The Better Operative Outcomes Software Tool (BOOST) Prospective Study: Improving the Quality of Cataract Surgery Outcomes in Low-Resource Settings.

PURPOSE: Post-operative vision impairment is common among patients who have undergone cataract surgery in low-resource settings, impacting quality of clinical outcomes and patient experience. This prospective, multisite, single-armed, pragmatic validation study aimed to assess whether receiving tailored recommendations via the free Better Operative Outcomes Software Tool (BOOST) app improved surgical outcomes, as quantified by post-operative unaided distance visual acuity (UVA) measured 1-3 days after surgery. METHODS: During the baseline data collection round, surgeons in low and middle-income countries recorded clinical characteristics of 60 consecutive cataract cases in BOOST. Additional data on the causes of poor outcomes from 20 consecutive cases with post-operative UVA of <6/60 (4-12 weeks post-surgery) were entered to automatically generate tailored recommendations for improvement, before 60 additional consecutive cases were recorded during the follow-up study round. Average UVA was compared between cases recorded in the baseline study round and those recorded during follow-up. RESULTS: Among 4,233 cataract surgeries performed by 41 surgeons in 18 countries, only 2,002 (47.3%) had post-operative UVA 6/12 or better. Among the 14 surgeons (34.1%) who completed both rounds of the study (1,680 cases total), there was no clinically significant improvement in post-operative average UVA (logMAR units ±SD) between baseline (0.50 ± 0.37) and follow-up (0.47 ± 0.36) rounds (mean improvement 0.03, p = 0.486). CONCLUSIONS: Receiving BOOST-generated recommendations did not result in improved UVA beyond what could be expected from prospective monitoring of surgical outcomes alone. Additional research is required to assess whether targeted support to implement changes could potentiate the uptake of app-generated recommendations and improve outcomes.

Global estimates on the number of people blind or visually impaired by cataract: a meta-analysis from 2000 to 2020.

BACKGROUND: To estimate global and regional trends from 2000 to 2020 of the number of persons visually impaired by cataract and their proportion of the total number of vision-impaired individuals. METHODS: A systematic review and meta-analysis of published population studies and gray literature from 2000 to 2020 was carried out to estimate global and regional trends. We developed prevalence estimates based on modeled distance visual impairment and blindness due to cataract, producing location-, year-, age-, and sex-specific estimates of moderate to severe vision impairment (MSVI presenting visual acuity <6/18, ≥3/60) and blindness (presenting visual acuity <3/60). Estimates are age-standardized using the GBD standard population. RESULTS: In 2020, among overall (all ages) 43.3 million blind and 295 million with MSVI, 17.0 million (39.6%) people were blind and 83.5 million (28.3%) had MSVI due to cataract blind 60% female, MSVI 59% female. From 1990 to 2020, the count of persons blind (MSVI) due to cataract increased by 29.7%(93.1%) whereas the age-standardized global prevalence of cataract-related blindness improved by -27.5% and MSVI increased by 7.2%. The contribution of cataract to the age-standardized prevalence of blindness exceeded the global figure only in South Asia (62.9%) and Southeast Asia and Oceania (47.9%). CONCLUSIONS: The number of people blind and with MSVI due to cataract has risen over the past 30 years, despite a decrease in the age-standardized prevalence of cataract. This indicates that cataract treatment programs have been beneficial, but population growth and aging have outpaced their impact. Growing numbers of cataract blind indicate that more, better-directed, resources are needed to increase global capacity for cataract surgery.

A large-scale analysis of refractive errors in students attending public primary schools in Mexico.

A cross-sectional, retrospective study was conducted from September 2013 through July 2014 to determine the prevalence of refractive errors among students attending public primary schools in Mexico. Among 3,861,156 students at 14,566 public primary schools in all 32 states of Mexico, teachers identified reduced visual acuity in 1,253,589 (32.5%) using visual acuity measurement. Optometrists confirmed 391,498 [31.2%, mean (SD) age: 8.8 (1.9) years; 204,110 girls (52.9%)] had refractive errors using visual acuity measurement and noncycloplegic static retinoscopy. Among 288,537 (72.4%) of children with previous eyeglasses usage data reported, 241,505 (83.7%) had uncorrected refractive errors. Before prescription eyeglasses were provided, 281,891 students (72%) had logMAR visual acuity ≤ 0.2; eyeglasses corrected vision loss in 85.6% (n = 241,352) of them. Simple myopic astigmatism was the most frequent refractive error (25.7%, n = 100,545). Astigmatism > - 1.00 diopters was present in 54.6% of all students with ametropia. The anisometropia rate based on spherical equivalent difference between right and left eye ≥ 1.50 diopters was 3.9% (n = 15,402). Uncorrected refractive errors are an important issue in primary school students in Mexico. An updated study is needed to analyze the evolving trends over the past decade.

Estimating mortality and disability in Peru before the COVID-19 pandemic: a systematic analysis from the Global Burden of the Disease Study 2019.

Background: Estimating and analyzing trends and patterns of health loss are essential to promote efficient resource allocation and improve Peru's healthcare system performance. Methods: Using estimates from the Global Burden of Disease (GBD), Injuries, and Risk Factors Study (2019), we assessed mortality and disability in Peru from 1990 to 2019. We report demographic and epidemiologic trends in terms of population, life expectancy at birth (LE), mortality, incidence, prevalence, years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life-years (DALYs) caused by the major diseases and risk factors in Peru. Finally, we compared Peru with 16 countries in the Latin American (LA) region. Results: The Peruvian population reached 33.9 million inhabitants (49.9% women) in 2019. From 1990 to 2019, LE at birth increased from 69.2 (95% uncertainty interval 67.8-70.3) to 80.3 (77.2-83.2) years. This increase was driven by the decline in under-5 mortality (-80.7%) and mortality from infectious diseases in older age groups (+60 years old). The number of DALYs in 1990 was 9.2 million (8.5-10.1) and reached 7.5 million (6.1-9.0) in 2019. The proportion of DALYs due to non-communicable diseases (NCDs) increased from 38.2% in 1990 to 67.9% in 2019. The all-ages and age-standardized DALYs rates and YLLs rates decreased, but YLDs rates remained constant. In 2019, the leading causes of DALYs were neonatal disorders, lower respiratory infections (LRIs), ischemic heart disease, road injuries, and low back pain. The leading risk factors associated with DALYs in 2019 were undernutrition, high body mass index, high fasting plasma glucose, and air pollution. Before the COVID-19 pandemic, Peru experienced one of the highest LRIs-DALYs rates in the LA region. Conclusion: In the last three decades, Peru experienced significant improvements in LE and child survival and an increase in the burden of NCDs and associated disability. The Peruvian healthcare system must be redesigned to respond to this epidemiological transition. The new design should aim to reduce premature deaths and maintain healthy longevity, focusing on effective coverage and treatment of NCDs and reducing and managing the related disability.

Preventable risk factors for type 2 diabetes can be detected using noninvasive spontaneous electroretinogram signals.

Given the ever-increasing prevalence of type 2 diabetes and obesity, the pressure on global healthcare is expected to be colossal, especially in terms of blindness. Electroretinogram (ERG) has long been perceived as a first-use technique for diagnosing eye diseases, and some studies suggested its use for preventable risk factors of type 2 diabetes and thereby diabetic retinopathy (DR). Here, we show that in a non-evoked mode, ERG signals contain spontaneous oscillations that predict disease cases in rodent models of obesity and in people with overweight, obesity, and metabolic syndrome but not yet diabetes, using one single random forest-based model. Classification performance was both internally and externally validated, and correlation analysis showed that the spontaneous oscillations of the non-evoked ERG are altered before oscillatory potentials, which are the current gold-standard for early DR. Principal component and discriminant analysis suggested that the slow frequency (0.4-0.7 Hz) components are the main discriminators for our predictive model. In addition, we established that the optimal conditions to record these informative signals, are 5-minute duration recordings under daylight conditions, using any ERG sensors, including ones working with portative, non-mydriatic devices. Our study provides an early warning system with promising applications for prevention, monitoring and even the development of new therapies against type 2 diabetes.

The prediction capability of a cataract surgery risk stratification model based on a large electronic medical record dataset.

Purpose: The aim of this study was to develop a risk stratification system that predicts visual outcomes (uncorrected corrected visual acuity at one week and five weeks postoperative) in patients undergoing cataract surgery. Methods: This was a retrospective analysis in a multitier ophthalmology network. Data from all patients who underwent phacoemulsification or manual small-incision cataract surgery between January 2018 and December 2019 were retrieved from an electronic medical record system. There were 122,911 records; 114,172 (92.9%) had complete data included. Logistic regression analyzed unsatisfactory postoperative outcomes using a main effects model only. The final model was cross-checked using forward stepwise selection. The Hosmer-Lemeshow goodness of fit test, the Bayesian information criterion, and Nagelkerke's R2 assessed model fit. Dispersion was calculated from deviance and degrees of freedom and C-stat from receiving operating characteristics analysis. Results: The final phacoemulsification model (n = 48,169) had a dispersion of 1.08 with a Hosmer-Lemeshow goodness of fit of 0.20, a Nagelkerke R2 of 0.19, and a C-stat of 0.72. The final manual small-incision cataract surgery model (n = 66,003) had a dispersion of 1.05 with a Hosmer-Lemeshow goodness of fit of 0.00015, a Nagelkerke R2 of 0.14, and a C-stat of 0.68. Conclusion: The phacoemulsification model had reasonable model fit; the manual small-incision cataract surgery model had poor fit and was likely missing variables. The predictive capability of these models based on a large, real-world cataract surgical dataset was suboptimal to determine which patients could benefit most from sight-restoring surgery. Appropriate patient selection for cataract surgery in developing settings should still rely on clinician thought processes, intuition, and experience, with more complex cases allocated to more experienced surgeons.

Assessment of a high-fidelity, virtual reality-based, manual small-incision cataract surgery simulator: A face and content validity study.

Purpose: To establish the face and content validity of the HelpMeSee Eye Surgery Simulator - a virtual reality-based cataract surgery simulator for manual small-incision cataract surgery (MSICS). Methods: The face and content validity were assessed on the sclero-corneal tunnel construction course. A questionnaire with 11 questions focused on the visual realism, with resemblance to real life surgery, and the training value of the simulator was developed. Thirty-five experienced MSICS surgeons participated in the study. Responses were recorded using a seven-point scoring system. Results: Overall, 74.3% (26/35) of the respondents agreed that the overall visual representation of the eye and the instruments in the simulator were realistic. The task of injecting a visco-elastic through the paracentesis was reported to be the most visually realistic task with a mean score of 5.78 (SD: 1.09; range: 2-7). With regard to content validity, 77.1% (27/35) of the subjects felt agreed that the errors and complications represented throughout the entire tunnel construction module were similar to those encountered in real life; the task of entering the anterior chamber with the keratome had a mean score of 5.54 (SD: 0.98; range 1-7), being rated the highest in that aspect. Overall, 94.3% (33/35) of the subjects agreed that the simulator would be useful in developing hand-eye co-ordination. A similar number of 94.3% (33/35) agreed that based on their experience, they would recommend cataract surgical training on this simulator. Conclusion: The results suggest that the HelpMeSee Eye Surgery Simulator appears to have sufficient face and content validity for cataract surgical training.

An objective evaluation of simulated surgical outcomes among surgical trainees using manual small-incision cataract surgery virtual reality simulator.

Purpose: The purpose of this study was to evaluate trainee performance across six modules of a virtual reality (VR) simulator. Methods: A retrospective observational study was conducted on 10 manual small-incision cataract surgery (MSICS) trainees who practiced cataract surgery on an MSICS VR simulator for one month. They were assessed in six major steps which included scleral groove, tunnel dissection, keratome entry, capsulorhexis, nucleus delivery, and intraocular lens (IOL) insertion under a trainer's supervision. The information included in their score metrics was collected, and their overall performance was evaluated. Results: Thirty attempts were evaluated for scleral groove, tunnel dissection, and capsulorhexis and 15 attempts for keratome entry. Candidates had varied results in the dimensional aspects and their rates of complications with a mean satisfactory score of 3.1 ± 4.17, 6.8 ± 5.75, 5.8 ± 7.74, and 1.8 ± 2.57, respectively. Nucleus delivery (n = 5) had more of iris pull and IOL insertion (n = 5) had more of lost IOL as complications but both had a higher satisfactory outcome. Conclusion: A VR simulator is a useful tool for training surgeons before their entry into live surgery. It is an effective method for evaluating objectively the structural characteristics of each phase in MSICS and their associated complications, helping them anticipate it earlier during live surgery by giving them a near real world experience.

Embracing technology in cataract surgical training - The way forward.

While ophthalmology as a surgical branch itself has evolved technologically with newer instruments, techniques and procedures; ophthalmic surgical training appears to have stagnated in terms of how it is delivered and how trainees' learning and performance are assessed. This collaborative editorial attempts to identify the lacunae in ophthalmic residency training and highlight how technological tools such as surgical simulators can be incorporated into ophthalmic training even in limited-resource settings with good results.

Update of a Simple Model to Calculate the Annual Global Productivity Loss Due to Blindness and Moderate and Severe Vision Impairment.

PURPOSE: To develop a simple but more precise model to calculate potential annual productivity losses due to blindness and moderate and severe vision impairment (MSVI) at the national, regional, and global level. METHODS: Productivity loss was defined as the loss of minimum wage/Gross National Income per capita (GNI) incurred by people aged 50-64 years with blindness or MSVI, who were not able to work or worked with reduced earnings in 2020. We developed a global list of minimum wage data from on-line sources. All other model data were sourced from international, standardised, and open-access databases. For blindness, the total productivity loss (not working) incurred by 64%-90% of the affected population was summed up with partial productivity loss, defined as 10%-36% of the affected population earning one-third of that of the sighted population. For MSVI, the total productivity loss for 30%-55% of the affected population was summed with the partial productivity loss, defined as 45%-70% of the affected population having 35% reduced earnings. The costs of blindness and MSVI were summed to obtain the cost of combined vision loss. RESULTS: The global cost of vision loss based on minimum wage was US$160-US$216.32 billion for 2020. The global cost of vision loss using GNI was US$449.36-US$584.66 billion. CONCLUSIONS: A parsimonious model that considers minimum wage and GNI potentially lost due to blindness and MSVI can be used for eye care programming planning and advocacy at the national, regional, and global level.

Meta-analysis of gender inequities in cataract surgical coverage in Latin America.

OBJECTIVE: To perform an updated meta-analysis of cataract surgical coverage (CSC) data in Latin American studies to confirm that gender equity exists in terms of receiving cataract surgery. MATERIALS AND METHODS: A literature search of Rapid Assessment of Avoidable Blindness (RAAB) studies in Latin American published since 2011 was done. Older studies from countries that did not have newer data published were also included. Using summary original study data of CSC rates on an individual basis, a random effects model of meta-analysis was performed to evaluate the differences in CSC between men and women. RESULTS: Nineteen studies from 17 countries were included (Mexico data were pooled). The odds ratios at a visual acuity (VA) of <3/60 and <6/18 were 1.04 [95% confidence interval (CI): 0.82-1.32] and 1.04 (95% CI: 0.90-1.19), respectively, without heterogeneity. There were no significant gender differences for CSC at any VA level. CONCLUSIONS: This updated meta-analysis of CSC data from Latin American countries supports that gender inequity in terms of receiving cataract surgery is not an issue in the region. The results do not provide insight into gender inequity in terms of the quality of cataract surgery and other types of eye care services.

OBJETIVO: Realizar un metaanálisis actualizado de la cobertura de cirugía de catarata en estudios latinoamericanos para confirmar que existe equidad de género en términos del acceso a cirugía de catarata. MATERIAL Y MÉTODOS: Se realizó una búsqueda de la literatura de "Rapid Assessments of Avoidable Blindness (Encuestas Rápida de Ceguera Evitable)" publicados en Latinoamérica desde el 2011. Se incluyeron también estudios anteriores de países que no tenían publicados datos más recientes. Utilizando el compendio de datos de los estudios originales de la cobertura de cirugía de catarata (Cataract Surgery Coverage, CSC por sus siglas en inglés) en base individual, se realizó un modelo de efectos aleatorios de metaanálisis para evaluar las diferencias en la CSC entre hombres y mujeres. RESULTADOS: Se incluyeron 19 estudios de 17 países (los datos de México fueron agrupados). La oportunidad relativa (razón de probabilidades) para una agudeza visual (AV) de <3/60 y <6/18 fueron de 1.04 [95% Intervalo de confianza (IC): 0.82-1.32] y 1.04 (95% IC: 0.90-1.19), respectivamente, sin heterogeneidad. No hubo diferencias significativas para la CSC a ningún nivel de AV. CONCLUSIONES: Este metaanálisis actualizado de la CSC de Latinoamérica, confirma que no existe inequidad de género en términos de acceso a cirugía de catarata en esta región.

Wikipedia, friend or foe regarding information on diabetic retinopathy? A content analysis in the world's leading 19 languages.

OBJECTIVE: To compare the completeness and quality of information about diabetic retinopathy on Wikipedia in the world's leading spoken languages in 2020. DESIGN AND METHODS: An observational, descriptive, cross-sectional study. The information on diabetic retinopathy obtained from the free encyclopedia Wikipedia® was assessed in languages with one hundred million or more total speakers. The term "diabetic retinopathy" was accessed in the corresponding Wikipedia entry in English, while the "more languages" function gives access to other languages. The information on the sites was collected by three ophthalmologist observers. A database was created with the most important subtopics for the education of patients with diabetic retinopathy in any of its classifications, based on a 25-question survey. The results were stratified on a scale from 0 to 4. A confirming correlation was found in the statistical analysis among the observers. RESULTS: No language achieved the label "excellent"; 2 languages were rated as "fair "; 4 languages qualified as "substandard"; and 7 languages were scored as "poor." No information could be found in five languages. CONCLUSIONS: As would be expected, the quality of content is variable across different languages. However, if anyone can edit Wikipedia, health professionals can do so as well to improve the quality and quantity of information for patients.

Keeping an eye on eye care: monitoring progress towards effective coverage.

The eye care sector is well positioned to contribute to the advancement of universal health coverage within countries. Given the large unmet need for care associated with cataract and refractive error, coupled with the fact that highly cost-effective interventions exist, we propose that effective cataract surgery coverage (eCSC) and effective refractive error coverage (eREC) serve as ideal indicators to track progress in the uptake and quality of eye care services at the global level, and to monitor progress towards universal health coverage in general. Global targets for 2030 for these two indicators were endorsed by WHO Member States at the 74th World Health Assembly in May, 2021. To develop consensus on the data requirements and methods of calculating eCSC and eREC, WHO convened a series of expert consultations to make recommendations for standardising the definitions and measurement approaches for eCSC and eREC and to identify areas in which future work is required.

Effectiveness of simulation-based training for manual small incision cataract surgery among novice surgeons: a randomized controlled trial.

This study was designed to determine the effect of a novel simulation-based training curriculum for scleral tunnel construction in manual small incision cataract surgery (MSICS) compared with traditional training. In this multicenter, investigator-masked, randomized clinical trial, resident surgeons within 3 months of matriculation with minimal or no prior experience with MSICS were assigned either to simulation-based training, the Experimental Group (EG), or to conventional training, the Control Group (CG). EG residents were trained to perform scleral tunnel construction using a simulation-based curriculum (HelpMeSee Eye Surgery Simulator), while residents in the CG followed institution-specific curriculum before progressing to live surgery. Surgical videos of the first 20 attempts at tunnel construction were reviewed by masked video raters. The primary outcome was the total number of any of 9 pre-specified errors. On average, the total number of errors was 9.25 (95% CI 0-18.95) in the EG and 17.56 (95% CI 6.63-28.49) in the CG (P = 0.05); the number of major errors was 4.86 (95% CI 0.13-9.59) in the EG and 10.09 (95% CI 4.76-15.41) in the CG (P = 0.02); and the number of minor errors was 4.39 (95% CI 0-9.75) in the EG and 7.47 (95% CI 1.43-13.51) in the CG (P = 0.16). These results support that novice surgeons trained using the novel simulation-based curriculum performed fewer errors in their first 20 attempts at tunnel construction compared to those trained with a conventional curriculum.

Cataract as a Cause of Blindness and Vision Impairment in Latin America: Progress Made and Challenges Beyond 2020.

PURPOSE: To provide an update of cataract as a cause of vision loss in Latin America and to analyze sex inequalities in cataract surgical coverage (CSC) and effective CSC (eCSC) in the region. DESIGN: Population-based systematic review with longitudinal comparisons. METHODS: The Latin American and Caribbean Health Sciences Literature (LILACS) and PubMed databased were searched for population-based studies reporting cataract blindness, surgical coverage, and outcomes published between January 2014 and December 2019. Information on the number of surgeries performed from the 2014-2016 period was obtained from ministries of health and was used for calculation of the cataract surgical rate (CSR). Sources such as Rapid Assessment of Avoidable Blindness (RAAB) and Rapid Assessment of Cataract Surgical Services data were reanalyzed to calculate sex inequality in CSC and eCSC by subtracting the rate in women from the rate in men. RESULTS: Cataract was the cause of 29.8%-77.6% of cases of blindness in the included studies; the CSR improved in 10 countries. The CSC pinhole visual acuity of 3/60 varied from 24.1% in Peru to 97.1% in Argentina, and the median absolute gender inequality CSC pinhole visual acuity 3/60 was -0.7%. The eCSC pinhole visual acuity 3/60 varied from 14.8% in Guatemala to 92.1% in Argentina, and the median absolute gender inequality eCSC pinhole visual acuity 3/60 was -0.8%. CONCLUSIONS: Cataract remains a leading cause of blindness in Latin America. Coverage is suboptimal, and surgical results are also below target levels in many countries. Incentives for a better distribution of human resources, adequate training of ophthalmologists, and the inclusion of vision services in universal health care coverage could reduce the burden of cataract in Latin America.

Knowledge, attitudes and eye health-seeking behaviours in a population-based sample of people with diabetes in rural China.

AIMS: To assess knowledge of diabetes and acceptance of eye care among people with diabetes in rural China, to improve service uptake. METHODS: Population-based study of people in Guangdong, China, with glycosylated haemoglobin A1c≥6.5% and/or known history of diabetes. Between August and November 2014, participants answered a questionnaire (based on Delphi process/previous focus groups) on medical history, demographic characteristics, self-rated health and vision, knowledge about diabetes and diabetic retinopathy, quality of local healthcare, barriers to treatment, likely acceptance of eye exams and treatment, and interventions rated most likely to improve service uptake. Presenting visual acuity was assessed, fundus photography performed and images graded by trained graders. Potential predictors of accepting care were evaluated and confounders adjusted for using logistic regression. RESULTS: A total of 562 people (9.6% (256/5825), mean age 66.2±9.84 years, 207 (36.8%) men) had diabetes, 118 (22.3%) previously diagnosed. 'Very likely' or 'likely' acceptance of laser treatment (140/530=26.4%) was lower than for eye exams (317/530=59.8%, p<0.001). Predictors of accepting both exams and laser included younger age (p<.001) and prior awareness of diabetes diagnosis (p=0.004 and p=0.035, respectively). The leading barrier to receiving diabetes treatment was unawareness of diagnosis (409/454, 97.2%), while interventions rated most likely to improve acceptance of eye exams included reimbursement of travel costs (387/562, 73.0%), video or other health education (359/562, 67.7%) and phone call reminders (346/562, 65.3%). CONCLUSIONS: Improving diagnosis of diabetes, along with incentives, education and communication strategies, is most likely to enhance poor acceptance of diabetic eye care in this setting.