Access to school-based eye health programs in Central Region, Malawi: a qualitative case study.

Vision impairment among children is associated with lower levels of educational attainment. School-based eye health programs have the potential to provide high-quality and cost-effective services that assist in the prevention of blindness and uncorrected vision impairment, particularly in low-resources settings. The aim of this study was to identify key factors that inhibit or facilitate the provision of school-based eye health programs, including referral to eye care services, for Malawian children in the Central Region. In-depth interviews (n = 10) and focus groups (n = 5) with children, parents, school staff, eye care practitioners, government and NGO workers (total participants n = 44) in rural and urban contexts within central region, Malawi, were conducted. Taking a rights-based approach, we used the AAAQ (availability, accessibility, acceptability, quality) framework to identify barriers and enablers to school eye health programs. Complex factors shape access to school-based eye health programs. While intersectoral collaboration between ministries was present, infrastructure and resourcing restricted the delivery of school eye health programs. School staff were supportive of being trained as vision screeners. Parents voiced geographic access to follow up eye care, and spectacle cost as a barrier; and children revealed experiences of stigma related to spectacle as barriers to uptake. School-based eye care may be facilitated through teachers, community informants and health workers through; the provision of school vision screening; increased awareness of the impact of vision impairment on education and future employment; and through educational approaches that seek to decrease stigma and misconceptions associated with wearing spectacles.

Indicators for Assessing the Quality of Refractive Error Care.

SIGNIFICANCE: Quality refractive error care is essential for reducing vision impairment. Quality indicators and standardized approaches for assessing the quality of refractive error care need to be established. PURPOSE: This study aimed to develop a set of indicators for assessing the quality of refractive error care and test their applicability in a real-world setting using unannounced standardized patients (USPs). METHODS: Patient outcomes and three quality of refractive error care (Q.REC) indicators (1, optimally prescribed spectacles; 2, adequately prescribed spectacles; 3, vector dioptric distance) were developed using existing literature, refraction training standards, and consulting educators. Twenty-one USPs with various refractive errors were trained to visit optical stores across Vietnam to have a refraction, observe techniques, and order spectacles. Spectacles were assessed against each Q.REC indicator and tested for associations with vision and comfort. RESULTS: Overall, 44.1% (184/417) of spectacles provided good vision and comfort. Of the spectacles that met Q.REC indicators 1 and 2, 62.5 and 54.9%, respectively, provided both good vision and comfort. Optimally prescribed spectacles (indicator 1) were significantly more likely to provide good vision and comfort independently compared with spectacles that did not meet any indicator (good vision: 94.6 vs. 85.0%, P = .01; comfortable: 66.1 vs. 36.3%, P < .01). Adequately prescribed spectacles (indicator 2) were more likely to provide good comfort compared with spectacles not meeting any indicator (57.7 vs. 36.3%, P < .01); however, vision outcomes were not significantly different (85.9 vs. 85.0%, P = .90). Good vision was associated with a lower mean vector dioptric distance (P < .01) but not with comfort (P = .52). CONCLUSIONS: The optimally prescribed spectacles indicator is a promising approach for assessing the quality of refractive error care without additional assessments of vision and comfort. Using USPs is a practical approach and could be used as a standardized method for evaluating the quality of refractive error care.

Access to school-based eye health programs: a qualitative case study, Bogotá, Colombia.

OBJECTIVES: To identify barriers and enablers to accessing school-based eye health programs in Bogotá, Colombia. METHODS: We undertook a qualitative case study that explored how structural factors, and social and cultural norms influence access to school-based eye health programs. We conducted focus groups discussions and interviews with a purposive sample of 37 participants: government stakeholders (n = 4), representatives from nongovernmental organizations (n = 3), and an eye-care practitioner, as well as teachers (n = 7), a school nurse, parents (n = 7), and children (n = 14) from private and public schools. Data were analyzed using a priori themes from the availability, accessibility, acceptability and quality framework. RESULTS: Routine vision screening in schools is not currently provided nor is there a budget to support it. Lack of collaboration between the health and education ministries and the absence of national planning affected the delivery of eye care in schools. Factors related to acceptability of school-based eye health programs included: poor acceptance of training teachers as vision screeners; stigma related to wearing spectacles; and distrust of health services. The cost of spectacles and poor access to eye health information were identified as barriers to positive child eye health outcomes by socioeconomically disadvantaged parents and children. CONCLUSION: Our findings suggest the need for a national school eye health plan and improved cooperation between health and education ministries. Interventions to improve trust in health services, tackle the lack of human resources while respecting professional qualifications, and raise awareness of the importance of eye health are recommended.

Non-clinical eye care support for Aboriginal and Torres Strait Islander Australians: a systematic review.

OBJECTIVES: To describe research into non-clinical support eye health care for Aboriginal and Torres Strait Islander (Indigenous) Australians, the people who provide such care, and its impact on eye health outcomes. STUDY DESIGN: Systematic review and qualitative analysis of peer-reviewed research publications. DATA SOURCES: Peer-reviewed research articles published between January 2000 and July 2018 and included in MEDLINE/EMBASE, Web of Science, Informit, EBSCO (CINAHL and Anthropology Plus), or ProQuest Central. STUDY SELECTION: We included English language, peer-reviewed articles reporting empirical data on non-clinical support for eye health for Indigenous Australians. Two authors independently assessed the titles and abstracts of 1678 unique articles for inclusion in a full text review; the full texts of 104 publications were reviewed, of which 77 were excluded and 27 included in our qualitative analysis. DATA SYNTHESIS: Qualitative analysis identified five key areas of non-clinical support for Indigenous eye health: coordination of eye care, integrating and linking services, cultural support, health promotion, and social and emotional support. People who provide non-clinical support include eye health coordinators, Aboriginal Health Workers, primary care clinicians, family members, carers, and community-based liaison workers. The availability of non-clinical support is associated with increased patient attendance at eye care services, higher visual acuity examination and cataract surgery rates, broader eye health knowledge, and greater cultural responsivity. CONCLUSION: Non-clinical support is critical for facilitating attendance at appointments by patients and ensuring that preventive, primary, and tertiary eye care services are accessible to Indigenous Australians. Greater financial investment is needed to support key providers of non-clinical support, especially eye health coordinators, community-based liaison officers, and family members and carers.

Using quality improvement strategies to strengthen regional systems for Aboriginal and Torres Strait Islander eye health in the Northern Territory.

PROBLEM: In the Katherine region, Northern Territory, barriers to eye care for Aboriginal and Torres Strait Islander people include unclear eye care referral processes, challenges coordinating patient eye care between various providers, complex socioeconomic determinants and a lengthy outpatient ophthalmology waiting list. DESIGN: Mixed methods participatory approach using a regional needs analysis, clinical file audit and stakeholder survey, to develop, implement and monitor quality improvement strategies. SETTING: Collaboration with Aboriginal Community Controlled Health Services and regional eye care stakeholders in the Katherine region. KEY MEASURES FOR IMPROVEMENT: Clinical audit data captured frequency and rates of primary eye checks, ophthalmology referrals and spectacle prescriptions. A survey was developed and applied to assess stakeholder perspectives of regional eye care systems. STRATEGY FOR CHANGE: Quality improvement strategies informed by regional data (clinical audits and survey) included increasing service delivery to match eye care needs, primary eye care training for Aboriginal Community Controlled Health Services staff, updating Aboriginal Community Controlled Health Services primary care templates and forming a regional eye care coalition group. EFFECTS OF CHANGE: Post-implementation, rates and frequency of recorded optometry examinations, number of spectacles prescribed and rates of annual dilated fundus examinations for patients with diabetes increased. There was a decrease in the number of patients with diabetes who had never had an eye examination. Eye care stakeholders perceived a marked improvement in the effectiveness of the regional eye care system. LESSONS LEARNT: Our findings highlight the importance of engaging services and stakeholders to ensure a systems approach that is evidence-informed, contextually appropriate and reflects commitment to improved eye health outcomes.

Global Prevalence of Presbyopia and Vision Impairment from Uncorrected Presbyopia: Systematic Review, Meta-analysis, and Modelling.

TOPIC: Presbyopia prevalence and spectacle-correction coverage were estimated by systematic review and meta-analysis of epidemiologic evidence, then modeled to expand to country, region, and global estimates. CLINICAL RELEVANCE: Understanding presbyopia epidemiologic factors and correction coverage is critical to overcoming the burden of vision impairment (VI) from uncorrected presbyopia. METHODS: We performed systematic reviews of presbyopia prevalence and spectacle-correction coverage. Accepted presbyopia prevalence data were gathered into 5-year age groups from 0 to 90 years or older and meta-analyzed within World Health Organization global burden of disease regions. We developed a model based on amplitude of accommodation adjusted for myopia rates to match the regionally meta-analyzed presbyopia prevalence. Presbyopia spectacle-correction coverage was analyzed against country-level variables from the year of data collection; variation in correction coverage was described best by a model based on the Human Development Index, Gini coefficient, and health expenditure, with adjustments for age and urbanization. We used the models to estimate presbyopia prevalence and spectacle-correction coverage in each age group in urban and rural areas of every country in the world, and combined with population data to estimate the number of people with near VI. RESULTS: We estimate there were 1.8 billion people (prevalence, 25%; 95% confidence interval [CI], 1.7-2.0 billion [23%-27%]) globally with presbyopia in 2015, 826 million (95% CI, 686-960 million) of whom had near VI because they had no, or inadequate, vision correction. Global unmet need for presbyopia correction in 2015 is estimated to be 45% (95% CI, 41%-49%). People with presbyopia are more likely to have adequate optical correction if they live in an urban area of a more developed country with higher health expenditure and lower inequality. CONCLUSIONS: There is a significant burden of VI from uncorrected presbyopia, with the greatest burden in rural areas of low-resource countries.

Interventions to improve school-based eye-care services in low- and middle-income countries: a systematic review.

OBJECTIVE: To review interventions improving eye-care services for schoolchildren in low- and middle-income countries. METHODS: We searched online databases (CINAHL, Embase®, ERIC, MEDLINE®, ProQuest, PubMed® and Web of ScienceTM) for articles published between January 2000 and May 2018. Eligible studies evaluated the delivery of school-based eye-care programmes, reporting results in terms of spectacle compliance rates, quality of screening or attitude changes. We considered studies to be ineligible if no follow-up data were reported. Two authors screened titles, abstracts and full-text articles, and we extracted data from eligible full-text articles using the availability, accessibility, acceptability and quality rights-based conceptual framework. FINDINGS: Of 24 559 publications screened, 48 articles from 13 countries met the inclusion criteria. Factors involved in the successful provision of school-based eye-care interventions included communication between health services and schools, the willingness of schools to schedule sufficient time, and the support of principals, staff and parents. Several studies found that where the numbers of eye-care specialists are insufficient, training teachers in vision screening enables the provision of a good-quality and cost-effective service. As well as the cost of spectacles, barriers to seeking eye-care included poor literacy, misconceptions and lack of eye health knowledge among parents. CONCLUSION: The provision of school-based eye-care programmes has great potential to reduce ocular morbidity and developmental delays caused by childhood vision impairment and blindness. Policy-based support, while also attempting to reduce misconceptions and stigma among children and their parents, is crucial for continued access.

Experiences of vision impairment in Papua New Guinea: implications for blindness prevention programs.

INTRODUCTION: A person's capability to access services and achieve good eye health is influenced by their behaviours, perceptions, beliefs and experiences. As evidence from Papua New Guinea (PNG) about people's lived experience with vision impairment is limited, the purpose of the present study was to better understand the beliefs, perceptions and emotional responses to vision impairment in PNG. METHODS: A qualitative study, using both purposive and convenience sampling, was undertaken to explore common beliefs and perceptions about vision impairment, as well as the emotional responses to vision impairment. In-depth interviews were undertaken with 51 adults from five provinces representing culturally and geographically diverse regions of PNG. Grounded theory was used to elicit key themes from interview data. RESULTS: Participants described activities of everyday life impacted by vision impairment and the related worry, sadness and social exclusion. Common beliefs about the causes of vision impairment were environmental stressors (sun, dust, dirt and smoke), ageing and sorcery. CONCLUSIONS: Findings provide insight into the unique social context in PNG and identify a number of programmatic and policy implications, such as the need for preventative eye health information and services, addressing persisting beliefs in sorcery when developing health information packages, and the importance of coordinating with counselling and well-being services for people experiencing vision impairment.

Papua New Guinea vision-specific quality of life questionnaire: a new patient-reported outcome instrument to assess the impact of impaired vision.

BACKGROUND: The aim of this study was to develop and validate a new vision-specific quality of life (VS QoL) instrument and to assess the impact of vision impairment and eye disease on the quality of life of adults in Papua New Guinea (PNG). DESIGN: This study was designed as community based cross-sectional. PARTICIPANTS: Six hundred fourteen adults aged 18 and above were included in this study. METHODS: Focus groups and interviews guided development of a 41-item instrument. Two valid subscales of the instrument were obtained using pilot data after an iterative item reduction process guided by Rasch-based parameters. The person measures (in logits) of 614 participants were used to assess quality of life using univariate and multivariate regression analysis. MAIN OUTCOME MEASURES: Rasch logits. RESULTS: Rasch analysis confirmed a 17-item instrument containing an 8-item activity limitation subscale and a 9-item well-being subscale. Both subscales were unidimensional and demonstrated good fit statistics, measurement precisions and absence of significant differential item functioning. A consistent deterioration in vision-specific quality of life was independently and significantly associated with levels of vision. Severity of vision impairment and ocular morbidity were independently associated with activity limitation and emotional well-being. Participants with refractive error had lower quality of life score than those with no ocular abnormality but higher score than those with cataract and other eye diseases. CONCLUSIONS: The 17-item PNG-VS QoL instrument is a valid and reliable instrument for the assessment of impact of impaired vision on quality of life in PNG. Vision-specific quality of life was significantly worse among participants who were older and less-educated, had lower income and have had ocular morbidities.

Quality of Refractive Error Care in Cambodia: An Unannounced Standardized Patient Study.

PURPOSE: Quality-of-care in refractive error services is essential, as it directly affects vision outcomes, wellbeing, educational attainment, and workforce participation. In Cambodia, uncorrected refractive error is a leading cause of mild and moderate vision impairment in adults. We evaluated the quality of refractive error care in Cambodia by estimating the proportion of prescribed and dispensed spectacles appropriate for people's refractive error needs and factors associated with spectacle quality. METHODS: A cross-sectional protocol was employed with 18 Khmer-speaking adult participants observing testing procedures in 156 optical services across six provinces in 2022. A total of 496 dispensed spectacles were assessed against spectacle quality indicators. RESULTS: The analysis revealed that 35.1% of dispensed spectacles were of optimal quality. The most common error observed in sub-optimal spectacles was the presence of horizontal prism outside of tolerance limits. The study also found that 44.0% of emmetrope visits involved unnecessary prescription spectacle recommendations, and 18.3% of written prescriptions did not correspond with dispensed spectacles. Sex differences were observed, with men predominantly providing refractive error care and women more likely to be unnecessarily recommended prescription spectacles. CONCLUSION: The findings highlight the importance of prioritizing quality-of-care in refractive error services. A key recommendation is to consider regulatory mechanisms to ensure optical services employ appropriately qualified staff. Additionally, efforts should be made to eliminate unnecessary prescriptions -- especially for emmetropes and females -- standardize written prescriptions, ensure consistent pupil distance measurements, reduce reliance on autorefraction, and address the gender imbalance in the refractive error workforce.

Quality of refractive error care in Pakistan: an unannounced standardised patient study.

OBJECTIVE: Undercorrected refractive errors are the primary cause of vision impairment worldwide, including in Pakistan. However, limited data exist on the quality of refractive error care. Our study assessed the quality of refractive error care in Punjab, Pakistan by estimating the proportion of spectacles that were optimally prescribed. METHODS AND ANALYSIS: In this cross-sectional study, 12 unannounced standardised patients (USPs) from Jhang, Khanewal and Sahiwal districts were recruited. USPs underwent baseline subjective refraction and were trained to attend optical services, observe consultations, request spectacles and obtain prescriptions. The spectacles received were compared with baseline refraction to determine quality. We also examined the associations between spectacle quality, service and patient characteristics. RESULTS: Out of 276 attempted visits to 69 optical services, 241 pairs of spectacles were dispensed. A population size-weighted percentage of 42.7% (95% CI 36.4% to 49.3%) of spectacles were optimal quality, with the range varying from 13.8% in Jhang to 67.0% in Khanewal. Half the suboptimal quality spectacles had horizontal prism deviations outside of tolerance limits. Optimal spectacles were associated with performing focimetry (unadjusted OR=7.15, 95% CI (3.02 to 16.94), p<0.001) and good communication (OR=2.23, 95% CI (1.06 to 4.67), p=0.03). Hyperopic USPs were less likely to receive optimal spectacles (OR=0.01 95% CI (0.00 to 0.11), p<0.001). CONCLUSION: The quality of refractive error care in Pakistan requires improvement, particularly in the Jhang district. Key areas for enhancing refractive error care in Pakistan include refining dispensing and refraction skills for hyperopic prescriptions, providing training on the risks of using previous spectacles, and emphasising the importance of effective communication skills.

TFOS lifestyle: Impact of societal challenges on the ocular surface.

Societal factors associated with ocular surface diseases were mapped using a framework to characterize the relationship between the individual, their health and environment. The impact of the COVID-19 pandemic and mitigating factors on ocular surface diseases were considered in a systematic review. Age and sex effects were generally well-characterized for inflammatory, infectious, autoimmune and trauma-related conditions. Sex and gender, through biological, socio-economic, and cultural factors impact the prevalence and severity of disease, access to, and use of, care. Genetic factors, race, smoking and co-morbidities are generally well characterized, with interdependencies with geographical, employment and socioeconomic factors. Living and working conditions include employment, education, water and sanitation, poverty and socioeconomic class. Employment type and hobbies are associated with eye trauma and burns. Regional, global socio-economic, cultural and environmental conditions, include remoteness, geography, seasonality, availability of and access to services. Violence associated with war, acid attacks and domestic violence are associated with traumatic injuries. The impacts of conflict, pandemic and climate are exacerbated by decreased food security, access to health services and workers. Digital technology can impact diseases through physical and mental health effects and access to health information and services. The COVID-19 pandemic and related mitigating strategies are mostly associated with an increased risk of developing new or worsening existing ocular surface diseases. Societal factors impact the type and severity of ocular surface diseases, although there is considerable interdependence between factors. The overlay of the digital environment, natural disasters, conflict and the pandemic have modified access to services in some regions.

Quality of refractive error care (Q.REC) in Cambodia, Malaysia and Pakistan: protocol for a cross-sectional unannounced standardised patient study.

INTRODUCTION: There are 161 million people living with vision impairment, due to uncorrected refractive errors. A further 510 million people are living with near-vision impairment. There is a need for clearly defined indicators that capture the quality of refractive error service outputs and outcomes and provide insights to shape, change and stimulate action. This study aims to evaluate the quality of refractive error care (Q.REC) in Cambodia, Malaysia and Pakistan, by using unannounced standardised patients (USPs) to identify the proportion of prescribed and dispensed spectacles appropriate for people's refractive error needs and pinpoint/detail opportunities for quality improvement. METHOD AND ANALYSIS: A cross-sectional Q.REC study will be conducted in randomly selected optical services in Cambodia (180 services, 900 USP visits), the Klang Valley in Malaysia (66 services, 198 USP visits) and in Jhang, Sahiwal and Khanewal districts of Punjab region/state in Pakistan (64 services, 256 USP visits). USPs will receive baseline refractions by three skilled study optometrists/refractionists trained in the Q.REC protocol. USPs will then visit individual optical services, undergo a refraction, purchase spectacles or lenses (if recommended) and record observations about which elements of a refraction and dispensing were conducted. The study optometrist/refractionist will assess each pair of dispensed spectacles by examining the USP's aided visual acuity and visual comfort at distance and/or near and compare the lens prescription to the averaged baseline refraction. ETHICS AND DISSEMINATION: This study has been approved by the University of New South Wales Human Research Ethics Committee (HC210102), the National Ethics Committee for Health Research in Cambodia (043 NECHR), National Medical Research Registry and the Medical Research and Ethics Committee (NMRR-21-689-59279) in Malaysia and the College of Ophthalmology & Allied Vision Sciences Ethical Review Board (COAVS 545/2021) in Pakistan. Written informed consent will be obtained from USPs. Service owners will have the opportunity to opt-out verbally or in writing. Results will be disseminated locally through workshops including the relevant local ministry of health personnel and stakeholders, published in peer-reviewed publications and presented at national and international conferences.

Re-examining the gap: A critical realist analysis of eye health inequity among Aboriginal and Torres Strait Islander Australians.

The prevalence of diabetes among Aboriginal and Torres Strait Islander (hereafter 'Aboriginal') Australians is three times greater than non-Aboriginal Australians, contributing to a greater risk of blindness from treatable and preventable ocular conditions, most prominently cataract and diabetic retinopathy. In rural and remote Aboriginal communities, blindness prevalence is higher, and ocular treatment coverage and uptake are lower. In collaboration with Aboriginal Community Based Researchers (CBRs), this study explored complex contingent factors that shape access to eye health services among rural and remote Aboriginal Australians living with diabetes. Interviews (n = 126) and focus groups (n = 12) were conducted with patients, primary care clinicians, and CBRs, in four rural communities in the Northern Territory and New South Wales. Factors internal and external to health systems were examined, drawing on Bourdieu's concepts of habitus, and doxa to understand agency and decision-making among patients and clinicians. The study used the ontology of critical realism, categorising contingent factors as underlying structures (generative mechanisms), and applying a decolonising approach that centred causal relationships and tensions between dominant (Western biomedical neoliberalism) and non-dominant (Aboriginal) value systems. Three forms of marginalisation; linguistic, economic, and cultural, were identified as the generative mechanisms that inhibit equitable eye health outcomes. Marginality is linked to structural factors that position Aboriginal culture as a barrier, and is reinforced through biomedical health systems, and the agents who operate in and influence them. In order to address eye health inequity, a shift in how Aboriginal cultural sovereignty is understood within health systems is needed, to position it as a strength that can facilitate eye care accessibility, and to support enhanced cultural responsivity among clinicians and service providers.

Eye care delivery models to improve access to eye care for Indigenous peoples in high-income countries: a scoping review.

PURPOSE: Globally, there are ~370 million Indigenous peoples. Indigenous peoples typically experience worse health compared with non-Indigenous people, including higher rates of avoidable vision impairment. Much of this gap in eye health can be attributed to barriers that impede access to eye care services. We conducted a scoping review to identify and summarise service delivery models designed to improve access to eye care for Indigenous peoples in high-income countries. METHODS: Searches were conducted on MEDLINE, Embase and Global Health in January 2019 and updated in July 2020. All study designs were eligible if they described a model of eye care service delivery aimed at populations with over 50% Indigenous peoples. Two reviewers independently screened titles, abstracts and full-text articles and completed data charting. We extracted data on publication details, study context, service delivery interventions, outcomes and evaluations, engagement with Indigenous peoples and access dimensions targeted. We summarised findings descriptively following thematic analysis. RESULTS: We screened 2604 abstracts and 67 studies fulfilled our eligibility criteria. Studies were focused on Indigenous peoples in Australia (n=45), USA (n=11), Canada (n=7), New Zealand (n=2), Taiwan (n=1) and Greenland (n=1). The main disease focus was diabetic retinopathy (n=30, 45%), followed by 'all eye care' (n=16, 24%). Most studies focused on targeted interventions to increase availability of services. Fewer than one-third of studies reported involving Indigenous communities when designing the service. 41 studies reflected on whether the model improved access, but none undertook rigorous evaluation or quantitative assessment. CONCLUSIONS: The geographical and clinical scope of service delivery models to improve access to eye care for Indigenous peoples in high-income countries is narrow, with most studies focused on Australia and services for diabetic retinopathy. More and better engagement with Indigenous communities is required to design and implement accessible eye care services.

Parents' willingness to pay for children's spectacles in Cambodia.

BACKGROUND/AIM: To determine willingness to pay for children's spectacles, and barriers to purchasing children's spectacles in Cambodia. METHODS: We conducted vision screenings, and eye examinations as indicated, for all consenting children at 21 randomly selected secondary schools. We invited parents/guardians of children found to have refractive problems to complete a willingness to pay for spectacles survey, using a binary-with-follow-up technique. RESULTS: We conducted vision screenings on 12 128 secondary schoolchildren, and willingness to pay for spectacles surveys with 491 parents/guardians (n=491) from Kandal and Phnom Penh provinces in Cambodia. We found 519 children with refractive error, 7 who had pre-existing spectacles and 14 recommended spectacles for lower ametropias. About half (53.2%; 95% CI 44.0% to 62.1%) of parents/guardians were willing to pay KHR70 000 (US$17.5; average market price) or more for spectacles. Mean willingness-to-pay price was KHR74 595 (US$18.6; 95% CI KHR64 505 to 86 262; 95% CI US$16.1 to US$21.6) in Phnom Penh and KHR55 651 (US$13.9; 95% CI KHR48 021 to 64 494; 95% CI US$12.0 to US$16.1) in Kandal province. Logistic regression suggested parents/guardians with college education (OR 6.8; p<0.001), higher household incomes (OR 8.0; p=0.006) and those wearing spectacles (OR 2.2; p=0.01) were more likely to be willing to pay ≥US$17.5. The most common reasons for being unwilling to pay US$17.5 were related to cost (58.8%). The most common barrier to spectacle wear was fear that spectacles weaken children's eyes (36.0%). CONCLUSIONS: With almost half of parents/guardians unwilling to pay for spectacles at the current average market price, financial support through a subsidised spectacle scheme might be required for children to access spectacles in Cambodia.

3-D printed spectacles: potential, challenges and the future.

Three-dimensional (3-D) printing offers the potential to custom-produce a wide range of manufactured objects and improve manufacturing processes. The additive manufacturing process involves material (resin, metal, ceramics or biological cells) being deposited layer upon layer, which is fused to create a 3-D object. While 3-D printing has been readily available in the aerospace and automotive industries, and is being used increasingly in the medical field, its potential for optometry and ophthalmic optics has rarely been discussed in depth. 3-D printing of spectacles has the potential to provide customised experiences, to cater for those who do not fit standardised frames or for those with irregular prescriptions, and to reduce delivery times and inventory with the opportunity of increasing access to underserved populations. Here we review available 3-D printing technologies, and the current 3-D printed spectacle market, including testing three commercially available spectacle frames to assess compliance with ISO:12870 standards. The article then explores the challenges faced and environmental impact of implementing 3-D printing of spectacles.

Eye care delivery models to improve access to eye care for Indigenous people in high-income countries: protocol for a scoping review.

INTRODUCTION: Globally, there are an estimated 370 million Indigenous people across 90 countries. Indigenous people experience worse health compared with non-Indigenous people, including higher rates of avoidable visual impairment. Countries such as Australia and Canada have service delivery models aimed at improving access to eye care for Indigenous people. We will conduct a scoping review to identify and summarise these service delivery models to improve access to eye care for Indigenous people in high-income countries. METHODS AND ANALYSIS: An information specialist will conduct searches on MEDLINE, Embase and Global Health. All databases will be searched from their inception date with no language limits used. We will search the grey literature via websites of relevant government and service provider agencies. Field experts will be contacted to identify additional articles, and reference lists of relevant articles will be searched. All quantitative and qualitative study designs will be eligible if they describe a model of eye care service delivery aimed at Indigenous populations. Two reviewers will independently screen titles, abstracts and full-text articles; and complete data extraction. For each service delivery model, we will extract data on the context, inputs, outputs, Indigenous engagement and enabling health system functions. Where models were evaluated, we will extract details. We will summarise findings using descriptive statistics and thematic analysis. ETHICS AND DISSEMINATION: Ethical approval is not required, as our review will include published and publicly accessible data. This review is part of a project to improve access to eye care services for Maori in Aotearoa New Zealand. The findings will be useful to policymakers, health service managers and clinicians responsible for eye care services in New Zealand, and other high-income countries with Indigenous populations. We will publish our findings in a peer-reviewed journal and develop an accessible summary of results for website posting and stakeholder meetings.

Rapid assessment of avoidable blindness in Papua New Guinea: a nationwide survey.

OBJECTIVE: To estimate the prevalence and main causes of blindness and vision impairment in people aged 50 years and older in Papua New Guinea (PNG). DESIGN: National cross-sectional population-based survey in National Capital District (NCD), Highlands, Coastal and Islands regions. METHODS: Adults aged 50 years and above were recruited from 100 randomly selected clusters. Each participant underwent monocular presenting and pinhole visual acuity (VA) assessment and lens examination. Those with pinhole VA<6/12 in either eye had a dilated fundus examination to determine the primary cause of reduced vision. Those with obvious lens opacity were interviewed on barriers to cataract surgery. RESULTS: A total of 4818 adults were examined. The age-adjusted and sex-adjusted prevalence of blindness (VA <3/60), severe vision impairment (SVI, VA <6/60 but ≥3/60), moderate vision impairment (MVI, VA <6/18 but ≥6/60) and early vision impairment (EVI, VA <6/12 but ≥6/18) was 5.6% (95% CI 4.9% to 6.3%), 2.9% (95% CI 2.5% to 3.4%), 10.9% (95% CI 9.9% to 11.9%) and 7.3% (95% CI 6.6% to 8.0%), respectively. The main cause of blindness, SVI and MVI was cataract, while uncorrected refractive error was the main cause of EVI. A significantly higher prevalence of blindness, SVI and MVI occurred in the Highlands compared with NCD. Across all regions, women had lower cataract surgical coverage and spectacle coverage than men. CONCLUSIONS: PNG has one of the highest reported prevalence of blindness globally. Cataract and uncorrected refractive error are the main causes, suggesting a need for increased accessible services with improved resources and advocacy for enhancing eye health literacy.