Task sharing: Development of evidence-based co-management strategy model for screening, detection, and management of diabetic retinopathy.

BACKGROUND: The number of adults with diabetes is increasing worldwide and also the number of people with diabetic retinopathy (DR), a major complication of diabetes. Task sharing in eye care for people with diabetes could address the shortage in the number of ophthalmologists and increase access to eye care services. This study investigated the opinion of eye care professionals for a checklist of tasks, which are involved in DR management, to be possibly shared by optometrists and mid-level eye and health care workers with ophthalmologists. METHODS: The study used a purposive sampling technique. All available eye and health care workers from five selected hospitals in two provinces in Pakistan were recruited. A cross-sectional survey was conducted to investigate the potential roles of various cadres in eye care delivery for people with diabetes. RESULTS: Ninety-six (79%) participants including doctors (n = 56), optometrists (n = 29), and mid-level eye care workers (n = 11) responded to the survey. Two-thirds of the participants suggested mid-level eye care workers, while 88.5% stated that lady health workers could provide education and health promotion to people with diabetes. Most of the participants (88.5%) suggested that optometrists could share the task of dilated ophthalmoscopy with ophthalmologists for detection of DR and make referrals to ophthalmologists if needed. Ophthalmologists remained the recommended cadre to undertake the eye examinations of patients with proliferative DR and diabetic macular edema. CONCLUSION: This research provided an insight on how task sharing in DR management can be implemented by optimizing the roles of eye care workers.

Task sharing in the eye care workforce: Screening, detection, and management of diabetic retinopathy in Pakistan. A case study.

PURPOSE: Diabetic retinopathy (DR) is a preventable cause of vision loss. Reducing vision loss due to DR and providing access to eye care services for people with diabetes have been severely constrained by a shortage in the number of ophthalmologists. This study aimed to explore the potential for task sharing in the eye care workforce for screening, detection, and management of DR. METHODS: Using purposive sampling, 24 participants were recruited from four selected hospitals in 2 provinces in Pakistan. Face-to-face interviews were conducted to explore the potential for task sharing in DR management. RESULTS: Amongst 24 participants recruited, 22 (91.7%) including administrators (n = 3), ophthalmologists (n = 10), optometrists (n = 3), mid-level eye care workers (n = 4), and endocrinologist (2) participated in the study. All participants indicated the need for an organised screening program for DR detection through task sharing. Participants suggested that people with diabetes can be sent directly to an optometrist for initial eye exams, rather than making them wait to be examined by an ophthalmologist. Factors favouring task sharing included the name task sharing rather than task shifting and a high demand for eye care services. Major barriers to implementation of task sharing included the lack of a trained eye care workforce in the healthcare system and the lack of coordination amongst health professionals and policy makers. CONCLUSION: Participants were accepting task sharing approach and believed that task sharing could improve access to eye care services for people with diabetes and better utilise the services of eye and healthcare providers.

Computer Vision Syndrome: Prevalence and Associated Risk Factors Among Computer-Using Bank Workers in Pakistan.

Objectives: The aim of this study was to investigate the prevalence of symptoms of computer vision syndrome (CVS) and identify its associated risk factors among computer-using bank workers in Pakistan. Materials and Methods: This cross-sectional study was conducted on computer-using bank workers. The data collection procedure included a self-administered questionnaire and comprehensive ocular health examination. The prevalence of CVS and its associated risk factors were investigated. The chi-square test was used to study the significance of the association of CVS with potential risk factors. Results: Of 127 participants, 95 (74.8%) were men. Most of the participants (n=53; 41.7%) were in the 30-40 years age group. A total of 101 participants (79.5%) reported any ocular symptom, with burning eyes being the most frequent ocular symptom (77.2%). General body fatigue was the most common non-ocular symptom of CVS (92.9%), followed by headache (83.5%). Out of 127 participants, 71 men and 30 women had some degree of CVS. Female participants had significantly higher risk of CVS than male participants (p=0.01). Total duration of computer use per day and duration of uninterrupted computer use were significantly associated with the occurrence of CVS (p=0.001 and p=0.008, respectively). No significant association was found between CVS and distance from computer screen (p=0.89), frequency of breaks (p=0.18), or font size (p=0.12). Conclusion: A high prevalence of CVS-related symptoms was observed among computer-using bank workers. Non-ocular symptoms associated with computer use were more common than ocular symptoms (92.9% vs. 77.2%).

Relationship Between Glycosylated Hemoglobin Levels and Contrast Sensitivity in People with Type 2 Diabetes Mellitus Without Diabetic Retinopathy.

Objectives: This study aimed to investigate the relationship between glycosylated hemoglobin (HbA1c) value and contrast sensitivity (CS) in people with Type 2 diabetes mellitus (T2DM) and no diabetic retinopathy (DR) changes. Materials and Methods: This cross-sectional study was conducted in the endocrinology department of a tertiary hospital and included 120 participants aged 30-40 years with T2DM without DR and with visual acuity of 6/6 in both eyes. Lea CS charts with one symbol size (10M) were used to measure CS. The relationship between HbA1c value and CS was calculated using linear regression analysis. Results: Of 120 participants with T2DM without DR, 83 (69.2%) were female. Sixty-four participants (53.3%) were in the 36-40 years age group. Mean known duration of diabetes was 3.3±1.65 years. Mean HbA1c value was 10.46±1.48%, with three-fourths of participants having an HbA1c value greater than 8%. Mean CS measured at distances of 1 meter, 2 meters, 3 meters and 4 meters were 164.75±21.12, 122.0±45.08, 93.0±45.37, and 58.67±20.04, respectively. Most participants (n=113, 94.2%) had normal CS (170 at 0.6% contrast) tested at 1 meter. More than half (53.3%) of the participants had reduced CS (40 at 2.5% contrast) at 4 meters. CS measured at 3 meters showed a strong negative correlation with duration of diabetes (r=-0.855, p<0.001; R2=0.731) and HbA1c values (r=-0.865; p<0.001; R2=0.747). Conclusion: CS was inversely associated with diabetes duration and HbA1c values in people with T2DM before any defect in visual acuity or clinical evidence of DR.

Causes of visual impairment in children with low vision.

OBJECTIVE: To determine the main causes of visual impairment in children with low vision. To assess the need of spectacles and low vision devices (LVDs) in children and to evaluate visual outcome after using their LVDs for far and near distance. STUDY DESIGN: Observational study. PLACE AND DURATION OF STUDY: Khyber Institute of Ophthalmic Medical Sciences, Peshawar, Pakistan, from June 2006 to December 2007. METHODOLOGY: The clinical record of 270 children with low vision age 4-16 years attending the Low Vision Clinic were included. All those children, aged 4-16 years, who had corrected visual acuity (VA) less than 6/18 in the better eye after medical or surgical treatment, were included in the study. WHO low vision criteria were used to classify into visually impaired, severe visually impaired and blind. Results were described as percentage frequencies. RESULTS: One hundred and eighty nine (70%) were males and 81 (30%) were females. The male to female ratio was 2.3:1. The main causes of visual impairment included nystagmus (15%), Stargardt's disease (14%), maculopathies (13%), myopic macular degeneration (11%) and oculocutaneous albinism (7%). The percentages of visually impaired, severe visually impaired and blind were 33.8%, 27.2% and 39.0% respectively. Spectacles were prescribed to 146 patients and telescopes were prescribed to 75 patients. Spectacles and telescope both were prescribed to 179 patients while Ocutech telescope was prescribed to 4 patients. CONCLUSION: Retinal diseases nystagmus and macular conditions were mainly responsible for low vision in children. Visually impaired children especially with hereditary/congenital ocular anomalies benefit from refraction and low vision services which facilitate vision enhancement and inclusive education.

Visual rehabilitation of people with oculocutaneous albinism in a tertiary clinical setting in Pakistan.

PURPOSE: All people with oculocutaneous albinism (OCA) have reduced vision. This study aimed to assess the benefits of low vision aids for people with OCA. METHODS: Seventy-seven consecutive people with OCA age 4 years and above examined in a low vision clinic were included in the study. Uncorrected and best-corrected visual acuity (VA), VA with low vision devices, types of low vision aids, and refractive errors data were analyzed. RESULTS: Of the 77 people with OCA, 57% were in the age group between 4 and 15 years and 43% in the age group of 16 years and above. At the time of presentation, the percentages of visually impaired, severe visually impaired, and blind (using WHO low vision criteria) were 52%, 22%, and 25%. Among them, 39% has near VA of 1 M or better. Difference in the means of the spherical equivalent refractive error in the right eyes and left eyes was -0.494 diopters (-01.686, 0.699; 95% confidence interval). VA improved significantly after adequate refractive correction by more than one log MAR lines in 38.6% (P < 0.01). With low vision devices, in 85.7% (n = 66) participants, VA was enhanced to normal level (6/18 or better) in the better eye while 7.8% still remained in the blind category. Telescopes were prescribed to 61% people for the enhancement of distance VA and hand hold magnifiers were prescribed to 22% people to meet their needs. CONCLUSION: Low vision aids can be successfully used in visual rehabilitation of people with OCA to meet their needs.

Task sharing: situation analysis about capacity and resources for management of diabetic retinopathy in Pakistan.

AIM: To assess the capacity and resources of eye care facilities, using the WHO Health Systems Framework, to manage diabetic retinopathy (DR) through task sharing. METHODS: Using purposive sampling, four participants (administrators) from four selected hospitals in two provinces in Pakistan were recruited for this cross-sectional study. A survey, to assess the capacity and resources of the selected eye care facilities for the feasibility to adopt task sharing in management of DR to prevent vision loss, was emailed to participants who were asked to complete. Responses to open-ended questions were entered into a Microsoft Excel spread sheet and inductive approach was applied for analysis. RESULTS: All the surveyed eye care facilities offer eye care services for people with diabetes and DR. All surveyed eye care facilities have a shortage in the number of human resources across all cadres. Optometrists and mid-level eye care workers did not have active roles in DR screening and management in all four hospitals. All the hospitals surveyed did not have a computerized record management system for patients who visit ophthalmologists for eye examinations. Equipment for detection and management of DR were short in number and main users were ophthalmologists. There was no policy for population-based screening program for detection of DR in any of the surveyed hospitals. CONCLUSION: A system-based approach to manage DR is needed. The capacity of eye care facilities and the potential to improve access of people with diabetes to eye care services can be enhanced through implementation of task sharing.

Worldwide inequality in access to full text scientific articles: the example of ophthalmology.

BACKGROUND: The problem of access to medical information, particularly in low-income countries, has been under discussion for many years. Although a number of developments have occurred in the last decade (e.g., the open access (OA) movement and the website Sci-Hub), everyone agrees that these difficulties still persist very widely, mainly due to the fact that paywalls still limit access to approximately 75% of scholarly documents. In this study, we compare the accessibility of recent full text articles in the field of ophthalmology in 27 established institutions located worldwide. METHODS: A total of 200 references from articles were retrieved using the PubMed database. Each article was individually checked for OA. Full texts of non-OA (i.e., "paywalled articles") were examined to determine whether they were available using institutional and Hinari access in each institution studied, using "alternative ways" (i.e., PubMed Central, ResearchGate, Google Scholar, and Online Reprint Request), and using the website Sci-Hub. RESULTS: The number of full texts of "paywalled articles" available using institutional and Hinari access showed strong heterogeneity, scattered between 0% full texts to 94.8% (mean = 46.8%; SD = 31.5; median = 51.3%). We found that complementary use of "alternative ways" and Sci-Hub leads to 95.5% of full text "paywalled articles," and also divides by 14 the average extra costs needed to obtain all full texts on publishers' websites using pay-per-view. CONCLUSIONS: The scant number of available full text "paywalled articles" in most institutions studied encourages researchers in the field of ophthalmology to use Sci-Hub to search for scientific information. The scientific community and decision-makers must unite and strengthen their efforts to find solutions to improve access to scientific literature worldwide and avoid an implosion of the scientific publishing model. This study is not an endorsement for using Sci-Hub. The authors, their institutions, and publishers accept no responsibility on behalf of readers.

Visual rehabilitation of patients with Stargardt's disease.

OBJECTIVE: To assess the role of low vision devices in visual rehabilitation of patients with Stargardt's disease. STUDY DESIGN: Descriptive study. PLACE AND DURATION OF STUDY: The Khyber Institute of Ophthalmic Medical Sciences, Hayatabad Medical Complex, Peshawar, Pakistan, from June 2003 to June 2005. PATIENTS AND METHODS: Patients diagnosed as having Stargardt's disease and confirmed by two senior ophthalmologists clinically and after fluorescein fundus angiography and Electro-Retinogram (ERG) when needed, were included in the study. Patients with fundus pathologies other than Stargardt's disease were excluded. Each subject underwent an ophthalmic examination. Visual acuity was tested with a logarithm of the minimum angle of resolution chart; Feinbloom chart and Snellen type. Low vision assessment was performed on all individuals. SPSS version 10 was used for analysis of the data regarding the severity of visual impairment, visual acuity and devices used for aiding vision. Chi-square test was used for comparison of proportions. RESULTS: Of this cohort of 64 patients, 72% were aged between 7 to 15 years and 28% were 16 to 32 years. Using WHO low vision criteria, the percentage of visually impaired, severe visually impaired and blind (at the time of presentation) were 56.3%; 31.3% and 9.4% respectively. Among those patients, 3.1% had distance visual acuity of 6/18 or better in the better eye and 53% had normal near visual acuity of 1M (0.8 print size). Telescopes were prescribed to 53% patients for enhancement of distance visual acuity to meet their needs. CONCLUSION: Stargardt's patients respond well to magnification. Simple bifocal glasses may be used in the early stages. Visual rehabilitation can help Stargardt's patients to learn independence in their activities of daily living.

Attitudes and perceptions of eye care workers and health administrators regarding task sharing in screening and detection for management of diabetic retinopathy in Pakistan.

PURPOSE: The shortage of ophthalmologists in many countries is a major barrier to timely provision of eye care. A team work approach to screen, detect and manage diabetic retinopathy (DR) could achieve greater screening coverage of people with diabetes to prevent vision loss. This study aimed to assess the attitudes and perceptions of eye care workers and health administrators regarding task sharing for management of DR. METHODS: Using purposive sampling, 121 eye and health care workers in five selected hospitals in two provinces in Pakistan were recruited. A cross-sectional survey explored the possibility for involvement of optometrists and mid-level eye care workers to share tasks with ophthalmologists for DR management and the potential outcomes of task sharing, through multiple choice and open-ended questions. RESULTS: Ninety-six (79%) participants-doctors (n = 56), optometrists (n = 29) and mid-level eye care workers (n = 11) responded to the survey. All participants supported task sharing in screening and detection for management of DR. There was no significant difference among the groups with respect to their positive attitude towards task sharing (p = 0.22). The majority in each group believed that the task sharing would not degrade the quality of care (p = 0.48). Two potential major outcomes of task sharing in the eye care system included the benefits for people with diabetes and potential DR and the strengthening of the health care system. CONCLUSION: Task sharing among various cadres of eye care workers has the potential to improve screening coverage of people with diabetes to prevent visual loss from DR.

Roles of the eye care workforce for task sharing in management of diabetic retinopathy in Cambodia.

AIM: To identify the current roles of eye and health care workers in eye care delivery and investigate their potential roles in screening and detection for management of diabetic retinopathy (DR) through task sharing. METHODS: Purposive sampling of 24 participants including health administrators, members from non-government organizations and all available eye care workers in Takeo province were recruited. This cross sectional mixed method study comprised a survey and in-depth interviews. Data were collected from medical records at Caritas Takeo Eye Hospital (CTEH) and Kiri Vong District Referral Hospital Vision Centre, and a survey and interviews with participants were done to explore the potential roles for task sharing in DR management. Qualitative data were transcribed into a text program and then entered into N-Vivo (version 10) software for data management and analysis. RESULTS: From 2009 to 2012, a total of 105 178 patients were examined and 14 030 eye surgeries were performed in CTEH by three ophthalmologists supported by ophthalmic nurses in operating and eye examination for patients. Between January 2011 and September 2012, 151 patients (72 males) with retinal pathology including 125 (83%) with DR visited CTEH. In addition 170 patients with diabetes were referred to CTEH for eye examinations from Mo Po Tsyo screening programs for people with diabetes. Factors favouring task sharing included high demand for eye care services and scarcity of ophthalmologists. CONCLUSION: Task sharing and team work for eye care services is functional. Participants favor the potential role of ophthalmic nurses in screening for DR through task sharing.

Clinical profile of amblyopia in Pakistani children age 3 to 14 years.

OBJECTIVE: To study the clinical profile of amblyopia in children age 3 to 14 years. DESIGN: A cohort study. PLACE AND DURATION OF STUDY: The study was conducted over a period of two years from June 2001 to June 2003 at Khyber Institute of Ophthalmic Medical Sciences, Hayatabad Medical Complex, Peshawar, Pakistan. PATIENTS AND METHODS: This study included 316 children. Visual acuity was tested with Snellen type and Lea symbols chart according to the level of cooperation of the children. Cycloplegic refraction and orthoptic assessment was performed on all children. RESULTS: One hundred and eighty-two children were between 3 to 8 years age and 134 were between 8 to 14 years. Mean age was 8 years. One hundred and twenty children had strabismic amblyopia, 136 children had anisometropic amblyopia, while 60 children had combined mechanism amblyopia (strabismus and anisometropia both). CONCLUSION: The results indicate the importance of screening school-going children for refractive error and amblyopia and the importance of a future prospective study on the magnitude, cause and treatment of amblyopia at more treatable age.