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This study examined the association between varying levels of visual acuity (VA) and physical performance (Short Physical Performance Battery) in older adults. A cross-sectional analysis of participants aged ≥50 years with a clinical diagnosis of vision loss across two studies was undertaken. Of 434 (96%) participants with available VA data, 74% (320/434) had nil, 7% (32/434) had mild, 8% (33/434) had moderate, and 11% (49/434) had severe visual impairment. Poorer VA of both better and worse eye was found to be significantly associated with poorer standing balance (p = .006 and p = .004, respectively); worse VA of the better eye was significantly associated with increased number of steps per meter (p = .005). Mean total Short Physical Performance Battery score of this study population was lower than published normative data for this age group. Physical activity programs for older people with reduced VA should be targeted at improving balance and gait skills to reduce falls risk.

Purpose: Findings from cross-sectional blindness prevalence surveys are at risk of several biases that cause the study estimate to differ from the ‘true’ population prevalence. For example, response bias occurs when people who participate (‘responders’) differ from those who do not (‘non-responders’) in ways that affect prevalence estimates. This study aimed to assess the extent to which response bias is considered and occurs in blindness prevalence surveys in low- and middle-income countries (LMICs). Methods: We searched MEDLINE, EMBASE and Web of Science for cross-sectional blindness prevalence surveys undertaken in LMICs and published 2009–2017. From included studies, we recorded and descriptively analysed details regarding enumeration processes, response, and non-response, including the impact of non-response on results. Results: Most (95%) of the 92 included studies reported a response rate (median 91.7%, inter-quartile range 85.9–95.6%). Approximately half clearly described enumeration processes (49%), and reported at least one strategy to increase the response rate (53%); a quarter (23%) statistically compared responders and non-responders. When differential response was assessed, men were more likely to be non-responders than women. Two-thirds (65%) of the time a sociodemographic difference was found between responders and non-responders, a difference in blindness prevalence was also found. Only 13 studies (14%) commented on implications of non-response on prevalence estimates. Conclusions: Response rates are commonly reported from blindness prevalence surveys, and tend to be high. High response rates reduce—but do not eliminate—the risk of response bias. Assessment and reporting of potential response bias in blindness prevalence surveys could be greatly improved.

Background Although cataract surgery can restore sight, lengthy waiting times are common in public hospitals in Australia. We investigated the driving status of older people during their surgical waiting period. Methods Baseline, cross-sectional data from two prospective cohort studies of patients aged 50 years and older on Australian public hospital cataract surgery waiting lists were analysed. Participants underwent assessment of vision and completed the Driving Habits Questionnaire. The vision status was compared between current drivers and former drivers. Results Participants (n = 442) were on average 73 ± 8 years of age and approximately half were women (229/442, 52 per cent). Habitual vision was 6/12+2 on average (0.26 ± 0.21 logMAR). There were 263 (60 per cent) current drivers, 110 (25 per cent) former drivers and 69 participants (16 per cent) who had never driven. Among the current drivers, 82/263 (31 per cent) failed visual acuity requirements for an unconditional drivers’ license (6/12 acuity with one or both eyes). The former drivers had worse visual acuity than the current drivers (between group difference 0.12 ± 0.20 logMAR, p

Background To assess the prevalence and predictors of depressive symptoms in a cohort of older adults awaiting cataract surgery and establish threshold vision at which depressive symptoms may emerge. Design Analysis of cross-sectional baseline data from a longitudinal cohort study of patients aged ≥65 years on Australian public hospital cataract surgery waiting lists. Participants We included 329 participants enrolled October 2013–August 2015. Methods Participants completed assessment of depressive symptoms, visual disability, quality of life, social participation and exercise frequency at least one month prior to cataract surgery. High and low contrast habitual vision was examined and systemic comorbidities noted. Main Outcome Measure Depressive symptoms prior to first eye cataract surgery. Results The prevalence of depressive symptoms was 28.6% (94/329). Univariate analysis identified that participants with poorer high contrast vision, reduced quality of life, greater patient-reported visual disability, higher comorbidity score and who were taking more medications were more likely to exhibit signs of depression. Greater patient-reported visual disability (P = 0.02), reduced quality of life (P = 0.003) and a higher comorbidity score (P = 0.02) remained significantly associated with depressive symptoms in the multivariable model. Depressive symptoms emerged at a visual acuity of 6/12. Conclusions These findings demonstrate a high prevalence of depressive symptoms in older persons with cataract, emerging at modest levels of vision loss. Efficient referral processes, timely surgical management, and improved screening and coordinated treatment of depressive symptoms during the surgical wait may minimize the negative psychological effects of cataract in this already vulnerable population.

PURPOSE: To clarify the effect of first-eye cataract surgery on the incidence of falls and identify components of visual function associated with fall risk. SETTING: Eight public hospital eye clinics in Sydney, Melbourne, and Perth, Australia. DESIGN: Prospective cohort study. METHODS: The study recruited patients who had bilateral cataract, were aged 65 years or older, and were on public hospital cataract surgery waiting lists. Comprehensive assessments of vision, physical function, and exercise activity were performed before and after first-eye cataract surgery. Falls were reported prospectively for up to 2 years and associations with falls were assessed using generalized linear mixed models. RESULTS: Of the 329 patients recruited, 196 (66.6%) completed first-eye surgery within the study period. First-eye cataract surgery reduced incident falls by 33% (adjusted incidence rate ratio 0.67; 95% confidence interval [CI], 0.49-0.92; P = .01). Poorer dominant-eye visual acuity was associated with falls during the study timeline (incidence rate ratio, 2.20; 95% CI, 1.02-4.74; P = .04). Patients with larger than a spherical equivalent of ±0.75 diopter change in the spectacle lens (operated eye) had a 2-fold greater incidence of falls in the period after first-eye cataract surgery than those with less or no change in lens power (incidence rate ratio, 2.17; 95% CI, 1.23-3.85; P = .008). CONCLUSIONS: First-eye cataract surgery significantly reduced incident falls. Major changes in the dioptric power of spectacle correction of the operated eye after surgery increased the fall risk. Cautious postoperative refractive management is important to maximize the benefit of cataract surgery as a fall-prevention measure.

Patient-reported outcome measures (PROMs) are becoming increasingly recognised as a key component in assessing the relative effectiveness of cataract surgery. This manuscript presents the protocol methodology and baseline characteristics of a prospective cohort study investigating patient-centred predictors of cataract surgery outcomes.Patients with bilateral cataract (aged ≥ 50 years) scheduled for their first eye cataract surgery were recruited at four public hospitals and three private ophthalmology clinics in Sydney, Australia. Participants underwent a comprehensive assessment of clinical measures of vision (for example, visual acuity, contrast sensitivity) and PROMs prior to first eye surgery and three months after first and second eye surgery. The PROMs of interest included health-related quality of life, visual disability and satisfaction with vision.The characteristics of the baseline cohort of 359 participants are reported in this manuscript. Enrolment occurred over a two-year period with the majority recruited from urban public hospitals (96 per cent, n = 345). Health-related quality of life was scored highly (80 out of 100). Self-reported visual disability was considered within normal ranges compared to cataract populations in other high-income countries (-0.94 logits). Three-quarters of participants (n = 263/351) were dissatisfied with their pre-operative vision.There is a complex and wide range of patient-centred experiences prior to first eye cataract surgery in the public hospital setting. Gaining further insight into the patient perspective may allow eye health professionals to more appropriately time surgery, better manage patient expectations and provide direction for future prioritisation initiatives of cataract wait lists. Companion papers will follow, detailing results of surgery in terms of PROMs.

Purpose To clarify the effect of first-eye cataract surgery on the incidence of falls and identify components of visual function associated with fall risk. Setting Eight public hospital eye clinics in Sydney, Melbourne, and Perth, Australia. Design Prospective cohort study. Methods The study recruited patients who had bilateral cataract, were aged 65 years or older, and were on public hospital cataract surgery waiting lists. Comprehensive assessments of vision, physical function, and exercise activity were performed before and after first-eye cataract surgery. Falls were reported prospectively for up to 2 years and associations with falls were assessed using generalized linear mixed models. Results Of the 329 patients recruited, 196 (66.6%) completed first-eye surgery within the study period. First-eye cataract surgery reduced incident falls by 33% (adjusted incidence rate ratio 0.67; 95% confidence interval [CI], 0.49-0.92; P = .01). Poorer dominant-eye visual acuity was associated with falls during the study timeline (incidence rate ratio, 2.20; 95% CI, 1.02-4.74; P = .04). Patients with larger than a spherical equivalent of ±0.75 diopter change in the spectacle lens (operated eye) had a 2-fold greater incidence of falls in the period after first-eye cataract surgery than those with less or no change in lens power (incidence rate ratio, 2.17; 95% CI, 1.23-3.85; P = .008). Conclusions First-eye cataract surgery significantly reduced incident falls. Major changes in the dioptric power of spectacle correction of the operated eye after surgery increased the fall risk. Cautious postoperative refractive management is important to maximize the benefit of cataract surgery as a fall-prevention measure.

Background The patient pathway to cataract surgery in Australia generally begins with optometric services; however, little is known about the cataract surgery referral criteria used by optometrists in Australia. Methods Members of Optometrists Association Australia were invited to complete an online survey in April 2013. The survey elicited information on practice demographics, professional characteristics of optometrists and cataract surgery referral considerations. Results We received responses from 533 of 4272 (13 per cent) practising optometrists. Over three-quarters (407 of 528, 77 per cent) indicated a visual acuity (VA) cataract referral benchmark of 6/9 to 6/12. Almost all respondents (499 out of 532, 94 per cent) stated they included glare sensitivity as part of their referral criteria, whereas a considerably lower proportion (40 of 528, eight per cent) used contrast sensitivity testing. Patient-centred factors such as hobbies (94 per cent) and driving (73 per cent) featured in the decision to refer patients sooner, while a patient not wanting surgery (79 per cent) was the most frequent reason cited for delaying referral. Respondents practising in more advantaged socioeconomic areas were 2.4 times more likely to refer privately (95% CI 1.6–3.6) and less likely to consider surgical costs as an important consideration (p < 0.001). Almost all respondents (97 per cent) who referred publicly discussed public hospital waiting times with their patients (median minimum wait estimate of 12 to 18 months), compared to the smaller proportion (64 per cent) of respondents discussing private waiting times (median minimum wait estimate of one to two months). Conclusion While modest reductions in VA were sufficient to prompt referral for cataract surgery by Australian optometrists, patient-reported visual disability guided the optometrist's overall referral decision. Socioeconomic status of practice location influenced the choice to refer publicly versus privately and surgical costs were also considered.

AIM: To examine fear of falling and associated factors in a cohort of older adults with cataract, and investigate the interplay of vision and physical function with respect to fear of falling. METHODS: We analyzed baseline data from a longitudinal study of adults aged ≥65 years referred for cataract surgery. Fear of falling was assessed by the Short Falls Efficacy Scale-International. Physical function was determined by the Short Physical Performance Battery. Participants underwent assessment of visual acuity, contrast sensitivity, visual disability, quality of life, depressive symptoms, exercise frequency, comorbidity and falls history. Factors associated with fear of falling were assessed using linear regression. Planned stepwise regression investigated vision as a potential moderator of the relationship between physical function and fear of falling. RESULTS: Among 322 participants, 32.9 % (n = 106) showed high fear of falling. Poorer physical function, more comorbidities and greater visual disability were independently associated with a higher fear of falling (all P

BACKGROUND: To assess the prevalence and predictors of depressive symptoms in a cohort of older adults awaiting cataract surgery and establish threshold vision at which depressive symptoms may emerge. DESIGN: Analysis of cross-sectional baseline data from a longitudinal cohort study of patients aged ≥65 years on Australian public hospital cataract surgery waiting lists. PARTICIPANTS: We included 329 participants enrolled October 2013-August 2015. METHODS: Participants completed assessment of depressive symptoms, visual disability, quality of life, social participation and exercise frequency at least one month prior to cataract surgery. High and low contrast habitual vision was examined and systemic comorbidities noted. MAIN OUTCOME MEASURE: Depressive symptoms prior to first eye cataract surgery. RESULTS: The prevalence of depressive symptoms was 28.6% (94/329). Univariate analysis identified that participants with poorer high contrast vision, reduced quality of life, greater patient-reported visual disability, higher comorbidity score and who were taking more medications were more likely to exhibit signs of depression. Greater patient-reported visual disability (P = 0.02), reduced quality of life (P = 0.003) and a higher comorbidity score (P = 0.02) remained significantly associated with depressive symptoms in the multivariable model. Depressive symptoms emerged at a visual acuity of 6/12. CONCLUSIONS: These findings demonstrate a high prevalence of depressive symptoms in older persons with cataract, emerging at modest levels of vision loss. Efficient referral processes, timely surgical management, and improved screening and coordinated treatment of depressive symptoms during the surgical wait may minimize the negative psychological effects of cataract in this already vulnerable population.

To examine fear of falling and associated factors in a cohort of older adults with cataract, and investigate the interplay of vision and physical function with respect to fear of falling.We analyzed baseline data from a longitudinal study of adults aged ≥65 years referred for cataract surgery. Fear of falling was assessed by the Short Falls Efficacy Scale-International. Physical function was determined by the Short Physical Performance Battery. Participants underwent assessment of visual acuity, contrast sensitivity, visual disability, quality of life, depressive symptoms, exercise frequency, comorbidity and falls history. Factors associated with fear of falling were assessed using linear regression. Planned stepwise regression investigated vision as a potential moderator of the relationship between physical function and fear of falling.Among 322 participants, 32.9 % (n = 106) showed high fear of falling. Poorer physical function, more comorbidities and greater visual disability were independently associated with a higher fear of falling (all P 0.001). Visual disability moderated the relationship between physical function and fear of falling (β = -0.10, P = 0.04). The impact of physical function on fear of falling was strongest in participants with higher (+1 standard deviation above the mean) visual disability (b = -0.21, P 0.001).Fear of falling in older adults with cataract is greatest in those with poorer physical function and higher levels of visual disability. Perceived visual ability has a moderating role in the relationship between physical function and fear of falling; physical function alone might not adequately predict falls concern. Geriatr Gerontol Int 2017; 17: 1551-1558.

Aim To examine fear of falling and associated factors in a cohort of older adults with cataract, and investigate the interplay of vision and physical function with respect to fear of falling. Methods We analyzed baseline data from a longitudinal study of adults aged ≥65 years referred for cataract surgery. Fear of falling was assessed by the Short Falls Efficacy Scale-International. Physical function was determined by the Short Physical Performance Battery. Participants underwent assessment of visual acuity, contrast sensitivity, visual disability, quality of life, depressive symptoms, exercise frequency, comorbidity and falls history. Factors associated with fear of falling were assessed using linear regression. Planned stepwise regression investigated vision as a potential moderator of the relationship between physical function and fear of falling. Results Among 322 participants, 32.9 % (n = 106) showed high fear of falling. Poorer physical function, more comorbidities and greater visual disability were independently associated with a higher fear of falling (all P

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.

Aim: To estimate the prevalence and causes of blindness and low vision in people aged ⩾40 years in Timor-Leste. Method: A population-based cross-sectional survey using multistage cluster random sampling to identify 50 clusters of 30 people. A cause of vision loss was determined for each eye presenting with visual acuity worse than 6/18. Results: Of 1470 people enumerated, 1414 (96.2%) were examined. The age, gender and domicile-adjusted prevalence of functional blindness (presenting vision worse than 6/60 in the better eye) was 7.4% (95% CI 6.1 to 8.8), and for blindness at 3/60 was 4.1% (95% CI 3.1 to 5.1). The adjusted prevalence for low vision (better eye presenting vision of 6/60 or better, but worse than 6/18) was 17.7% (95% CI 15.7 to 19.7). Gender was not a risk factor for blindness or low vision, but increasing age, illiteracy, subsistence farming, unemployment and rural domicile were risk factors for both. Cataract was the commonest cause of blindness (72.9%) and an important cause of low vision (17.8%). Uncorrected refractive error caused 81.3% of low vision. Conclusion: Strategies that make good-quality cataract and refractive error services available, affordable and accessible, especially in rural areas, will have the greatest impact on vision impairment.

Purpose: To determine the prevalence of visually significant and unoperated blinding cataract, and the coverage, characteristics and outcome of cataract surgery in Timor-Leste. Methods: Based on the World Health Organization Rapid Assessment of Cataract Surgical Services protocol, a population-based cross-sectional survey was conducted in 2005. By two-stage cluster random sampling, 50 clusters of 30 people aged 40 years and older were selected. Each eye with a presenting visual acuity worse than 6/18 and/or a history of cataract surgery was examined. Results: Of the 1470 people enumerated, 96.2% were examined. Of the eyes examined, 11.5% were blind (presenting vision less than 6/60). Cataract caused 66.3% of this, and 40.2% of vision impairment (presenting vision less than 6/18). For those people who were blind (7.7%; presenting vision less than 6/60 in the better eye), cataract was the most frequent cause (76.1%). Cataract surgery had occurred in 2% of participants. Gender and domicile were not associated with cataract blindness or surgery. Cataract Surgical Coverage (6/60) was 16.3% for Eyes and 20.2% for Persons. Surgical outcomes were poor, falling well short of World Health Organization guidelines. Astigmatism and posterior capsule opacity were important contributors to this. Conclusions: Until census data are available, age-gender-domicile correction of sample findings cannot be calculated. In the meantime, it is estimated there are 11 500 cataract blind in Timor-Leste. Long-term, indigenous cataract surgical services need to be capable of significantly increased output. Better surgical outcomes are required to ensure scarce resources are well used. Laser capsulotomy needs to be planned for as surgical numbers increase.

Falls result in$1 billion in treatment, disability, lost output and mortality each year in Australia and people with cataract are at increased risk. Previous research is inconclusive; one large Australian study using linked hospital data found no protective effect of cataract surgery. We aim to examine the impact of cataract-related vision impairment on falls risk and the additional effects of delays in access to surgery, refractive management (type of spectacles and changes to spectacle prescription) and the resulting level of function, particularly binocular function which can impact balance.A prospective, 24-month cohort study is planned involving over 700 patients aged 70 years or older with bilateral cataract presenting for surgery at five public hospital eye clinics in Sydney, Melbourne and Perth, Australia. The primary outcomes will be self-reported falls and falls requiring medical care, assessed objectively using administrative data sets. Secondary outcomes include community participation, quality of life, mood and depressive symptoms. McNemar's test will be used to evaluate differences in falls rate before, after first eye and after second eye cataract surgery. Generalised Estimating Equations linear regression analysis will be undertaken to examine factors associated with falls risk and the secondary outcomes.With limited resources to further shorten public waiting lists, there is a need to better understand an individuals' risk of fall injury or other negative consequences while waiting for surgery. The findings of this project will inform the development of strategies to reduce falls risk in the many older people with cataract.

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

To determine the independent, relative, and combined impact of reduced distance and near vision on the vision-specific quality of life (VS QOL) of adults in Timor-Leste.A population-based cross-sectional eye health survey was conducted in urban and rural areas in Timor-Leste.Participants were 40 years or older. Those with better eye presenting distance vision worse than 6/18, and every third participant with 6/18 or better vision, completed the VS QOL questionnaire: in total 704 of the 1414 participants.Distance and near visual acuities were measured and eye health was assessed. The VS QOL questionnaire administered by interview was analyzed using Rasch analysis, univariate analysis, and linear regression to determine associations between VS QOL, demographic factors, and levels of visual impairment.The Timor-Leste VS QOL questionnaire results.Rasch analysis confirmed that for participants both with and without visual impairment, the Timor-Leste VS QOL questionnaire provided a valid and reliable measure, was unidimensional, and had appropriate response categories. There was a consistent pattern of deterioration in VS QOL as vision worsened: for each category of distance- and near-vision impairment, there was an independent and significant change in Timor-Leste VS QOL scores between no visual impairment and either mild, moderate, or severe impairment (P0.05). Combined distance- and near-vision impairment was associated with a greater impact on VS QOL than categories separately, the impact of severe distance- and near-vision impairment being the greatest and clinically significant: -3.05 (95% confidence interval [CI], -3.60 to -2.49; P0.05; and 95% CI,-1.0). Distance vision (37.2%) contributed relatively more than near vision (4.7%) to the total variance in VS QOL (41.9%). Older people, those not married, not literate, and rural dwellers had significantly worse Timor-Leste VS QOL scores (P0.05).This study provides evidence of independent dose-response relationships between distance- and near-vision impairment and poorer VS QOL. Distance-vision impairment had a relatively larger impact on VS QOL than near-vision impairment. Combined distance- and near-vision impairment was associated with a greater impact on VS QOL compared with the independent impact of distance- or near-vision impairment at similar levels.

PURPOSE. To develop and determine the reliability and validity of a vision-specific quality-of-life instrument (TL-VSQOL) designed to assess the impact of distance and near vision impairment in adults living in Timor-Leste. METHODS. A vision-specific quality-of-life questionnaire was developed, piloted, and administered to 704 Timorese aged 40 years during a population-based eye health rapid assessment. Rasch analysis was performed on the data of 457 participants with presenting near vision worse than N8 (78.5%) and/or distance vision worse than 6/18 (69.8%). Unidimensionality, item fit to the model, response category performance, differential item functioning, and targeting of items to participants were assessed. RESULTS. Initially, the questionnaire lacked fit to the Rasch model. Removal of two items concerning emotional well-being resulted in a fit of the data (overall item‐trait interaction: 2 (df) 81 (51); mean (SD) person and item fit residual values: 0.30 (1.02) and 0.32 (1.46), and good targeting of person ability and item difficulty was evident. Poorer distance and near visual acuities were significantly associated with worse qualityof-life scores (P 0.001). Person separation reliability was substantial (0.93), indicating that the instrument can discriminate between groups with normal and impaired vision. All 17 items were free of differential item functioning, and there was no evidence of multidimensionality. CONCLUSIONS. This 17-item TL-VSQOL has high reliability, construct, and criterion validity and effective targeting. It can effectively assess the impact on quality of life of adult Timorese with distance and near vision impairment. The TLVSQOL could be adapted for use in other low-resource settings. (Invest Ophthalmol Vis Sci. 2008;49:4284‐4289)