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

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

Visual Impairment from Uncorrected Refractive Error among Participants in a Novel Program to Improve Eye Care Access among Low-Income Adults in Michigan.

PURPOSE: To assess the rate of visual impairment (VI) from uncorrected refractive error (URE) and associations with demographic and socioeconomic factors among low-income patients presenting to the Michigan Screening and Intervention for Glaucoma and Eye Health through Telemedicine (MI-SIGHT) program. DESIGN: Cross-sectional study. PARTICIPANTS: Adults ≥ 18 years without acute ocular symptoms. METHODS: MI-SIGHT program participants received a telemedicine-based eye disease screening and ordered glasses through an online optical store. Participants were categorized based on refractive error (RE) status: VI from URE (presenting visual acuity [PVA], ≤ 20/50; best-corrected visual acuity [BCVA], ≥ 20/40), URE without VI (PVA, ≥ 20/40; ≥ 2-line improvement to BCVA), and no or adequately corrected RE (PVA, ≥ 20/40; < 2-line improvement to BCVA). Patient demographics, self-reported visual function, and satisfaction with glasses obtained through the program were compared among groups using analysis of variance, Kruskal-Wallis, chi-square, and Fisher exact testing. MAIN OUTCOME MEASURES: PVA, BCVA, and presence of VI (defined as PVA ≤ 20/50). RESULTS: Of 1171 participants enrolled in the MI-SIGHT program during the first year, average age was 55.1 years (SD = 14.5), 37.7% were male, 54.1% identified as Black, and 1166 (99.6%) had both PVA and BCVA measured. VI was observed in 120 participants (10.3%); 96 had VI from URE (8.2%), 168 participants (14.4%) had URE without VI, and 878 (75.3%) had no or adequately corrected RE. A smaller percentage of participants with VI resulting from URE reported having a college degree, and a larger percentage reported income < $10 000 compared with participants with no or adequately corrected RE (3.2% vs. 14.2% [P = 0.02]; 45.5% vs. 21.6% [P < 0.0001], respectively). Visual function was lowest among participants with VI from URE, followed by those with URE without VI, and then those with no or adequately corrected RE (9-item National Eye Institute Visual Function Questionnaire composite score, 67.3 ± 19.6 vs. 77.0 ± 14.4 vs. 82.2 ± 13.3, respectively; P < 0.0001). In total, 71.2% (n = 830) ordered glasses for an average cost of $36.80 ± $32.60; 97.7% were satisfied with their glasses. CONCLUSIONS: URE was the main cause of VI at 2 clinics serving low-income communities and was associated with reduced vision-related quality of life. An online optical store with lower prices made eyeglasses accessible to low-income patients. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

A population-level post-screening treatment cost framework to help inform vision screening choices for children under the age of seven.

PURPOSE/BACKGROUND: Visual acuity (VA) screening in children primarily detects low VA and amblyopia between 3 and 6 years of age. Photoscreening is a low-cost, lower-expertise alternative which can be carried out on younger children and looks instead for refractive amblyopia risk factors so that early glasses may prevent or mitigate the conditions. The long-term benefits and costs of providing many children with glasses in an attempt to avoid development of amblyopia for some of them needs clarification. This paper presents a framework for modeling potential post-referral costs of different screening models once referred children reach specialist services. METHODS: The EUSCREEN Screening Cost-Effectiveness Model was used together with published literature to estimate referral rates and case mix of referrals from different screening modalities (photoscreening and VA screening at 2, 3-4 years and 4-5 years). UK 2019-20 published National Health Service (NHS) costings were used across all scenarios to model the comparative post-referral costs to the point of discharge from specialist services. Potential costs were compared between a) orthoptist, b) state funded ophthalmologist and c) private ophthalmologist care. RESULTS: Earlier VA screening and photoscreening yield higher numbers of referrals because of lower sensitivity and specificity for disease, and a different case mix, compared to later VA screening. Photoscreening referrals are a mixture of reduced VA caused by amblyopia and refractive error, and children with amblyopia risk factors, most of which are treated with glasses. Costs relate mainly to the secondary care providers and the number of visits per child. Treatment by an ophthalmologist of a referral at 2 years of age can be more than x10 more expensive than an orthoptist service receiving referrals at 5 years, but outcomes can still be good from referrals aged 5. CONCLUSIONS: All children should be screened for amblyopia and low vision before the age of 6. Very early detection of amblyopia refractive risk factors may prevent or mitigate amblyopia for some affected children, but population-level outcomes from a single high-quality VA screening at 4-5 years can also be very good. Total patient-journey costs incurred by earlier detection and treatment are much higher than if screening is carried out later because younger children need more professional input before discharge, so early screening is less cost-effective in the long term. Population coverage, local healthcare models, local case-mix, public health awareness, training, data monitoring and audit are critical factors to consider when planning, evaluating, or changing any screening programme.

Determinants of Health Care Needs in Relation to Vision Correction among Adolescents in the United Arab Emirates: A Cross-Sectional Study.

BACKGROUND: Uncorrected refractive error has been suggested to affect children's development, educational performance, and socialization. Sociodemographic and environmental differences among individuals may impact their accessibility to utilizing appropriate services, impacting their vision-dependent activities. METHODS: Guided by the population health framework, this retrospective study assessed the prevalence of self-reported vision correction needs and its determinants for a sample of adolescents (n = 6363) from the United Arab Emirates (UAE) aged 13 to 20 years between 2007 to 2009. RESULTS: The findings suggest a relatively high prevalence of self-reported vision correction needs (26.8%), with among 24.8% males and 31.7% among females. Factors that were significantly associated with vision correction needs included age, biological sex, location of residence (emirate), nationality, parental education and employment level, household financial status, screen time use, visiting an eye specialist in the past year, and daily functional capacity. CONCLUSION: Reporting the vision correction needs of the adolescent population and identifying its determinants may help identify and resolve modifiable barriers to accessing the appropriate vision care resources. Further research in assessing the type of refractive error, potential genetic and environmental factors, and vision care services in each emirate may help decision-makers set appropriate policies to improve the overall quality of eye health.

A Qualitative Assessment of the Experiences with Eye Health and Barriers to Eyeglasses among U.S. Youth.

SIGNIFICANCE: Uncorrected refractive error is the main cause of visual impairment in U.S. youth and has profound impacts on individuals and society. Identifying and addressing barriers to eyeglasses in this population are critical to maximize youth academic performance, workplace productivity, and quality of life. PURPOSE: We aimed to understand youth experiences with eye health, assess the value that youth place on vision, and identify barriers to refractive correction directly from a nationwide sample of youth to inform interventions to address uncorrected refractive error in this population. METHODS: An open-ended poll was distributed to the MyVoice Text Message Cohort of U.S. youth eliciting youth experiences with eye health and barriers to wearing eyeglasses. Text message responses were coded using grounded theory. RESULTS: Of 1204 recipients, 88.3% (n = 1063) responded. The mean age ± standard deviation was 20.3 ± 2.4 years, 58.8% (n = 625) were male, 74.0% (n = 787) were White, and 41.4% (n = 440) reported low socioeconomic status. Four major themes emerged from the open-ended responses: (1) many youth have experienced problems with their eyes or eyesight (n = 699 [65.8%]); (2) many youth value their eyesight highly (n = 905 [85.1%]; e.g., "Eyesight is one of the most important aspects of my health, particularly in our digital world…"); (3) common reasons youth might not wear glasses even if they need them include concerns over appearance (n = 553 [52.0%]; e.g., "I thought every pair made me look ugly…"), cost (n = 171 [16.1%]), inconvenience (n = 166 [15.6%]), and discomfort (n = 104 [9.8%]); and (4) youth are open to purchasing eyeglasses online (n = 539 [50.7%]). CONCLUSIONS: Appearance, cost, inconvenience, and discomfort are critical barriers to wearing eyeglasses among U.S. youth. A multisectoral response is necessary to address these barriers.

Modelling ready-made spectacle coverage for children and adults using a large global database.

BACKGROUND/AIMS: To model the suitability of conventional ready-made spectacles (RMS) and interchangeable-lens ready-made spectacles (IRMS) with reference to prescribing guidelines among children and adults using a large, global database and to introduce a web-based application for exploring the database with user-defined eligibility criteria. METHODS: Using refractive power and interpupillary distance data for near and distance spectacles prescribed to children and adults during OneSight clinics in 27 countries, from 2 January 2016 to 19 November 2019, we modelled the expected suitability of RMS and IRMS spectacle designs, compared with custom-made spectacles, according to published prescribing guidelines. RESULTS: Records of 18 782 presbyopic adult prescriptions, 70 619 distance adult prescriptions and 40 862 paediatric prescriptions were included. Globally, 58.7%-63.9% of adults could be corrected at distance with RMS, depending on the prescribing cut-off. For presbyopic adult prescriptions, coverage was 44.1%-60.9%. Among children, 51.8% were eligible for conventional RMS. Coverage for all groups was similar to the above for IRMS. The most common reason for ineligibility for RMS in all service groups was astigmatism, responsible for 27.2% of all ineligible adult distance prescriptions using the strictest cut-off, 31.4% of children's prescriptions and 28.0% of all adults near prescriptions globally. CONCLUSION: Despite their advantages in cost and convenience, coverage delivered by RMS is limited under current prescribing guidelines, particularly for children and presbyopic adults. Interchangeable designs do little to remediate this, despite extending coverage for anisometropia. Our free application allows users to estimate RMS coverage in specific target populations.

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

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

A pilot cost-benefit analysis of a children's spectacle reimbursement scheme: Evidence for Including children's spectacles in Mongolia's Social Health Insurance.

BACKGROUND AND AIM: Globally, 12.8 million children have vision impairment due to uncorrected refractive error (URE). In Mongolia, one in five children needs but do not have access to spectacles. This pilot cost-benefit analysis aims to estimate the net benefits of a children's spectacles reimbursement scheme in Mongolia. METHODS: A willingness-to-pay (WTP) survey using the contingent valuation method was administered to rural and urban Mongolia respondents. The survey assessed WTP in additional annual taxes for any child with refractive error to be provided government-subsidised spectacles. Net benefits were then calculated based on mean WTP (i.e. benefit) and cost of spectacles. RESULTS: The survey recruited 50 respondents (mean age 40.2 ± 9.86 years; 78.0% women; 100% response rate) from rural and urban Mongolia. Mean WTP was US$24.00 ± 5.15 (95% CI US$22.55 to 25.35). The average cost of a pair of spectacles in Mongolia is US$15.00. Subtracting the average cost of spectacles from mean WTP yielded a mean positive net benefit of US$9.00. CONCLUSION: A spectacle reimbursement scheme is potentially a cost-effective intervention to address childhood vision impairment due to URE in Mongolia. These preliminary findings support the proposal of the inclusion of children's spectacles into existing Social Health Insurance. A much larger random sample could be employed in future research to increase the precision and generalisability of findings.

Assessment of stereopsis in pediatric and adolescent spectacle-corrected refractive error - A cross-sectional study.

PURPOSE: To assess the level of stereopsis in school children with spectacle-corrected refractive errors using Titmus fly and Randot stereo tests, evaluate the factors associated with the level of stereopsis, and determine the level of agreement between the two tests. METHODS: A cross-sectional study was done on 5- to 18-year-old school-children wearing spectacles for at least 1-month duration. Visual acuity was assessed using Snellen's visual acuity chart, and their spectacle correction being used currently was measured using an auto lensmeter. The level of stereopsis was assessed using Randot and Titmus fly stereo tests. Data were entered using Microsoft Excel and analyzed using IBM-SPSS version 20, Chicago, IL. The associations between stereopsis and type of refractive error, visual acuity, age, and gender were analyzed. An agreement between Randot and Titmus fly test was done using Kappa statistics. RESULTS: A total of 222 children (101 boys and 121 girls; mean age 13 years) were assessed. Astigmatism was the most prevalent refractive error (60.4%), followed by myopia (24.8%) and hypermetropia (1.4%). Thirty children (13.5%) had anisometropia. All hyperopes had normal stereopsis. Children with spherical myopia had better stereopsis, followed by astigmatism and anisometropia in the same order (P = 0.036). Children with anisometropia ≤1.5 D had better stereopsis than anisometropia more than 1.5 D. Stereopsis was also found to have no correlation with the age and visual acuity at the time of testing or the age at which the child first started wearing spectacles. Stereopsis values obtained from Randot and Titmus fly stereo tests showed moderate agreement with Kappa value 0.581. CONCLUSION: Anisometropia and astigmatism are the most critical factors determining the level of stereopsis in refractive errors.

Socio-economic differences in accessing NHS spectacles amongst children with differing refractive errors living in Scotland.

BACKGROUND/OBJECTIVES: Adults living in more deprived areas are less likely to attend an eye examination, resulting in greater visual impairment from undiagnosed eye disease and a widening of health inequalities. It is unknown if the introduction of free NHS eye examinations and help with spectacle costs has benefited children in Scotland. This study aimed to explore factors associated with accessing NHS spectacles including level of deprivation, refractive error, urbanity and age. SUBJECTS/METHODS: NHS-financed General Ophthalmic Services (GOS) 3 supplement the cost of spectacles for children under 16 years. Administrative data on the spectacle refraction dispensed were obtained from Information Services Division (ISD) for mainland Scotland, 2018, and categorised by: Emmetropes/low hyperopes (reference group), myopes and moderate/high hyperopes. Data were linked to the Scottish Index of Multiple Deprivation (SIMD) quintile. RESULTS: Data included 108, 043 GOS 3 claims. Greater deprivation was associated with greater GOS 3 claims p = 0.041. This was most evident in emmetropic/low hyperopic children and in moderate/high hyperopic children. GOS 3 claims in the myopes group increased with age across all SIMD and decreased with age in the moderate/high hyperope group (all p < 0.001). GOS 3 claims were not associated with urbanity for all Health Boards (p = 0.13). CONCLUSIONS: Children in areas of greater deprivation and in more rural areas are not disadvantaged in accessing NHS spectacles. This did not vary by refractive error group. This suggests that health policy in Scotland is accessible to those from all deprivation levels and refractive errors.

Population-based assessment of prevalence of spectacle use and effective spectacle coverage for distance vision in Andhra Pradesh, India - Akividu Visual Impairment Study.

CLINICAL RELEVANCE: Effective spectacle coverage is a useful indicator to assess the coverage of refraction services in a given region. We found a low coverage in the Akividu region suggesting a need to develop effective refraction services. BACKGROUND: To assess the prevalence of spectacle use and effective spectacle coverage for distance vision among people aged 40 years and older in the Indian state of Andhra Pradesh. METHODS: A population-based cross-sectional survey was carried out in the Akividu region in West Godavari and Krishna districts. The study teams visited selected households and conducted eye examinations in the selected clusters. A structured questionnaire was used to collect information on spectacle use. 'Met Need' was defined as unaided VA worse than 6/12 but improved to 6/12 or better with their current spectacles. 'Unmet Need' was defined as unaided VA worse than 6/12 but improved to 6/12 with pinhole, among those not using spectacles. The 'Under-met Need' was defined as aided VA worse than 6/12 but improving with pinhole to 6/12 or better. Based on these definitions, Effective Refractive Error Coverage (e-REC) is calculated as: e-REC (%) s = ((met need)/(met need + under-met need + unmet need)) X100. RESULTS: Of 3,000 enumerated from 60 clusters, 2,587 (86.2%) participants were examined. The prevalence of current spectacle use was 43.1% (95% CI:41.2-45.0). The e-REC was 37.4%. It was also lower in men compared to women and among those without any education. Participants who had cataract surgery in either eye had similar e-REC compared to those who were not operated. CONCLUSION: Though spectacle use was found to be high, there is a still large unmet need for refractive correction for distance. Effective service delivery models to provide refraction and spectacle dispensing services are needed to achieve universal eye health coverage in the region.

Investigation of the Accuracy of a Low-Cost, Portable Autorefractor to Provide Well-Tolerated Eyeglass Prescriptions: A Randomized Crossover Trial.

PURPOSE: To compare patient preferences for eyeglasses prescribed using a low-cost, portable wavefront autorefractor versus standard subjective refraction (SR). DESIGN: Randomized, cross-over clinical trial. PARTICIPANTS: Patients aged 18 to 40 years presenting with refractive errors (REs) to a tertiary eye hospital in Southern India. METHODS: Participants underwent SR followed by autorefraction (AR) using the monocular version of the QuickSee device (PlenOptika Inc). An independent optician, masked to the refraction approach, prepared eyeglasses based on each refraction approach. Participants (masked to refraction source) were randomly assigned to use SR- or AR-based eyeglasses first, followed by the other pair, for 1 week each. At the end of each week, participants had their vision checked and were interviewed about their experience with the eyeglasses. MAIN OUTCOME MEASURES: Patients preferring eyeglasses were chosen using AR and SR. RESULTS: The 400 participants enrolled between March 26, 2018, and August 2, 2019, had a mean (standard deviation) age of 28.4 (6.6) years, and 68.8% were women. There was a strong correlation between spherical equivalents using SR and AR (r = 0.97, P < 0.001) with a mean difference of -0.07 diopters (D) (95% limits of agreement [LoA], -0.68 to 0.83). Of the 301 patients (75.2%) who completed both follow-up visits, 50.5% (n = 152) and 49.5% (n = 149) preferred glasses prescribed using SR and AR, respectively (95% CI, 45.7-56.3; P = 0.86). There were no differences in demographic or vision characteristics between participants with different preferences (P > 0.05 for all). CONCLUSIONS: We observed a strong agreement between the prescriptions from SR and AR, and eyeglasses prescribed using SR and AR were equally preferred by patients. Wider use of prescribing based on AR alone in resource-limited settings is supported by these findings.

Visual and Ocular Conditions among a Homeless Adult Population of Boston.

SIGNIFICANCE: The eye care needs of the homeless population in the United States are not well known. This study elucidates those needs for health care for the homeless programs and eye care practitioners. This information could result in an increase in the provision of necessary eye care services. PURPOSE: The purpose of this study was to assess the extent of visual and ocular conditions, the frequency of eyeglass orders and receipt of eyeglasses, and the frequency of ophthalmology referrals and receipt of ophthalmological care in an adult homeless population in Boston. METHODS: A cross-sectional retrospective chart review was conducted for patients of the Boston Health Care for the Homeless Program's Pine Street Inn eye clinic from September 26, 2016, to December 31, 2017. Data on sociodemographics, medical history, comprehensive eye examination findings, glasses orders and receipt, and ophthalmology referrals and receipt of care were collected and analyzed. RESULTS: A total of 424 patients were included in the study. The mean age of the study population was 52.7 (interquartile range, 46 to 60), and the majority were male (74%). The most common systemic conditions were hypertension (40.6%) and diabetes (23.8%). The most common refractive error was presbyopia (67.7%), followed by astigmatism (38.9%), hyperopia (34.0%), and myopia (30.7%). The most common ocular conditions were dry eye (28.6%), visually or clinically significant cataract (20%), and glaucoma/glaucoma suspicion (13.9%). Refractive correction was indicated for 356 patients (84%), but 82 (29%) did not receive ordered eyeglasses. Ophthalmology referrals were placed for 61 patients (14.4%), yet only 20 (32.8%) of those referrals were completed. CONCLUSIONS: A significant need for refractive correction and a large gap for ophthalmological care were found among the study population. Health care for the homeless programs and eye care practitioners should be aware of the visual and ocular needs of this patient population so as to better meet their needs.

Barriers and Facilitators to Obtaining Eyeglasses for Vulnerable Patients in a Michigan Free Clinic.

SIGNIFICANCE: Uncorrected refractive error is the main cause of visual impairment globally. Understanding barriers and facilitators underserved individuals face in obtaining eyeglasses will help address high rates of uncorrected refractive error. PURPOSE: The purpose of this study was to understand the barriers and facilitators to obtaining eyeglasses among low-income patients in Michigan. METHODS: Participants older than 18 years with hyperopia, myopia, or presbyopia and without active eye disease, severe mental illness, or cognitive impairment at Hope Clinic, Ypsilanti, Michigan, were included in this study. The participants answered a sociodemographic survey and underwent autorefraction and an interview. Interviews were audiorecorded, transcribed, and analyzed by two investigators. RESULTS: Interviews were completed by 43 participants, and 30 participants' interviews were analyzed. The mean ± standard deviation age of 30 participants was 55 ± 12 years, 70% were female, 57% were African American, 40% had high school diploma or less, 57% earned less than U.S. $25,000 per year, 93% had worn glasses previously, and 87% had some medical insurance. Uncorrected visual acuity was logMAR 0.73 ± 0.61; best-corrected visual acuity was logMAR 0.16 ± 0.21. Thematic saturation was reached after 25 transcripts. Top barriers to using eyeglasses were cost (312 mentions, 29 participants), negative experiences with eyeglasses (263, 29), and limited access to eye care (175, 27). Top facilitators were positive experiences with glasses (230, 29), easy access to eyeglasses (143, 27), and availability of transportation (65, 27). Most participants (97%, 29) reported being negatively impacted by uncorrected refractive error. Most (97%, 29) were skeptical about obtaining eyeglasses online because of possible prescription problems. CONCLUSIONS: Key barriers to correcting uncorrected refractive error in our community span across multiple health domains but are predominately rooted in external factors such as cost and access to vision care. Online eyeglasses may address access issues, but many participants were uncomfortable or unable to obtain glasses online.

Responsibility for Funding Refractive Correction in Publicly Funded Health Care Systems: An Ethical Analysis.

Allocating on the basis of need is a distinguishing principle in publicly funded health care systems. Resources ought to be directed to patients, or the health program, where the need is considered greatest. In Sweden support of this principle can be found in health care legislation. Today however some domains of what appear to be health care needs are excluded from the responsibilities of the publicly funded health care system. Corrections of eye disorders known as refractive errors is one such domain. In this article the moral legitimacy of this exception is explored. Individuals with refractive errors need spectacles, contact lenses or refractive surgery to do all kinds of thing, including participating in everyday activities, managing certain jobs, and accomplishing various goals in life. The relief of correctable visual impairments fits well into the category of what we typically consider a health care need. The study of refractive errors does belong to the field of medical science, interventions to correct such errors can be performed by medical means, and the skills of registered health care professionals are required when it comes to correcting refractive error. As visual impairments caused by other conditions than refractive errors are treated and funded within the public health care system in Sweden this is an inconsistency that needs to be addressed.

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 Refractive Error Changes and Factors for Decompensation in Patients With Fully Accommodative Esotropia.

PURPOSE: To determine the factors affecting the risk of deterioration and evaluate the refractive error change in patients with fully accommodative esotropia. METHODS: Patients diagnosed as having fully accommodative esotropia (esotropic deviation that started before 7 years of age and less than 8 to 10 prism diopters [PD] of esotropia with full hyperopic correction and/or bifocals) were included in this retrospective population-based cohort study. Refractive error changes were recorded. For comparisons, patients were divided into two groups: nondecompensated fully accommodative esotropia group and decompen-sated fully accommodative esotropia group. RESULTS: Two hundred and twenty-three patients met the inclusion criteria. The mean follow-up time was 5.94 ± 0.31 years (range: 5 to 8 years). The changes in spherical equivalent in the younger than 7 years, 7 to 12 years, and 12 to 17 years groups were statistically significant (P < .001). The decrease of hypermetropia was 0.13 diopters/year between 7 and 12 years and 0.06 diopters/year between 12 and 17 years. Forty-one of 223 patients (18.4%) discontinued spectacle therapy during the follow-up period. Hyperopic error and presence of amblyopia were lower, whereas visual acuity level and presence of near-distance disparity were higher in the spectacle discontinuation group (P < .001, .007, .01, and 0.01, respectively). Deterioration of fully accommodative esotropia occurred in 30 of 223 patients (13.5%). Boys were more likely to require strabismus surgery (P = .32). The mean age at presentation, esotropia angle with and without refractive correction at both near and distance fixation, near distance disparity, and inferior oblique overaction were significantly higher in patients with decompensated fully accommodative esotropia. CONCLUSIONS: Hyperopic error increased from the initial level until 7 years of age, followed by a myopic shift thereafter. Few children had resolution of fully accommodative esotropia and could discontinue spectacle therapy. Children with male gender, higher esotropia angle, older age at presentation, near-distance disparity, and inferior oblique overaction experienced a greater deterioration of the fully accommodative esotropia. [J Pediatr Ophthalmol Strabismus. 2020;57(4):217-223.].

Characteristics, Behaviors, and Awareness of Contact Lens Wearers Purchasing Lenses Over the Internet.

OBJECTIVES: To describe the characteristics and hygiene habits of contact lens (CL) wearers who acquire CLs over the Internet, as well as their awareness of modifiable risk factors (RFs). METHODS: A web-based survey was conducted among clients of an online CL sales platform during 6 months. Demographic data, CL hygiene-related awareness, and compliance were collected and analyzed. RESULTS: The questionnaire was completed by 1,264 CL wearers: the average age was 40.8 years; most were women (71.1%), had myopia (76.4%), and wore monthly disposable CLs (63.6%). The frequency of eye examination was significantly lower among those buying the CL exclusively online (15.8% vs. 6.6%, P<0.001) and those who had begun CL use on their own (17.5% vs. 8.8%, P<0.001). Initiation to CL wear without the intervention of an eye care practitioner was more frequent in wearers with less experience. Common risk behaviors included water exposure (68.1% in swimming and 64.9% in the shower), use of the case (61.9%) and CL (65.1%) beyond the recommended replacement time, and reuse of the maintenance solution (31.9%). Ignorance of recommended hygiene increased the probability of risky behavior. CONCLUSION: There were no differences in compliance or awareness of risks between those purchasing exclusively online and other CL wearers. However, the growing frequency of self-taught initiation in CL wear among less-experienced online customers and online exclusive purchase was associated with a decrease in eye examination frequency and therefore worse compliance and increased risks. This finding underlines the importance of publicizing correct hygiene habits by all possible means so as to increase compliance.

Use of spectacles for distance vision: coverage, unmet needs and barriers in a rural area of North India.

BACKGROUND: Uncorrected refractive errors contribute enormously to the burden of avoidable visual impairment worldwide. There is a huge disparity in different parts of the globe in context to spectacle coverage for distance vision. This study was undertaken with objectives of determining prevalence of spectacle coverage, unmet needs and associated factors among adults in a rural community of north India. METHODS: A community-based cross-sectional study was carried out within selected clusters of Jhajjar district of Haryana. All participants aged > 15 years underwent visual acuity assessment by LogMAR "E" screening chart. Participants with presenting visual acuity < 6/12 in any eye and all current spectacle users underwent detailed ophthalmic examination and refraction. Additional details about spectacles, barriers for their use and willingness to pay for them were collected. Participants with met and unmet need for spectacle use at visual acuity > 6/12 was computed. These are reported as proportions with 95% confidence intervals. Associated factors with unmet need were determined using bivariable and multivariable logistic regression analysis. RESULTS: A total of 6910 participants were examined. The current spectacle use was 7.5% (95% Confidence Interval CI: 6.5, 8.7). The spectacle coverage was found in 33.3% (95% CI: 30.0, 36.7) participants among those in need. The unmet need was found in 10.8% of participants (95% CI: 10.1, 11.6). On multivariable analysis, odds of unmet need was associated with age, gender, level of education and marriage status. The most common barrier for refractive correction was lack of perceived need for refraction and its correction. CONCLUSION: There is substantial unmet need for distance vision spectacles in this population. It is imperative that multi-component intervention be implemented to improve spectacle coverage in this rural north Indian setting.

Teachers' influence on purchase and wear of children's glasses in rural China: The PRICE study.

IMPORTANCE: Uncorrected refractive error causes 90% of poor vision among Chinese children. BACKGROUND: Little is known about teachers' influence on children's glasses wear. DESIGN: Cohort study. PARTICIPANTS: Children at 138 randomly selected primary schools in Guangdong and Yunnan provinces, China, with uncorrected visual acuity (VA) ≤6/12 in either eye correctable to >6/12 in both eyes, and their teachers. METHODS: Teachers and children underwent VA testing and completed questionnaires about spectacles use and attitudes towards children's vision. MAIN OUTCOME MEASURES: Children's acceptance of free glasses, spectacle purchase and wear. RESULTS: A total of 882 children (mean age 10.6 years, 45.5% boys) and 276 teachers (mean age 37.9 years, 67.8% female) participated. Among teachers, 20.4% (56/275) believed glasses worsened children's vision, 68.4% (188/275) felt eye exercises prevented myopia, 55.0% (151/275) thought children with modest myopia should not wear glasses and 93.1% (256/275) encouraged children to obtain glasses. Teacher factors associated with children's glasses-related behaviour included believing glasses harm children's vision (decreased purchase, univariate model: relative risk [RR] 0.65, 95% CI 0.43, 0.98, P < 0.05); supporting children's classroom glasses wear (increased glasses wear, univariate model: RR 2.20, 95% CI 1.23, 3.95, P < 0.01); and advising children to obtain glasses (increased free glasses acceptance, multivariate model: RR 2.74, 95% CI 1.29, 5.84, P < 0.01; increased wear, univariate model: RR 2.93, 95% CI 1.45, 5.90, P < 0.01), but not teacher's ownership/wear of glasses. CONCLUSIONS AND RELEVANCE: Though teachers had limited knowledge about children's vision, they influenced children's glasses acceptance.