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.

Autonomous artificial intelligence increases real-world specialist clinic productivity in a cluster-randomized trial.

Autonomous artificial intelligence (AI) promises to increase healthcare productivity, but real-world evidence is lacking. We developed a clinic productivity model to generate testable hypotheses and study design for a preregistered cluster-randomized clinical trial, in which we tested the hypothesis that a previously validated US FDA-authorized AI for diabetic eye exams increases clinic productivity (number of completed care encounters per hour per specialist physician) among patients with diabetes. Here we report that 105 clinic days are cluster randomized to either intervention (using AI diagnosis; 51 days; 494 patients) or control (not using AI diagnosis; 54 days; 499 patients). The prespecified primary endpoint is met: AI leads to 40% higher productivity (1.59 encounters/hour, 95% confidence interval [CI]: 1.37-1.80) than control (1.14 encounters/hour, 95% CI: 1.02-1.25), p < 0.00; the secondary endpoint (productivity in all patients) is also met. Autonomous AI increases healthcare system productivity, which could potentially increase access and reduce health disparities. ClinicalTrials.gov NCT05182580.

Feasibility and acceptance of artificial intelligence-based diabetic retinopathy screening in Rwanda.

BACKGROUND: Evidence on the practical application of artificial intelligence (AI)-based diabetic retinopathy (DR) screening is needed. METHODS: Consented participants were screened for DR using retinal imaging with AI interpretation from March 2021 to June 2021 at four diabetes clinics in Rwanda. Additionally, images were graded by a UK National Health System-certified retinal image grader. DR grades based on the International Classification of Diabetic Retinopathy with a grade of 2.0 or higher were considered referable. The AI system was designed to detect optic nerve and macular anomalies outside of DR. A vertical cup to disc ratio of 0.7 and higher and/or macular anomalies recognised at a cut-off of 60% and higher were also considered referable by AI. RESULTS: Among 827 participants (59.6% women (n=493)) screened by AI, 33.2% (n=275) were referred for follow-up. Satisfaction with AI screening was high (99.5%, n=823), and 63.7% of participants (n=527) preferred AI over human grading. Compared with human grading, the sensitivity of the AI for referable DR was 92% (95% CI 0.863%, 0.968%), with a specificity of 85% (95% CI 0.751%, 0.882%). Of the participants referred by AI: 88 (32.0%) were for DR only, 109 (39.6%) for DR and an anomaly, 65 (23.6%) for an anomaly only and 13 (4.73%) for other reasons. Adherence to referrals was highest for those referred for DR at 53.4%. CONCLUSION: DR screening using AI led to accurate referrals from diabetes clinics in Rwanda and high rates of participant satisfaction, suggesting AI screening for DR is practical and acceptable.

Impact of Artificial Intelligence Assessment of Diabetic Retinopathy on Referral Service Uptake in a Low-Resource Setting: The RAIDERS Randomized Trial.

Purpose: This trial was designed to determine if artificial intelligence (AI)-supported diabetic retinopathy (DR) screening improved referral uptake in Rwanda. Design: The Rwanda Artificial Intelligence for Diabetic Retinopathy Screening (RAIDERS) study was an investigator-masked, parallel-group randomized controlled trial. Participants: Patients ≥ 18 years of age with known diabetes who required referral for DR based on AI interpretation. Methods: The RAIDERS study screened for DR using retinal imaging with AI interpretation implemented at 4 facilities from March 2021 through July 2021. Eligible participants were assigned randomly (1:1) to immediate feedback of AI grading (intervention) or communication of referral advice after human grading was completed 3 to 5 days after the initial screening (control). Main Outcome Measures: Difference between study groups in the rate of presentation for referral services within 30 days of being informed of the need for a referral visit. Results: Of the 823 clinic patients who met inclusion criteria, 275 participants (33.4%) showed positive findings for referable DR based on AI screening and were randomized for inclusion in the trial. Study participants (mean age, 50.7 years; 58.2% women) were randomized to the intervention (n = 136 [49.5%]) or control (n = 139 [50.5%]) groups. No significant intergroup differences were found at baseline, and main outcome data were available for analyses for 100% of participants. Referral adherence was statistically significantly higher in the intervention group (70/136 [51.5%]) versus the control group (55/139 [39.6%]; P = 0.048), a 30.1% increase. Older age (odds ratio [OR], 1.04; 95% confidence interval [CI], 1.02-1.05; P < 0.0001), male sex (OR, 2.07; 95% CI, 1.22-3.51; P = 0.007), rural residence (OR, 1.79; 95% CI, 1.07-3.01; P = 0.027), and intervention group (OR, 1.74; 95% CI, 1.05-2.88; P = 0.031) were statistically significantly associated with acceptance of referral in multivariate analyses. Conclusions: Immediate feedback on referral status based on AI-supported screening was associated with statistically significantly higher referral adherence compared with delayed communications of results from human graders. These results provide evidence for an important benefit of AI screening in promoting adherence to prescribed treatment for diabetic eye care in sub-Saharan Africa.

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.

Visual Impairment and Risk of Self-Reported Road Traffic Crashes Among Bus Drivers in Bangladesh.

PURPOSE: This study assesses the prevalence and the causes of visual impairment among bus drivers undergoing screening in Bangladesh and associations with self-reported crashes. METHODS: Eye health screenings including refraction and questionnaires were conducted at 10 bus terminals in 7 districts of Bangladesh from June through August 2019. Presenting near and distance visual impairment and self-reported road traffic crashes were recorded. RESULTS: Among 700 participants, nearly 1 in 5 (n = 126, 18.0%) had presented visual acuity (VA) in the better-seeing eye ≤6/9, not meeting the vision standard of Bangladesh for bus drivers. A majority of drivers (n = 492, 70.3%) had near or distance refractive error, and most who failed to reach the driving standard (88.1%, n = 111) could be improved with readily available treatment, either glasses or cataract surgery. A history of 1 or more road traffic crashes while driving a bus or minibus was reported by 62 (8.97%) participants. In multivariable models, factors significantly associated with near or distance visual impairment included older age [odds ratio (OR) per year 1.15, 95% confidence interval (CI): 1.12-1.18, P < 0.0001] and having no driver's license (OR 1.80, 95% CI: 1.04-3.13, P = 0.037). Self-reported history of a motor vehicle crash was associated with near or distance visual impairment (OR 2.45, 95% CI: 1.09-5.49, P = 0.030), even when adjusting for other factors such as age and weekly miles are driven. CONCLUSIONS: Ensuring that bus drivers are screened to meet the required visual standards for driving while referring those who do not for treatment, can contribute to safer roads in this high-risk setting.

Effect of providing near glasses on productivity among rural Indian tea workers with presbyopia (PROSPER): a randomised trial.

BACKGROUND: Presbyopia, age-related decline in near vision, is the most common cause of vision impairment globally, but no trials have assessed its workplace effects. We aimed to study the effect of near glasses on the productivity of tea workers with presbyopia. METHODS: This randomised trial was done in tea pickers aged 40 years or older in Assam, India, with unaided near visual acuity (NVA) lower than 6/12 in both eyes, correctable to 6/7·5 with near glasses; unaided distance vision 6/7·5 or greater; and no eye disease. Participants were randomly assigned (1:1) to receive free glasses optimising NVA at working distance (cost including delivery US$10·20 per person), either immediately (intervention group) or at closeout (control group). Participants were stratified by age, sex, and productivity. The primary outcome (investigator-masked) was the difference between groups in the change in mean daily weight of tea picked (productivity), between the 4-week baseline period (June, 2017) and the 11-week evaluation period (July 24, 2017, to Oct 7, 2017). Workers' income was tied to their productivity. Compliance with study glasses was assessed at seven unannounced visits. Results were analysed on an intention-to-treat basis. This trial is registered with ClinicalTrials.gov, number NCT03228199. FINDINGS: Between July 3, 2017, and July 15, 2017, 1297 (48·1%) of 2699 permanent workers met the age criteria and consented for eye examinations. 751 (57·9%) fulfilled vision criteria and were randomly assigned to the intervention (n=376) or control (n=375) groups. Groups did not differ substantially in baseline characteristics. No participants owned glasses at baseline, 707 (94·1%) received the allocated intervention, and all were followed up and analysed. Between the baseline and evaluation periods, mean productivity in the intervention group increased from 25·0 kg per day to 34·8 kg per day (an increase of 9·84 kg per day), a significantly higher increase than in the control group (from 26·0 kg per day to 30·6 kg per day; an increase of 4·59 kg per day), corresponding to a between-group difference of 5·25 kg per day (95% CI 4·50-5·99; 21·7% relative productivity increase; effect size 1·01 [95% CI 0·86-1·16]; p<0·0001). Intervention-group compliance with study glasses reached 84·5% by closeout. Regression model predictors of greater productivity increase included intervention group membership (5·25 kg per day [95% CI 4·60-5·91], p<0·0001) and, among intervention participants, older age (p=0·039) and better compliance with the intervention (p<0·0001). INTERPRETATION: A substantial productivity increase was achieved in this rural cohort by providing glasses to correct presbyopia, with little cost and high intervention uptake. FUNDING: Clearly.