Trachoma in the Pacific Islands: evidence from Trachoma Rapid Assessment.

AIMS: To establish the presence or absence of trachoma in the Pacific Island region. METHODS: Trachoma Rapid Assessment methodology was used in Kiribati, Nauru, Vanuatu, Solomon Islands and Fiji. Advised by key informants, high-risk communities were chosen from each country. All available children aged 1-9 years and adults > or = 40 years were examined. RESULTS: A total of 903 adults > or = 40 years and 3102 children aged 1-9 years were screened at 67 sites. Rates of active trachoma in children were >15% in all sites in Kiribati and >20% in all sites in Nauru. However, there was a high variability of rates of active trachoma in survey sites in Vanuatu, Solomon Islands and Fiji with rates ranging from 0% to 43% (average 23.3%), 6.0% to 51.9% (average 30.5%) and 0% to 48.8% (average 22.1%) respectively. Average rates of scarring trachoma in adults were 61.9% in Kiribati, 12.5% in Nauru, 38.2% in Vanuatu, 67.0% in the Solomon Islands and 18.8% in Fiji. Rates of trichiasis and trichiasis surgeries suggest the possibility of blinding trachoma in the region. CONCLUSION: The findings indicate that trachoma is present in all the Pacific Island countries screened. Further prevalence studies are required, and trachoma control measures should be considered.

Predicting the need for low vision rehabilitation services.

AIMS: To determine the independent predictors of rehabilitation needs for people with low vision using the Impact of Vision Impairment questionnaire (IVI) to measure the quality-of-life consequences of vision-specific restrictions on participation in activities of daily living. METHODS: Patients attending low vision clinics completed the IVI and provided personal and clinical information such as co-morbidities and visual acuity. Rasch analysis was used to generate person measures for the IVI total and three domain scores. Rehabilitation needs were based on "mild", "moderate" or "severe" levels of restriction in participation as determined by the lower, moderate and higher tertiles of persons measures. Logistic regression analyses were used to determine independent predictors of rehabilitation needs. RESULTS: 477 patients (56% women) with a mean age 72 years (SD 15.3) were recruited. Most (74%) had moderate or severe vision loss (presenting visual acuity (VA)<6/18), and 43% had age-related macular degeneration (AMD). Females, shorter duration of vision impairment, having AMD, worse VA, a greater impact of co-morbidities on daily living and reliance on family or friends were univariately associated with poorer IVI scores (p<0.05). In all regression models, VA, the impact of comorbidities on daily living and dependence on family/friends emerged as the three strongest independent predictors of rehabilitation needs. CONCLUSION: In addition to vision, clinicians also need to consider issues relating to dependency when assessing rehabilitation needs. A more holistic approach to patient referral and rehabilitation provision is therefore warranted.

Self-management programs for adults with low vision: needs and challenges.

OBJECTIVE: To explore the needs of individuals with low vision in order to inform the contents of a low vision self-management (SM) program and determine potential barriers to participation. METHODS: Semi-structured interviews were conducted with 48 participants with low vision resulting different from eye conditions. Qualitative analysis was conducted in order to identify major themes. RESULTS: All participants described a range of consequences as a result of vision loss including difficulties with functional activities, social interaction and emotional distress. Less than half were interested in attending a SM program. Barriers included practical reasons as well as a perceived lack of need and unclear or negative perceptions of such a program. CONCLUSION: SM programs for low vision are a promising way to help address the range of difficulties experienced by this population if barriers to participation can be overcome. PRACTICE IMPLICATIONS: SM programs should include vision-specific strategies, training in generic problem-solving and goal setting skills and how to cope with emotional reactions to vision impairment. Programs should be delivered and promoted in such a way to enhance access and encourage uptake by those with a range of vision loss in the community.

The reliability of data collection periods of personal costs associated with vision impairment.

PURPOSE: To determine the reliability of vision-related personal costs collected over 1, 3 and 6 months (extrapolated to 12 months) compared to one-year data. METHODS: Participants of any age, with a presenting visual acuity of < 20/40 in the better eye and an ability to converse in English, were recruited. Monthly cost diaries, in large print and electronic copies with instructions available in audio and Braille, were used prospectively to collect personal costs. The personal expenses were grouped under four categories, namely: (a) medicines, products and equipment, (b) health and community services, (c) informal care and support and (d) other expenses. Sociodemographic and clinical data were also collected. RESULTS: 104 participants (59 females) with a mean age of 64 years completed the 12-months diaries. Almost 40% of the participants had severe visual impairment (< 20/200) in the better eye and the most common cause of vision loss was AMD (n=40; 38%). The mean total personal costs collected from the 12-months diaries were 3,330+/-2,887 AUS dollars. There were no significant differences between the 12-months data and extrapolated 1, 3 and 6-months diaries (t-tests; p=0.17, 0.89 and 0.73, respectively). However, the 1-month variation was substantially larger (SD+/-5,860) compared to the 3-month and 6-month variances (SD+/-3,037 and 3,030, respectively) for total costs. Also, compared to the 12-months diaries, the 1-month data consistently recorded the weakest correlation coefficients for all cost categories compared to the other time intervals. CONCLUSIONS: Given that diary completion can be particularly challenging for individuals with impaired vision, a minimum 3-months data collection period can provide reliable estimates of annual costs associated with vision impairment.

The economic impact and cost of visual impairment in Australia.

AIMS: To quantify the total economic costs of vision loss in Australia. METHODS: Prevalence data of visual impairment, unpublished data on indirect costs, and national healthcare cost databases were used. RESULTS: Vision disorders cost Australia an estimated A$9.85 billion in 2004. A$4.8 billion is the loss of wellbeing (years of life lost as a result of disability and premature mortality). Vision disorders rank seventh and account for 2.7% of the national loss of wellbeing. Direct health system costs total A$1.8 billion. They have increased by A$1 billion over the last 10 years and will increase a further A$1-2 billion in the next 10 years. Cataract, the largest direct cost, takes 18% of expenditure. The health system costs place vision disorders seventh, ahead of coronary heart disease, diabetes, depression, and stroke. Indirect costs, A$3.2 billion, include carers' costs, low vision aids, lost earnings, and other welfare payments and taxes. CONCLUSIONS: Even a developed economy such as Australia's cannot afford avoidable vision loss. Priority needs to be given to prevent preventable vision loss; to treat treatable eye diseases; and to increase research into vision loss that can be neither prevented nor treated.

Costs of mobile screening for diabetic retinopathy: a practical framework for rural populations.

Australia's rural and remote residents experience considerably higher hospitalisation and death rates due to diabetes than their metropolitan counterparts. There is clearly a need for improved diabetes care services in these areas and interventions that target conditions associated with diabetes will yield beneficial results for the community. All people with diabetes are at risk for diabetic retinopathy, which can cause vision loss and blindness. Although vision loss and blindness due to diabetes is nearly 100% preventable through regular eye examinations, 35% of Victoria's rural population with diabetes do not have their eyes examined on a regular basis. A pilot, mobile screening program for the early detection of diabetic eye disease was conducted in rural Victoria and proved to be a successful model of adjunct eye care for people with diabetes. Actual costs from the pilot screening were applied to a permanent model for rural eye care. At A$41 per participant, costs for mobile screening were competitive with Medicare rebate costs for eye examinations. The model addresses barriers of accessibility and availability, targets a portion of the rural population with diabetes that is not otherwise having eye examinations, and is cost-saving to the Government.

Assessment of trachoma prevalence in a mobile population in Central Australia.

Trachoma is reported to be hyperendemic in Australia. This study was conducted in a desert area of Central Australia to implement and evaluate the WHO SAFE strategy to control trachoma. The aim of the study was to obtain baseline trachoma prevalence data and to determine whether a single annual visit is adequate for a treatment program targeting households with active cases in a highly mobile population. All registered residents of two Aboriginal communities were eligible for examination. Four visits over the course of 13 months were made to the communities for ocular examinations of residents present at the time of the visit. Examination, diagnosis, and grading of trachoma followed WHO guidelines. The overall examination rate was 75%, refusal rate was <1%, but approximately 50% of community residents were absent during the examination period. Prevalence varied on each visit, but the overall prevalence of active trachoma was 49% over the 13-month period. Children less than 10 years of age had the highest prevalence of active trachoma (79%), over the course of the 13 months, yet the prevalence at any one visit was approximately 60%. Trachomatous scarring was present in 23% of the population. These results suggest that many cases of active trachoma may be missed if a prevalence survey is conducted at only one point in time. Multiple examinations should be conducted to adequately establish prevalence in the population. Antibiotic treatment and health promotion campaigns need to be developed in consideration of local community dynamics.

Direct costs of blindness in Australia.

This study calculated the direct financial costs of blindness to the Australian government and community. Three case studies, representative of Australians with severely impaired vision, were used to calculate the annual costs associated with blindness. The costs include pensions, subsidies, concessions, equipment and services. Case I was a retired person with age-related macular degeneration, case 2 a working aged person with diabetic retinopathy, and case 3 a school student with congenital vision impairment. Sensitivity analysis was used to show the possible range of costs for each case. For case I, direct cost was $ 14686 with a range from $9749 to $22507. The cost for case 2 was $17701 ranging from $9669 to $26720. Costs associated with care and education of case 3 were $15948 ranging from $5106 to $23798. In addition to the social costs to a person who is blind, there are significant financial costs to the government and the community that will increase substantially with the ageing of the Australian population.

Detection of vision impairment in people admitted to aged care assessment centres.

Vision is not routinely tested when the health of older people is assessed, and the aim of this study was to detect older people with vision impairment for referral to appropriate eye care services. People admitted for assessment and or rehabilitation in three aged care assessment centres had distance and near visual acuity assessed with a simplified vision test. A pinhole test was used when necessary. Referral criteria were distance visual acuity of less than 6/12; near vision of less than N8, and people with diabetes who had not attended a dilated fundus examination in the last 2 years. Visual acuity results were obtained in 93% of patients (685/735). Those unable to perform the vision test were very ill or had severe cognitive impairment. Forty-three per cent of patients (266/646) had impaired vision and, of these, 70.6% (188/266) were referred to eye care specialists. Forty-five per cent were referred to ophthalmologists, 36% to optometrists and 20% to low vision services. This significant proportion of patients with poor vision suggests that vision screening is warranted.

Referral to low vision services by ophthalmologists.

PURPOSE: People in need of low vision rehabilitation services often experience delays in referral to services. This study investigates referral criteria of Australian ophthalmologists, the frequency of referral of their patients with low vision and their perceptions of low vision services. METHODS: A survey was sent to a representative, random sample of 200 ophthalmologists. They were asked about criteria used for the referral of their patients with low vision. The survey included questions on the frequency with which they prescribed low vision devices (LVD) and referral of their patients to low vision and rehabilitation services and peer support groups. Perceptions of the quality and availability of low vision services were also investigated. RESULTS: The response rate was 82%. Approximately 11% of ophthalmologists' patients have low vision. It is uncommon for ophthalmologists to prescribe LVD but 67% refer most of their patients with low vision. It is less common for them to refer to rehabilitation services (29%) or peer support services (18%). The perceived local availability of services influences the rate of referral. Ophthalmologists who used the criteria of moderate low vision (< 6/21 to < 6/60) are more likely to refer more of their patients than those who use the criteria of severe low vision. CONCLUSIONS: Australian ophthalmologists refer most of their visually impaired patients to low vision services, but infrequently to rehabilitation services or peer support groups. Differences in perceived need for low vision services indicated by the criteria used for referral, and the perceived availability, influence the rate at which ophthalmologists refer their patients for services. Ophthalmologists are encouraged to refer patients with permanent visual loss to low vision services earlier.

Assessment and educational implications of albinism.

Forty-seven visually impaired albino schoolchildren were identified from the Victorian school population. 28 (aged 7-18) who had had a standard ophthalmic examination including the LH5 Visual Acuity Test for Contrast Sensitivity agreed to try a battery of educational tests in addition. The tests were the Non-Verbal Ability Test, Visual Motor Integration Test, Torch Reading, reading miscue analysis and reading of test to measure sustained near visual acuity. The most useful of these was the Non-Verbal Ability Test (NAT) which indicated that this group of albinos was of above average cognitive ability. This was independent of the findings on ophthalmic examination. The NAT is also useful in identifying relative strengths and weaknesses in information processing abilities in albino subjects.