The Use of Key Informant Method for Identifying Children with Blindness and Severe Visual Impairment in Developing Countries

Purpose: An estimated 19 million children are visually impaired; of these, 1.4 million are irreversibly blind. A key challenge is to identify them early in life to benefit maximally from visual rehabilitation, and/or treatment. This aggregative review and structured literature analysis summarizes evidence of what it is about the key informant (KI) approach that works to identify children with blindness or severe visual impairment (B/SVI) in the community (for whom, to what extent, in what circumstances, in what respect, how and why).

Methods: Peer-reviewed (PubMed, hand search) and grey literature (Google, World Health Organization website, academic theses, direct requests) were included, and methods and criteria used for identification, productivity (number of children referred per KI), accuracy of referrals (positive predictive value, PPV), age of children with B/SVI, KI definition, sex, information about cost and comparisons aggregated.

Results: We included 31 documents describing 22 unique KI programs. Mostly KIs identified children with B/SVI in 1–3 weeks, i.e. “campaign mode.” In 60%, KIs were community volunteers, others formal health sector workers (FHSW). Around 0.02–1.56 children per KI (median = 0.25) were successfully recruited. PPV ranged from 12 to 66%. In two studies comparing FHSWs and community KIs, the latter were 8 and 10 times more productive.

Conclusion: KIs working in campaign mode may provide an effective approach to identifying children with B/SVI in communities. Including identification of ocular problems and/or other impairments has been recommended. Research on factors that influence effectiveness and on whether KIs continue to contribute could inform programs.     

Gender-related effects of vision impairment characteristics on depression in Korea

Purpose: To investigate the gender-specific associations between perceived vision impairment and symptoms of depression.

Methods: We used the data from the 2012 Korean Longitudinal Study of Aging database of 7448 individuals aged 45 years and older. Questionnaires assessing depression symptoms and perceived visual impairment at near, distance, and in general were administered. Logistic regression analyses were used to evaluate if visual impairment could lead to depression, adjusting for the potential confounders of age, socioeconomic status (household income, education level, marital status, and employment status), and health behaviors (alcohol consumption, smoking, and physical activity level) after gender stratification.

Results: Perceived general and near vision impairment were significantly associated with symptoms of depression in males (odds ratio [OR] = 2.78 and 2.54; 95% confidence interval [CI], 1.91–4.04 and 1.78–3.63). Perceived general and distance vision impairment were significantly associated with symptoms of depression in females (OR = 2.16 and 2.08; 95% CI, 1.67–2.79 and 1.61–2.69). General sight with near vision impairment in males and general sight with distance vision impairment in females could be stronger predictors of depression than other vision impairment combinations (area under the receiver operating characteristic curve [AUROC], 0.6461; p = 0.0425 in males; AUROC, 0.6270; p = 0.0318 in females).

Conclusion Gender differences were found in the characteristics of visual impairment on symptoms of depression. Ophthalmologists should be aware that near vision impairment in males and distance vision impairment in females have an adjunctive effect that might contribute to symptoms of depression.     

Validity of Teacher-Based Vision Screening and Factors Associated with the Accuracy of Vision Screening in Vietnamese Children

Purpose: To assess validity of teacher-based vision screening and elicit factors associated with accuracy of vision screening in Vietnam.

Methods: After brief training, teachers independently measured visual acuity (VA) in 555 children aged 12–15 years in Ba Ria – Vung Tau Province. Teacher VA measurements were compared to those of refractionists. Sensitivity, specificity, positive predictive value and negative predictive value were calculated for uncorrected VA (UVA) and presenting VA (PVA) 20/40 or worse in either eye. Chi-square, Fisher’s exact test and multivariate logistic regression were used to assess factors associated with accuracy of vision screening. Level of significance was set at 5%.

Results: Trained teachers in Vietnam demonstrated 86.7% sensitivity, 95.7% specificity, 86.7% positive predictive value and 95.7% negative predictive value in identifying children with visual impairment using the UVA measurement. PVA measurement revealed low accuracy for teachers, which was significantly associated with child’s age, sex, spectacle wear and myopic status, but UVA measurement showed no such associations.

Conclusions: Better accuracy was achieved in measurement of VA and identification of children with visual impairment using UVA measurement compared to PVA. UVA measurement is recommended for teacher-based vision screening programs.     

School-entry Vision Screening in the United Kingdom: Practical Aspects and Outcomes

Purpose: To describe and assess an orthoptist-led vision screening service for school-entry (reception class) children, and report outcomes from one healthcare trust in the UK.

Methods: A total of 3721 children (aged 4–5 years) in reception class primary school (155 state, 3 private) underwent orthoptist-conducted vision screening. Children who failed to meet the screening criteria were referred to hospital-based eye services for re-testing and final diagnosis.

Results: The screening take-up rate was 96.41%; the remaining 3.59% refused/failed to consent to screening. The screening capture rate of participating children was 99.7%. A total of 11.14% of screened children failed to meet the screening criteria and were referred elsewhere; no abnormalities were found in 14% (false referral rate) of these children. Of the referred children, 53% had refractive errors requiring glasses and 42% had squints. The estimated percentages of common visual problems in screened children were 9.15% for refractive error and 3.81% for squint.

Conclusion: An orthoptist-led, time-of-school-entry vision screening service is ideal for successful childhood vision screening and is, thus, a valuable source of information regarding the prevalence of common visual problems among children.     

Poor Vision and Self-Reported Functional Difficulties among Recently Hospitalized Individuals in the United States

Purpose: Many hospitalized adults may have limited vision and as a result be at increased risk of worse functional outcomes. Here, we determine the prevalence of poor vision among recently hospitalized United States adults. Additionally, we evaluate the impact of objective vision defects on reading difficulty and external mobility outcomes (difficulty with falls and going down steps).

Methods: Our cross-sectional study included 1,347 adult Americans aged 50 years and older, all recently hospitalized, participating in the 2001–2008 National Health and Nutrition Examination Survey (NHANES). Self-reported difficulty with reading and going down steps/stairs/curbs data were collected for all participants, while data on self-reported falling difficulty were only available for the 2001–2004 NHANES (n=631). Presenting near and distance visual acuity (VA) were measured, with poor vision defined as VA worse than 20/40.

Results: Poor near and distance vision were present in 17.4% and 9.8% of individuals, respectively. Multivariable analyses showed that the odds of reading difficulty were greater with worse VA (odds ratio, OR, 1.9 per 0.3 logMAR increment in near VA, 95% confidence interval, CI, 1.6–2.4, P<0.01), as were the odds of difficulty going down steps/stairs/curbs (OR 2.4 per 0.3 logMAR increment in distance VA, 95% CI 1.9–3.1, P<0.01) and odds of falling difficulty (OR 1.6 per 0.3 logMAR increment in distance VA, 95% CI 1.1–2.4, P=0.04).

Conclusion: About 1 in 10 and 1 in 6 recently hospitalized older Americans had poor distance and near vision, respectively. Many of these individuals may experience trouble reading hospital documents and ambulating, and may be at increased risk of falls.     

Student-led screening of school children for refractive error correction

Purpose: Detection and correction of uncorrected refractive errors among 12 million children is an overwhelming task for the 500 currently available eye-care professionals in Nepal. A mid-term review of VISION 2020 goals in Nepal has recommended utilizing alternative human resources that could screen children for visual impairment. This study was conducted to assess the validity of vision screening of school children by trained high school students when compared to optometrist testing as the gold standard.

Methods: A total of 150 students were selected, based on their merit by the headmasters of 25 schools in Nepal and trained for two days by optometrists to screen visual acuity of their peers. Visual acuity ≤ 6/12 in either eye was referred as abnormal vision. A random sample of 1,209 screened students was selected and their visual acuity was reassessed by optometrists under the same settings adopted by trained students. Using optometrist scores as the gold standard, screening results of trained students were analyzed for validity.

Results: Mean age of screened students was 12.2 ± 3.03 years (range: 4–19 years) and 57.4% of them were female. Sensitivity of vision screening test done by trained students was 81.7% and the specificity was 97.6%. A positive predictive value of the test was 77.3% and negative predictive value was 98.2%.

Conclusions: With high sensitivity and specificity values, vision screening done by trained students is effective for screening visual acuity of school children. Countries with limited eye-care professionals and infrastructures can effectively train and utilize students for timely detection of poor vision among children.     

Phacoemulsification with Intraocular Lens Implantation in Pediatric Uveitis: A Retrospective Study

Purpose: To analyze the outcome of phacoemulsification with primary posterior chamber intraocular lens (IOL) implantation without primary posterior capsulorhexis in older children with uveitis.

Methods: Retrospective study of children with uveitis who underwent phacoemulsification with IOL implantation between January 2006 and May 2014.

Results: Twenty-one eyes of 16 children were included. Mean age at cataract surgery was 10.9 years. Juvenile idiopathic arthritis was associated in 37.5%, tuberculosis in 18.7%, Vogt Koyanagi Harada disease in 6.2%, and idiopathic uveitis in 37.5%. Anterior uveitis occurred in 8/21 eyes, intermediate uveitis in 9/21 eyes, and panuveitis in 4/21 eyes. Mean follow-up was 29.9 months. Posterior capsule opacification occurred in 15 eyes, glaucoma in two eyes, choroidal neovascular membrane in one eye, and cystoid macular edema in five eyes. At the last follow up, 19/21 eyes had improved vision and 14 had 20/40 or better vision.

Conclusion: Tight perioperative inflammatory control with immunosuppression may result in good vision after phacoemulsification and IOL implantation without posterior capsulorrhexis in older children with uveitic cataract.     

Evaluation of retinopathy of prematurity incidence with telemedicine confirmation in Gansu,China: a pilot study

Purpose: To determine the incidence of retinopathy of prematurity (ROP) in Gansu, China by combining bedside examinations with remote RetCam (Clarity Medical Systems, Pleasanton, CA, USA) diagnosis.

Methods: ROP screening via indirect ophthalmoscopy followed by RetCam imaging was performed from 2014 to 2015. Three ROP-experienced ophthalmologists interpreted images remotely. Incidence of ROP was determined by combining bedside and telemedicine diagnoses.

Results: Of 139 examined infants and 137 complete records, 20 (14.6%) patients developed ROP, with 11 (8.0%) stage 1, six (4.4%) stage 2, and three (2.2%) stage 3 based on combined diagnoses. Perinatal asphyxia was significantly associated with ROP incidence (p = 0.01). ROP incidence by combined diagnosis (20/137 or 14.6%) versus clinician diagnosis alone (21/137 or 15.3%, p = 0.50) was similar. Telemedicine changed diagnoses in 4/21 (19.0%) ROP cases.

Conclusions: Telemedicine may be helpful in confirming ROP incidence and may serve as a training and support model for less experienced and professionally isolated ROP examiners.     

Varicella Zoster-related Occlusive Retinal Vasculopathy—A Rare Presentation

Purpose: To report a case of occlusive retinal vasculopathy following varicella zoster infection in an immunocompetent adult.

Design: Observational case report.

Methods: A patient with defective vision following chickenpox was evaluated with fluorescein angiography, spectral domain optical coherence tomography and fundus auto fluorescence.

Results: Fundus showed multiple cotton wool spots and a well-demarcated zone of retinal ischemia in the posterior pole with normal optic disc without any evidence of anterior or posterior uveitis. Fluorescein angiography, spectral domain optical coherence tomography and fundus auto fluorescence findings revealed occlusive vasculopathy as the cause of defective vision.

Conclusions: We report a hitherto undescribed case of purely occlusive vasculopathy following varicella zoster infection without features of vasculitis or anterior and posterior uveitis in an immunocompetent individual.     

Ocular Morbidity among Street Children in Kathmandu Valley

Purpose: Prevalence of ocular morbidity among street children is largely unknown. The present study was carried out to determine the prevalence of ocular morbidity among street children in the Kathmandu Valley.

Methods: A cross-sectional study consisting of an eye examination program among 569 street children aged younger than 18 years was conducted from March 2013 to February 2014. Children were included from 11 safe houses of 6 non-governmental organizations and an independent eye camp. Eye examination included visual acuity testing, anterior segment and posterior segment examination, retinoscopy and refraction, cover test, convergence, accommodation and color vision tests. Chi-square test was used to analyze the association of ocular morbidity with age, sex and living conditions.

Results: The majority of children (43.8%) were in the age group of 12–15 years, and the male to female ratio was 3.9:1. Uncorrected and best-corrected visual acuity ≥6/9 in at least one eye was found in 89.8% and 98.4% of children, respectively. Total ocular morbidity was observed at 31.6%. The most common types of ocular morbidity were conjunctivitis (11.0%) and refractive error (11.6%). Ocular morbidity was more common in children over 15 years of age (40.9%; p?<?0.01; odds ratio 1.8).

Conclusions: Ocular infection and refractive error represent the most common ocular morbidities in street children in the Kathmandu Valley.     

Trends in Eye Injuries and Associated Medical Costs among Children in the United States, 2002–2014

Purpose: To describe the trends in eye injuries and associated medical costs among children in the United States.

Methods: Data were from the 2002–2014 Medical Expenditure Panel Survey (MEPS). Eye injuries in children aged <18 years were identified by the International Classification of Diseases-9 (ICD-9) codes. The trends of cumulative incidence of eye injury, total costs, and average costs were estimated from 2002-2014 MEPS data. All costs were adjusted to 2014 US dollars. Analyses accounted for the complex stratified multistage survey design of the MEPS. We used MarketScan data (2010–2013) to validate outpatient cost estimates.

Results: The 3-year average cumulative incidence of eye injuries declined from 0.56% in 2002–2004 to 0.31% in 2012–2014 (Trend p < 0.001). The average annual total costs decreased from $193 million during 2002–2004 to $66 million during 2012–2014 (p < 0.001).

Conclusion: The MEPS data showed that among children aged <18 years, the incidence of eye injuries and associated financial burden substantially declined during 2002–2014, highlighting the progress in preventing children eye injuries. Continuing efforts are needed to further reduce the burden in this population.     

Punctal Ectropion repair using the Raus–Garito clamp

Purpose: To evaluate the results from the correction of ectropion of the punctum lacrimale in lower eyelids with a new surgical clamp.

Design: Prospective study.

Methods: Eighty eight eyelids in 55 patients with mild and moderate ectropion were included in the study. An excision of a diamond of tarso-conjunctiva with retractor reattachment and concomitant correction of horizontal lid laxity, if present, was performed.

Results: Resolution of tearing was obtained in 77 eyes. In 11 eyes, persistent tearing was reported.

Conclusion: Conclusion:Conclusion: Repair of early to intermediate ectropion of the lacrimal punctum using the Raus–Garito clamp is associated with a good functional and cosmetic outcome.     

Self-reported healthcare utilization by adults with diabetic retinopathy in the United States

Purpose: To assess healthcare utilization patterns across diabetic retinopathy (DR) severity levels in the United States (US).

Design: Cross-sectional study of 699 adults, participating in the 2005–2008 National Health and Nutritional Examination Surveys.

Methods: Diagnosis of DR was based on fundus photographs and categorized as: (1) no DR; (2) mild/moderate nonproliferative DR (NPDR); and (3) severe NPDR/proliferative DR (PDR). Healthcare utilization patterns were assessed during a household questionnaire where survey participants self-reported: (1) awareness that diabetes had affected their eyes; (2) pupil-dilation during the past year; and (3) visits to a diabetes education/nutrition specialist during the past year.

Results: Among adults with self-reported diabetes, the proportion of those that were aware that diabetes had affected their eye was 15.3% [95% confidence interval (C.I.)] 10.9–19.6%), 21.7% (95% C.I. 14.6–28.7%), and 81.5% (95% C.I. 66.5–96.5%) across those with no retinopathy, mild/moderate NPDR, and severe NPDR/PDR, respectively (p < 0.01). The utilization of a diabetic education/nutrition specialist during the past year was 30.4% (95% C.I. 24.8–36.0%), 31.8% (95% C.I 23.4–40.2%), and 55.9% (95% C.I. 32.3–79.6%) across those with no retinopathy, mild/moderate NPDR, and severe NPDR/PDR, respectively (p = 0.13). Pupil dilation within the past year was 62.2% (95% C.I. 56.3–68.1%), 62.1% (95% C.I. 53.4–70.8%), and 93.8% (95% C.I. 87.3–100.0%) across those with no DR, mild/moderate NPDR, and severe NPDR/PDR, respectively (p = 0.01).

Conclusions: Adults with diabetes in the United States, even those with the most severe forms of DR, do not fully utilize healthcare services for diabetic eye disease. Future studies should aim to address barriers to appropriate diabetes care.     

Presence of Vision Impairment and Risk of Hospitalization among Elderly Medicare Beneficiaries

Purpose: To examine the association between vision impairment and all-cause hospitalization among elderly Medicare beneficiaries.

Methods: A population-based study (N = 22,681) of community-dwelling Medicare beneficiaries aged 65 years and older who participated in the Medicare Current Beneficiary Survey for the years 2001–2007. Beneficiaries were classified into self-reported presence of vision impairment versus no vision impairment. Inpatient hospitalizations were identified using Medicare claims data. A multivariable Cox proportional hazard model examined the association between presence of vision impairment and time to first hospitalization within 3 years of survey entry after adjusting for sociodemographics, comorbidities, hearing impairment, and activity limitation stages derived from difficulty performing the activities of daily living.

Results: Medicare beneficiaries who self-reported the presence of vision impairment were significantly more likely to be hospitalized over 3 years compared to beneficiaries without vision impairment even after adjustment for potentially influential covariates (hazard ratio = 1.14 and 95% confidence interval: 1.05–1.23).

Conclusions: Medicare beneficiaries with self-reported vision impairment were at higher risk of hospitalization during a 3-year period. Further research may identify reasons that are amenable to policy interventions.     

Multivariable Regression Model of the EuroQol 5-Dimension Questionnaire in Patients Seeking Outpatient Low Vision Rehabilitation

Purpose: To understand the source of between-person variance in baseline health utilities estimated from EuroQol 5-dimension questionnaire (EQ-5D) responses of a representative sample of the US low vision outpatient population prior to rehabilitation.

Methods: A prospective, observational study of 779 new low vision patients at 28 clinic centers in the US. The EQ-5D, Activity Inventory (AI), Telephone Interview for Cognitive Status (TICS), Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) physical functioning component, and Geriatric Depression Scale (GDS) were administered by telephone interview prior to rehabilitation. EQ-5D responses were transformed into health utilities, which served as the dependent variable in all analyses. Data were then analyzed to determine how much overall visual ability, functional domains of visual ability, and comorbidities (e.g. physical functioning, depression, cognition) independently contribute to the EQ-5D-based health utility index.

Results: Multivariable regression analyses showed that the GDS and SF-36 physical account for nearly 40% of the variance observed in health utilities estimated from EQ-5D responses of low vision patients. Age was also a significant predictor of health utilities, but accounted for very little variance. None of the other variables were significant predictors.

Conclusions: Health utilities of low vision patients estimated from the EQ-5D primarily are associated with comorbid factors that are not likely to be responsive to low vision rehabilitation, thereby rendering the EQ-5D an unsuitable outcome measure for this population. However, because the EQ-5D is responsive to comorbid states, it could be a useful tool for evaluating the impact of comorbidities on low vision patient quality of life.     

Prevalence and Causes of Visual Impairment in Fundong District,North West Cameroon: Results of a Population-Based Survey

Purpose: To estimate the prevalence and causes of visual impairment in Fundong Health District, North West Cameroon.

Methods: A total of 51 clusters of 80 people (all ages) were sampled with probability proportionate to size and compact segment sampling. Visual acuity (VA) was measured with a tumbling “E” chart. An ophthalmic nurse examined people with VA<6/18 in either eye. The presence of hearing and physical impairments were assessed using clinical examination, and self-reported visual problems using the Washington Group Short Set.

Results: In total, 4080 people were enumerated of whom 3567 were screened (response rate 87%). The overall prevalence of visual impairment was 2.3% (95% CI 1.8–3.0%) and blindness was 0.6% (0.3–1.0%). The prevalence of both blindness and visual impairment increased rapidly with age, so that the vast majority of cases of visual impairment (84%) and blindness (82%) were in people aged 50+. Posterior segment disease and cataract were the main causes of blindness and visual impairment, with refractive error also an important cause of visual impairment. Cataract surgical coverage (proportion of all cataracts that had received surgery) was relatively high (87% of people at VA<6/60). Post-surgery outcomes were poor, with 31% of operated eyes having VA<6/60. Among the 82 people with visual impairment, 22% had a physical impairment or epilepsy and 30% had a hearing impairment. Self-reported difficulties in vision were relatively closely related to clinical measures of visual impairment.

Conclusions: Ophthalmic programmes in Cameroon need to incorporate control of posterior segment diseases while also working to improve outcomes after cataract surgery.     

Associations of Physical Activity and Sedentary Behaviour with Vision-Threatening Diabetic Retinopathy in Indonesian Population with Type 2 Diabetes Mellitus: Jogjakarta Eye Diabetic Study in the Community (JOGED.COM)

Purpose: To investigate the association of physical activity (PA) and sedentary behaviour with diabetic retinopathy (DR) in type 2 diabetes adults.

Methods: A community-based cross-sectional study of adults with type 2 diabetes. DR was assessed from disc- and macula-centred fundus photograph, and categorised into mild, moderate non-proliferative DR (NPDR), and Vision-Threatening DR (VTDR). Worse eye was used to determine the person’s DR severity. PA was assessed using WHO Global Physical Activity Questionnaire (GPAQ). All of the PA components, including daily sitting time, walking distance, sleeping duration, and exercise were converted based on the physical activity ratio and then calculated to obtain the mean physical activity level (PAL). The mean PAL was then classified into sedentary, moderate, and vigorous lifestyle.

Results: There were 1116 participants, 43.1% with any DR and 26.3% VTDR. The prevalence of DR/VTDR in sedentary, moderate, and vigorous physical activity group was 41.9%/22.7%, 39.2%/23.9%, and 32.7%/20.4% respectively. A longer duration of daily sedentary lifestyle (>3 hours) was significantly associated with presence of DR (OR 1.66; 95% CI 1.17–2.35; p < 0.01) and VTDR (OR 1.74; 1.16–2.62; p < 0.01). These associations remained significant after adjusting for age, gender, duration of diabetes, systolic blood pressure and physical activity. There was no significant association between sleeping duration, walking distance, and vigorous activity and DR.

Conclusions: In this study, prolonged daily sedentary activity was strongly associated with VTDR. This finding suggests that public health campaign for reducing daily sedentary activities in individuals with type 2 diabetes may offer benefit to reduce the burden of DR and VTDR.     

Trends in cataract surgical rate and resource utilisation in Egypt

Purpose: To describe cataract services in Egypt and explore resources and practices in public and private sectors.

Methods: The study was conducted between June and August 2015. All facilities in the country providing cataract services were contacted to obtain information on surgeries performed in 2014. Hospitals performing eye surgery in Quena, Sharkia, and Fayoum regions were visited and a questionnaire on resources for cataract surgery was completed.

Results: Cataract surgery was offered in the public sector by 64 government and 16 university teaching hospitals and in the private sector by 101 hospitals. Over 90% of all facilities in the country contacted participated in the study. In 2014, the national cataract surgical rate (CSR) was 3674 varying in governorates from 7579 in Ismailia to 402 in Suez. The private sector performed 70% of cataract surgeries.

Analysis of three regions showed an 11.7% increase in cataract output between 2010 and 2014. The average number of cataract surgeries per unit in 2014 was 2272 in private, 1633 in university, and 824 in government hospitals. Private hospitals had 60% of human resources for eye care. Phacoemulsification was the surgical technique in 85.6% of private, 72.1% of university, and 41% of government hospitals.

Reasons explaining the differences in output between public and private sectors were the lack of trainers, supervisors, and incentives.

Conclusion: The private sector provides most of the cataract services in Egypt, resulting in inadequate services for the poor. There is a 15-fold variation in CSR between the best and least served regions. The public sector could increase cataract output by improving training, supervision, and incentives.