Rationale and Methodology for a Community-Based Study of Diabetic Retinopathy in an Indonesian Population with Type 2 Diabetes Mellitus: The Jogjakarta Eye Diabetic Study in the Community

Purpose: There are no available data about diabetic retinopathy (DR) in the Indonesian population. This report summarizes the rationale and study design of the Jogjakarta Eye Diabetic Study in the Community (JOGED.COM), a community-based study to estimate the prevalence and risk factors of DR in persons with type 2 diabetes in Jogjakarta, Indonesia.

Methods: The JOGED.COM aimed to examine a cross-sectional sample of 1200 persons with type 2 diabetes aged 30 years and older residing in the study area. We identified 121 community health centers (CHCs) in Jogjakarta and listed 35 CHCs with non-communicable diseases facilities. Multi-stage, clustered random sampling was used to select 22 CHCs randomly. We included CHCs with coverage population >30,000, and excluded those classified as 100% rural. Lists of persons with diabetes confirmed by their family physician were provided from each CHC. Examinations procedures included detailed interviews, general and eye examinations, anthropometry and body composition scan, and dilated fundus photography.

Results: We collaborated with local health authorities, family physicians, and local health practitioners in the recruitment phase. A total of 1435 invitations were distributed, and 1184 people (82.5%) with type 2 diabetes participated in this study, of whom 1138 (79.3%) had completed data with gradable retinal images.

Conclusions: JOGED.COM is the first epidemiologic study of DR in an Indonesian population. This study will provide key information about the prevalence and risk factors of DR in the community. These data are very important for future health promotion programs to reduce the burden of DR in the population.     

The Multi-Ethnic Pediatric Eye Disease Study: Design and Methods

Purpose: To summarize the study design of the Multi-Ethnic Pediatric Eye Disease Study (MEPEDS). Methods: The objectives of the MEPEDS are to: (1) estimate age- and ethnicity-specific prevalence of strabismus, amblyopia, and refractive error; (2) evaluate the association of selected risk factors with these ocular disorders; and (3) evaluate the association of ocular conditions on limitations in health-related functional status in a population-based sample of 12,000 children aged 6–72 months from four ethnic groups—African-American, Asian-American, Hispanics/Latinos and non-Hispanic White. Each eligible child undergoes an eye examination, which includes an interview with his/her parent. The interview includes an assessment of demographic, behavioral, biological, and ocular risk factors and health-related functional status. The examination includes fixation preference testing, visual acuity, stereoacuity, axial length measurement, cycloplegic refraction, keratometry, eye alignment, and anterior and posterior segment examination.     

The Association between Diabetes and Herpes Simplex Eye Disease

Purpose: To evaluate the association between diabetes mellitus (DM) and presence and severity of Herpes simplex eye disease (HSED).

Methods: We conducted two sub-studies. We included the patients seen on the Cornea Service of the Wills Eye Hospital from January 2008 to August 2012. Study 1 included 541 patients with HSED and 3226 controls. Study 2 involved 40 diabetic and 120 non-diabetic ocular surface HSED patients. Severity of ocular surface HSED was graded as mild, moderate, or severe, based on best-corrected visual acuity (BCVA). Patients were excluded if they had fewer than two office visits or had non-Herpes simplex-related vision-threatening conditions. Diabetes was graded as: diet group (DM controlled with diet), oral group (DM controlled with oral medications), and insulin group (DM control required insulin).

Results: Five of 541 (0.93%) HSED patients had type 1 DM, similar to 19/3246 (0.59%) controls (p = 0.375); 48 of 541 (8.88%) HSED patients had type 2 DM, similar to 287/3246 (8.84%) controls (p = 0.981). Using multinomial logistic regression analyses, the probability/risk of being in the severe ocular surface HSED group as opposed to the mild ocular surface HSED group were not statistically significantly different between DM patients and those without DM (p = 0.120; OR, 1.900; 95% CI, 0.846–4.266).

Conclusions: There may not be a positive association between type 2 DM and HSED.     

Comparison of Outcomes of Glaucoma Screening in Primary Care and Community Settings

Purpose: To compare outcomes of glaucoma screening in primary care and community settings, including the follow-up rates of subjects with positive screening results.

Methods: This was a comparative, prospective, non-randomized study. Subjects were recruited by medical students in community-based and primary care settings and screened for glaucoma using the same screening strategy.

Results: Two hundred and fifteen total patients were screened, 117 in community settings and 98 in primary care settings. Positive screenings were seen in 34% of patients in the community setting group (n = 40) and 40% of patients in the primary care setting group (n = 39). Of the patients who screened positive, 74% completed their initial follow-up appointment in the primary care setting group compared with 47.5% in the community-based setting group (p = .015). In the primary care setting, 18% were lost to follow up compared with 42.5% in the community-setting (P = .018). African-Americans were more likely to follow-up (P = .025) and less likely to be lost to follow-up (P = .033) in the primary care setting compared with the community-based setting.

Conclusion: Patients with a positive glaucoma screening result in a primary care setting are more likely to follow up than those in a community-based setting.     

Design,Methodology and Baseline Data of a School-based Cohort Study in Central China: The Anyang Childhood Eye Study

Abstract

Purpose: To report the design, methods and baseline data of the Anyang Childhood Eye Study (ACES), aiming to determine the prevalence, incidence and risk factors of myopia and other ocular diseases in children in central China.

Methods: The ACES was a school-based cohort study conducted in Anyang city. Students have been examined and will be followed-up annually for 3–5 years. Ocular examinations included visual acuity, identification of amblyopia and strabismus, ocular biometry, optical coherence tomography, retinal photography, cycloplegic autorefraction, accommodative response, peripheral refraction, visual perception and so on. A questionnaire survey was performed to collect risk factors for myopia including near work, outdoor activity, parental myopia, birth history, habits of wearing spectacles and reading, living habits, food habits and so on.

Results: Of 3112 grade 1 and 2363 grade 7 students eligible for the ACES, 2893 (93.0%) and 2267 (95.9%) participated in the study, with a mean age of 7.1 years (range 5.7–9.3 years) and 12.7 years (range 10.0–15.9 years), and proportions of male to be 57.8% and 50.0%, respectively. The prevalence rates of myopia, high myopia, emmetropia and hyperopia were 3.9%, 0.1%, 72.9% and 23.3% in grade 1, and 67.3%, 2.7%, 31.4% and 1.2% in grade 7, respectively. Similar data were found in the children confined in 6-year-old and 12-year-old ages.

Conclusions: The ACES is the first large-scale cohort study in China with baseline response rates over 90%. Continuous documentation of changes and risk factors of refractive errors in these cohorts would provide new insights into myopia control in school-aged children.     

The Pavagada Pediatric Eye Disease Study: Objectives,Methodology and Participant Characteristics

ABSTRACT

Purpose: To explain the objectives and methodology of a population-based survey of children ≤15 years in rural South India.

Methods: A population-based cross sectional survey was performed by trained field workers (1st phase). Children with eye disease were referred to the peripheral rural hospital (2nd phase) to be examined by a general ophthalmologist. If major eye disease (cataract, strabismus) was identified they were referred to a pediatric ophthalmologist (3rd phase).

Results: The sample size was 29,850. In the 1st phase, 23,100 children were screened (response rate 77.39%). There were about 33% of children in each of the three stratified age groups (0–5, 6–10 and 11–15 years), with a nearly equal sex distribution in each group (range 47% to 52%). Of the 23,100 screened, 1538 were referred to the peripheral rural hospital. The general ophthalmologist evaluated 647 patients (42%) who came to the peripheral rural hospital (2nd phase) and referred 59 children to the pediatric ophthalmologist (3rd phase). The pediatric ophthalmologist, in addition to evaluating the 59 children referred from the 2nd phase, also evaluated those who did not report (891/1538) to the peripheral rural hospital. This evaluation was done in the field itself. All the 1538 children referred by the field workers were thus seen by an ophthalmologist (647 by the general ophthalmologist, 891 by the pediatric ophthalmologist and 59 by both).

Conclusion: The study is expected to provide information about the prevalence of pediatric ocular morbidity that could help plan intervention strategies in this area.     

The Chinese American Eye Study: Design and Methods

Abstract

Purpose: To summarize the study design, operational strategies and procedures of the Chinese American Eye Study (CHES), a population-based assessment of the prevalence of visual impairment, ocular disease, and visual functioning in Chinese Americans.

Methods: This population-based, cross-sectional study included 4570 Chinese participants aged 50 years and older, residing in the city of Monterey Park, California. Each eligible participant completed a detailed interview and eye examination. The interview included an assessment of demographic, behavioral and ocular risk factors and health-related and vision-related quality of life. The eye examination included measurements of visual acuity, intraocular pressure, visual fields, fundus and optic disc photography, a detailed anterior and posterior segment examination, and measurements of blood pressure, glycosylated hemoglobin levels, and blood glucose levels.

Results: The objectives of the CHES are to obtain prevalence estimates of visual impairment, refractive error, diabetic retinopathy, open-angle and angle-closure glaucoma, lens opacities, and age-related macular degeneration in Chinese Americans. In addition, outcomes include effect estimates for risk factors associated with eye diseases. Lastly, CHES will investigate the genetic determinants of myopia and glaucoma.

Conclusion: The CHES will provide information about the prevalence and risk factors of ocular diseases in one of the fastest growing minority groups in the United States.     

Progress in Screening and Treatment of Common Congenital Eye Diseases

Congenital eye illnesses are caused by congenital ocular malformations and are a primary cause of poor visual acuity and blindness in infants.Early diagnosis and treatment of congenital eye illnesses are of great significance for affected infants,their families,and even society as a whole.This study describes the current situation for prenatal and infant screening for congenital eye diseases and briefly summarizes novel progress in the treatment of the five most common eye diseases （congenital dacryocystitis,congenital cataract,retinopathy of prematurity,congenital glaucoma and retinoblastoma）.Current programs are now aimed at improvements in the prevention and treatment of congenital eye diseases in China.     

The Brazilian Amazon Region Eye Survey: Design and Methods

Purpose: To describe the study design, operational strategies, procedures, and baseline characteristics of the Brazilian Amazon Region Eye Survey (BARES), a population-based survey of the prevalence and causes of distance and near visual impairment and blindness in older adults residing in the city of Parintins.

Methods: Cluster sampling, based on geographically defined census sectors, was used for cross-sectional random sampling of persons 45 years and older from urban and rural areas. Subjects were enumerated through a door-to-door survey and invited for measurement of uncorrected, presenting and best-corrected visual acuity and an ocular examination.

Results: Of 9931 residents (5878 urban and 4053 rural), 2384 individuals (1410 urban and 974 rural) were eligible and 2041 (1180 urban and 861 rural) had a clinical examination (response rate 85.6%). The majority of participants were female (1041, 51.0%); the average age was 59.9 ± 11.1 years (60.2 ± 11.2 years for urban and 59.4 ± 11.1 years for rural); 1360 (66.6%) had primary schooling or less (58.1% in urban and 78.4% in rural) and 57.8% were resident in urban areas. The age distribution between sexes was similar (p = 0.178). Both sex and age distributions of the sample were comparable to that of the Brazilian Amazon Region population.

Conclusions: The BARES cohort will provide information about the prevalence and causes of near and distance vision in this underprivileged and remote population in Brazil.     

LV Prasad Eye Institute Glaucoma Epidemiology and Molecular Genetic Study (LVPEI- GLEAMS). Report 1: Study Design and Research Methodology

Abstract

Purpose: In the developing world, more than 90% of glaucoma is undetected due to the lack of appropriate screening methods. The LV Prasad Eye Institute Glaucoma Epidemiology and Molecular Genetic Study (LVPEI-GLEAMS) is a population-based study which aims to estimate the prevalence of, along with clinical, systemic and genetic risk factors for glaucoma in a rural population sampled from the state of Andhra Pradesh, India. The study aims to develop community screening strategies to diagnose glaucoma. This article describes the methodology adopted in LVPEI-GLEAMS.

Methods: A sample of 3833 participants aged 40 years and older has been estimated to be enrolled using a compact segment sampling method with probability proportionate to size. Each participant will undergo a complete medical history and comprehensive eye examination including slit lamp photography, imaging of anterior and posterior segment, frequency doubling technology and standard automated perimetry. Additionally, glycosylated hemoglobin will be measured and a genetic profile based on candidate gene analysis will be undertaken. Clinical, biochemical and genetic data will be stored in a computerized database and analyzed. The novelty of this study lies in the fact that it is conducted at a vision center (primary eye care center serving a population of 50,000) by a vision technician (high school educated rural youth trained in basic ophthalmic techniques for a year).

Conclusion: Information from the diagnostic techniques of the study will be used to develop effective community-level screening strategies, and insights from risk factors associated with glaucoma will help develop appropriate detection and management strategies.     

Rationale and Methodology for a Population-Based Study of Eye Diseases in Malay People: The Singapore Malay Eye Study (SiMES)

Purpose: Although there are approximately 200 million people of Malay ethnicity living in Asia, the burden and risk factors of blinding eye diseases in this ethnic group are unknown. This study summarizes the rationale and study design of a population-based study of eye diseases among adult Malays in Singapore. Methods: A population-based cross-sectional study of Malays was designed in Singapore. The sampling frame consisted of all Malays aged 40–79 living in designated study areas in southwestern Singapore. From a list of 16,069 names provided by the Ministry of Home Affairs, age-stratified random sampling was used to select 5,600 names (1,400 people from each decade of 40–49, 50–59, 60–69, and 70–79 years). The target sample size for this study was 3,150 persons. Selected individuals were invited to a centralized clinic by letters, telephone calls, and home visits. Participants underwent standardized interview and assessment of blood pressure, anthropometry, presenting and best-corrected visual acuity, subjective refraction, ocular biometry, Goldmann tonometry, slit-lamp biomicroscopy, optic disc imaging, digital lens, and retinal photography. Blood and urine samples were collected for biochemical analyses and further stored for future studies. Selected participants also had gonioscopic examination, visual fields test, and assessment of ankle and brachial blood pressure to detect presence of peripheral vascular disease. Conclusions: This study provides population-based data on the prevalence of and risk factors for age-related eye diseases in people of Malay ethnicity in Singapore. Data from this study allow further understanding of the etiology and impact of eye diseases in this ethnic group.     

Recruitment and Testing Protocol in the National Eye Health Survey: A Population-Based Eye Study in Australia

Purpose: To present the recruitment and testing methodology of the National Eye Health Survey (NEHS), a population-based study that aimed to determine the prevalence and causes of vision impairment and blindness in Australia.

Methods: Non-Indigenous Australians aged 50 years and older and Indigenous Australians aged 40 years and older were recruited using a door-to-door approach from 30 randomly selected geographical areas, stratified by remoteness. Participants underwent a vision examination, anterior segment assessment, intraocular pressure testing, perimetry, and fundus photography.

Results: In total, recruiters approached 23,235 residences, and 11,883 residents were successfully contacted (51.1%). Of these, 6760 (56.9%) were deemed eligible and 5764 agreed to participate (positive response rate = 85.3%). Of those who agreed, 4836 residents attended the examination (4836/6760 = 71.5%). This included 1738 Indigenous Australians (41.1% male) aged 40–92 years (mean ± standard deviation = 55.0 ± 10.0 years) and 3098 non-Indigenous Australians (46.4% male), aged 50–98 years (mean ± standard deviation = 66.6 ± 9.7 years).

Conclusions: The NEHS achieved an excellent positive response rate, and the data collected from 4836 Australians will provide the first population-based national estimate of the prevalence of vision impairment and blindness. This data will guide future economic analysis, policy formulation, and eye health service delivery in Australia.     

The African American Eye Disease Study: Design and Methods

Purpose: To describe the study design, operational and recruitment strategies, procedures, and baseline characteristics of the African American Eye Disease Study (AFEDS), a population-based assement of the prevalence of visual impairment, ocular disease, visual function, and health-related quality of life in African Americans.

Methods: This population-based, cross-sectional study included over 6000 African Americans 40 years and older residing in and around Inglewood, California. A detailed interview and eye examination was performed on each eligible participant. The interview included an assessment of demographic, behavioral, and ocular risk factors and health-related and vision-related quality of life. The eye examination included measurements of visual acuity, intraocular pressure, visual fields; fundus and optic disc photography; a detailed anterior and posterior segment examination; and measurements of blood pressure, glycosylated hemoglobin levels, and blood glucose levels.

Results: The AFEDS cohort includes more than 6000 participants that have completed a home questionnaire and a comprehensive eye examination. The majority of participants were female (63%), the average (± standard deviation) overall age was 60.9 (±11.3). Participants are mostly working (40%) or retired (41%), non-smoking (57%), partial drinking (54%), and with at least some college education (38%). A trust-development recruitment strategy was refined in order to overcome challenges in study participation.

Conclusion: The AFEDS is the largest epidemiologic eye study among African Americans to date. The AFEDS cohort will provide information about the prevalence and risk factors of ocular disease in the largest ophthalmologic study population of African Americans in the United States.     

Hazardous Drinking Among Adults With Diabetes and Related Eye Disease or Visual Problems: A Population-Based Cross-Sectional Survey

Purpose: To estimate the prevalence of problem drinking and related risk behaviors among adults with diabetes and eye disease in the United States. Methods: In a population-based, cross-sectional telephone survey of the noninstitutionalized U.S. adult population (18 years of age or older) conducted in 47 U.S. states in 2002 and 40 U.S. states in 1999, we identified the prevalence of binge drinking (5 or more drinks on an occasion in the last month), drinking and driving in the last month, and binge drinking and concurrent unlocked firearm ownership. We used sample weights to estimate the prevalence and number of individuals reporting each measure in the full U.S. population. Results: In 2002, 130 of 3,670 respondents with diabetes-related eye disease reported binge drinking within the last month (prevalence 4%; 95% confidence interval [CI]: 3%–6%), corresponding to an estimated 116,501 adults in the United States (95% CI: 80,020–152,981). Approximately 0.4% (95% CI: 0.2%–0.9%) of all affected adults, and 0.8% (95% CI: 0.3%–2%) of all affected males, endorsed driving after drinking within the last month, corresponding to an estimated 12,150 Americans with diabetic eye disease who drink and drive (95% CI: 2,414–21,887). An estimated total of 15,356 (95% CI: 2,180–28,533) also reported having a loaded and unlocked firearm at home. Estimates of binge drinking and drinking and driving were at least as high among the 1,854 respondents with diabetes and visual impairment in 1999. Conclusions: Binge drinking occurs in 4%–5% of adults with diabetes and eye disease. Driving after drinking and unlocked gun ownership, while uncommon, also occur among such individuals, who are apt to be at extraordinarily high risk for injury and other alcohol-related complications.     

Eye Care Use Among Rural Adults in China: The Handan Eye Study

Abstract

Purpose: To assess the use of eye care services in a rural population in North China and to analyze the factors associated with underuse of these services.

Methods: In a cross-sectional population-based study, demographic, health and vision-related information including use of eye care services were determined during a face-to-face interview. A single visit to an eye care provider qualified as “use” of eye care services.

Results: Of 6612 participants, 754 (11.4%, 95% confidence interval, CI, 8.7–14.1%) had used eye care services. The most common reason cited for not seeing an eye care provider was “no need” (n?=?5754). Of the 5754 who thought that there was no need to see an ophthalmologist, 3458 (60.1%) were found to have one or more type of eye disease, including glaucoma (56, 1.0%), cataract (1056, 18.4%), age-related macular degeneration (AMD; 164, 2.9%) and refractive error (3048, 53.0%). Also, 74 (1.3%) and 409 (7.1%) of the 5754 participants had visual impairment (<20/60) according to best-corrected visual acuity and presenting visual acuity, respectively. In a multiple regression model, participants who had glaucoma (adjusted odds ratio, OR, 4.0, 95% CI 3.0–5.4), AMD (adjusted OR 1.6, 95% CI 1.2–2.3) or refractive error (adjusted OR 1.4, 95% CI 1.1–1.8), were more likely to visit an eye care provider.

Conclusion: A high proportion of the Chinese rural population had never used eye care services although three fifths had eye diseases. Further efforts towards better education of the general population about common eye problems as well as increasing the number of ocular health providers would be necessary in future.     

Eye injuries in twentieth century warfare: A historical perspective

With successive wars in the twentieth century, there has been a relative increase in injuries to the eye compared to injuries of other parts of the body. The main causes of eye injury have changed with advances in techniques and weaponry of warfare, with blast fragmentation injuries accounting for 50–80% of cases. Penetrating and perforating injuries are most common, and injuries associated with intraocular foreign bodies pose special diagnostic and management problems. Injuries are bilateral in 15–25% of cases. Injuries associated with chemical, nuclear, and laser weapons have distinct characteristics and epidemiology. Enucleation was commonly performed at the turn of the century, but incidence has declined with better understanding of the pathophysiology of ocular trauma, improved surgical techniques and sepsis control with antibiotics. Sympathetic ophthalmia appears to be uncommon and earlier fears of this complication seem to have been exaggerated. Timely evacuation to a surgical facility is important for a good visual prognosis and preservation of the globe. However, prevention of injuries with eye armor is ultimately the best management, and the need for a comprehensive eye protection program in the military cannot be overemphasized, especially since eye injuries pose important socioeconomic, as well as medical, problems.     

New Perspectives on Dry Eye Definition and Diagnosis: A Consensus Report by the Asia Dry Eye Society

For the last 20 years, a great amount of evidence has accumulated through epidemiological studies that most of the dry eye disease encountered in daily life, especially in video display terminal (VDT) workers, involves short tear film breakup time (TFBUT) type dry eye, a category characterized by severe symptoms but minimal clinical signs other than short TFBUT. An unstable tear film also affects the visual function, possibly due to the increase of higher order aberrations. Based on the change in the understanding of the types, symptoms, and signs of dry eye disease, the Asia Dry Eye Society agreed to the following definition of dry eye: “Dry eye is a multifactorial disease characterized by unstable tear film causing a variety of symptoms and/or visual impairment, potentially accompanied by ocular surface damage.” The definition stresses instability of the tear film as well as the importance of visual impairment, highlighting an essential role for TFBUT assessment. This paper discusses the concept of Tear Film Oriented Therapy (TFOT), which evolved from the definition of dry eye, emphasizing the importance of a stable tear film.     

Disparities in Adherence to Screening Guidelines for Diabetic Retinopathy in the United States: A Comprehensive Review and Guide for Future Directions

ABSTRACT

Diabetic retinopathy (DR) is the leading cause of new-onset blindness in American adults aged 20–74 years old. The number of diabetics living with diagnosed DR increased by 89%, from 4.06 million to 7.69 million, between 2000 and 2010. Projected numbers from the Vision Health Initiative by the CDC predict that the rate of DR will triple by 2050, from 5.5 million people living with DR to 16 million. Screening guidelines aim to detect cases early because the treatments for DR can reduce severe vision loss by up to 94%. However, adherence to these guidelines is quite low. It is estimated that more than half of patients with diabetes may fail to receive necessary screening. Risk factors for non-screening discussed in this study include low health literacy, lack of access to care, pregnancy, physician adherence to guidelines, unique factors present in different minority populations, gender and age disparities, and living in rural regions. This paper also aims to address potential interventions that may improve adherence rates.     

Eye screening can be used to perform anemia screening and treatment in adolescent girls using ToucHb

Purpose:Anemia is common in adolescent girls. Apprehension while drawing blood to estimate hemoglobin concentration is a barrier for confirming anemia. ToucHb, a noninvasive instrument that estimates the hemoglobin by taking an image of the exposed conjunctiva, was used during eye screening to help diagnose and treat anemia.Methods:ToucHb was used during secondary school eye screening and during house-to-house eye screening to estimate the hemoglobin concentration in the body. Each of the girls was distributed a packet of 60 tablets of ferrous and folate and a tablet of albendazole. They were followed up after 3 months.Results:Exactly 1511 municipal school girls aged 10-19 years (mean 12.9; standard deviation [SD] 1.64) were examined. Of them, 949 (62.8%) had hemoglobin of ≤9 mg%. Among those girls with hemoglobin ≤9 mg%, the mean (SD) during the initial and follow-up examinations was 6.1 (1.4) and 9.6 (1.03), respectively, by paired t-test (P < 0.001). Another 588 girls (average age 14.4 years, SD 1.2) had their eyes examined and hemoglobin estimated during a house-to-house eye screening. Of them, 116 (19.7%) had hemoglobin level of ≤9 mg%. Their pre-Hb was 7.9 (SD 1.05) on average and after 3 months, it was 9.6 (SD 1.02). Among those girls with hemoglobin ≤9 mg%, the mean (SD) during the initial and follow-up examinations was 6.2 (1.4) and 7.9 (1.1), respectively, by paired t-test (P < 0.001)Conclusion:ToucHb was useful to diagnose anemia while doing eye screening and to ensure its treatment. Anemia diagnosis and management would enhance the health of adolescent girls.