Clinical outcomes following the dispensing of ready‐made and recycled spectacles: A systematic literature review

Uncorrected refractive error is the leading cause of global visual impairment. Given resource constraints in developing countries, the gold standard method of refractive error correction, custom‐made spectacles, is unlikely to be available for some time. Therefore, ready‐made and recycled spectacles are in wide use in the developing world. To ensure that refractive error interventions are successful, it is important that only appropriate modes of refractive error correction are used. As a basis for policy development, a systematic literature review was conducted of interventional studies analysing visual function, patient satisfaction and continued use outcomes of ready‐made and recycled spectacles dispensed to individuals in developing countries with refractive errors or presbyopia. PubMed and CINAHL were searched by MESH terms and keywords related to ready‐made and recycled spectacle interventions, yielding 185 non‐duplicated papers. After applying exclusion criteria, eight papers describing seven studies of clinical outcomes of dispensing ready‐made spectacles were retained for analysis. The two randomised controlled trials and five non‐experimental studies suggest that ready‐made spectacles can provide sufficient visual function for a large portion of the world's population with refractive error, including those with astigmatism and/or anisometropia. The follow‐up period for many of the studies was too short to confidently comment on patient satisfaction and continued‐use outcomes. No studies were found that met inclusion criteria and discussed recycled spectacles. The literature also notes concerns about quality and cost effectiveness of recycled spectacles, as well as their tendency to increase developing countries' reliance on outside sources of help. In light of the findings, the dispensing of ready‐made spectacles should be favoured over the dispensing of recycled spectacles in developing countries.     

Treating uncorrected refractive error in adults in the developing world with autorefractors and ready-made spectacles

Background: To evaluate a method for treating uncorrected refractive error in adults in the developing world. Design: Prospective, cross‐sectional study in outpatient community health centres. Participants: Eight hundred and forty subjects aged 18 and older from rural villages in Haiti and Belize. Methods: Undilated refractive error screening exams were conducted over a 5‐day period in rural Haiti and Belize using portable autorefractors. Isometropic, spherical, ready‐made spectacles were provided to patients with bilateral refractive error, astigmatism ≤1 dioptre in each eye and visual acuity worse than 6/9 in each eye. Visual acuity was measured with and without corrective spectacles. Main Outcome Measures: The mean visual improvement and median final visual acuity after treatment with ready‐made glasses. Results: Eight hundred and forty patients aged 18 and older were screened with autorefractors. One hundred and eighty‐nine subjects (22.5%) were found to have visually significant bilateral refractive error. Fifty‐eight per cent (110/189) of these patients met criteria for treatment with ready‐made spectacles. Visual acuity improved an average of 4.2 lines in the better eye and 4.1 lines in the worse eye with corrective glasses. The median visual acuity in the better eye was 6/6 after treatment. Conclusion: Autorefractors and ready‐made spectacles allow for effective treatment of uncorrected refractive error in adults in the developing world.     

Uncorrected refractive error in the northern and eastern provinces of Sri Lanka

Background: The 2004 tsunami focused unprecedented international aid and resources on Sri Lanka. Among other responses, a program delivered by volunteer optometrists enabled many local people to access eye examinations and spectacles for the first time. The data collected from the eye‐care delivery program during 2005 are summarised in this report, as an evidence base for planning future eye‐care interventions in these provinces or similar areas. Methods: A total of 96 eye clinics were conducted by visiting volunteer optometrists in the northern and eastern provinces of Sri Lanka, at which 20,090 people were examined. Clinical records were reviewed for conditions causing visual impairment, conditions that could cause impaired vision in future if left untreated, eye‐care outcomes and barriers to seeking care. Results: Complete records were available for 14,669 people. Seventy‐nine per cent of this clinical population had never had an eye examination. Uncorrected refractive error including presbyopia caused visual impairment for 78 per cent (11,388) of people who presented for an eye examination. Cataract caused impaired vision for 15 per cent (2,180) of people and was the main reason for referral beyond primary eye‐care, although only five per cent (695) of people presenting were referred for cataract surgery, as local capacity constraints set a visual acuity requirement of 6/36 or worse. The gender and age profiles of people attending the clinics were not consistent with equitable blindness prevention. Conclusion: The high proportion of people who had not previously had an eye examination, particularly those with significant uncorrected refractive error, provides evidence for the acute need for further development and support of community‐level eye‐care services in the regions visited. Women and older people should be targeted by future programs to achieve equity of blindness prevention.     

The rationale for shifting from a voluntary clinical approach to a public health approach in addressing refractive errors

Millions of people need eyeglasses and do not have them. Assuming that the average pair of eyeglasses has an effective life span of two to five years, an additional 60 to 150 million spectacles would be needed each year for the estimated 303 million individuals who currently need correction. Optometrists are engaged in a variety of capacities in an attempt to address the significant public health problem of uncorrected refractive error. One popular method used by many voluntary optometry‐led organisations is to provide direct clinical services to individual patients in developing countries. Considerable manpower, materials, money and logistical resources are used in conducting these short‐term missions, yet scarce evidence exists regarding their cost effectiveness or the efficacy and long‐term impact of these interventions. The provision of direct clinical services by most foreign volunteers does not directly build local capacity and may hinder development of sustainable local services. Adopting public health approaches will enable volunteer provider organisations to dramatically increase their program effectiveness and output, while developing local capacities in a sustainable way. These approaches should include:

• 1 Following the national strategy for blindness prevention as determined by the Ministry of Health and forming partnerships with relevant local, national and international organisations.
• 2 Using need‐based criteria to target programs more efficiently.
• 3 Developing sustainable services via local capacity building.
• 4 Monitoring, evaluating and using evidence to guide programs.

By using these approaches, a larger contribution will be made by the volunteer organisations in addressing the unmet need for refractive correction.     

Poverty and blindness in Africa

Africa carries a disproportionate responsibility in terms of blindness and visual impairment. With approximately 10 per cent of the world’s population, Africa has 19 per cent of the world’s blindness. It is no surprise that this reality also mirrors the situation in terms of the burden of world poverty. There is an increasing recognition of the need to highlight the link between poverty, development and health care. Blindness, disabling visual impairment and the overall lack of eye‐care services are too often the result of social, economic and developmental challenges of the developing world. The state of eye care in Africa stands in alarming contrast to that in the rest of the world. Poor practitioner‐to‐patient ratios, absence of eye‐care personnel, inadequate facilities, poor state funding and a lack of educational programs are the hallmarks of eye care in Africa, with preventable and treatable conditions being the leading cause of blindness. Eye diseases causing preventable blindness are often the result of a combination of factors such as poverty, lack of education and inadequate health‐care services. The challenge that Vision 2020 has set itself in Africa is enormous. Africa is not a homogenous entity, the inter‐ and intra‐country differences in economic development, prevalence of disease, delivery infrastructure and human resources amplify the challenges of meeting eye‐care needs. The successful implementation of Vision 2020 programs will be hindered without the development of a comprehensive, co‐ordinated strategy that is cognisant of the differences that exist and the need for comprehensive solutions that are rooted in the economic and political realities of the continent as well as the individual countries and regions within countries. This strategy should recognise the need for economic growth that results in greater state funded eye‐care services that focus on health promotion to ensure the prevention of eye disease, the development of eye clinics in hospitals and health clinics, and the training of the appropriate human resources.     

Public sector refraction and spectacle dispensing in low-resource countries of the Western Pacific

Background:  Given that uncorrected refractive error is a frequent cause of vision impairment, and that there is a high unmet need for spectacles, an appraisal of public sector arrangements for the correction of refractive error was conducted in eight Pacific Island countries.
Methods:  Mixed methods (questionnaire and semi-structured interviews) were used to collect information from eye care personnel (from Fiji, Papua New Guinea, Solomon Islands, Vanuatu, Cook Islands, Samoa, Tonga and Tuvalu) attending a regional eye health workshop in 2005.
Results:  Fiji, Tonga and Vanuatu had Vision 2020 eye care plans that included refraction services, but not spectacle provision. There was wide variation in public sector spectacle dispensing services, but, except in Samoa, ready-made spectacles and a full cost recovery pricing strategy were the mainstay. There were no systems for the registration of personnel, nor guidelines for clinical or systems management. The refraction staff to population ratio varied considerably. Solomon Islands, Tuvalu and Vanuatu had the best coverage by services, either fixed or outreach. Most services had little promotional activity or community engagement.
Conclusions:  To be successful, it would seem that public sector refraction services should answer a real and perceived need, fit within prevailing policy and legislation, value, train, retain and equip employees, be well managed, be accessible and affordable, be responsive to consumers, and provide ongoing good quality outcomes. To this end, a checklist to aid the initiation and maintenance of refraction and spectacle systems in low-resource countries has been constructed.     

The prevalence and causes of visual impairment in seven‐year‐old children

Background

To report the prevalence and causes of visual impairment in seven‐year‐old children in Iran and its relationship with socio‐economic conditions.

Methods

In a cross‐sectional population‐based study, first‐grade students in the primary schools of eight cities in the country were randomly selected from different geographic locations using multistage cluster sampling. The examinations included visual acuity measurement, ocular motility evaluation, and cycloplegic and non‐cycloplegic refraction. Using the definitions of the World Health Organization (presenting visual acuity less than or equal to 6/18 in the better eye) to estimate the prevalence of vision impairment, the present study reported presenting visual impairment in seven‐year‐old children.

Results

Of 4,614 selected students, 4,106 students participated in the study (response rate 89 per cent), of whom 2,127 (51.8 per cent) were male. The prevalence of visual impairment according to a visual acuity of 6/18 was 0.341 per cent (95 per cent confidence interval 0.187–0.571); 1.34 per cent (95 per cent confidence interval 1.011–1.74) of children had visual impairment according to a visual acuity of 6/18 in at least one eye. Sixty‐six (1.6 per cent) and 23 (0.24 per cent) children had visual impairment according to a visual acuity of 6/12 in the worse and better eye, respectively. The most common causes of visual impairment were refractive errors (81.8 per cent) and amblyopia (14.5 per cent). Among different types of refractive errors, astigmatism was the main refractive error leading to visual impairment. According to the concentration index, the distribution of visual impairment in children from low‐income families was higher.

Conclusion

This study revealed a high prevalence of visual impairment in a representative sample of seven‐year‐old Iranian children. Astigmatism and amblyopia were the most common causes of visual impairment. The distribution of visual impairment was higher in children from low‐income families. Cost‐effective strategies are needed to address these easily treatable causes of visual impairment.

     

Need and challenges of refractive correction in urban Chinese school children.

PURPOSE: Uncorrected refractive error is recognized as the principal cause of visual impairment in school-aged children. Although correction of refractive error is easy, safe, and effective, many children are without the necessary spectacles. Empiric research on barriers to refractive correction remains limited, precluding the formulation of effective remedial actions. The aims of this study were to characterize parental awareness and other barriers to spectacle use among children considered to be in need of refractive correction and to determine the proportion undercorrected for those already with spectacles. METHODS: A population-based sample of children 5 to 15 years of age was examined in Guangzhou, China. Visual acuity was measured followed by cycloplegic refraction and best-corrected vision. Parental awareness of the child's vision difficulties, spectacle use, and frequency of vision checkups were collected by questionnaire. Associations between these variables and demographic and socioeconomic characteristics were investigated with multiple logistic regression. RESULTS: Among the 4359 examined children, 919 (21.1%) were found to be in need of refractive correction. Need was defined as uncorrected visual acuity < or = 0.50 in both eyes correctable by at least two lines in the better eye. Parental awareness was apparent for 85% of cases; 74% had spectacles. Awareness of vision difficulties was associated with older child age, greater visual impairment, and higher parental education. The purchase of spectacles was associated with greater visual impairment; the child's age, gender, parental education, and family income were not significant factors. Undercorrection by two lines or more in the better eye was found in 30% of those already with spectacles; undercorrection was associated with greater visual impairment and less frequent refraction checkups. CONCLUSIONS: Half of the children in need of first-time or updated spectacles are without them, an unacceptably high proportion. Younger children with moderate visual impairment are at particular risk for uncorrected refractive error. Parental education and enhanced school-based screening programs may be necessary to address the unfilled need for refractive correction among school-aged children.     

Frequency, Course, and Impact of Correctable Visual Impairment (Uncorrected Refractive Error)

Uncorrected refractive error has been identified by the World Health Organization (WHO) as one of the priorities for Vision 2020 and a frequent cause of visual impairment. In the past, only the terms presenting visual impairment (PVI) and visual impairment after best refractive correction (BCVI) were used, so that PVI also included BCVI cases. In the more recent literature, visual impairment has been subdivided into two mutually exclusive entities: that which is correctable by refraction (which we now term correctable visual impairment, CVI) and that which cannot be corrected by refraction due to ocular or neurological disease (which we now term non-correctable visual impairment, NCVI, and which is identical to BCVI). PVI remains a useful concept as it includes both types of impairment. Although CVI is reported to be the major form of visual impairment worldwide, its impacts are not yet well understood. CVI has a higher prevalence among vulnerable groups such as older people, less well educated people and those living alone or in rural areas. Systematic data on barriers to refractive correction remain scant, but these may be present at the individual level, within the health service context, or at a social level. Our review indicates that research on CVI is at a relatively early stage and that more detailed research, particularly determining whether it has impacts on independent living and quality of life, is needed before CVI can be justifiably prioritized in health policy.     

The challenge of uncorrected refractive error: driving the agenda of the Durban Declaration on refractive error and service development

The purpose of this article is to highlight the challenge of uncorrected refractive error globally, as well as to discuss recent advocacy successes and innovative programs designed to address the need for broader refractive error service development, particularly in developing countries. The World Health Organization's VISION 2020: The Right to Sight program first posed the challenge to national governments to give priority to strategies and resources targeted towards avoidable causes of blindness and visual impairment, so that these unnecessary forms of blindness or visual impairment can be eliminated globally by the year 2020. The blindness prevention community is challenged to increase in scale its initiatives, which support the attainment of VISION 2020: The Right to Sight goals primarily and the United Nation's Millennium Development Goals indirectly. The Durban Declaration on Refractive Error and Service Development was the outcome of a meeting of eye‐care professionals, researchers, governments, civil society and industry in March 2007 and still stands as a guiding document to the blindness prevention community for the elimination of avoidable blindness due to uncorrected refractive error.     

A comparison of spectacle and contact lens wearing times in the ACHIEVE study

Purpose: The aim was to compare vision correction wearing time between myopic children and teenagers in a clinical trial of contact lenses and spectacles. Methods: Parents of subjects in the Adolescent and Child Health Initiative for Vision Empowerment (ACHIEVE) study provided wearing times for spectacle and contact lens wear. Hours wearing primary correction and total correction were compared between the two treatment groups. Other factors hypothesised to be associated with wearing time were analysed. Results: The average wearing time of the primary correction differed significantly with the wearing time for the spectacles group being 91.5 hours per week compared to 80.3 hours per week for the contact lens wearers (p < 0.0001). Total correction time was slightly higher for the contact lens wearers, 97.5 hours per week, after accounting for time wearing spectacles. Higher refractive error was strongly related to longer wearing times (p < 0.0002). Age and treatment group were associated with wearing time (p = 0.005). Young contact lens wearers wore their lenses less than young spectacle wearers and older contact lens wearers. Low scores on an appearance quality‐of‐life scale were associated with longer wearing time in spectacle wearers compared to the low‐ and high‐scoring contact lens wearers. Gender, spectacle satisfaction and activities were not related to wearing time. Conclusions: While contact lens wearers, on average, wear their contact lenses less than spectacle wearers, they spend roughly the same amount of time wearing a refractive correction. Higher refractive error resulted in longer wearing times for both spectacle and contact lens wearers. Younger contact lens wearers wore their contact lenses for shorter periods than the spectacle wearers, but still wore them, on average, 74.4 hours per week (about 10 hours per day), suggesting that contact lenses are a viable alternative mode of correction for children.     

Review of preschool vision screening referrals in South Auckland, New Zealand

Background: Limited data are available on the causes of visual impairment in preschool children in New Zealand. We aimed to review demographic and visual parameters in children referred to the Ophthalmology Department, Manukau Super Clinic from vision screening programs in South Auckland. Methods: Retrospective medical record review of 131 children, aged three to five years, referred from community‐based vision screening programs to the Ophthalmology Department for further assessment. Medical records were reviewed to determine: the reason for referral; findings from ophthalmic assessments; treatment received; and visual acuity at the final visit. The main outcome measures were the cause of visual impairment in children referred from preschool vision screening and the visual acuity at the final follow‐up visit. Results: Thirty‐eight (29.0 per cent) children were discharged after their initial assessment as false positive referrals. Almost half (45.5 per cent) of the children were prescribed glasses for the correction of refractive error, amblyopia or strabismus. Twenty‐nine (22.1 per cent) children were diagnosed with amblyopia with an average follow‐up period of 17.5 ± 2.7 months. In general, compliance with therapy for amblyopia was poor with 48.3 per cent non‐compliant with their prescribed treatment regimen. Despite this, visual outcomes were good with an average final visual acuity in the amblyopic eye of 0.294 ± 0.231 logMAR (Snellen 6/12). Conclusions: The ‘positive predictive value’ for the Counties‐Manukau preschool vision screening program was 47.4 per cent, suggesting that the visual acuity measurements alone produce a significant number of false positive results. In children diagnosed with amblyopia, early detection and intervention showed significant improvement in vision in the amblyopic eye, with many children also showing improved binocular function.     

Visual defects in Nepalese children with Down syndrome

Background: Down syndrome (DS) is a common chromosomal anomaly. People with this syndrome have recognisable physical characteristics and limited intellectual abilities. The aim of this study was to determine visual defects, especially refractive error and binocular anomalies, in a sample of Nepalese children with DS. Methods: Thirty‐six children with DS (19 boys and 17 girls) from the Kathmandu valley, aged from four months to 18 years, underwent detailed optometric examination. Cycloplegic refraction was performed on all subjects. Vision on presentation of all the children was assessed with preferential looking cards, the Kay picture cards, the Bailey‐Lovie logMAR chart or the Snellen chart. Binocular function was assessed with cover test, Hirschberg or Bruckner test. Results: Cycloplegic refraction of the children revealed that 80 per cent of the children had significant refractive error. Most of them had hyperopia (55 per cent), followed by astigmatism (44 per cent), myopia (25 per cent) and anisometropia (19 per cent). Only two (5.6 per cent) children were strabismic and both of them were alternating esotropes. Nystagmus was present in 10 (28 per cent). Other ocular findings were upward slanting palpebral fissures, blepharitis, congenital nasolacrimal duct obstruction, blepharoconjunctivitis, chalazion and lenticular opacities. Conclusion: Nepalese children with DS have a high prevalence of refractive error and nystagmus. Regular eye examinations are indicated for these children to enable early diagnosis and appropriate management of ocular disorders to improve their vision and quality of life.     

Volunteer-based vision nongovernmental organizations and VISION 2020

BACKGROUND: The World Health Organization and the International Agency for the Prevention of Blindness developed the global initiative, VISION 2020, with the goal of eliminating avoidable blindness by 2020. An unknown number of volunteer-based organizations conduct short-term vision camps as a means of eliminating blindness in developing countries. METHODS: VISION 2020 strategies are reviewed and volunteer organizations' understanding of VISION 2020 and methods of service delivery are considered through survey results. RESULTS: From the surveys it is apparent that volunteer organizations are not aware of the VISION 2020 initiative and do not conduct their projects and programs in a way that is supported by VISION 2020. CONCLUSION: Volunteer organizations have the skills, resources, and enthusiasm to make an impact on the burden of visual impairment. They do not, however, follow strategies accepted as most appropriate by the larger global eye health care community. Volunteer organizations are encouraged to reprioritize the work they do and change the methods they use.     

Refractive error and vision correction in a general sports‐playing population

Purpose

To evaluate, in an amateur sports‐playing population, the prevalence of refractive error, the type of vision correction used during sport and attitudes toward different kinds of vision correction used in various types of sports.

Method

A questionnaire was used for people engaging in sport and data was collected from sport centres, gyms and universities that focused on the motor sciences.

Results

One thousand, five hundred and seventy‐three questionnaires were collected (mean age 26.5 ± 12.9 years; 63.5 per cent male). Nearly all (93.8 per cent) subjects stated that their vision had been checked at least once. Fifty‐three subjects (3.4 per cent) had undergone refractive surgery. Of the remainder who did not have refractive surgery (n = 1,519), 580 (38.2 per cent) reported a defect of vision, 474 (31.2 per cent) were myopic, 63 (4.1 per cent) hyperopic and 241 (15.9 per cent) astigmatic. Logistic regression analysis showed that the best predictors for myopia prevalence were gender (p < 0.001) and location of sport practice (p < 0.001). Sports that present higher prevalence of outdoor activity have lower prevalence of myopia. Contact lens penetration over the study sample was 18.7 per cent. Contact lenses were the favourite system of correction among people interviewed compared to spectacles and refractive surgery (p < 0.001).

Conclusions

This study showed that sport was not associated with different levels of myopia prevalence in the adult population. However, subjects engaging in outdoor sports had lower rates of myopia prevalence. Penetration of contact lens use in sport was four times higher than the overall adult population. Contact lenses were the preferred system of correction in sports compared to spectacles or refractive surgery, but this preference was affected by the type of sport practised and by the age and level of sports activity for which the preference was required.

     

Monitoring and evaluation of refractive error and presbyopia for Vision 2020

Purpose: To develop output and outcome indicators for the correction of refractive error and presbyopia to a level comparable with those advocated by Vision 2020 for cataract. Methods: World Health Organization, Vision 2020 and published eye care intervention literature were searched to find evidence of best practice. This information was used to construct a suite of indicators for monitoring the correction of refractive error and presbyopia. Results: Indicators for the monitoring and evaluation of refractive error and presbyopia correction were proposed, addressing refraction and spectacle dispensing outputs and rates, and refractive error correction and presbyopia correction coverage. Conclusion: Using data collection that should be occurring in everyday clinical practice, the proposed indicators would provide more comprehensive information than those currently suggested by Vision 2020. As such, they would be more useful in the monitoring and evaluation of the correction of refractive error and presbyopia in the context of Vision 2020.