Search

Competing Interests: The authors declare that they have no conflicts of interest to disclose.

Objective: To estimate the association between (1) visual impairment (VI) and (2) eye disease and 6-year mortality risk within a cohort of elderly Kenyan people., Design, Setting and Participants: The baseline of the Nakuru Posterior Segment Eye Disease Study was formed from a population-based survey of 4318 participants aged ≥50 years, enrolled in 2007-2008. Ophthalmic and anthropometric examinations were undertaken on all participants at baseline, and a questionnaire was administered, including medical and ophthalmic history. Participants were retraced in 2013-2014 for a second examination. Vital status was recorded for all participants through information from community members. Cumulative incidence of mortality, and its relationship with baseline VI and types of eye disease was estimated. Inverse probability weighting was used to adjust for non-participation., Primary Outcome Measures: Cumulative incidence of mortality in relation to VI level at baseline., Results: Of the baseline sample, 2170 (50%) were re-examined at follow-up and 407 (10%) were known to have died (adjusted risk of 11.9% over 6 years). Compared to those with normal vision (visual acuity (VA) ≥6/12, risk=9.7%), the 6-year mortality risk was higher among people with VI (<6/18 to ≥6/60; risk=28.3%; risk ratio (RR) 1.75, 95% CI 1.28 to 2.40) or severe VI (SVI)/blindness (<6/60; risk=34.9%; RR 1.98, 95% CI 1.04 to 3.80). These associations remained after adjustment for non-communicable disease (NCD) risk factors (mortality: RR 1.56, 95% CI 1.14 to 2.15; SVI/blind: RR 1.46, 95% CI 0.80 to 2.68). Mortality risk was also associated with presence of diabetic retinopathy at baseline (RR 3.18, 95% CI 1.98 to 5.09), cataract (RR 1.26, 95% CI 0.95 to 1.66) and presence of both cataract and VI (RR 1.57, 95% CI 1.24 to 1.98). Mortality risk was higher among people with age-related macular degeneration at baseline (with or without VI), compared with those without (RR 1.42, 95% CI 0.91 to 2.22 and RR 1.34, 95% CI 0.99 to 1.81, respectively)., Conclusions: Visual acuity was related to 6-year mortality risk in this cohort of elderly Kenyan people, potentially because both VI and mortality are related to ageing and risk factors for NCD., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ.)

With a global target set at reducing vision loss by 25% by the year 2019, sub-Saharan Africa with an estimated 4.8 million blind persons will require human resources for eye health (HReH) that need to be available, appropriately skilled, supported, and productive. Targets for HReH are useful for planning, monitoring, and resource mobilization, but they need to be updated and informed by evidence of effectiveness and efficiency. Supporting evidence should take into consideration (1) ever-changing disease-specific issues including the epidemiology, the complexity of diagnosis and treatment, and the technology needed for diagnosis and treatment of each condition; (2) the changing demands for vision-related services of an increasingly urbanized population; and (3) interconnected health system issues that affect productivity and quality. The existing targets for HReH and some of the existing strategies such as task shifting of cataract surgery and trichiasis surgery, as well as the scope of eye care interventions for primary eye care workers, will need to be re-evaluated and re-defined against such evidence or supported by new evidence.

Background: No longitudinal data from population-based studies of eye disease in sub-Saharan-Africa are available. A population-based survey was undertaken in 2007/08 to estimate the prevalence and determinants of blindness and low vision in Nakuru district, Kenya. This survey formed the baseline to a six-year prospective cohort study to estimate the incidence and progression of eye disease in this population., Methods/design: A nationally representative sample of persons aged 50 years and above were selected between January 2007 and November 2008 through probability proportionate to size sampling of clusters, with sampling of individuals within clusters through compact segment sampling. Selected participants underwent detailed ophthalmic examinations which included: visual acuity, autorefraction, visual fields, slit lamp assessment of the anterior and posterior segments, lens grading and fundus photography. In addition, anthropometric measures were taken and risk factors were assessed through structured interviews. Six years later (2013/2014) all subjects were invited for follow-up assessment, repeating the baseline examination methodology., Discussion: The methodology will provide estimates of the progression of eye diseases and incidence of blindness, visual impairment, and eye diseases in an adult Kenyan population.

Background: The inclusion of primary eye care (PEC) in the scope of services provided by general primary health care (PHC) workers is a 'task shifting' strategy to help increase access to eye care in Africa. PEC training, in theory, teaches PHC workers to recognize specific symptoms and signs and to treat or refer according to these. We tested the sensitivity of these symptoms and signs at identifying significant eye pathology., Methods: Specialized eye care personnel in three African countries evaluated specific symptoms and signs, using a torch alone, in patients who presented to eye clinics. Following this, they conducted a more thorough examination necessary to make a definite diagnosis and manage the patient. The sensitivities and specificities of the symptoms and signs for identifying eyes with conditions requiring referral or threatening sight were calculated., Results: Sensitivities of individual symptoms and signs to detect sight threatening pathology ranged from 6.0% to 55.1%; specificities ranged from 8.6 to 98.9. Using a combination of symptoms or signs increased the sensitivity to 80.8 but specificity was 53.2., Conclusions: In this study, the sensitivity and specificity of commonly used symptoms and signs were too low to be useful in guiding PHC workers to accurately identify and refer patients with eye complaints. This raises the question of whether this task shifting strategy is likely to contribute to reducing visual loss or to providing an acceptable quality service.

Background: The impact of unmet eye care needs in sub-Saharan Africa is compounded by barriers to accessing eye care, limited engagement with communities, a shortage of appropriately skilled health personnel, and inadequate support from health systems. The renewed focus on primary health care has led to support for greater integration of eye health into national health systems. The aim of this paper is to demonstrate available evidence of integration of eye health into primary health care in sub-Saharan Africa from a health systems strengthening perspective., Methods: A scoping review method was used to gather and assess information from published literature, reviews, WHO policy documents and examples of eye and health care interventions in sub-Saharan Africa. Findings were compiled using a health systems strengthening framework., Results: Limited information is available about eye health from a health systems strengthening approach. Particular components of the health systems framework lacking evidence are service delivery, equipment and supplies, financing, leadership and governance. There is some information to support interventions to strengthen human resources at all levels, partnerships and community participation; but little evidence showing their successful application to improve quality of care and access to comprehensive eye health services at the primary health level, and referral to other levels for specialist eye care., Conclusion: Evidence of integration of eye health into primary health care is currently weak, particularly when applying a health systems framework. A realignment of eye health in the primary health care agenda will require context specific planning and a holistic approach, with careful attention to each of the health system components and to the public health system as a whole. Documentation and evaluation of existing projects are required, as are pilot projects of systematic approaches to interventions and application of best practices. Multi-national research may provide guidance about how to scale up eye health interventions that are integrated into primary health systems.

Objectives: To estimate the prevalence of blindness and visual impairment (VI) in adults aged ≥50 years in the Nakuru district of Kenya and to identify sociodemographic risk factors for these conditions. We also sought to validate the Rapid Assessment of Avoidable Blindness (RAAB) methodology., Participants: There were 5010 subjects enumerated for this study. Of these, 4414 participants underwent examination, for a response rate of 88.1%., Design: Cross-sectional, population-based survey., Methods: Cluster random samplings with probability proportionate to size procedures were used to select a representative cross-sectional sample of adults aged ≥50 years. Each participant was interviewed, had distance visual acuity (VA) measured with reduced logarithm of the minimal angle of resolution tumbling-E chart, underwent autorefraction, and thereby had measurements of presenting, uncorrected, and best-corrected VA. All participants, regardless of vision, underwent detailed ophthalmic examinations including slit-lamp assessment and dilated retinal photographs., Main Outcome Measures: Visual acuity of <6/12., Results: A representative sample of 4414 adults were enumerated (response rate, 88.1%). The prevalence of blindness (VA < 3/60 in better eye) was 1.6% (95% confidence interval [CI], 1.2-2.1%) and of VI, 0.4% (95% CI, 0.3-0.7%); 8.1% (95% CI, 7.2-9.2%); and 5.1% (95% CI, 4.3-6.1%) were severely (<6/60-3/60), moderately (<6/18-6/60), or mildly (<6/12-6/18) visually impaired, respectively. Being male, having less education, having Kalenjin tribal origin, and being ≥80 years old were associated with increased blindness prevalence. Prevalence estimates were comparable to a RAAB performed in the same area 2 years earlier., Conclusions: This survey provides reliable estimates of blindness and VI prevalence in Nakuru. Older age and tribal origin were identified as predictors of these conditions. This survey validates the use of RAAB as a method of estimating blindness and VI prevalence., (Copyright © 2012 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Objective: Assessment of a primary eye care programme in rural Rwanda over 2 years, with the aim of providing evidence to guide the development, training, supervision, or monitoring of primary eye care in Africa., Method: A comprehensive eye care programme in Rubavu District including a surgical service, health promotion, diagnostic and treatment services, training of health centre nurses and village health workers, and periodic visits by eye professionals to the health centres was implemented. Monitoring systems put in place from the beginning of the programme facilitated assessment of service use over 2 years., Results: A total of 6495 people received eye care services at eight health centres (3912 from nurses and 2583 from visiting eye professionals) and 149 Rubavu residents had surgery for cataract. Increases in service use in the first few months were not maintained over the 2-year period. The number of patients receiving surgery for cataract was less than half of the number referred for surgery., Conclusion: In this setting, initial increases in use of services at health centres were not maintained. Reasons varied and included the observation that VHW tend to refer patients to health centres only when there was a visiting eye professional. Reductions in visits to health centres could also be traced to changing government policies on medicines provided through insurance coverage. Increasing rates of referral and uptake of cataract surgery will require revising programme activities and adopting additional strategies.

Objective To assess factors associated with high output of recently trained medical personnel in Rwanda. Methods Nurses and village health workers (VHW) from all health centres in Rubavu district were included. Data were collected during focus group discussions and through one-to-one interviews. Follow-up interviews were carried out in January 2009. Results There was a wide range from none to all VHW referring people to a health centre. VHW brought more people to the health centre if there was a visiting ophthalmic clinical officer from the Eye Unit offering free screening. VHW output varied; male VHW brought 66.7% of patients identified (regardless of the sex of the health centre nurse), while female VHW brought 5.2 times as many people if the health centre nurse was male compared to if the nurse was female. Conclusion Changes in training curriculum and support and supervision of health workers trained in primary eye care (PEC) are likely to lead to improved outputs. Information efforts should reinforce that male and female nurses have the same training and skills in PEC. [ABSTRACT FROM AUTHOR]

Background: Presbyopia is the most common reason for requiring spectacles in low-income regions, although the unmet need for presbyopic spectacles in these regions is very high. The aim of this study was to estimate the prevalence of presbyopia, and the functional impairment and spectacle use among persons with presbyopia in a rural Kenyan population. Methods: A cross-sectional study was carried out in the Rift Valley, Kenya. Clusters were selected through probability-proportionate to size sampling, and people aged ≥50 years within the clusters were identified through compact segment sampling. Within the context of this survey, 130 eligible participants were selected for interview and underwent near-vision testing. Functional presbyopia was defined as requiring at least +1.00 dioptre in order to read the N8 optotype at a distance of 40 cm in the participant's usual visual state. Participants were corrected to the nearest 0.25 dioptre in order to see N8. Unmet and met presbyopic need, and presbyopic correction coverage were calculated. Results: Functional presbyopia was found in 111 participants (85.4%). Mean age was lower in those with presbyopia (64.1 years vs. 71.5 years, P = 0.004). Increasing degree of addition required to see N8 was significantly associated with increased difficulty with reading ( P = 0.04), sewing ( P = 0.03), recognizing small objects ( P = 0.02) and harvesting grains ( P = 0.05). Among participants with functional presbyopia, 5.4% wore reading glasses and 25.2% had prior contact with an eye care professional. The unmet presbyopic need was 80.0%, met presbyopic need was 5.4% and presbyopic correction coverage was 6.3%. Cost was cited as the main barrier to spectacle use in 62% of participants with presbyopia. Conclusion: In low-income regions, there is a high prevalence of uncorrected presbyopia, which is associated with near-vision functional impairment. Provision of spectacles for near vision remains a priority in low-income regions. [ABSTRACT FROM AUTHOR]

Objectives: To estimate the prevalence of avoidable blindness in ≥50-year-olds in Nakuru district, Kenya, and to evaluate the Rapid Assessment for Avoidable Blindness (RAAB), a new methodology to measure the magnitude and causes of blindness. Design: Cross-sectional population-based survey. Participants: Seventy-six clusters of 50 people 50 years or older were selected by probability proportionate to size sampling of clusters. Households within clusters were selected through compact segment sampling. Three thousand seven hundred eighty-four eligible subjects were selected, of whom 3503 (92.6%) were examined. Methods: Participants underwent a comprehensive ophthalmic examination in their homes by an ophthalmologist, including measurement of visual acuity (VA) with a tumbling-E chart and the diagnosis of the principal cause of visual impairment. Those who had undergone cataract surgery were questioned about the details of the operation and their satisfaction with surgery. Those who were visually impaired from cataract were asked why they had not gone for surgery. Main Outcome Measures: Visual acuity and principal cause of VA<6/18. Results: The prevalence of bilateral blindness (presenting VA < 3/60) was 2.0% (95% confidence interval [CI], 1.5%–2.4%), and prevalence of bilateral visual impairment (VA of <6/18–≥6/60) was 5.8% (95% CI, 4.8%–6.8%) in the sample. Definite avoidable causes of blindness (i.e., cataract, refractive error, trachoma, and corneal scarring) were responsible for 69.6% of bilateral blindness and 74.9% of bilateral visual impairment. Cataract was the major cause of blindness (42.0%) and visual impairment (36.0%). The cataract surgical coverage was high, with 78% of those with bilateral cataract who needed surgery having had surgery at VA<3/60. The quality of surgery was of concern because 22% of the 222 eyes that had undergone cataract surgery had VA<6/60 with best correction. The main barriers to surgery were lack of awareness and cost. The RAAB methodology was easy to use, and each team could visit one cluster per day. Conclusions: The prevalence of blindness in ≥50-year-olds in Nakuru district was low, in part due to the high cataract surgical coverage. The RAAB is easy to use and inexpensive and provides information about the magnitude and causes of avoidable blindness that can be used for planning and monitoring eye care services. [Copyright &y& Elsevier]