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

IntroductionIn its recent World Report on Vision, the WHO called for an updated approach to monitor eye health as part of universal health coverage (UHC). This project sought to develop a consensus among eye health experts from all world regions to produce a menu of indicators for countries to monitor eye health within UHC.MethodsWe reviewed the literature to create a long-list of indicators aligned to the conceptual framework for monitoring outlined in WHO’s World Report on Vision. We recruited a panel of 72 global eye health experts (40% women) to participate in a two-round, online prioritisation exercise. Two-hundred indicators were presented in Round 1 and participants prioritised each on a 4-point Likert scale. The highest-ranked 95 were presented in Round 2 and were (1) scored against four criteria (feasible, actionable, reliable and internationally comparable) and (2) ranked according to their suitability as a ‘core’ indicator for collection by all countries. The top 30 indicators ranked by these two parameters were then used as the basis for the steering group to develop a final menu.ResultsThe menu consists of 22 indicators, including 7 core indicators, that represent important concepts in eye health for 2020 and beyond, and are considered feasible, actionable, reliable and internationally comparable.ConclusionWe believe this list can inform the development of new national eye health monitoring frameworks, monitor progress on key challenges to eye health and be considered in broader UHC monitoring indices at national and international levels.

Background Vision loss due to diabetic retinopathy can largely be prevented or delayed through treatment. Patients with vision-threatening diabetic retinopathy are typically offered laser or intravitreal injections which often require more than one treatment cycle. However, treatment is not always initiated, or it is not completed, resulting in poor visual outcomes. Interventions aimed at improving the uptake or completion of treatment for diabetic retinopathy can potentially help prevent or delay visual loss in people with diabetes. Methods We will search MEDLINE, Embase, Global Health and Cochrane Register of Studies for studies reporting interventions to improve the uptake of treatment for diabetic retinopathy (DR) and/or diabetic macular oedema (DMO), compared with usual care, in adults with diabetes. The review will include studies published in the last 20 years in the English language. We will include any study design that measured any of the following outcomes in relation to treatment uptake and completion for DR and/or DMO: (1) proportion of patients initiating treatment for DR and/or DMO among those to whom it is recommended, (2) proportion of patients completing treatment for DR and/or DMO among those to whom it is recommended, (3) proportion of patients completing treatment for DR and/or DMO among those initiating treatment and (4) number and proportion of DR and/or DMO rounds of treatment completed per patient, as dictated by the treatment protocol. For included studies, we will also report any measures of cost-effectiveness when available. Two reviewers will screen search results independently. Risk of bias assessment will be done by two reviewers, and data extraction will be done by one reviewer with verification of 10% of the papers by a second reviewer. The results will be synthesised narratively. Discussion This rapid review aims to identify and synthesise the peer-reviewed literature on the effectiveness of interventions to increase uptake and completion of treatment for DR and/or DMO in LMICs. The rapid review methodology was chosen in order to rapidly synthesise the available evidence to support programme implementers and policy-makers in designing evidence-based health programmes and public health policy and inform the allocation of resources. Systematic review registration OSF osf.io/h5wgr

Objective We sought to understand the extent to which Cochrane Eyes and Vision systematic reviews of interventions for cataract, and primary studies, consider equity. Study Design and Setting This is a review of Cochrane Eyes and Vision systematic reviews (CSRs) on cataract published on the Cochrane Library (end of March 2019) (n = 23), and recently published primary studies included in those reviews (n = 62), using the PROGRESSPlus framework. Results One CSR considered equity as a topic. Four (17%) CSRs included a low- and middle-income country (LMIC) author; one of them was a first author. The CSR with equity as a main topic restricted primary studies to those conducted in LMICs; otherwise none of the systematic reviews used PROGRESS factors as inclusion or exclusion criteria. None of the CSRs reported subgroup analyses by any PROGRESS factor, although these were planned in two. Two of the primary studies were led by an LMIC author; 42% involved LMIC authors; 37% were conducted in LMICs; 73% of studies reported on gender/sex of participants, but other PROGRESS factors were less frequently reported. Three studies reported subgroup analyses by sex; one reported subgroup analyses by race/ethnicity. Conclusion PROGRESS factors and equity are rarely considered in studies of interventions for cataract, and this is reflected in the associated Cochrane reviews.

PurposePeople who are distinct from the dominant ethnic group within a country can experience a variety of barriers to accessing eyecare services. We conducted a scoping review to map published interventions aimed at improving access to eyecare for non-Indigenous, non-dominant ethnic groups residing in high-income countries.MethodsWe searched MEDLINE, Embase and Global Health for studies that described an intervention to promote access to eyecare for the target population. Two authors independently screened titles and abstracts followed by review of the full text of potentially relevant sources. For included studies, data extraction was carried out independently by two authors. Findings were summarised using a combination of descriptive statistics and thematic analysis.ResultsWe screened 5220 titles/abstracts, of which 82 reports describing 67 studies met the inclusion criteria. Most studies were conducted in the USA (90%), attempted to improve access for Black (48%) or Latinx (28%) communities at-risk for diabetic retinopathy (42%) and glaucoma (18%). Only 30% included the target population in the design of the intervention; those that did tended to be larger, collaborative initiatives, which addressed both patient and provider components of access. Forty-eight studies (72%) evaluated whether an intervention changed an outcome measure. Among these, attendance at a follow-up eye examination after screening was the most common (n=20/48, 42%), and directly supporting patients to overcome barriers to attendance was reported as the most effective approach. Building relationships between patients and providers, running coordinated, longitudinal initiatives and supporting reduction of root causes for inequity (education and economic) were key themes highlighted for success.ConclusionAlthough research evaluating interventions for non-dominant, non-Indigenous ethnic groups exist, key gaps remain. In particular, the paucity of relevant studies outside the USA needs to be addressed, and target communities need to be involved in the design and implementation of interventions more frequently.

IntroductionCochrane Eyes and Vision (CEV) is an international network of individuals working to prepare, maintain and promote access to systematic reviews of interventions to treat, prevent or diagnose eye diseases or vision impairment. CEV plans to undertake a priority setting exercise to identify systematically research questions relevant to our scope, and to formally incorporate input from a wide range of stakeholders to set priorities for new and updated reviews.Methods and analysisThe scope of CEV is broad and our reviews include conditions that are common and have a high global disease burden, for example, cataract and dry eye disease, and conditions that are rare but have a high impact on quality of life and high individual cost such as eye cancer. We plan to focus on conditions prioritised by WHO during the development of the Package of Eye Care Interventions. These conditions were selected based on a combination of data on disease magnitude, healthcare use and expert opinion. We will identify priority review questions systematically by summarising relevant data on research in Eyes and Vision from a range of sources, and compiling a list of 10–15 potential review questions (new and/or updates) for each condition group. We will seek the views of external and internal stakeholders on this list by conducting an online survey. Equity will be a specific consideration.Ethics and disseminationThe study has been approved by the ethics committee of the London School of Hygiene & Tropical Medicine. We will disseminate the findings through Cochrane channels and prepare a summary of the work for publication in a peer-reviewed journal.

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Eye health and vision have widespread and profound implications for many aspects of life, health, sustainable development, and the economy. Yet nowadays, many people, families, and populations continue to suffer the consequences of poor access to high-quality, affordable eye care, leading to vision impairment and blindness.\ud In 2020, an estimated 596 million people had distance vision impairment worldwide, of whom 43 million were blind. Another 510 million people had uncorrected near vision impairment, simply because of not having reading spectacles. A large proportion of those affected (90%), live in low-income and middle-income countries (LMICs). However, encouragingly, more than 90% of people with vision impairment have a preventable or treatable cause with existing highly cost-effective interventions. Eye conditions affect all stages of life, with young children and older people being particularly affected. Crucially, women, rural populations, and ethnic minority groups are more likely to have vision impairment, and this pervasive inequality needs to be addressed. By 2050, population ageing, growth, and urbanisation might lead to an estimated 895 million people with distance vision impairment, of whom 61 million will be blind. Action to prioritise eye health is needed now.\ud This Commission defines eye health as maximised vision, ocular health, and functional ability, thereby contributing to overall health and wellbeing, social inclusion, and quality of life. Eye health is essential to achieve many of the Sustainable Development Goals (SDGs). Poor eye health and impaired vision have a negative effect on quality of life and restrict equitable access to and achievement in education and the workplace. Vision loss has substantial financial implications for affected individuals, families, and communities. Although high-quality data for global economic estimates are scarce, particularly for LMICs, conservative assessments based on the latest prevalence figures for 2020 suggest that annual global productivity loss from vision impairment is approximately US$410·7 billion purchasing power parity. Vision impairment reduces mobility, affects mental wellbeing, exacerbates risk of dementia, increases likelihood of falls and road traffic crashes, increases the need for social care, and ultimately leads to higher mortality rates.\ud By contrast, vision facilitates many daily life activities, enables better educational outcomes, and increases work productivity, reducing inequality. An increasing amount of evidence shows the potential for vision to advance the SDGs, by contributing towards poverty reduction, zero hunger, good health and wellbeing, quality education, gender equality, and decent work. Eye health is a global public priority, transforming lives in both poor and wealthy communities. Therefore, eye health needs to be reframed as a development as well as a health issue and given greater prominence within the global development and health agendas.\ud Vision loss has many causes that require promotional, preventive, treatment, and rehabilitative interventions. Cataract, uncorrected refractive error, glaucoma, age-related macular degeneration, and diabetic retinopathy are responsible for most global vision impairment. Research has identified treatments to reduce or eliminate blindness from all these conditions; the priority is to deliver treatments where they are most needed. Proven eye care interventions, such as cataract surgery and spectacle provision, are among the most cost-effective in all of health care. Greater financial investment is needed so that millions of people living with unnecessary vision impairment and blindness can benefit from these interventions.\ud Lessons from the past three decades give hope that this challenge can be met. Between 1990 and 2020, the age-standardised global prevalence of blindness fell by 28·5%. Since the 1990s, prevalence of major infectious causes of blindness—onchocerciasis and trachoma—have declined substantially. Hope remains that by 2030, the transmission of onchocerciasis will be interrupted, and trachoma will be eliminated as a public health problem in every country worldwide. However, the ageing population has led to a higher crude prevalence of age-related causes of blindness, and thus an increased total number of people with blindness in some regions.\ud Despite this progress, business as usual will not keep pace with the demographic trends of an ageing global population or address the inequities that persist in each country. New threats to eye health are emerging, including the worldwide increase in diabetic retinopathy, high myopia, retinopathy of prematurity, and chronic eye diseases of ageing such as glaucoma and age-related macular degeneration. With the projected increase in such conditions and their associated vision loss over the coming decades, urgent action is needed to develop innovative treatments and deliver services at a greater scale than previously achieved.\ud Good eye health at the community and national level has been marginalised as a luxury available to only wealthy or urban areas. Eye health needs to be urgently brought into the mainstream of national health and development policy, planning, financing, and action.\ud The challenge is to develop and deliver comprehensive eye health services (promotion, prevention, treatment, rehabilitation) that address the full range of eye conditions within the context of universal health coverage. Accessing services should not bring the risk of falling into poverty and services should be of high quality, as envisaged by the WHO framework for health-care quality: effective, safe, people-centred, timely, equitable, integrated, and efficient. To this framework we add the need for services to be environmentally sustainable. Universal health coverage is not universal without eye care.\ud Multiple obstacles need to be overcome to achieve universal coverage for eye health. Important issues include complex barriers to availability and access to quality services, cost, major shortages and maldistribution of well-trained personnel, and lack of suitable, well maintained equipment and consumables. These issues are particularly widespread in LMICs, but also occur in underserved communities in high-income countries. Strong partnerships need to be formed with natural allies working in areas affected by eye health, such as non-communicable diseases, neglected tropical diseases, healthy ageing, children's services, education, disability, and rehabilitation. The eye health sector has traditionally focused on treatment and rehabilitation, and underused health promotion and prevention strategies to lessen the impact of eye disease and reduce inequality.\ud Solving these problems will depend on solutions established from high quality evidence that can guide more effective implementation at scale. Evidence-based approaches will need to address existing deficiencies in the supply and demand. Strategic investments in discovery research, harnessing new findings from diverse fields, and implementation research to guide effective scale up are needed globally. Encouragingly, developments in telemedicine, mobile health, artificial intelligence, and distance learning could potentially enable eye care professionals to deliver higher quality care that is more plentiful, equitable, and cost-effective.\ud This Commission did a Grand Challenges in Global Eye Health prioritisation exercise to highlight key areas for concerted research and action. This exercise has identified a broad set of challenges spanning the fields of epidemiology, health systems, diagnostics, therapeutics, and implementation. The most compelling of these issues, picked from among 3400 suggestions proposed by 336 people from 118 countries, can help to frame the future research agenda for global eye health.\ud In this Commission, we harness lessons learned from over two decades, present the growing evidence for the life-transforming impact of eye care, and provide a thorough understanding of rapid developments in the field. This report was created through a broad consultation involving experts within and outside the eye care sector to help inform governments and other stakeholders about the path forward for eye health beyond 2020, to further the SDGs (including universal health coverage), and work towards a world without avoidable vision loss.\ud The next few years are a crucial time for the global eye health community and its partners in health care, government, and other sectors to consider the successes and challenges encountered in the past two decades, and at the same time to chart a way forward for the upcoming decades. Moving forward requires building on the strong foundation laid by WHO and partners in VISION 2020 with renewed impetus to ultimately deliver high quality universal eye health care for all.

Summary Background The number of individuals with vision impairment worldwide is increasing because of an ageing population. We aimed to systematically identify studies describing the association between vision impairment and mortality, and to assess the association between vision impairment and all-cause mortality. Methods For this systematic review and meta-analysis, we searched MEDLINE (Ovid), Embase, and Global Health database on Feb 1, 2020, for studies published in English between database inception and Feb 1, 2020. We included prospective and retrospective cohort studies that measured the association between vision impairment and all-cause mortality in people aged 40 years or older who were followed up for 1 year or more. In a protocol amendment, we also included randomised controlled trials that met the same criteria as for cohort studies, in which the association between visual impairment and mortality was independent of the study intervention. Studies that did not report age-adjusted mortality data, or that focused only on populations with specific health conditions were excluded. Two reviewers independently assessed study eligibility, extracted the data, and assessed risk of bias. We graded the overall certainty of the evidence using the Grading of Recommendations, Assessment, Development and Evaluations framework. We did a random-effects meta-analysis to calculate pooled maximally adjusted hazard ratios (HRs) for all-cause mortality for individuals with a visual acuity of

Background In the absence of accessible, good quality eye health services and inclusive environments, vision loss can impact individuals, households and communities in many ways, including through increased poverty, reduced quality of life and reduced employment. We aimed to estimate the annual potential productivity losses associated with reduced employment due to blindness and moderate and severe vision impairment (MSVI) at a regional and global level. Methods We constructed a model using the most recent economic, demographic (2018) and prevalence (2020) data. Calculations were limited to the working age population (15–64 years) and presented in 2018 US Dollars purchasing power parity (ppp). Two separate models, using Gross Domestic Product (GDP) and Gross National Income (GNI), were calculated to maximise comparability with previous estimates. Findings We found that 160.7 million people with MSVI or blindness were within the working age and estimated that the overall relative reduction in employment by people with vision loss was 30.2%. Globally, using GDP we estimated that the annual cost of potential productivity losses of MSVI and blindness was $410.7 billion ppp (range $322.1 - $518.7 billion), or 0.3% of GDP. Using GNI, overall productivity losses were estimated at $408.5 billion ppp (range $320.4 - $515.9 billion), 0.5% lower than estimates using GDP. Interpretation These findings support the view that blindness and MSVI are associated with a large economic impact worldwide. Reducing and preventing vision loss and developing and implementing strategies to help visually impaired people to find and keep employment may result in significant productivity gains Funding MJB is supported by the Wellcome Trust (207472/Z/17/Z). JR's appointment at the University of Auckland is funded by the Buchanan Charitable Foundation, New Zealand. The Lancet Global Health Commission on Global Eye Health was supported by grants from The Queen Elizabeth Diamond Jubilee Trust, Moorfields Eye Charity (GR001061), NIHR Moorfields Biomedical Research Centre, The Wellcome Trust, Sightsavers, The Fred Hollows Foundation, The SEVA Foundation, The British Council for the Prevention of Blindness and Christian Blind Mission. The funders had no role in the design, conduct, data analysis of the study, or writing of the manuscript.

Key Points Question What is the association between vision impairment, eye diseases, or ophthalmic interventions and quality of life? Findings In this cross-sectional study of systematic reviews, vision impairment and eye diseases were associated with lower quality of life. More than half of the ophthalmic interventions included had a positive association with quality of life. Meaning The associations of quality of life with vision impairment and the improvements in quality of life with ophthalmic interventions support efforts to improve access to ophthalmic treatments globally to reach the millions of people affected by eye disease each year., This cross-sectional study examines the association between vision impairment or eye disease and quality of life and the outcome of ophthalmic interventions on quality of life globally and across the life span., Importance More than 1 billion people worldwide have vision impairment or blindness from potentially preventable or correctable causes. Quality of life, an important measure of physical, emotional, and social well-being, appears to be negatively associated with vision impairment, and increasingly, ophthalmic interventions are being assessed for their association with quality of life. Objective To examine the association between vision impairment or eye disease and quality of life, and the outcome of ophthalmic interventions on quality of life globally and across the life span, through an umbrella review or systematic review of systematic reviews. Evidence Review The electronic databases MEDLINE, Ovid, Embase, Cochrane Database of Systematic Reviews, Proquest Dissertations, and Theses Global were searched from inception through June 29, 2020, using a comprehensive search strategy. Systematic reviews addressing vision impairment, eye disease, or ophthalmic interventions and quantitatively or qualitatively assessing health-related, vision-related, or disease-specific quality of life were included. Article screening, quality appraisal, and data extraction were performed by 4 reviewers working independently and in duplicate. The Joanna Briggs Institute critical appraisal and data extraction forms for umbrella reviews were used. Findings Nine systematic reviews evaluated the association between quality of life and vision impairment, age-related macular degeneration, glaucoma, diabetic retinopathy, or mendelian eye conditions (including retinitis pigmentosa). Of these, 5 were reviews of quantitative observational studies, 3 were reviews of qualitative studies, and 1 was a review of qualitative and quantitative studies. All found an association between vision impairment and lower quality of life. Sixty systematic reviews addressed at least 1 ophthalmic intervention in association with quality of life. Overall, 33 unique interventions were investigated, of which 25 were found to improve quality of life compared with baseline measurements or a group receiving no intervention. These interventions included timely cataract surgery, anti–vascular endothelial growth factor therapy for age-related macular degeneration, and macular edema. Conclusions and Relevance There is a consistent association between vision impairment, eye diseases, and reduced quality of life. These findings support pursuing ophthalmic interventions, such as timely cataract surgery and anti–vascular endothelial growth factor therapy, for common retinal diseases, where indicated, to improve quality of life for millions of people globally each year.

IntroductionDue to growth and ageing of the world’s population, the number of individuals worldwide with vision impairment (VI) and blindness is projected to increase rapidly over the coming decades. VI and blindness are an important cause of years lived with disability. However, the association of VI and blindness with mortality, including the risk of bias in published studies and certainty of the evidence, has not been adequately studied in an up-to-date systematic review and meta-analysis.Methods and analysisThe planned systematic review and meta-analysis will adhere to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Databases, including MEDLINE Ovid, Embase Ovid and Global Health, will be searched for relevant studies. Two reviewers will then screen studies and review full texts to identify studies for inclusion. Data extraction will be performed, and for included studies, the risk of bias and certainty of the evidence will be assessed using the Grades of Recommendation, Assessment, Development and Evaluation approach. The prognostic factor in this study is visual function, which must have been measured using a standard objective ophthalmic clinical or research instrument. We will use standard criteria from WHO to categorise VI and blindness. All-cause mortality may be assessed by any method one or more years after baseline assessment of vision. Results from included studies will be meta-analysed according to relevant sections of the Meta-analysis Of Observational Studies in Epidemiology checklist.Ethics and disseminationThis review will only include published data; therefore, ethics approval will not be sought. The findings of this review and meta-analysis will be published in an open-access, peer-reviewed journal and will be included in the ongoing Lancet Global Health Commission on Global Eye Health.

Background Diabetic retinopathy is the most common ocular complication of diabetes and a cause of vision loss in adults. Diabetic retinopathy screening leading to early identification of the disease followed by timely treatment, can prevent vision loss in people living with diabetes. A key barrier to the implementation of screening services in low- and middle-income countries is the low number of ophthalmologists per million population. Interventions that shift screening to non-ophthalmology cadres have been implemented in programmes in low- and middle-income countries and are routinely used in high-income countries. The aim of this rapid review is to summarise the published literature reporting the effectiveness of task-shifting interventions for the detection of diabetic retinopathy by non-ophthalmologists in low- and middle-income countries. Methods We will search MEDLINE, Embase, Global Health and Cochrane Register of Studies for studies reporting task-shifting interventions for diabetic retinopathy detection. The review will include studies published in the last 10 years in the English language. We will include any interventional or observational comparative study measuring outcomes in terms of participation or access to diabetic retinopathy detection services (uptake) and quality of diabetic retinopathy detection services (detection, severity, diagnostic accuracy). For included studies, cost-effectiveness of the task-shifting intervention will also be presented. Two reviewers will screen search results independently. The risk of bias assessment and data extraction will be carried out by one reviewer with verification of 10% of the papers by a second reviewer. The results will be synthesised narratively. Discussion Differences in health systems organization, structure and resources will determine the need and success of task-shifting interventions for DR screening. The review will examine how these interventions have been used and/or tested in LMICs. The results will be of interest to policy makers and programme managers tasked with designing and implementing services to prevent and manage diabetes and its complications in similar settings. Systematic review registration OSF: https://osf.io/dfhg6/.

IntroductionIn 2015, most governments of the world committed to achieving 17 sustainable development goals (SDGs) by the year 2030. Efforts to improve eye health contribute to the advancement of several SDGs, including those not exclusively health-related. This scoping review will summarise the nature and extent of the published literature that demonstrates a link between improved eye health and advancement of the SDGs.Methods and analysisSearches will be conducted in MEDLINE, Embase and Global Health for published, peer-reviewed manuscripts, with no time period, language or geographic limits. All intervention and observational studies will be included if they report a link between a change in eye health and (1) an outcome related to one of the SDGs or (2) an element on a pathway between eye health and an SDG (eg, productivity). Two investigators will independently screen titles and abstracts, followed by full-text screening of potentially relevant articles. Reference lists of all included articles will be examined to identify further potentially relevant studies. Conflicts between the two independent investigators will be discussed and resolved with a third investigator. For included articles, data regarding publication characteristics, study details and SDG-related outcomes will be extracted. Results will be synthesised by mapping the extracted data to a logic model, which will be refined through an iterative process during data synthesis.Ethics and disseminationAs this scoping review will only include published data, ethics approval will not be sought. The findings of the review will be published in an open-access, peer-reviewed journal. A summary of the results will be developed for website posting, stakeholder meetings and inclusion in the ongoing Lancet Global Health Commission on Global Eye Health.

Two national surveys of vision impairment and blindness were undertaken in The Gambia in 1986 and 1996. These provided data for the inception of The Gambia’s National Eye Health Programme (NEHP) within the Ministry of Health and Social Welfare. There have been important developments in the eye health services provided by the NEHP in the last 20 years. At the same time, the population has also undergone major demographic changes that may have led to substantial changes in the burden of eye disease. We conducted a National Eye Health Survey of vision impairment, blindness and its comorbidities in adults in The Gambia in 2019. We examined a nationally representative population-based sample of adults 35 years and above to permit direct comparison with the data available from the previous surveys. Alongside a comprehensive vision and eye examination, the survey provides nationally representative data on important comorbidities in this population: diabetes, hypertension, obesity, hearing impairment, disability and mental health. Secondly, it estimates access to assistive technologies and eye health services. Thirdly, it is powered to allow a five-year follow up cohort study to measure the incidence and progression of eye disease.

Throughout the world, people who are socially or economically disadvantaged disproportionately experience blindness and vision impairment caused by cataract. Reducing vision loss from cataract and its unequal distribution must be a priority if the WHO’s aim of ‘universal eye health’ is to be realised. To help achieve this, decision-makers and service planners need evidence on which strategies improve access to cataract services among disadvantaged populations, and under what circumstances. Unfortunately, despite many strategies to improve cataract services being implemented in recent decades, evidence of what works, for who and in what circumstances is not readily available. This paper summarises the extent of the evidence on interventions to reduce inequity of vision loss from cataract and makes suggestions for how the evidence base can be strengthened.

The Sustainable Development Goals aim to leave no one behind. We explored the hypothesis that women without a living spouse&mdash, including those who are widowed, divorced, separated, and never married&mdash, are a vulnerable group being left behind by cataract services. Using national cross-sectional blindness surveys from Nigeria (2005&ndash, 2007, n = 13,591) and Sri Lanka (2012&ndash, 2014, n = 5779) we categorized women and men by marital status (married/not-married) and place of residence (urban/rural) concurrently. For each of the eight subgroups we calculated cataract blindness, cataract surgical coverage (CSC), and effective cataract surgical coverage (eCSC). Not-married women, who were predominantly widows, experienced disproportionate cataract blindness&mdash, in Nigeria they were 19% of the population yet represented 56% of those with cataract blindness, in Sri Lanka they were 18% of the population and accounted for 54% of those with cataract blindness. Not-married rural women fared worst in access to services&mdash, in Nigeria their CSC of 25.2% (95% confidence interval, CI 17.8&ndash, 33.8%) was far lower than the best-off subgroup (married urban men, CSC 80.0% 95% CI 56.3&ndash, 94.3), in Sri Lanka they also lagged behind (CSC 68.5% 95% CI 56.6&ndash, 78.9 compared to 100% in the best-off subgroup). Service quality was also comparably poor for rural not-married women&mdash, eCSC was 8.9% (95% CI 4.5&ndash, 15.4) in Nigeria and 37.0% (95% CI 26.0&ndash, 49.1) in Sri Lanka. Women who are not married are a vulnerable group who experience poor access to cataract services and high cataract blindness. To &ldquo, leave no one behind&rdquo, multi-faceted strategies are needed to address their needs.

ObjectiveTo explore sociogeographical inequalities in the availability and distribution of ear, nose and throat specialists (ENTs) in 15 Latin American (LA) countries.DesignEcological.SettingSpanish and Portuguese-speaking countries of LA.The number of registered ENTs in 2017 was obtained from the National ENT Society in each country.Outcome measuresThe ENT rate/million population was calculated at the national and subnational (eg, state) level. Three measures were calculated to assess subnational distributive inequality of ENTs: (1) absolute and (2) relative index of dissimilarity; and (3) concentration index (using the Human Development Index as the equity stratifier). Finally, the ratio of ENTs/million population in the capital area compared with the rest of the country was calculated.ResultsThere was more than a 30-fold difference in the number of ENTs/million population across the included countries—from 61.0 in Argentina (95% CI 58.7 to 63.4) to 2.8 in Guatemala (95% CI 2.1 to 3.8). In all countries, ENTs were more prevalent in advantaged areas and in capital areas. To attain distributive equality, Paraguay would need to redistribute the greatest proportion of its ENT workforce (67.3%; 95% CI 57.8% to 75.6%) and Brazil the least (18.5%; 95% CI 17.6% to 19.5%).ConclusionsThere is high inequality in the number and distribution of ENTs between and within the 15 studied countries in LA. This evidence can be used to inform policies that improve access to ear and hearing services in the region, such as scale-up of training of ENTs and incentives to distribute specialists equally. These actions to reduce inequities, alongside addressing the social determinants of ear and hearing health, are essential to realise Universal Health Coverage.

To examine differences in incidence, prevalence and screening for diabetic retinopathy in New Zealand, we searched MEDLINE, EMBASE and CINAHL up to 6 December 2018 for observational studies reporting diabetic eye disease or attendance at retinal screening, disaggregated by ethnicity. Two authors separately screened and selected studies, and extracted data. None of the 11 included studies reported data on visual impairment from diabetic retinopathy. All nine studies reporting diabetic eye disease by ethnicity found Pacific people and Māori had higher rates of sight-threatening disease and lower rates of screening attendance compared to Europeans. Data for Asian people were infrequently reported, but when they were, they also fared worse than Europeans. This review highlights that equity-focused strategies are needed to address ethnic disparities in eye health among New Zealanders with diabetes. The review also identifies how research methods can be strengthened to enable future calculation of robust disease prevalence estimates.

IntroductionDriving is one of the main modes of transport with safe driving requiring a combination of visual, cognitive and physical skills. With population ageing, the number of people living with vision impairment is set to increase in the decades ahead. Vision impairment may negatively impact an individual’s ability to safely drive. The association between vision impairment and motor vehicle crash involvement or driving participation has yet to be systematically investigated. Further, the evidence for the effectiveness of vision-related interventions aimed at decreasing crashes and driving errors has not been synthesised.Methods and analysisA search will be conducted for relevant studies on Medline (Ovid), EMBASE and Global Health from their inception to March 2020 without date or geographical restrictions. Two investigators will independently screen abstracts and full texts using Covidence software with conflicts resolved by a third investigator. Data extraction will be conducted on all included studies, and their quality assessed to determine the risk of bias using the Joanna Briggs Institute Critical Appraisal Tools. Outcome measures include crash risk, driving cessation and surrogate measures of driving safety (eg, driving errors and performance). The results of this review will be reported using the Preferred Reporting Items for Systematic Review and Meta-Analysis guideline. Meta-analysis will be undertaken for outcomes with sufficient data and reported following the Meta-analyses of Observational Studies in Epidemiology guideline. Where statistical pooling is not feasible or appropriate, narrative summaries will be presented following the Synthesis Without Meta-analysis in systematic reviews guideline.Ethics and disseminationThis review will only report on published data thus no ethics approval is required. Results will be included in the Lancet Global Health Commission on Global Eye Health, published in a peer-reviewed journal and presented at relevant conferences.PROSPERO registration numberCRD42020172153.

IntroductionVision impairment (VI) places a burden on individuals, health systems and society in general. In order to support the case for investing in eye health services, an updated cost of illness study that measures the global impact of VI is necessary. To perform such a study, a systematic review of the literature is needed. Here we outline the protocol for a systematic review to describe and summarise the costs associated with VI and its major causes.Methods and analysisWe will systematically search in Medline (Ovid) and the Centre for Reviews and Dissemination database which includes the National Health Service Economics Evaluation Database. No language or geographical restriction will be applied. Additional literature will be identified by reviewing the references in the included studies and by contacting field experts. Grey literature will be considered. The review will include any study published from 1 January 2000 to November 2019 that provides information about costs of illness, burden of disease and/or loss of well-being in participants with VI due to an unspecified cause or due to one of the seven leading causes globally.Two reviewers will independently screen studies and extract relevant data from included studies. Methodological quality of economic studies will be assessed based on the British Medical Journal checklist for economic submissions adapted to costs of illness studies. This protocol has been prepared following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis protocols and has been published prospectively in Open Science Framework.Ethics and disseminationFormal ethical approval is not required, as primary data will not be collected in this review. The findings of this study will be disseminated through peer-reviewed publications, stakeholder meetings and inclusion in the ongoing Lancet Global Health Commission on Global Eye Health.Registration detailshttps://osf.io/9au3w (DOI 10.17605/OSF.IO/6F8VM).

IntroductionCataract is the leading cause of blindness globally and a major cause of vision impairment. Cataract surgery is an efficacious intervention that usually restores vision. Although it is one of the most commonly conducted surgical interventions worldwide, good quality services (from being detected with operable cataract to undergoing surgery and receiving postoperative care) are not universally accessible. Poor quality understandably reduces the willingness of people with operable cataract to undergo surgery. Therefore, it is critical to improve the quality of care to subsequently reduce vision loss from cataract. This scoping review aims to summarise the nature and extent of the published literature on interventions to improve the quality of services for primary age-related cataract globally.Methods and analysisWe will search MEDLINE, Embase and Global Health for peer-reviewed manuscripts published since 1990, with no language, geographic or study design restrictions. To define quality, we have used the elements adopted by the WHO—effectiveness, safety, people-centredness, timeliness, equity, integration and efficiency—to which we have added the element of planetary health. We will exclude studies focused on the technical aspects of the surgical procedure and studies that only involve children (Ethics and disseminationEthical approval was not sought, as our review will only include published and publicly accessible information. We will publish our findings in an open-access peer-reviewed journal and develop an accessible summary of the results for website posting. A summary of the results will be included in the ongoing Lancet Global Health Commission on Global Eye Health.Registration detailsOpen Science Framework (https://osf.io/8gktz).

IntroductionUniversal health coverage (UHC) includes the dimensions of equity in access, quality services that improve health and protection against financial hardship. Cataract continues to be the leading cause of blindness globally, despite cataract surgery being an efficacious intervention. The aim of this scoping review is to map the nature, extent and global distribution of data on cataract services for UHC in terms of equity, access, quality and financial protection.Methods and analysisThe search will be constructed by an Information Specialist and undertaken in MEDLINE, Embase and Global Health databases. We will include all published non-interventional primary research studies and systematic reviews that report a quantitative assessment of access, equity, quality or financial protection of cataract surgical services for adults at the subnational, national, regional or global level from population-based surveys or routinely collected health service data since 1 January 2000 and published through to February 2020.Screening and data charting will be undertaken using Covidence systematic review software. Titles and abstracts of identified studies will be screened by two authors independently. Full-text articles of potentially relevant studies will be obtained and reviewed independently by two authors against the inclusion criteria. Any discrepancies between the authors will be resolved by discussion, and with a third author as necessary. A data charting form will be developed and piloted on three studies by three authors and amendments made as necessary. Data will be extracted by two reviewers independently and summarised narratively and using maps.Ethics and disseminationEthical approval was not sought as the scoping review will only use published and publicly accessible data. The review will be published in an open access peer-reviewed journal. A summary of the results will be developed for website posting, stakeholder meetings and inclusion in the ongoing Lancet Global Health Commission on Global Eye Health.

IntroductionFor many people, settling in a new country is associated with a new identity as an ‘ethnic minority’, one that can remain through future generations. People who are culturally distinct from the dominant population group may experience a variety of barriers to accessing healthcare, including linguistic and cultural barriers in communication, navigation of an unfamiliar health system and unconscious or overt discrimination. Here, we outline the protocol of a scoping review to identify, describe and summarise interventions aimed at improving access to eye care for non-Indigenous, non-dominant ethnic groups residing in high-income countries.Methods and analysisWe will search MEDLINE, Embase and Global Health from their inception to July 2019. We will include studies of any design that describe an intervention to promote access to eye care for non-Indigenous, non-dominant ethnic groups. Two authors will independently review titles, abstracts and full-text articles for inclusion. Reference lists from all included articles will also be searched. In cases of disagreement between initial reviewers, a third author will help resolve the conflict. For each included article, we will extract data about the target population, details of the intervention delivered and the effectiveness of or feedback from the intervention. Overall findings will be summarised with descriptive statistics and thematic analysis.Ethics and disseminationThis review will summarise existing literature and as such ethics approval is not required. We will publish the review in an open-access, peer-reviewed journal, and draft appropriate summaries for dissemination to the wider community. This wider community could include clinicians, policymakers, health service managers and organisations that work with non-dominant ethnic groups. Our findings will also feed into the ongoing Lancet Global Health Commission on Global Eye Health.

PURPOSE: Direct medical and non-medical costs incurred by those undergoing subsidised cataract surgery at Gusau eye clinic, Zamfara state, were recently determined. The aim of this study was to assess the willingness to pay for cataract surgery among adults with severe visual impairment or blindness from cataract in rural Zamfara and to compare this to actual costs. METHODS: In three rural villages served by Gusau eye clinic, key informants helped identify 80 adults with bilateral severe visual impairment or blindness (

When prevention efforts fail, injured children require high-quality health services to support their recovery. Disparities in non-fatal injury outcomes, an indicator of health-care quality, have received minimal attention. We evaluated the extent to which general trauma follow-up studies published in the peer-reviewed scientific literature provide evidence of socially patterned inequities in health, functional or disability outcomes ≥4 weeks after childhood injuries. Using a systematic search, we identified 27 eligible cohort studies from 13 high-income countries. We examined the extent to which the reported health outcomes varied across the PROGRESS criteria: place of residence, race/ethnicity, occupation, gender/sex, religion, socio-economic status, and social capital. The available evidence on differential outcomes is limited as many studies were compromised by selection or retention biases that reduced the participation of children from demographic groups at increased risk of adverse outcomes, or the analyses mainly focused on variations in outcomes by sex. Given the limited research evidence, we recommend greater attention to systematic collection and reporting of non-fatal injury outcomes disaggregated by socio-demographic indicators in order to identify disparities where these exist and inform equity-focused interventions promoting the recovery of injured children.

Purpose: Sources of avoidable waste in ophthalmic epidemiology include duplication of effort, and survey reports remaining unpublished, gaining publication after a long delay, or being incomplete or of poor quality. The aim of this review was to assess these sources of avoidable waste by examining blindness prevalence surveys undertaken in low and middle income countries (LMICs) between 2000 and 2014. Methods: On December 1, 2016 we searched MEDLINE, EMBASE and Web of Science databases for cross-sectional blindness prevalence surveys undertaken in LMICs between 2000 and 2014. All surveys listed on the Rapid Assessment of Avoidable Blindness (RAAB) Repository website (“the Repository”) were also considered. For each survey we assessed (1) availability of scientific publication, survey report, summary results tables and/or datasets; (2) time to publication from year of survey completion and journal attributes; (3) extent of blindness information reported; and (4) rigour when information was available from two sources (i.e. whether it matched). Results: Of the 279 included surveys (from 68 countries) 186 (67%) used RAAB methodology; 146 (52%) were published in a scientific journal, 57 (20%) were published in a journal and on the Repository, and 76 (27%) were on the Repository only (8% had tables; 19% had no information available beyond registration). Datasets were available for 50 RAABs (18% of included surveys). Time to publication ranged from Conclusion: Strategies are needed to improve the availability, consistency, and quality of information reported from blindness prevalence surveys, and hence reduce avoidable waste.

Objective Cross-sectional blindness prevalence surveys are essential to plan and monitor eye care services. Incomplete or inaccurate reporting can prevent effective translation of research findings. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement is a 32 item checklist developed to improve reporting of observational studies. The aim of this study was to assess the completeness of reporting in blindness prevalence surveys in low and middle income countries (LMICs) using STROBE. Methods MEDLINE, EMBASE and Web of Science databases were searched on April 8 2016 to identify cross-sectional blindness prevalence surveys undertaken in LMICs and published after STROBE was published in December 2007. The STROBE tool was applied to all included studies, and each STROBE item was categorized as ‘yes’ (met criteria), ‘no’ (did not meet criteria) or ‘not applicable’. The ‘Completeness of reporting (COR) score’ for each manuscript was calculated: COR score = yes / [yes + no]. In journals with included studies the instructions to authors and reviewers were checked for reference to STROBE. Results The 89 included studies were undertaken in 32 countries and published in 37 journals. The mean COR score was 60.9% (95% confidence interval [CI] 58.1–63.7%; range 30.8–88.9%). The mean COR score did not differ between surveys published in journals with author instructions referring to STROBE (10/37 journals; 61.1%, 95%CI 56.4–65.8%) or in journals where STROBE was not mentioned (60.9%, 95%CI 57.4–64.3%; p = 0.93). Conclusion While reporting in blindness prevalence surveys is strong in some areas, others need improvement. We recommend that more journals adopt the STROBE checklist and ensure it is used by authors and reviewers.

Objective To define and demonstrate effective cataract surgical coverage (eCSC), a candidate UHC indicator that combines a coverage measure (cataract surgical coverage, CSC) with quality (post-operative visual outcome). Methods All Rapid Assessment of Avoidable Blindness (RAAB) surveys with datasets on the online RAAB Repository on April 1 2016 were downloaded. The most recent study from each country was included. By country, cataract surgical outcome (CSOGood, 6/18 or better; CSOPoor, worse than 6/60), CSC (operated cataract as a proportion of operable plus operated cataract) and eCSC (operated cataract and a good outcome as a proportion of operable plus operated cataract) were calculated. The association between CSC and CSO was assessed by linear regression. Gender inequality in CSC and eCSC was calculated. Findings Datasets from 20 countries were included (2005–2013; 67,337 participants; 5,474 cataract surgeries). Median CSC was 53.7% (inter-quartile range[IQR] 46.1–66.6%), CSOGood was 58.9% (IQR 53.7–67.6%) and CSOPoor was 17.7% (IQR 11.3–21.1%). Coverage and quality of cataract surgery were moderately associated—every 1% CSC increase was associated with a 0.46% CSOGood increase and 0.28% CSOPoor decrease. Median eCSC was 36.7% (IQR 30.2–50.6%), approximately one-third lower than the median CSC. Women tended to fare worse than men, and gender inequality was slightly higher for eCSC (4.6% IQR 0.5–7.1%) than for CSC (median 2.3% IQR -1.5–11.6%). Conclusion eCSC allows monitoring of quality in conjunction with coverage of cataract surgery. In the surveys analysed, on average 36.7% of people who could benefit from cataract surgery had undergone surgery and obtained a good visual outcome.

Objective: To assess whether there was an improvement in the knowledge, attitudes and practices of students after the Healthy Eyes in Schools Project intervention and to complete a process evaluation to inform future implementation of health promotion interventions. Design: A descriptive, mixed-methods design was used, including questionnaires and interviews. Setting: Four primary schools in Aileu District, Timor-Leste. Local teachers received training and resources to implement nine lessons about eye health. The intervention was supported in two schools by the concurrent creation of school gardens and improvements to the water and sanitation, where required. Method: Students from classes 5 and 6 participated: 384 students aged 10–17 years (median = 12 years, inter-quartile range = 12–13 years) completed the baseline knowledge, attitudes and practices survey and 237 students participated in a follow-up survey. Interviews with teachers, students and parents informed the process evaluation. Results: The intervention was associated with an improvement in eye health knowledge and some attitudes and practices of students. Attitudes about the capabilities of blind children and adults did not change. The teachers’ attitude and support from principals and an international non-governmental organisation appeared to be key factors in the successful implementation of the Healthy Eyes in Schools Project. The limited eye health in the existing curriculum, limited parent participation and access to healthy food may have influenced the effectiveness of the Healthy Eyes in Schools Project intervention. Conclusion: A number of benefits appeared to be associated with the inclusion of eye health topics in school health and hygiene education in Timor-Leste. Concurrent development of a supportive environment appeared to enable this initiative. The results of this evaluation can be used to advocate to the Ministries of Education and Health and other education stakeholders for the inclusion of eye health in the health and hygiene curriculum.

IntroductionGlobally, there are an estimated 370 million Indigenous people across 90 countries. Indigenous people experience worse health compared with non-Indigenous people, including higher rates of avoidable visual impairment. Countries such as Australia and Canada have service delivery models aimed at improving access to eye care for Indigenous people. We will conduct a scoping review to identify and summarise these service delivery models to improve access to eye care for Indigenous people in high-income countries.Methods and analysisAn information specialist will conduct searches on MEDLINE, Embase and Global Health. All databases will be searched from their inception date with no language limits used. We will search the grey literature via websites of relevant government and service provider agencies. Field experts will be contacted to identify additional articles, and reference lists of relevant articles will be searched. All quantitative and qualitative study designs will be eligible if they describe a model of eye care service delivery aimed at Indigenous populations. Two reviewers will independently screen titles, abstracts and full-text articles; and complete data extraction. For each service delivery model, we will extract data on the context, inputs, outputs, Indigenous engagement and enabling health system functions. Where models were evaluated, we will extract details. We will summarise findings using descriptive statistics and thematic analysis.Ethics and disseminationEthical approval is not required, as our review will include published and publicly accessible data. This review is part of a project to improve access to eye care services for Māori in Aotearoa New Zealand. The findings will be useful to policymakers, health service managers and clinicians responsible for eye care services in New Zealand, and other high-income countries with Indigenous populations. We will publish our findings in a peer-reviewed journal and develop an accessible summary of results for website posting and stakeholder meetings.

To examine the financial viability of the Timor-Leste National Spectacle Program as it increases spectacle availability, affordability and uptake, particularly for Timor's poor.In rural areas, three models of ready-made spectacles were dispensed according to a tiered pricing structure of US$3.00, 1.00, 0.10 and 0.00. In addition, custom-made spectacles were available in the capital, Dili. Spectacle costs, dispensing data and income for the National Spectacle Program for 18 months from March 2007 were analyzed.Rural services dispensed 3415 readymade spectacles: 47.1% to women, and 51.4% at subsidized prices, being 39.8% at US$0.10 and 11.6% free. A profit of US$1,529 was generated, mainly from the sale of US$3.00 spectacles. Women (odds ratio, OR, 1.3, 95% confidence interval, CI, 1.1-1.4) and consumers aged ≥65 years (OR 2.1; 95% CI 1.7-2.6) were more likely to receive subsidized spectacles. Urban services dispensed 2768 spectacles; mostly US$3.00 readymade (52.8%) and custom-made single vision (29.6%) units. Custom-made spectacles accounted for 36.7% of dispensing, but 73.1% of the US$12,264 urban profit. The combined rural and urban profit covered all rural costs, leaving US$2,200 to meet administration and other urban expenses.It is instructive and encouraging that a national spectacle dispensing program in one of the ten poorest countries of the world can use tiered-pricing based on willingness-to-pay information to cover spectacle stock replacement costs and produce profit, while using cross-subsidization to provide spectacles to the poor.

Background: To estimate the prevalence and causes of blindness and low vision among adults aged ≥40 years in Fiji. Design: Population-based cross-sectional study. Participants: Adults aged ≥40 years in Viti Levu, Fiji. Method: A population-based cross-sectional survey used multistage cluster random sampling to identify 34 clusters of 40 people. A cause of vision loss was determined for each eye with presenting vision worse than 6/18. Main Outcome Measures: Blindness (better eye presenting vision worse than 6/60), low vision (better eye presenting vision worse than 6/18, but 6/60 or better). Results: Of 1892 people enumerated, 1381 participated (73.0%). Adjusting sample data for ethnicity, gender, age and domicile, the prevalence of blindness was 2.6% (95% confidence interval 1.7, 3.4) and low vision was 7.2% (95% confidence interval 5.9, 8.6) among adults aged ≥40 years. On multivariate analysis, being ≥70 years was a risk factor for blindness, but ethnicity, gender and urban/rural domicile were not. Being Indo-Fijian, female and older were risk factors for vision impairment (better eye presenting vision worse than 6/18). Cataract was the most common cause of bilateral blindness (71.1%). Among participants with low vision, uncorrected refractive error caused 63.3% and cataract was responsible for 25.0%. Conclusion: Strategies that provide accessible cataract and refractive error services producing good quality outcomes will likely have the greatest impact on reducing vision impairment.

ObjectiveTo determine the distribution and sociodemographic associations of BMI (kg/m2) among adults aged ≥40 years living in Timor-Leste.DesignBMI was calculated for participants of a population-based cross-sectional survey.SettingUrban and rural Timor-Leste.SubjectsAdults aged ≥40 years living in Timor-Leste.ResultsOf those enumerated, 2014 participated (89·5 %). Male gender, rural domicile, older age, illiteracy and source of household income were associated with BMI < 18·5 kg/m2 on multivariate analysis. Female gender, urban domicile and literacy were associated with BMI ≥25·0 and ≥30·0 kg/m2. Adjusting for gender, age and domicile, and extrapolating to those aged ≥40 years across Timor-Leste, 9·9 %, 36·0 %, 6·6 % and 0·8 % had BMI 2, respectively.ConclusionsAt this time, being ‘underweight’ or ‘severely thin’ is more prevalent in the Timorese adult population than being ‘overweight’ or ‘obese’.

Background: To determine the prevalence and severity of diabetic eye disease among adults aged ≥40 years with unrecognized diabetes in Fiji. Design: Population-based cross-sectional survey using multistage cluster random sampling. Participants: 1381 (=73.0% participation). Methods: Interview-based questionnaire; visual acuity measured; dilated ocular examination performed; glycosylated haemoglobin (HbA1c) concentration determined. Main Outcome Measures: Prevalence and grade of diabetic retinopathy/maculopathy. Results: Sample prevalence of diabetes was 44.8% (95%CI 42.2–47.5%), with 63.4% (95%CI 59.5–67.1%) previously undiagnosed (384/606). Predictors of undiagnosed compared with previously diagnosed diabetes were female gender (P = 0.001), rural residence (P = 0.049) and not having a relative with known diabetes (P 50 years), this was vision-threatening (1.0%; 95%CI 0.3–2.8). Mean HbA1c (10.7 ± 2.6%) of participants undiagnosed and with diabetes eye disease was higher (P

To characterize refractive error, presbyopia and their correction among adults aged ≥ 40 years in Fiji, and contribute to a regional overview of these conditions.A population-based cross-sectional survey using multistage cluster random sampling. Presenting distance and near vision were measured and dilated slitlamp examination performed.The survey achieved 73.0% participation (n=1381). Presenting binocular distance vision ≥ 6/18 was achieved by 1223 participants. Another 79 had vision impaired by refractive error. Three of these were blind. At threshold 6/18, 204 participants had refractive error. Among these, 125 had spectacle-corrected presenting vision ≥ 6/18 ("met refractive error need"); 79 presented wearing no (n=74) or under-correcting (n=5) distance spectacles ("unmet refractive error need"). Presenting binocular near vision ≥ N8 was achieved by 833 participants. At threshold N8, 811 participants had presbyopia. Among these, 336 attained N8 with presenting near spectacles ("met presbyopia need"); 475 presented with no (n=402) or under-correcting (n=73) near spectacles ("unmet presbyopia need"). Rural residence was predictive of unmet refractive error (p=0.040) and presbyopia (p=0.016) need. Gender and household income source were not. Ethnicity-gender-age-domicile-adjusted to the Fiji population aged ≥ 40 years, "met refractive error need" was 10.3% (95% confidence interval [CI] 8.7-11.9%), "unmet refractive error need" was 4.8% (95%CI 3.6-5.9%), "refractive error correction coverage" was 68.3% (95%CI 54.4-82.2%),"met presbyopia need" was 24.6% (95%CI 22.4-26.9%), "unmet presbyopia need" was 33.8% (95%CI 31.3-36.3%), and "presbyopia correction coverage" was 42.2% (95%CI 37.6-46.8%).Fiji refraction and dispensing services should encourage uptake by rural dwellers and promote presbyopia correction. Lack of comparable data from neighbouring countries prevents a regional overview.

Background: To characterize cataract and its surgery among adults aged ≥40 years in Fiji. Design: Population-based cross-sectional survey using multistage cluster random sampling. Participants: 1381 (= 73.0% participation); eight provinces on Viti Levu. Methods: Interview-based questionnaire; visual acuity measured; autorefraction; dilated ocular examination. Main Outcome Measures: Prevalence; predictors; surgical outcomes. Results: Being Indian (P = 0.001), elderly (P

Background: To characterize causes, risk factors and outcomes for ocular trauma among adults aged ≥40 years in Fiji. Design: Population-based cross-sectional survey; multistage cluster random sampling. Participants: 1381 (= 73.0% participation); eight provinces on Viti Levu. Methods: Interview-based questionnaire. Visual acuity measurement. Dilated ocular examination. Main Outcome Measures: Circumstances, management and consequences of self-reported ocular trauma. Results: Of participants, 20.6% recalled ocular trauma: being Melanesian (P 15 years: 38.5% occurred inside the home, most by sharp objects (51.6%) and domestic violence (28.4%); agricultural activities caused 20.6% of injuries; non-agricultural workplace incidents caused 16.2%, with chemicals responsible for 27.5% of these; public alcohol consumption was associated with 13.8% of injuries, mostly by assault (91.2%). Conventional medical services were the primary source of care for 47.2% of injured participants: 61.9% attended on injury day. For trauma: sample prevalence of vision impairment in at least one eye was 1.7% (95% confidence interval 1.1–2.4%), and 0.1% (95% confidence interval 0.02–0.5) for bilateral blindness. Injury at ≤15 years (P = 0.008) and at the workplace (P = 0.044) were predictive of ongoing vision impairment. Of visually impaired eyes, 36% had corneal opacity that may have been caused by relatively minor trauma. Conclusions: Ophthalmic service strengthening (including minor corneal trauma management) and specific injury prevention strategies (including behaviour change education and advocacy for legislation) are required to decrease the ocular trauma burden in Fiji.

Background: To characterize diabetic eye disease and its management among adults aged ≥40 years with self-reported diabetes in Fiji. Methods: During a population-based cross-sectional survey using multistage cluster random sampling, participants reported health information, including whether a doctor had diagnosed diabetes. HbA1c and visual acuity were measured. Diabetic eye disease was assessed using 90-dioptre lens dilated funduscopy. Results: Of those enumerated, 1381 (73.0%) participated, with 222 reporting diabetes. Twenty fundi were not examined (19 due to cataract). Of the remaining 424 eyes, 75.5% had no diabetic disease, 1.2% had proliferative retinopathy, 7.5% had active significant maculopathy and 0.7% had burnt-out/treated disease. By person, 27.2% had retinopathy and/or maculopathy in at least one eye. Mean HbA1c (9.9 ± 2.3%) for this group was significantly higher (P = 0.004) than for those without eye disease. Vision-threat occurred in at least one eye of 11.5%. Diabetes (predominantly maculopathy) caused pinhole acuity 10 years ago was predictive of any (odds ratio [OR] 8.13; 95% confidence interval [CI] 3.28–20.21; P

Background: A 12-month Diploma of Eye Care course for mid-level eye care workers was initiated in 2007 as part of Timor-Leste’s National Eye Health Strategy. This paper reports the development and implementation of this course, examines its initial results and makes suggestions for improvements to the training and deployment of these workers. Methods: Course curriculum development and delivery, trainee selection and candidate assessment were examined. Graduate clinical knowledge retention at 6 months after course completion was investigated using clinical vignettes to determine diagnosis, management and patient counselling knowledge for common primary eye health conditions. Graduate workplace environments and activities were appraised. Results: Development of the course curriculum and its delivery were in response to local circumstance, and according to education best practice teaching and learning strategies. Four rural nurses successfully completed the inaugural course. Although all remained in rural eye care services at 6 months after graduation, there was considerable variation in activity. Substantial depletion of clinical competency was revealed across the cohort. Conclusions: Adherence to current best practice in the design and delivery of the curriculum and course was insufficient to ensure productive graduates of ongoing clinical competency, positioned to make an impact on eye health. Attention needs to be directed to postgraduation integration into the workplace, and continuing support once there. The efficacy of this mid-level cadre and its impact on eye health requires further evaluation.