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

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

The impact of spectacle correction on the well-being of children with vision impairment due to uncorrected refractive error: a systematic review.

BACKGROUND: Despite being easily corrected with eyeglasses, over two-thirds of the world's child population presents with vision impairment (VI) due to uncorrected refractive errors. While systematic reviews have shown that VI can significantly impact children's depression and anxiety, none have reviewed the existing literature on the association between spectacle correction and well-being. This review aims to address this knowledge gap. MAIN OUTCOME MEASURES: The main outcome measures were i) cognitive and education well-being which included mathematics and english literacy, reading fluency, school function, academic performance and grades; ii) psychological and mental health well-being which included physical anxiety, learning anxiety and mental health test scores and iii) quality of life. METHODS: We searched eight databases for articles published between 1999 to 2021 that assessed the associations between spectacle correction and children's (0 to 18 years) well-being. There were no restrictions on language or geographic location. Two reviewers independently screened all publications using validated quality checklists. The findings of the review were analysed using narrative synthesis. [PROSPERO CRD42020196847]. RESULTS: Of 692 records found in the databases, six randomised control trials, one cohort, one cross-sectional and one qualitative study (N = 9, 1.3%) were eligible for analysis. Data were collected from 25 522 children, 20 parents and 25 teachers across the nine studies. Seven were rated as good quality (67 to 100% of quality criteria fulfilled), and two were satisfactory (33 to 66% of quality criteria fulfilled). Spectacle correction was found to improve children's educational well-being (n = 4 very strong evidence; n = 2 strong evidence), quality of life (n = 1, very strong evidence) and decrease anxiety and increase mental health scores (n = 1, strong evidence). CONCLUSION: Evidence suggests that spectacle correction improves children's cognitive and educational well-being, psychological well-being, mental health, and quality of life. More research is needed, given the paucity of published literature and the focus on only three aspects of well-being.

Caretakers' stated willingness to pay for children's spectacles in cross river state, Nigeria and its implication for a cross-subsidisation scheme: a cross-sectional study.

BACKGROUND: Understanding caretakers' willingness to pay (WTP) for their children's spectacles is essential to improving the sustainability of refractive error services and spectacle provision. Therefore, we investigated the willingness of caretakers to pay for their children's spectacles in a multi-centre study to develop a spectacle cross-subsidisation scheme in the Cross River State (CRS), Nigeria. METHODS: We administered the questionnaire to all caretakers whose children were referred from school vision screenings to four eye centres for full refraction assessment and dispensing of corrective spectacles from 9 August to 31 October 2019. We collected information on socio-demography, children's refractive error types, and spectacle prescription and then asked the caretakers about their WTP for the spectacles using a structured questionnaire and bidding format (in the local currency, Naira, ₦). RESULTS: A total of 137 respondents (response rate = 100%) from four centres were interviewed: with greater proportion of women (n = 92, 67.1%), aged between 41 and 50 years (n = 59, 43.1%), government employees (n = 64, 46.7%) and had acquired college or university education (n = 77, 56.2%). Of the 137 spectacles dispensed to their children, 74 (54.0%) had myopia or myopic astigmatism (equal to or greater than 0.50D). The mean stated WTP for the sample population was ₦3,560 (US$ 8.9) (SD ± ₦1,913.4). Men (p = 0.039), those with higher education (p < 0.001), higher monthly incomes (p = 0.042), and government employees (p = 0.001) were more willing to pay ₦3,600 (US$9.0) or more. CONCLUSION: Combining our previous findings from marketing analysis, these findings provided a basis to plan for a children's spectacles cross-subsidisation scheme in CRS. Further research will be needed to determine the acceptability of the scheme and the actual WTP.

Contextual factors affecting integration of eye health into school health programme in Zanzibar: a qualitative health system research.

BACKGROUND: Short-term school eye health programmes supported by external funders have sustainability issues. This study aimed to understand the contextual factors affecting integrating eye health into the school health programme. METHODS: We elicited responses from 83 respondents, purposefully selected from the Ministry of Health (n = 7), Ministry of Education and Vocational Training (n = 7), hospitals/eye centres (n = 5), master trainers (4) and schools (n = 60) who participated in in-depth interviews. Their responses were analysed and grouped into contextual factors according to the WHO Consolidated Framework for Implementation Research: stakeholders/political, institutional, physical, cultural, delivery system and others. Themes were then generated, and quotations were presented to illustrate the findings. RESULTS: The six contextual factors affecting the integration of eye health into the school eye health programme were i) Stakeholders/political (Good ministry coordination, defined departmental roles and resource mobilisation from multiple stakeholders; Good stakeholder synergies and address current gaps); ii) Institutional (Institutional coordination and adequate clinic space; Securing human and financial resources; Strategic advocacy for institutional resources); iii) Physical (Long travel distance to service points); vi) Cultural (low eye health awareness among parents, teachers and children); iv) Delivery system (Practical approach to increase screening coverage using teachers as screeners; Balance teachers' workload, increase screening sensitivity and follow up and; v) Others (Comprehensive training material and effective training delivery; Improved curriculum, teacher selection and supervision and incentives). CONCLUSION: Integrated school eye health delivery is generally well-received by stakeholders in Zanzibar, with the caveat that investment is required to address the six contextual factors identified in the study.

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

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

Can we scale up a comprehensive school-based eye health programme in Zambia?

BACKGROUND: Globally, 19 million children have preventable vision impairment simply because refractive and eye health services are inaccessible to most of them. In Zambia, approximately 50,000 school children need spectacle provision. The School-based Eye Health Programme (SEHP) has been identified worldwide as a proven strategy to address childhood blindness. Given its great benefits, the Zambian government intends to scale up the programme. This scalability assessment aims to identify and evaluate the essential components of an effective SEHP, determine roles, assess existing capacities within user organisations, identify environmental facilitating and inhibiting factors, and estimate the minimum resources necessary for the scaling up and their proposed scale-up strategies. METHODS: Five elements (innovation, user organisation, resource team, environment, and strategies for horizontal and vertical scaling-up) were assessed guided by the ExpandNet-WHO Nine Steps for Developing a Scaling-Up Strategy. Literature review on proven strategies to reduce childhood blindness and the credibility of SEHP implemented in resource-limited settings, document review on the pilot project, questionnaires, and stakeholders' interviews were conducted to collect data for this assessment. Subsequently, twenty questions in the Worksheets for Developing a Scaling-up Strategy were used to report the assessment outcome systematically. RESULTS: Additional components of SEHP incorporated in Zambia's model enhanced the innovation's credibility and relevance. The resource team was relatively competent in the pilot project, and the same team will be employed during the scaling-up. Potential change in political parties, the lack of supply chain, and unstable financial support were identified as inhibiting factors. The objectives of SEHP were aligned with the National Eye Health Strategic Plan 2017-2021, which supports the institutionalisation of the SEHP into the existing School Health and Nutrition Programme. For the pace of expansion, replicating SEHP to another district rather than a province will be more realistic. CONCLUSION: Scaling up a comprehensive SEHP in Zambia is feasible if sufficient funding is available. Additionally, the pace must be adapted to the local context to ensure that every component within the SEHP is intact.

Prevalence of Refractive Error, Presbyopia, and Spectacle Coverage in Bogotá, Colombia: A Rapid Assessment of Refractive Error.

SIGNIFICANCE: Uncorrected refractive error is the leading cause of visual impairment; therefore, reducing its prevalence is important worldwide. For two decades, there has not been a comprehensive assessment of refractive error in Latin America. PURPOSE: The purpose of this study was to determine the current prevalence of refractive error, presbyopia, spectacle coverage, barriers to uptake refractive services, and spectacle correction in people 15 years and older in Bogotá, Colombia. METHODS: A cross-sectional community-based survey was conducted using 50 randomly selected clusters from 10 districts of Bogotá reflecting the socioeconomic status of the city. Respondents 15 years and older were interviewed and underwent standardized clinical eye examinations. Prevalence of uncorrected refractive error, spectacle coverage, and visual impairment were standardized to 2015 age-sex population distribution of Bogotá and further analyzed. RESULTS: A total of 2886 subjects (90% of 3206 eligible subjects) participated in the study; 39.1% were male and 60.9% were female in the age range of 15 to 96 years, with a median age of 46 years (interquartile range, 45 to 54 years). Age- and sex-standardized prevalence of visual impairment was 19.3% (95% confidence interval [CI], 17.8 to 20.8%). Prevalence of uncorrected refractive error was 12.5% (95% CI, 11.3 to 13.7%). Prevalence of presbyopia among participants 35 years and older was 55.2% (95% CI, 52.9 to 57.4%). Spectacle coverage was 50.9% for distance vision, and it was 33.9% for presbyopia. Main barrier to spectacle uptake was a limitation in affording spectacles because of economic factors (29.5%). CONCLUSIONS: This study provides a current estimate of refractive error using the Rapid Assessment of Refractive Error for Colombia and the Latin American region. The prevalence of uncorrected refractive error and presbyopia was high, and the barriers to spectacle uptake were higher in the lowest socioeconomic strata. The results obtained in the present study will help in making evidence-based decisions related to eye care service delivery in Colombia.

How Do Patients Choose Their Spectacles in the Public Sector of South Africa?

PURPOSE: This study was designed to understand the profiles of the patients who attended and chose to purchase spectacles from the public sector eye clinics in KwaZulu Natal, South Africa. Furthermore, we wished to explore patients' perceptions of the spectacle frames on offer and to understand the motivation of the patients in selecting their spectacle frames. METHODS: This descriptive study consented 674 patients from seven eye clinics in KwaZulu Natal. Each was interviewed using a questionnaire containing open-ended, close-ended questions and questions with a Likert-scale response. RESULTS: Females comprised 68.4% of the study population. The majority of participants had not completed secondary school or had no schooling (78.9%), were unemployed (70.9%), and earned less than R2000 per month or did not have any form of income (89.2%). Of the 670 who chose to buy spectacles from the eye clinics, 79.4% indicated that this was convenient (79.4%) and 23.0% said that they were motivated in their decision because they liked the available frames. More than 95% of participants rated the design, quality, and price as good to excellent. Factors influencing their decisions included design, recommendations from staff, and quality. Those who bought the spectacles from the budget range were prepared to pay more for the next pair of spectacles, whereas almost all reported that they would return to the same eye clinic for their next pair of spectacles and that they would recommend relatives and friends to the clinic. CONCLUSIONS: The results from the study indicate that there is high acceptance by patients of the range of spectacles offered in public sector eye clinics with specific suggestions to improve it. Increased understanding of the perceptions and motivations in spectacle choice will help inform planning and procurement decisions in supplying the needs of the patients and broadening the patient base.

Needs and views on eye health and women's empowerment and theory of change map: implication on the development of a women-targeted eyecare programme for older Zanzibari craftswomen.

OBJECTIVES: To assess needs and views regarding eye health and empowerment from craftswomen's perspectives to develop a theory of change (ToC) for a women-targeted eyecare programme. MATERIAL AND METHODS: Eighteen stakeholders participated in a 2-day consultation workshop in Zanzibar. The composition was (1) 15 women and 3 men; (2) Unguja (n=8), Pemba (n=6) and Tanzania mainland (n=4) and (3) craftswomen (n=14) and governmental stakeholders (n=4). Thematic analysis determined the craftswomen's needs and views regarding eye health and empowerment and subsequently inputs, activities, outputs, outcomes and impact to develop the programme's initial ToC. In refining the initial ToC, we used insights from a qualitative study suggesting that improved near vision is perceived by craftswomen as a potential source of empowerment across economic, psychological, social, political and educational dimensions. RESULTS: The eye conditions experienced by the craftswomen were eye irritation caused by foreign bodies, the need for near spectacles and other eye morbidities. They were advised by the cooperatives to visit eye health centres for treatment. The main barriers to accessing services were inaccessibility and unaffordability of eye services and a lack of eye health knowledge and practices. Nineteen subthemes on women empowerment (economic n=4, social n=4, psychological n=6, education n=2 and political n=3) were obtained. We created a ToC on how investing in improving craftswomen near vision could achieve empowerment. CONCLUSION: The participants provided insights into their needs and how they would like the eyecare programme to be implemented and how they see they could be empowered in the process.

Prevalence of presbyopia and spectacle coverage in an African population in Durban, South Africa.

PURPOSE: To assess the prevalence of near vision impairment caused by uncorrected presbyopia and to determine the spectacle coverage for presbyopia in Durban, KwaZulu Natal, South Africa. METHODS: A cross-sectional community-based survey was conducted to determine the prevalence of presbyopia in Durban. Eighteen clusters were randomly selected from the suburbs of Durban--Inanda, Ntuzuma, and KwaMashu. Adults over 35 years of age were enumerated through a door-to-door method using aged-based sampling. Respondents were interviewed and then underwent standardized clinical eye examinations. Spectacle coverage was determined. Applying multivariate logistic regressions, the strengths of association of presbyopia and spectacle coverage with the participants' demographic profile were determined. RESULTS: A total of 2764 participants were enumerated while 1939 (70.2%) were examined with a median age of 52 years (interquartile range 45, 60). The prevalence of presbyopia was 77.0% (95% confidence interval [CI] 74.3%-79.2%), significantly higher in those 50-64 years old (OR 10.2, 95% CI 5.3-19.6) and 65-79 years old (OR 10.7, 95% CI 3.2-35.6) and significantly lower in those who had secondary and higher education (p < 0.05). The spectacle coverage for presbyopia was 4.84% (95% CI 3.35%-6.33%), significantly higher in those who were 65-79 years old (OR 4.4, 95% CI 1.5-12.9) and 50-64 years old (OR 2.6, 95% CI 1.1-6.1). CONCLUSIONS: This study indicated that there is a high prevalence of presbyopia in the study area, with low spectacle coverage, and therefore suggests that uncorrected presbyopia is a major public health concern. The findings of this study may help in making recommendations for strategic planning for eye health intervention efforts.

Effectiveness of community outreach screening for glaucoma in improving equity and access to eye care in Nigeria.

PURPOSE: To determine the effectiveness of community outreach screening for glaucoma in improving equity and access to eye care in Nigeria. METHODOLOGY: This was a prospective study in which two cohort of participants were recruited in Nigeria: 1 from 24 outreach screenings and another from consecutive patients presenting spontaneously to a tertiary eye clinic in Nigeria. Sociodemographic and clinical data were obtained from participants and compared. RESULTS: Our sample consisted of 120 patients with glaucoma or suspected glaucoma (6.38% of 1881 screenees) recruited from the 24 outreach screenings, and another 123 patients with glaucoma who presented spontaneously at the eye clinic. Participants from the screenings were significantly older (p=0.012), less educated (p<0.001), had lower incomes (p<0.001), lower glaucoma knowledge scores and were less aware of their glaucoma (both p<0.001) and were more likely to be dependent on relations and children (p=0.002) compared with clinic participants. Of the 120 patients identified at the screenings and referred to the clinic for definitive care, 39 (32.5%) presented at the clinic within 3 months. Reasons for poor uptake of referral services were lack of a felt need and lack of money for transportation. Considering only patients who accepted referral, they were still less educated (p<0.001), poorer (p=0.001) and less knowledgeable about glaucoma (p=0.003) than spontaneous clinic presenters. CONCLUSION: Outreach screening improved equity of access but its effects were somewhat reduced by poor uptake of referral care. Interventions such as free transportation and educational efforts may improve the uptake of referral services and maximise equity gains.

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.

Refractive error, eye care needs and attitude towards spectacle wearing among older Zanzibari craftswomen and implications for developing women-targeted services: a cross-sectional study.

BACKGROUND: Aged Zanzibari women are in a disadvantaged position, having high demand for near-vision spectacles. Currently, there is no information on the eye health status of craftswomen, which makes planning a women-targeted project to deliver eye health services to older craftswomen in Zanzibar difficult. We assessed the prevalence of vision impairment, refractive error, presbyopia, effective spectacle coverage (distance and near) and attitude towards spectacle wearing among older Zanzibari craftswomen. METHODS AND ANALYSIS: This was a cross-sectional study. Unaided and presenting distance and near vision of craftswomen 35 years and older were assessed at the women's co-operatives. We determined the number of those with distance vision poorer than 6/12 and their causes (distance-vision impairment), the number of those with near vision poorer than N8 at 40 cm (presbyopia) and the number of those whose distance and/or near-vision needs were met adequately with their habitual spectacles (effective distance and near spectacle coverages). A piloted and validated questionnaire (15 statements) was used to determine their attitude towards spectacle wearing. RESULTS: In all, 263 craftswomen participated in the survey (mean age 52.1 years±9.4 years). The prevalence of distance vision impairment among the craftswomen was 29.7% (95% CI 24.2% to 35.6%), the primary cause being uncorrected refractive error (n=51, 65.4%), and none were corrected. The prevalence of presbyopia was 86.6% (95% CI 81.5% to 90.7%, n=231) and the effective near spectacle coverage was 0.99%. The craftswomen showed a positive attitude towards spectacle wearing (strongly agree or agree) based on 12 out of 15 statements. CONCLUSION: The high burden of vision impairment, uncorrected distance refractive error and presbyopia, and a positive attitude towards spectacle wearing among older craftswomen in Zanzibar indicated the need for women-targeted eye health programmes in low-resource settings.

Willingness to pay for diabetic retinopathy screening in Qujiang District, rural Guangdong, southern China: a cross-sectional study.

OBJECTIVE: To determine willingness to pay for a diabetic retinopathy screening, and its determinants, among people with diabetes mellitus in Qujiang District of Shaoguan City, rural Guangdong, southern China. DESIGN: This cross-sectional study was conducted through a large-scale screening programme in 2019. We randomly selected 575 (21.5%) among 2677 people over 18 years old with known diabetes who attended the screening. Participants elected to pay nothing or RMB10-RMB120 (US$1.6-US$18.8), in RMB10 intervals, displayed on printed cards. One trained interviewer collected all the data. SETTING: Ten primary health centres in Qujiang District of Shaoguan City, Guangdong. PARTICIPANTS: 545 from the 575 randomly selected people (94.8%) agreed to participate in the study. OUTCOME MEASURES: Proportion of participants willing to pay anything for screening, mean amount they were willing to pay and determinants of these figures. RESULTS: Among 545 participants (mean age 64.6 years (SD±10.4), 40.7% men), 327 (60.0%) were willing to pay something for screening, of whom 273 (83.5%) would pay RMB10-RMB30 (US$1.6-US$4.7). People living in rural areas and those from lower-income families were more likely to be willing to pay anything, while men, urban residents and those covered by employer-linked insurance were willing to pay larger sums (p<0.05 for all). CONCLUSION: Nearly two-thirds of participants were willing to pay for screening in this screening programme organised at the primary care level in rural China. This finding offers the potential that such activities can be sustained and scaled up through user fees.

Subjective Wellbeing, Work Performance and Lived Experience of Zanzibari Women Entrepreneurs with Uncorrected Functional Presbyopia: A Pre-Post Mixed-Methods Study.

PURPOSE: Uncorrected presbyopia has been shown to reduce Zanzibari women's quality of life. In this mixed-methods study, we examined the subjective wellbeing and self-reported work performance among older women entrepreneurs with functional presbyopia before and shortly after correction, and how poor vision at close distance affected their daily lives. METHODS: Women entrepreneurs underwent eye examination to identify those with uncorrected functional presbyopia. Their subjective wellbeing and work performance were both measured in Cantril's ladder. Ready-made glasses were then provided and 30 minutes to an hour later, their subjective wellbeing and work performance was remeasured. Twenty women entrepreneurs were interviewed to understand their lived experience with uncorrected presbyopia. RESULTS: Two-hundred-seventeen women entrepreneurs were included in the survey (mean age 51.6 years, SD 8.64). Women entrepreneurs had a mean subjective wellbeing score of 3.32 (SD 1.10) pre-correction and 5.99 (SD 1.13) post-correction (p < .001), and a mean self-rated current work performance score of 4.62 (SD 1.36) before correction and 5.47 (SD 1.35) post-correction (p < .001). One-hundred-and-ninety (87.6%) and 121 women entrepreneurs (55.8%) rated their current subjective wellbeing and work performance scores < 5, respectively. Around 1/4 of women entrepreneurs reported having severe difficulties with near tasks. CONCLUSION: Poor vision at a close distance caused by uncorrected functional presbyopia negatively affected economic, physical and psychosocial aspects of women entrepreneurs' lives. Subjective wellbeing and self-reported work productivity scores improved significantly shortly after presbyopia was corrected. More research with longer follow-up is needed to understand the full benefits of correcting presbyopia.

Impact of a short online course on the accuracy of non-ophthalmic diabetic retinopathy graders in recognising glaucomatous optic nerves in Vietnam.

PURPOSE: To test an online training course for non-ophthalmic diabetic retinopathy (DR) graders for recognition of glaucomatous optic nerves in Vietnam. METHODS: This was an uncontrolled, experimental, before-and-after study in which 43 non-ophthalmic DR graders underwent baseline testing on a standard image set, completed a self-paced, online training course and were retested using the same photographs presented randomly. Twenty-nine local ophthalmologists completed the same test without the training course. DR graders then underwent additional one-to-one training by a glaucoma specialist and were retested. Test performance (% correct, compared with consensus grades from four fellowship-trained glaucoma experts), sensitivity, specificity, positive and negative predictive value, and area under the receiver operating (AUC) curve, were computed. RESULTS: Mean age of DR graders (32.6±5.5 years) did not differ from ophthalmologists (32.3±7.3 years, p=0.13). Online training required a mean of 297.9 (SD 144.6) minutes. Graders' mean baseline score (33.3%±14.3%) improved significantly after training (55.8%±12.6%, p<0.001), and post-training score did not differ from ophthalmologists (58.7±15.4%, p=0.384). Although grader sensitivity reduced before [85.5% (95% CI 83.5% to 87.3%)] versus after [80.4% (78.3% to 82.4%)] training, specificity improved significantly [47.8 (44.9 to 50.7) vs 79.8 (77.3 to 82.0), p<0.001]. Grader AUC also improved after training [66.6 (64.9 to 68.3)] to [80.1 (78.5 to 81.6), p<0.001]. Additional one-to-one grader training by a glaucoma specialist did not further improve grader scores. CONCLUSION: Non-ophthalmic DR graders can be trained to recognise glaucoma using a short online course in this setting, with no additional benefit from more expensive one-to-one training. After 5-hour online training in recognising glaucomatous optic nerve head, scores of non-ophthalmic DR graders doubled, and did not differ from local ophthalmologists. Intensive one-to-one training did not further improve performance.

How does a pair of near-vision spectacle correction empower older Zanzibari craftswomen?: A qualitative study on perception.

BACKGROUND: Studies have shown that correcting presbyopia among women could increase short-term income and quality of life. However, it is unclear whether these short-term outcomes translate to long-term empowerment. This is partly due to women's empowerment being under-studied in the eye health field. Hence, we attempted to understand Zanzibari craftswomen's perception of how near-vision spectacle correction could empower them. METHODS: Semi-structured interviews were conducted with 24 craftswomen with presbyopia (7 to 21 April 2022), identified from Zanzibari cooperatives using quota and heterogeneity sampling. We included a sample of tailors, beaders/weavers, and potters who were 40 years and older. Directed content analysis was performed on interview transcripts. RESULTS: Two themes and seven sub-themes emerged from the data. Craftswomen perceived that at the personal level, near-vision spectacle correction could improve their economic empowerment (better income and savings and buying things for themselves), psychological empowerment (more self-confidence and decision-making), political empowerment (taking up leadership roles), and educational empowerment (acquiring new skills). At a relational level, they perceived that near-vision spectacle correction could bring about economic empowerment (ability to buy things for the family), social empowerment (ability to participate in social activities), and educational empowerment (ability to educate other women). CONCLUSION: Older craftswomen perceived that correcting near vision could empower them at personal and relational levels that encompass economic, psychological, social, political and educational empowerment. The findings laid the foundation for future research into eye health and women's empowerment.

Depression, anxiety, stress symptoms and their determinants among secondary students with vision impairment in rural Northwestern China during the COVID-19 pandemic.

Objective: The measures implemented to control the spread of Coronavirus disease 2019 (COVID-19) could affect children's mental and vision health. Youth particularly from minority and socioeconomically disadvantaged backgrounds were more likely to be impacted by these measures. This study aimed to examine the mental health of children with vision impairment and associated factors in North-western China during the COVID-19 pandemic. Methods: A cross-sectional study was conducted among 2,036 secondary school children living in Ningxia Hui Autonomous Region. Participants completed a survey on sociodemographic and lifestyle information and answered the Chinese version of the 21-item Depression Anxiety Stress Scales (DASS-21) questionnaire. Presenting visual acuity was measured by a trained enumerator. Multivariate logistic regression analysis was used to identify potential risk factors for mental health problems. Results: Responses from 1,992 (97.8%) children were included in the analysis after excluding those with incomplete mental health outcome data. The prevalence of depression, anxiety and stress symptoms within the dataset were 28.9, 46.4, and 22.3%, respectively. The distribution of children with different stress levels differed significantly between those with and without vision impairment (p = 0.03). Multivariable logistic regression analyses revealed that depression symptoms decreased with higher parental education (OR, 0.76, 95% confidence intervals (CI):0.63-0.96), longer sleep duration (OR, 0.90, 95% CI: 0.81-0.97) and longer study time (OR, 0.82, 95% CI: 0.74-0.91), whereas they increased with higher recreational screen time (OR, 1.19, 95% CI: 1.08-1.32). Anxiety symptoms decreased with higher parental education (OR, 0.80, 95% CI: 0.66-0.96) and increased with higher recreational screen time (OR, 1.15, 95% CI: 1.04-1.27) and being a left-behind child (OR, 1.26, 95% CI: 1.04-1.54). In addition, stress symptoms decreased with longer sleep duration (OR, 0.92, 95%CI: 0.85-0.99) and increased with higher number of siblings (OR, 1.10, 95% CI: 1.01-1.19), higher recreational screen time (OR, 1.15, 95% CI: 1.04-1.28) and older age (OR,1.12, 95% CI: 1.004-1.24). Conclusion: A considerable proportion of our sample experienced mental health problems during the pandemic. Healthcare planners in China should consider interventions such as reducing recreational screen time, ensuring sufficient sleep, and timely detection of mental health symptoms among socioeconomically disadvantaged groups.