recherches opérationnelles ou interventionnelles. Il faudra définir et mettre en œuvre des stratégies réalistes pour passer de l'intention à l'action. Pour en savoir plus sur la manière dont un pays peut renforcer son approche d'élaboration de plans de santé oculaire à partir de données factuelles, nous nous intéressons à l'élaboration, en cours, du septième plan national du Kenya (2019­2023).

Muchos países con ingresos entre bajos y medios utilizan planes nacionales de atención oftalmológica para orientar los esfuerzos a fortalecer los servicios de atención oftalmológica. La Organización Mundial de la Salud reconoce que las pruebas son esenciales para informar a estos planes. Se evaluó cómo se incorporaron las pruebas en una muestra de 28 planes nacionales de atención oftalmológica generados desde que la Asamblea Mundial de la Salud aprobó Universal eye health: a global action plan 2014­2019 (Atención oftalmológica universal: un plan de acción mundial para 2014-2019) en 2013. La mayoría de los países (26, 93 %) citaron estimaciones de la prevalencia de la ceguera y 18 países (64 %) habían establecido metas para la tasa quirúrgica de cataratas en sus planes. Rara vez se citaron o utilizaron otras pruebas para establecer objetivos mensurables. Ningún país citó pruebas de revisiones sistemáticas o investigaciones basadas en soluciones. Este uso limitado de las pruebas refleja su baja disponibilidad, pero también destaca el uso incompleto de las pruebas existentes. Por ejemplo, a pesar de que los datos desglosados por sexo y la cobertura quirúrgica de cataratas están disponibles en las encuestas de 20 países (71 %), estos datos solo se reflejaron en los planes de atención oftalmológica de nueve países (32 %). Solo tres países establecieron indicadores desglosados por sexo y solo un país había establecido una meta para la cobertura quirúrgica de cataratas para el seguimiento futuro. Los países reconocieron casi universalmente la necesidad de fortalecer los sistemas de información sanitaria y casi un tercio tenía previsto realizar investigaciones operacionales o de intervención. Es necesario identificar y apoyar estrategias realistas para convertir estas intenciones en acciones. Para comprender mejor cómo un país puede fortalecer su enfoque basado en pruebas para la planificación de la atención oftalmológica, se ha analizado el proceso en curso para desarrollar el séptimo plan nacional en Kenia (2019-2023).

Public health system integration of avoidable blindness screening and management, India.

In India, 73 million people have diabetes and 3.5 million infants are born preterm. Without timely screening, there is a risk of visual loss due to diabetic retinopathy and retinopathy of prematurity in these two groups, respectively. Both conditions are emerging causes of visual impairment in India but there is no public health programme for screening or management. Pilot projects were initiated in 2014 to integrate the screening and management of these conditions into existing public health systems, particularly in rural communities and their referral networks. The World Health Organization's health systems framework was used to develop the projects and strategies were developed with all stakeholders, including the government. Both projects involved hub-and-spoke models of care units around medical schools. For diabetic retinopathy, screening was established at primary health-care facilities and treatment was provided at district hospitals. For retinopathy of prematurity, screening was integrated into sick newborn care units at the district level and treatment facilities were improved at the closest publically funded medical schools. In the first two years, there were substantial improvements in awareness, screening, treatment and partnership between stakeholders, and changes in public health policy. By March 2018, diabetic retinopathy screening was established at 50 facilities in 10 states and treatment had been improved at 10 hospitals, whereas retinopathy of prematurity screening was established at 16 sick newborn care units in district hospital in four states and treatment had been improved at six medical schools. Advocacy within state governments was critical to the success of the initiative.

En Inde, 73 millions de personnes sont atteintes de diabète et 3,5 millions de nourrissons naissent avant terme. Lorsque le dépistage n'est pas effectué à temps, il existe un risque de perte de la vue due à la rétinopathie diabétique dans le cas du premier groupe et à la rétinopathie du prématuré dans le cas du second. Bien que ces deux maladies soient de nouvelles causes de déficience visuelle en Inde, aucun programme de santé publique ne vise leur dépistage ou leur prise en charge. Des projets pilotes ont été lancés en 2014 pour intégrer le dépistage et la prise en charge de ces maladies dans les systèmes de santé publique existants, en particulier dans les communautés rurales et leurs réseaux d'orientation. Le cadre des systèmes de santé de l'Organisation mondiale de la Santé a été utilisé pour développer ces projets et des stratégies ont été élaborées avec toutes les parties prenantes, et notamment le gouvernement. Les deux projets impliquaient des réseaux en étoile d'unités de soins autour des écoles de médecine. Dans le cas de la rétinopathie diabétique, le dépistage a été assuré dans des établissements de soins de santé primaires, tandis que le traitement a été appliqué dans des hôpitaux de district. Dans le cas de la rétinopathie du prématuré, le dépistage a été intégré dans des unités de soins pour les pathologies néo-natales au niveau des districts et les installations de traitement ont été améliorées dans les écoles de médecine financées par l'État les plus proches. Au cours des deux premières années, des améliorations considérables ont été constatées en matière de sensibilisation, de dépistage, de traitement et de partenariat entre les parties prenantes, et des changements ont été apportés à la politique de santé publique. En mars 2018, le dépistage de la rétinopathie diabétique était assuré dans 50 établissements répartis dans 10 États et le traitement avait été amélioré dans 10 hôpitaux, tandis que le dépistage de la rétinopathie du prématuré était assuré dans 16 unités de soins pour les pathologies néo-natales dans les hôpitaux de district de quatre États et le traitement avait été amélioré dans six écoles de médecine. Un soutien au sein des administrations des États fédérés a été essentiel au succès de l'initiative.

En la India, 73 millones de personas son diabéticas y 3,5 millones de niños nacen prematuros. Sin exámenes de detección oportunos, existe un riesgo de pérdida de la visión por la retinopatía diabética y la retinopatía por prematuridad en estos dos grupos, respectivamente. Ambas afecciones son causas emergentes de discapacidad visual en la India, pero no existe un programa de salud pública para la detección o el tratamiento. En 2014 se iniciaron proyectos piloto para integrar el análisis y la gestión de estas condiciones en los sistemas de salud pública existentes, en particular en las comunidades rurales y sus redes de derivación. Se utilizó el marco de sistemas de salud de la Organización Mundial de la Salud para desarrollar los proyectos y se desarrollaron estrategias con todas las partes interesadas, incluido el gobierno. En ambos proyectos se utilizaron modelos de unidades de atención centralizados en torno a las facultades de medicina. En cuanto a la retinopatía diabética, se establecieron exámenes de detección en los centros de atención primaria y se ofreció tratamiento en los hospitales de distrito. En cuanto a la retinopatía por prematuridad, los exámenes de detección se integraron en las unidades de atención neonatal a nivel de distrito y se mejoraron las instalaciones de tratamiento en las facultades de medicina más cercanas financiadas con fondos públicos. En los dos primeros años se produjeron mejoras sustanciales en la sensibilización, la detección, el tratamiento y la asociación entre las partes interesadas, así como cambios en la política de salud pública. Para marzo de 2018, se establecieron exámenes de detección de retinopatía diabética en 50 establecimientos de 10 estados y se mejoró el tratamiento en 10 hospitales, mientras que se establecieron exámenes de detección de retinopatía por prematuridad en 16 unidades de atención neonatal en hospitales de distrito de cuatro estados y se mejoró el tratamiento en seis facultades de medicina. La promoción dentro de los gobiernos estatales fue fundamental para el éxito de la iniciativa.

Assessment of Response Bias Is Neglected in Cross-Sectional Blindness Prevalence Surveys: A Review of Recent Surveys in Low- and Middle-Income Countries.

PURPOSE: Findings from cross-sectional blindness prevalence surveys are at risk of several biases that cause the study estimate to differ from the 'true' population prevalence. For example, response bias occurs when people who participate ('responders') differ from those who do not ('non-responders') in ways that affect prevalence estimates. This study aimed to assess the extent to which response bias is considered and occurs in blindness prevalence surveys in low- and middle-income countries (LMICs). METHODS: We searched MEDLINE, EMBASE and Web of Science for cross-sectional blindness prevalence surveys undertaken in LMICs and published 2009-2017. From included studies, we recorded and descriptively analysed details regarding enumeration processes, response, and non-response, including the impact of non-response on results. RESULTS: Most (95%) of the 92 included studies reported a response rate (median 91.7%, inter-quartile range 85.9-95.6%). Approximately half clearly described enumeration processes (49%), and reported at least one strategy to increase the response rate (53%); a quarter (23%) statistically compared responders and non-responders. When differential response was assessed, men were more likely to be non-responders than women. Two-thirds (65%) of the time a sociodemographic difference was found between responders and non-responders, a difference in blindness prevalence was also found. Only 13 studies (14%) commented on implications of non-response on prevalence estimates. CONCLUSIONS: Response rates are commonly reported from blindness prevalence surveys, and tend to be high. High response rates reduce-but do not eliminate-the risk of response bias. Assessment and reporting of potential response bias in blindness prevalence surveys could be greatly improved.

Willingness to pay for cataract surgery is much lower than actual costs in Zamfara state, northern Nigeria.

PURPOSE: Direct medical and non-medical costs incurred by those undergoing subsidised cataract surgery at Gusau eye clinic, Zamfara state, were recently determined. The aim of this study was to assess the willingness to pay for cataract surgery among adults with severe visual impairment or blindness from cataract in rural Zamfara and to compare this to actual costs. METHODS: In three rural villages served by Gusau eye clinic, key informants helped identify 80 adults with bilateral severe visual impairment or blindness (<6/60), with cataract being the cause in at least one eye. The median amount participants were willing to pay for cataract surgery was determined. The proportion willing to pay actual costs of the (i) subsidised surgical fee (US$18.5), (ii) average non-medical expenses (US$25.2), and (iii) average total expenses (US$51.2) at Gusau eye clinic were calculated. Where participants would seek funds for surgery was determined. RESULTS: Among 80 participants (38% women), most (n = 73, 91%) were willing to pay something, ranging from

Integrating primary eye care into global child health policies.

Globally, approximately 75% of blind children live in low-income countries (LICs). Almost half of blindness and low vision in LICs is due to avoidable causes such as corneal scarring from measles infection, vitamin A deficiency disorders, use of harmful traditional eye remedies, ophthalmia neonatorum and cataract.

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

BACKGROUND: Cataract is the leading cause of blindness in low- and middle-income countries (LMICs), and the prevalence is inequitably distributed between and within countries. Interventions have been undertaken to improve cataract surgical services, however, the effectiveness of these interventions on promoting equity is not known. OBJECTIVES: To assess the effects on equity of interventions to improve access to cataract services for populations with cataract blindness (and visual impairment) in LMICs. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2017, Issue 3), MEDLINE Ovid (1946 to 12 April 2017), Embase Ovid (1980 to 12 April 2017), LILACS (Latin American and Caribbean Health Sciences Literature Database) (1982 to 12 April 2017), the ISRCTN registry (www.isrctn.com/editAdvancedSearch); searched 12 April 2017, ClinicalTrials.gov (www.clinicaltrials.gov); searched 12 April 2017 and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en); searched 12 April 2017. We did not use any date or language restrictions in the electronic searches for trials. SELECTION CRITERIA: We included studies that reported on strategies to improve access to cataract services in LMICs using the following study designs: randomised and quasi-randomised controlled trials (RCTs), controlled before-and-after studies, and interrupted time series studies. Included studies were conducted in LMICs, and were targeted at disadvantaged populations, or disaggregated outcome data by 'PROGRESS-Plus' factors (Place of residence; Race/ethnicity/ culture/ language; Occupation; Gender/sex; Religion; Education; Socio-economic status; Social capital/networks. The 'Plus' component includes disability, sexual orientation and age). DATA COLLECTION AND ANALYSIS: Two authors (JR and JP) independently selected studies, extracted data and assessed them for risk of bias. Meta-analysis was not possible, so included studies were synthesised in table and text. MAIN RESULTS: From a total of 2865 studies identified in the search, two met our eligibility criteria, both of which were cluster-RCTs conducted in rural China. The way in which the trials were conducted means that the risk of bias is unclear. In both studies, villages were randomised to be either an intervention or control group. Adults identified with vision-impairing cataract, following village-based vision and eye health assessment, either received an intervention to increase uptake of cataract surgery (if their village was an intervention group), or to receive 'standard care' (if their village was a control group).One study (n = 434), randomly allocated 26 villages or townships to the intervention, which involved watching an informational video and receiving counselling about cataract and cataract surgery, while the control group were advised that they had decreased vision due to cataract and it could be treated, without being shown the video or receiving counselling. There was low-certainty evidence that providing information and counselling had no effect on uptake of referral to the hospital (OR 1.03, 95% CI 0.63 to 1.67, 1 RCT, 434 participants) and little or no effect on the uptake of surgery (OR 1.11, 95% CI 0.67 to 1.84, 1 RCT, 434 participants). We assessed the level of evidence to be of low-certainty for both outcomes, due to indirectness of evidence and imprecision of results.The other study (n = 355, 24 towns randomised) included three intervention arms: free surgery; free surgery plus reimbursement of transport costs; and free surgery plus free transport to and from the hospital. These were compared to the control group, which was reminded to use the "low-cost" (˜USD 38) surgical service. There was low-certainty evidence that surgical fee waiver with/without transport provision or reimbursement increased uptake of surgery (RR 1.94, 95% CI 1.14 to 3.31, 1 RCT, 355 participants). We assessed the level of evidence to be of low-certainty due to indirectness of evidence and imprecision of results.Neither of the studies reported our primary outcome of change in prevalence of cataract blindness, or other outcomes such as cataract surgical coverage, surgical outcome, or adverse effects. Neither study disaggregated outcomes by social subgroups to enable further assessment of equity effects. We sought data from both studies and obtained data from one; the information video and counselling intervention did not have a differential effect across the PROGRESS-Plus categories with available data (place of residence, gender, education level, socioeconomic status and social capital). AUTHORS' CONCLUSIONS: Current evidence on the effect on equity of interventions to improve access to cataract services in LMICs is limited. We identified only two studies, both conducted in rural China. Assessment of equity effects will be improved if future studies disaggregate outcomes by relevant social subgroups. To assist with assessing generalisability of findings to other settings, robust data on contextual factors are also needed.

Effective cataract surgical coverage: An indicator for measuring quality-of-care in the context of Universal Health Coverage.

OBJECTIVE: To define and demonstrate effective cataract surgical coverage (eCSC), a candidate UHC indicator that combines a coverage measure (cataract surgical coverage, CSC) with quality (post-operative visual outcome). METHODS: All Rapid Assessment of Avoidable Blindness (RAAB) surveys with datasets on the online RAAB Repository on April 1 2016 were downloaded. The most recent study from each country was included. By country, cataract surgical outcome (CSOGood, 6/18 or better; CSOPoor, worse than 6/60), CSC (operated cataract as a proportion of operable plus operated cataract) and eCSC (operated cataract and a good outcome as a proportion of operable plus operated cataract) were calculated. The association between CSC and CSO was assessed by linear regression. Gender inequality in CSC and eCSC was calculated. FINDINGS: Datasets from 20 countries were included (2005-2013; 67,337 participants; 5,474 cataract surgeries). Median CSC was 53.7% (inter-quartile range[IQR] 46.1-66.6%), CSOGood was 58.9% (IQR 53.7-67.6%) and CSOPoor was 17.7% (IQR 11.3-21.1%). Coverage and quality of cataract surgery were moderately associated-every 1% CSC increase was associated with a 0.46% CSOGood increase and 0.28% CSOPoor decrease. Median eCSC was 36.7% (IQR 30.2-50.6%), approximately one-third lower than the median CSC. Women tended to fare worse than men, and gender inequality was slightly higher for eCSC (4.6% IQR 0.5-7.1%) than for CSC (median 2.3% IQR -1.5-11.6%). CONCLUSION: eCSC allows monitoring of quality in conjunction with coverage of cataract surgery. In the surveys analysed, on average 36.7% of people who could benefit from cataract surgery had undergone surgery and obtained a good visual outcome.

Improving services for glaucoma care in Nigeria: implications for policy and programmes to achieve universal health coverage.

Glaucoma in Africa is sometimes referred to as the silent thief of sight. In Nigeria, glaucoma is common, it is serious, ophthalmologists face many constraints in managing it, people do not even know they have it until it is advanced, patients do not understand or comply with treatment after they are diagnosed and the poor are more likely to be glaucoma blind. Available evidence indicates that the health system in Nigeria is failing to meet the needs of patients with glaucoma. Based on evidence, we propose future directions for improving services for glaucoma care in Nigeria, and the implications for policy and programmes to control glaucoma blindness, using a health system-oriented approach. Three complementary strategies are required: (i) strengthening clinical services for glaucoma-by developing models of glaucoma care, improving clinical treatment options, making medicines and equipment available, financing glaucoma care and training eye care workers; (ii) introducing initiatives for earlier detection of glaucoma in the clinic and approaches in the community and (iii) strengthening health system governance. Glaucoma is a complex disease to manage and addressing it as a public health problem is challenging. However, we need to change the paradigm to recognise that glaucoma is a potentially avoidable cause of blindness in Africa.

Assessment of Nifedipine Therapy in Hyperinsulinemic Hypoglycemia due to Mutations in the ABCC8 Gene.

CONTEXT: Previous case reports have documented the effectiveness of l-type calcium channel blockers (such as nifedipine and verapamil) for treating different forms of hyperinsulinemic hypoglycemia (HH). OBJECTIVE: To systematically assess the glycemic response to nifedipine therapy in 11 patients with HH due to mutations in the ABCC8 gene. DESIGN: Dose escalation of nifedipine therapy. SETTINGS AND PATIENTS: Eleven children who were inpatients at a tertiary hospital and had diazoxide unresponsive HH due to mutations in the ABCC8 gene. INTERVENTION(S): Nifedipine was administered orally at an escalating dose up to a maximum of 2.5 mg/kg/d. MAIN OUTCOME MEASURES: Improvement in glycemic control, avoidance of hypoglycemic episodes, reduction of intravenous glucose infusion, and reduction in the requirements of other medical therapies. RESULTS: The median age of the patients was 0.44 years (range 0.14 to 3.77). The ABCC8 gene mutations were homozygous in 3 cases, paternally inherited heterozygous in 4, and compound heterozygous in 4. 18F-DOPA PET/CT scan demonstrated a focal lesion in 2 cases and the rest were diffuse HH disease. One subject had nifedipine as monotherapy, whereas the rest had it in combination with octreotide/glucagon/diazoxide or cornstarch. After a median of 6.5 (3 to 23) days of maximal (2.5 mg/kg/d) dose of nifedipine therapy, none of the patients showed any improvement in glycemic control and patients continued to have hypoglycemic episodes. CONCLUSIONS: HH due to mutations in the ABCC8 gene does not respond to nifedipine therapy. Mutations in the KATP channel genes might render the l-type calcium channel ineffective to therapy with nifedipine.