The 2023 Doyne Lecture-a cornea care system: evolution.

Blindness and visual impairment affect the quality of life of the individual and their family members. Corneal opacities are a key cause of vision loss around the world, especially in low-income and middle-income countries (LMIC). Corneal blindness and vision loss impacts every age group, and the risk factors and the causes are also varied. Socio-economic factors also play a significant role in its prevalence. Preventing, treating, and managing corneal conditions in LMIC contexts can therefore be quite complex and challenging. A model of eye care delivery developed and refined over the past four decades, the L V Prasad Eye Institute's cornea care system presents an example and a sense of hope. The model takes corneal care from world-class facilities in urban locations to rural locations, overcoming a variety of challenges. The initial breakthrough came with solving and ensuring a steady supply of corneal tissue. Then to training high-quality resources, building capacity, and investing in research that translates from the bench to the bedside. A variety of innovations, both in diagnosis and the operating theatre, have paved for improved outcomes that are tailored for the contexts in which this system operates. The institute envisions a future where its work further narrows the gap in eye care disparities and leads to life-changing impact in ophthalmic care of the cornea.

Incidence of primary open angle glaucoma in the Andhra Pradesh Eye Disease Study (APEDS).

BACKGROUND: To report 15-year incidence rate of primary open angle glaucoma (POAG) in the Andhra Pradesh Eye Disease Study (APEDS). METHODS: A population-based longitudinal study was carried out at three rural study sites. Phakic participants aged ≥40 years who participated at baseline (APEDS I) and the mean 15-year follow-up visit (APEDS III) were included. A comprehensive ophthalmic examination was performed on all participants. Mean intraocular pressure (IOP) was average of IOPs of right and left eyes. The definition of glaucoma was based on the International Society of Geographical and Epidemiological Ophthalmology (ISGEO) classification. The main outcome measure was incidence of POAG during the follow-up period in participants without glaucoma or suspicion of glaucoma at baseline. RESULTS: Data from the available and eligible participants from the original cohort (1241/2790; 44.4%) were analysed. The mean age (standard deviation) of participants at baseline was 50.2 (8.1) years; 580 (46.7%) were men. Thirty-six participants developed POAG [bilateral in 17 (47.2%)] over 15 years. The incidence rate of POAG per 100-person years (95% confidence interval) was 2.83 (2.6, 3.08). Compared to baseline, the reduction in mean IOP [median (range) mm Hg] was -0.75 (-7.5, 9) in participants with incident POAG and -2.5 (-14.5, 14.5) in those without. The inter-visit difference in mean IOP was a significant risk factor on logistic regression analysis. CONCLUSION: We report the long-term incidence of POAG in rural India. A longitudinal change in IOP, specifically a less pronounced reduction in IOP with increasing age, was a novel risk factor.

Regional variation in the incidence of pseudo-exfoliation in the Andhra Pradesh Eye Disease Study (APEDS).

BACKGROUND: To report the 15-year incidence rate of pseudo-exfoliation (PXF),  PXF glaucoma and regional variation among rural participants in the Andhra Pradesh Eye Disease Study (APEDS) III. METHODS: This population-based longitudinal study was carried out at three rural study sites. Individuals of all ages who participated at baseline with a mean 15-year follow-up visit were included. Detailed Comprehensive ophthalmic examination was performed on all participants. The main outcome measure was development of PXF during the follow-up period in participants who were phakic in one or both eyes without PXF at baseline. RESULTS: Among 5395 participants, 5108 (94.6%) met the inclusion criteria. There were 93 (1.82%; 95% confidence interval (CI), 1.47-2.22) cases of incident PXF. Their median baseline age (1st, 3rd quartiles) was 51 (44, 59) years and the male: female ratio was 1.3:1. There was no case of incident PXF in participants aged <30 years at baseline. The incidence rate per 100 person years (95% CI) among all ages and those aged ≥30 years at baseline was 1.73 (1.64-1.82) and 3.73 (3.53-3.93), respectively. PXF material was located on iris as well as anterior surface of lens and it was often bilateral. Participants living in two study sites and increasing age were associated with the incidence of PXF. The 15-year incidence of PXF glaucoma (95% CI) in participants ≥30 years of age at baseline was 0.33% (0.14-0.66). CONCLUSION: There is significant regional variation in incidence of PXF in south India which warrants further investigation.

Fifteen-Year Incidence Rate of Primary Angle Closure Disease in the Andhra Pradesh Eye Disease Study.

PURPOSE: To report on the 15-year incidence of primary angle closure disease (PACD) among participants aged ≥40 years in rural southern India DESIGN: Population-based longitudinal incidence rate study METHODS: Setting: 3 rural study centres. STUDY POPULATION: Phakic participants aged ≥40 years who participated in both examination time points. OBSERVATION PROCEDURES: All participants at the baseline and at the mean 15-year follow-up visit underwent a detailed interview, anthropometry, blood pressure measurement, and comprehensive eye examination. Automated perimetry was attempted based on predefined criteria. Main outcome measures included development of any form of PACD, as defined by the International Society for Geographical and Epidemiological Ophthalmology (ISGEO), during the follow-up period in phakic participants, who did not have the disease at baseline. RESULTS: We analyzed data obtained from 1,197 (81.4% out of available 1,470) participants to calculate the incidence of the disease. The mean age (standard deviation) of the study participants at the baseline was 50.2 (8.1) years, with 670 male (45.5%) and 800 female (54.4%) participants. The incidence rate per 100 person-years (95% confidence interval) for primary angle closure suspect, primary angle closure, and primary angle closure glaucoma was 8.8 (8.4, 9.2), 6.2 (5.9, 6.6), and 1.6 (1.4, 1.8), respectively. Thus, the incidence of all forms of PACD was 16.4 (15.9, 17) per 100 person-years. On logistic regression analysis, female gender was a significant risk factor whereas presence of myopia was protective. CONCLUSIONS: This study reports long-term incidence of PACD from rural India. It has implications for eye health care policies, strategies, and planning.

Healthcare in post-COVID India: A call for a decentralized healthcare system.

Over the years, healthcare system in India has been largely centralized, expensive and impersonal. In a country where expenditure on healthcare is low, most healthcare expenditure is out-of-pocket and where most of the population continue to live in rural areas or in urban fringes, such a care is inaccessible, unresponsive and unaffordable. COVID pandemic exposed these realities further. Based on experiences of directly managing health services during COVID-19 pandemic in different settings and across different levels, authors of this paper argue for a decentralized, distributed and responsive health systems for India, that is likely to be more effective and sustainable in normal times, and in times of crisis.

Incidence, Incident Causes, and Risk Factors of Visual Impairment and Blindness in a Rural Population in India: 15-Year Follow-up of the Andhra Pradesh Eye Disease Study.

PURPOSE: To report 15-year incidence rate of visual loss (blindness and visual impairment [VI]), causes, and risk factors for participants in Andhra Pradesh Eye Disease Study III (APEDS III). DESIGN: Population-based cohort study. METHODS: From 2012 to 2016, all rural participants were interviewed and underwent a comprehensive eye examination, including dilated fundus examination and imaging. Presenting visual acuity (PVA) and best-corrected visual acuity (BCVA) were measured using a standard logarithm of Minimum Angle of Resolution chart at 3 meters. World Health Organization (WHO) and United States of America (USA) categories of VI and blindness were used. Incident visual loss was defined as the development of or worsening of visual loss of one or more categories. RESULTS: In APEDS I, 7,771 rural participants were examined using stratified, random-cluster systematic sampling; in APEDS III, 5,395 participants (69.4% of rural or 52.4% of total participants) were re-examined. Using WHO categories, the crude incidence rate of any visual loss based on PVA and BCVA were 14.6 (95% confidence interval [CI]:13.6-15.7) and 6.3 (95% CI: 6.1-6.4) per 100 person-years, respectively. Using USA criteria, the values were 22.6 (95% CI: 22.3-23.0) and 10.6 (95% CI: 10.3-10.8) per 100 person-years, respectively. More than 90% of visual loss was attributable to cataract and uncorrected refractive error. Using WHO categories, significant independent risk factors for the incident visual loss were increasing age, female gender, illiteracy, past or current smoker, and current use of alcohol. Using the USA definition, an additional risk factor was lower level of education. CONCLUSIONS: The high incidence likely reflects poor access to eye care in this population, which needs to be taken into account when planning eye care programs.

Population-based Assessment of Vision Impairment in the Elderly Population in Telangana State in India - Policy Implications for Eye Health Programmes.

PURPOSE: To investigate the prevalence, causes and risk factors for vision impairment (VI) among the elderly population in Telangana State, India. METHODS: A population-based cross-sectional study were conducted in four districts. All participants had eye examinations including visual acuity assessment for distance and near, anterior segment examination and non-mydriatic fundus imaging by trained personnel. VI was defined as presenting visual acuity worse than 6/18 in the better eye. Individuals aged ≥60 years were considered as elderly. RESULTS: In total, 11,238/12,150 (92.5%) individuals aged ≥40 years were examined. Of this, the dataset of 3,640 individuals (32.4%) elderly participants was used for analysis. Among the 3,640 participants, 53.1% were women and 78.1% had no education. The mean age of the participants was 67.8 years (standard deviation: 7 years; range: 60 to 102 years). The age and gender-adjusted prevalence of VI was 32.1% (95% CI: 29.5-34.8). On multivariable analysis, the odds of VI was significantly higher in older age groups, and among those with no education. Gender and district of residence were not associated with the prevalence of VI. Cataract (54.8%) was the leading cause of VI followed by uncorrected refractive errors (37.6%). CONCLUSIONS AND RELEVANCE: VI was common and largely avoidable in the elderly population in Telangana state in India. Elderly centric eye care including screening for vision loss, provision of cataract surgery and spectacles can be used as strategies to address VI in the elderly.

Capacity building for universal eye health coverage in South East Asia beyond 2020.

BACKGROUND: The World Report on Vision suggests that universal eye health coverage (UEHC) can be achieved through an integrated people-centered eye care (IPCEC) delivery. This study provides an estimation of capacity building of facilities and workforce to attain UEHC through IPCEC in South East Asia (SEA) beyond 2020. METHODS: The data sources on the magnitude of blindness and visual impairment in the SEA region included reports of the Vision Loss Expert Group, most recent population-based studies from the member states and unpublished data from the study teams. The model is based on the estimated or projected population of the member states in 2020 and 2030. RESULTS: Data from the ten member states of the World Health Organization (WHO) SEA show that the magnitude of blindness and moderate to severe visual impairment (MSVI) has decreased between 1990 and 2015, but still higher than global average. Cataract and uncorrected refractive errors were the common causes of blindness and MSVI, respectively. The estimated WHO SEA region share of world population is likely to increase from 38.39% in 2020 to 44.32% in 2030, and so also will be the visually impaired people. By adopting the IPCEC the WHO SEA countries would require at least 429,802 community workers, 164,784 allied ophthalmic personnel and 10,744 ophthalmologists in the public facilities in 2030. CONCLUSION: In order to attain UEHC and use the IPCEC model, each country in the region should invest substantially more in structured eye care delivery and workforce.

The L V Prasad Eye Institute: A comprehensive case study of excellent and equitable eye care.

Global healthcare delivery systems are facing ever-increasing challenges on multiple fronts. The need to study and define successful models of care delivery systems has become increasingly important. The L V Prasad Eye Institute (LVPEI) has a distinctive eye care delivery system offering rich lessons at many operational levels. The system has been developed on the basis of LVPEI's foundational public eye health study, and follows a complexity-driven (dependent on disease complexity) clinical care system forming a five-tier pyramidal model - at the apex is the quaternary care centre at Hyderabad, followed by increasing numbers of tertiary, secondary or community, primary, and rural eye care centres, where the revenue from paying patients covers free-care via an economic cross-subsidy. This has achieved a level of scale, efficiency, social impact, and clinical and scientific innovation rarely seen in a single health system. Building on the foundational principles of this pyramidal care with a robust economic cross-subsidy model, LVPEI has seamlessly established successful professional, academic, and educational systems that combine innovation, scientific discovery, and the development of in-house technologies focused on improving service quality and clinical decision making. In this case study, we show that all elements of the LVPEI model are practical and may be applicable to academic medical centres in diverse healthcare settings; currently, this is being tested in Liberia, West Africa.

Agreement and diagnostic accuracy of vision screening in children by teachers, community eye-health workers and vision technicians.

BACKGROUND: To compare the agreement and diagnostic accuracy of vision screening conducted by trained community eye-health workers (CEHWs) and teachers with reference to vision technicians in Movva Mandal (sub-district) in Krishna District in the Indian state of Andhra Pradesh. METHODS: As part of a large epidemiological study on visual impairment in children, vision screening was conducted in all the schools in a sub-district. The children were screened using a screening card with 6/12 tumbling E optotypes by trained CEHWs, teachers and a vision technician. Teachers were included if they had screened at least 100 children and had at least five children identified with visual impairment. RESULTS: Of a total 6,197 children from 75 schools, 4,929 children were screened by all three categories of examiners (one vision technician, five CEHWs and 79 teachers). The overall agreement between the vision technician and CEHWs was 0.84 (95 per cent CI: 0.79-0.9) with a range of 0.77-0.9. Overall sensitivity of CEHWs to detect visual impairment was 83.3 per cent (95 per cent CI: 73.6-90.6) with a range of 71.4-87.1 per cent. Overall agreement of the five teachers with the vision technician was 0.81 (95 per cent CI: 0.74-0.88) with a range of 0.32-0.92. The overall sensitivity of teachers to detect vision problem was 72.3 per cent (95 per cent CI: 61.4-81.6) with a range from 20 per cent to 85.7 per cent and specificity was near 100 per cent. CONCLUSION: There was no significant difference in the agreement and diagnostic accuracy of CEHWs and teachers compared to those of the vision technician. There was a large variability among teachers, which needs to be considered in school vision screening programs.

Is the 2015 eye care service delivery profile in Southeast Asia closer to universal eye health need!

PURPOSE: The year 2015 status of eye care service profile in Southeast Asia countries was compared with year 2010 data to determine the state of preparedness to achieve the World Health Organization global action plan 2019. METHODS: Information was collected from the International Agency for Prevention of Blindness country chairs and from the recent PubMed referenced articles. The data included the following: blindness and low vision prevalence, national eye health policy, eye health expenses, presence of international non-governmental organizations, density of eye health personnel, and the cataract surgical rate and coverage. The last two key parameters were compared with year 2010 data. RESULTS: Ten of 11 country chairs shared the information, and 28 PubMed referenced publications were assessed. The prevalence of blindness was lowest in Bhutan and highest in Timor-Leste. Cataract surgical rate was high in India and Sri Lanka. Cataract surgical coverage was high in Thailand and Sri Lanka. Despite increase in number of ophthalmologists in all countries (except Timor-Leste), the ratio of the population was adequate (1:100,000) only in 4 of 10 countries (Bhutan, India, Maldives and Thailand), but this did not benefit much due to unequal urban-rural divide. CONCLUSION: The midterm assessment suggests that all countries must design the current programs to effectively address both current and emerging causes of blindness. Capacity building and proportionate distribution of human resources for adequate rural reach along with poverty alleviation could be the keys to achieve the universal eye health by 2019.

International Vision Care: Issues and Approaches.

Globally, 32.4 million individuals are blind and 191 million have moderate or severe visual impairment (MSVI); 80% of cases of blindness and MSVI are avoidable. However, great efforts are needed to tackle blindness and MSVI, as eye care in most places is delivered in isolation from and without significant integration with general health sectors. Success stories, including control of vitamin A deficiency, onchocerciasis, and trachoma, showed that global partnerships, multisectoral collaboration, public-private partnerships, corporate philanthropy, support from nongovernmental organizations-both local and international-and governments are responsible for the success of these programs. Hence, the World Health Organization's universal eye health global action plan for 2014-2019 has a goal of reducing the public health problem of blindness and ensuring access to comprehensive eye care; the plan aims to integrate eye health into health systems, thus providing universal eye health coverage (UEHC). This article discusses the challenges faced by low- and middle-income countries in strengthening the six building blocks of the health system. It discusses how the health systems in these countries need to be geared toward tackling the issues of emerging noncommunicable eye diseases, existing infectious diseases, and the common causes of blindness and visual impairment, such as cataract and refractive error. It also discusses how some of the comprehensive eye care models in the developing world have addressed these challenges. Moving ahead, if we are to achieve UEHC, we need to develop robust, sustainable, good-quality, comprehensive eye care programs throughout the world, focusing on the areas of greatest need. We also need to develop public health approaches for more complex problems such as diabetic retinopathy, glaucoma, childhood blindness, corneal blindness, and low vision. There is also a great need to train high-level human resources of all cadres in adequate numbers and quality. In addition to this, we need to exploit the benefits of modern technological innovations in information, communications, biomedical technology, and other domains to enhance quality of, access to, and equity in eye care.

Spectacles use in a rural population in the state of Telangana in South India.

CONTEXT: Uncorrected refractive errors are the leading cause of visual impairment. AIMS: To assess the prevalence and patterns of spectacles use among those aged ≥40 years in the South Indian state of Telangana. SETTINGS AND DESIGN: This was a population-based, cross-sectional study, in which 6150 people were enumerated from 123 clusters in the two districts of Telangana state (Adilabad and Mahbubnagar) using a two-stage cluster random sampling methodology. MATERIALS AND METHODS: Participants were visited in their households and presenting visual acuity (VA) was assessed in all cases followed by pinhole VA if presenting VA was worse than 6/12. A questionnaire was used to collect information on the current and previous spectacles use, type of spectacles, and details of the spectacles provider. STATISTICAL ANALYSIS USED: Stata statistical software version 12. RESULTS: Among 5881 participants examined, 53.7% were women, and 82% had no formal education. The prevalence of current spectacles use was 28.8% (95% confidence interval: 27.6-30.0). On applying multiple logistic regression analysis, spectacles use was significantly associated with older age groups, female gender, higher levels of education, and residing in Adilabad district. Bifocals were the most commonly used type of spectacles (56.3%), and private eye clinics (70.3%) were the leading service providers. The spectacles coverage was 53.6%. CONCLUSIONS: We reported on prevalence and patterns of spectacles use using a large representative sample and a high response rate. More than half of those who may benefit from spectacles were using them, suggestive of a reasonable primary eye care coverage in the two districts studied.

Near visual impairment and spectacle coverage in Telangana, India.

IMPORTANCE: The study highlights the burden of near visual impairment (NVI) in India. BACKGROUND: NVI is a common condition that can be addressed through provision of spectacles. The study aims to assess the prevalence of NVI and spectacle coverage among those aged ≥40 years in south Indian state of Telangana. DESIGN: Population-based cross-sectional study using a rapid assessment methodology. PARTICIPANTS: Five thousand one hundred forty participants enumerated from 123 clusters in two districts and have presenting distance visual acuity of ≥6/18 in the better eye. METHODS: Presenting near vision was assessed binocularly at a fixed distance of 40 cm using a log MAR chart with tumbling E optotypes in ambient lighting conditions. If the presenting near vision was worse than 6/12 (log MAR 0.3), then it was re-assessed with addition lens appropriate to the age. NVI was defined as binocular presenting near vision worse than 6/12. MAIN OUTCOME MEASURES: Prevalence of NVI and spectacle coverage. RESULTS: The mean age of the participants was 51.1 years (standard deviation: 9.3 years), and 46.5% (n = 2392) were women. About 80% (n = 4142) of them had no education, and 21.9% (n = 1126) were using spectacles for near vision. Nearly half of the participants were from Adilabad district (n = 2665). The prevalence of NVI was 58.3% (95% confidence interval: 56.9-59.6). NVI was associated with older age groups, male gender and no education. The spectacle coverage was 26.5%. CONCLUSIONS AND RELEVANCE: NVI is common in rural Telangana with low spectacle coverage. Service delivery programs should use a multi-pronged approach to address the burden of NVI.

Development and validation of an instrument to assess job satisfaction in eye-care personnel.

PURPOSE: The aim was to develop and validate an instrument to measure job satisfaction in eye-care personnel and assess the job satisfaction of one-year trained vision technicians in India. METHODS: A pilot instrument for assessing job satisfaction was developed, based on a literature review and input from a public health expert panel. Rasch analysis was used to assess psychometric properties and to undertake an iterative item reduction. The instrument was then administered to vision technicians in vision centres of Andhra Pradesh in India. Associations between vision technicians' job satisfaction and factors such as age, gender and experience were analysed using t-test and one-way analysis of variance. RESULTS: Rasch analysis confirmed that the 15-item job satisfaction in eye-care personnel (JSEP) was a unidimensional instrument with good fit statistics, measurement precisions and absence of differential item functioning. Overall, vision technicians reported high rates of job satisfaction (0.46 logits). Age, gender and experience were not associated with high job satisfaction score. Item score analysis showed non-financial incentives, salary and workload were the most important determinants of job satisfaction. CONCLUSIONS: The 15-item JSEP instrument is a valid instrument for assessing job satisfaction among eye-care personnel. Overall, vision technicians in India demonstrated high rates of job satisfaction.

Population-based assessment of prevalence and causes of visual impairment in the state of Telangana, India: a cross-sectional study using the Rapid Assessment of Visual Impairment (RAVI) methodology.

OBJECTIVE: To assess the prevalence and causes of visual impairment (VI) among a rural population aged 40 years and older in the state of Telangana in India. DESIGN: Population-based cross-sectional study. SETTING: Districts of Adilabad and Mahbubnagar in south Indian state of Telangana, India. PARTICIPANTS: A sample of 6150 people was selected using cluster random sampling methodology. A team comprising a trained vision technician and a field worker visited the households and conducted the eye examination. Presenting, pinhole and aided visual acuity were assessed. Anterior segment was examined using a torchlight. Lens was examined using distant direct ophthalmoscopy in a semidark room. In all, 5881 (95.6%) participants were examined from 123 study clusters. Among those examined, 2723 (46.3%) were men, 4824 (82%) had no education, 2974 (50.6%) were from Adilabad district and 1694 (28.8%) of them were using spectacles at the time of eye examination. PRIMARY OUTCOME MEASURE: VI was defined as presenting visual acuity <6/18 in the better eye and it included moderate VI (<6/18 to 6/60) and blindness (<6/60). RESULTS: The age-adjusted and gender-adjusted prevalence of VI was 15.0% (95% CI 14.1% to 15.9%). On applying binary logistic regression analysis, VI was associated with older age groups. The odds of having VI were higher among women (OR 1.2; 95% CI 1.0 to 1.4). Having any education (OR 0.4; 95% CI 0.3 to 0.6) and current use of glasses (OR 0.19; 95% CI 0.1 to 0.2) were protective. VI was also higher in Mahbubnagar (OR 1.0 to 1.5) district. Cataract (54.7%) was the leading cause of VI followed by uncorrected refractive errors (38.6%). CONCLUSIONS: VI continues to remain a challenge in rural Telangana. As over 90% of the VI is avoidable, massive eye care programmes are required to address the burden of VI in Telangana.