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In 2021, WHO Member States endorsed a global target of a 40-percentage-point increase in effective refractive error coverage (eREC; with a 6/12 visual acuity threshold) by 2030. This study models global and regional estimates of eREC as a baseline for the WHO initiative.The Vision Loss Expert Group analysed data from 565 448 participants of 169 population-based eye surveys conducted since 2000 to calculate eREC (met need/[met need + undermet need + unmet need]). A binary logistic regression model was used to estimate eREC by Global Burden of Disease (GBD) Study super region among adults aged 50 years and older.In 2021, distance eREC was 79·1% (95% CI 72·4-85·0) in the high-income super region; 62·1% (54·7-68·8) in north Africa and Middle East; 49·5% (45·0-54·0) in central Europe, eastern Europe, and central Asia; 40·0% (31·7-48·2) in southeast Asia, east Asia, and Oceania; 34·5% (29·4-40·0) in Latin America and the Caribbean; 9·0% (6·5-12·0) in south Asia; and 5·7% (3·1-9·0) in sub-Saharan Africa. eREC was higher in men and reduced with increasing age. Global distance eREC increased from 2000 to 2021 by 19·0%. Global near vision eREC for 2021 was 20·5% (95% CI 17·8-24·4).Over the past 20 years, distance eREC has increased in each super region yet the WHO target will require substantial improvements in quantity and quality of refractive services in particular for near vision impairment.WHO, Sightsavers, The Fred Hollows Foundation, Fondation Thea, Brien Holden Vision Institute, Lions Clubs International Foundation.

Cataract surgery is a safe, effective and common elective procedure in Australia but access is inequitable. True waiting times for cataract care are undisclosed or inconsistently reported by governments. Estimates of true waiting times range from 4 to 30 months and have been extended during the coronavirus disease 2019 (COVID-19) pandemic. Comparative analysis revealed that reducing waiting periods from 12 to 3 months would result in estimated public health system cost savings of $6.6 million by preventing 50 679 falls. Investment in public cataract services to address current unmet needs would prevent avoidable vision impairment and associated negative consequences.

BACKGROUND The prevalence of myopia is increasing globally including in Europe and parts of Asia but Australian data are lacking. This study aim described the change in myopia prevalence in middle-aged Australian adults over approximately a 20-year period. METHODS Two contemporary Western Australian studies (conducted in mid-late 2010s): the coastal-regional Busselton Healthy Ageing Study (BHAS) and the urban Gen1 of the Raine Study (G1RS) were compared to two earlier studies (early-mid 1990s) in Australia: the urban Blue Mountains Eye Study (BMES) and urban/regional Melbourne Visual Impairment Project (MVIP). Refractive error was measured by autorefraction, vertometry, or subjective refraction. Participants (49-70 years) of European descent without self-reported/diagnosed cataract, corneal disease, or refractive or corneal surgery were included. RESULTS After exclusions, data were available from 2217, 1760, 700, 2987 and 756 participants from BMES, urban MVIP, regional MVIP, BHAS, and G1RS, respectively. The mean age ranged from 57.1 ± 4.6 years in the G1RS to 60.1 ± 6.0 years in the BMES; 44-48% of participants were male. When stratified by location, the contemporary urban G1RS cohort had a higher age-standardised myopia prevalence than the urban MVIP and BMES cohorts (29.2%, 16.4%, and 23.9%, p

Diabetic retinopathy (DR) is a global health burden. Screening for sight-threatening DR (STDR) is the first cost-effective step to decrease this burden. We analyzed the similarities and variations between the recent country-specific and the International Council of Ophthalmology (ICO) DR guideline to identify gaps and suggest possible solutions for future universal screening. We selected six representative national DR guidelines, one from each World Health Organization region, including Canada (North America), England (Europe), India (South- East Asia), Kenya (Africa), New Zealand (Western Pacific), and American Academy of Ophthalmology Preferred Practice Pattern (used in Latin America and East Mediterranean). We weighed the newer camera and artificial intelligence (AI) technology against the traditional screening methodologies. All guidelines agree that screening for DR and STDR in people with diabetes is currently led by an ophthalmologist; few engage non-ophthalmologists. Significant variations exist in the screening location and referral timelines. Screening with digital fundus photography has largely replaced traditional slit-lamp examination and ophthalmoscopy. The use of mydriatic digital 2-or 4-field fundus photography is the current norm; there is increasing interest in using non-mydriatic fundus cameras. The use of automated DR grading and tele-screening is currently sparse. Country-specific guidelines are necessary to align with national priorities and human resources. International guidelines such as the ICO DR guidelines remain useful in countries where no guidelines exist. Validation studies on AI and tele-screening call for urgent policy decisions to integrate DR screening into universal health coverage to reduce this global public health burden.摘要: 糖尿病视网膜病变(DR)是全球性的健康负担。筛查威胁视力的DR (STDR)是降低这一负担的第一个具有成本效益的步骤。我们分析了不同国家特有的指南和国际眼科理事会(ICO)指南之间的共同点和差异点, 以确定差距, 并为未来的普遍筛查提出可能的解决方案。我们选择了六个具有代表性国家的DR指南, 每个世界卫生组织区域各一个, 包括加拿大 (北美) 、英国 (欧洲) 、印度 (东南亚) 、肯尼亚 (非洲) 、新西兰 (西太平洋) 和美国眼科学会首选的临床模式 (拉丁美洲和东地中海) 。我们考量了较新的照相技术、人工智能 (AI) 技术与传统筛查方法之间的差别。所有指南都认为糖尿病患者的DR和STDR筛查应该由眼科医生主导进行, 仅少量主张非眼科医生参与。但筛选地点和转诊时间不同指南之间存在显著差异。数字眼底照相筛检在很大程度上取代了传统的裂隙灯检查和检眼镜。散瞳后的数字眼底照相视野2个或4个视野范围是目前的标准, 但免散瞳的眼底照相也逐渐兴起。目前很少使用自动进行DR分级和远程筛查。根据各国的重点政策和人力资源情况制定相应的具体指南必不可少。但国际指南如ICO-DR指南在没有具体指南的国家仍然可以使用。为了减轻这一全球公共卫生负担, 有关AI和远程筛查的有效性研究需要立刻进行政策决策, 以将DR筛查纳入全民健康的覆盖范围。.

AIM: To determine the prevalence and associations of non-retinopathy ocular conditions among older Australian adults with diabetes. METHODS: Multistage random-cluster sampling was used to select 3098 non-indigenous Australians aged 50y or older (46.4% male) and 1738 indigenous Australians aged 40y or older (41.1% male) from all levels of geographic remoteness in Australia. Participants underwent a standardised questionnaire to ascertain diabetes history, and a clinical examination to identify eye disease. We determined the prevalence of uncorrected refractive error, visually significant cataract, cataract surgery, age-related macular degeneration, glaucoma, ocular hypertension, retinal vein occlusion and epiretinal membrane among those with and without self-reported diabetes. RESULTS: Participants with self-reported diabetes had a higher prevalence of cataract surgery than those without diabetes (28.8% vs 16.9%, OR 1.78, 95%CI: 1.35-2.34 among non-indigenous Australians, and 11.3% vs 5.2%, OR 1.62, 95%CI: 1.22-2.14 among indigenous Australians). Diabetic retinopathy (DR) increased the odds of cataract surgery among self-reported diabetic indigenous and non-indigenous Australians (OR 1.89, P=0.004 and OR 2.33, P

A simplified grading system for trachoma was published by the World Health Organization (WHO) in 1987. Intended for use by non-specialist personnel working at community level, the system includes five signs, each of which can be present or absent in any eye: (i) trachomatous trichiasis; (ii) corneal opacity; (iii) trachomatous inflammation-follicular; (iv) trachomatous inflammation-intense; and (v) trachomatous scarring. Though neither perfectly sensitive nor perfectly specific for trachoma, these signs have been essential tools for identifying populations that need interventions to eliminate trachoma as a public health problem. In 2018, at WHO's 4th global scientific meeting on trachoma, the definition of one of the signs, trachomatous trichiasis, was amended to exclude trichiasis that affects only the lower eyelid. This paper presents the amended system, updates its presentation, offers notes on its use and identifies areas of ongoing debate.En 1987, l'Organisation mondiale de la Santé a publié un système de codage simplifié du trachome. Destiné au personnel non qualifié travaillant au sein des communautés, il comporte cinq signes, chacun pouvant être présent ou absent dans l'un ou l'autre œil: (i) le trichiasis trachomateux; (ii) l'opacité cornéenne; (iii) l'inflammation trachomateuse — folliculaire; (iv) l'inflammation trachomateuse — intense; et enfin, (v) la cicatrice trachomateuse. Bien qu'ils ne soient ni parfaitement précis, ni totalement spécifiques au trachome, ces signes constituent des outils essentiels pour identifier les populations qui nécessitent une intervention afin d'éliminer le trachome en tant que problème de santé publique. En 2018, lors de la quatrième réunion scientifique mondiale sur le trachome, la définition de l'un des signes, le trichiasis trachomateux, a été modifiée pour exclure du système de codage le trichiasis qui n'affecte que la paupière inférieure. Ce document expose le nouveau système, actualise sa présentation, formule des remarques sur son utilisation et identifie les domaines qui font encore l'objet de débats.En 1987, la Organización Mundial de la Salud (OMS) publicó un sistema de clasificación simplificado para el tracoma. Este sistema fue diseñado para que lo utilice el personal no especializado que trabaja a nivel comunitario e incluye cinco signos, cada uno de los cuales puede estar presente o ausente en los ojos: i) la triquiasis tracomatosa; ii) la opacidad corneal; iii) la inflamación tracomatosa-folicular; iv) la inflamación tracomatosa-intensa; y v) la cicatrización tracomatosa. Si bien no son perfectamente sensibles ni muy específicos del tracoma, estos signos han sido herramientas esenciales para identificar a las poblaciones que requieren intervenciones para eliminar el tracoma como problema de salud pública. En 2018, se modificó la definición de uno de los signos, la triquiasis tracomatosa, en la 4.ª Reunión Científica Mundial sobre el Tracoma de la OMS, para descartar la triquiasis que solo afecta al párpado inferior. En el presente documento se describe el sistema modificado, se actualiza su presentación, se ofrecen observaciones sobre su aplicación y se identifican los ámbitos de debate en curso.تم نشر نظام تصنيف مبسط للتراكوما من جانب منظمة الصحة العالمية (WHO) في عام 1987. وهو مخصص للاستخدام بواسطة الأشخاص غير المتخصصين الذين يعملون على مستوى المجتمع، ويشمل النظام خمس علامات يمكن أن يكون كل منها موجودًا أو غير موجود في أي عين: (1) داء الشعرة التراكومي؛ و(2) عتامة القرنية؛ و(3) الالتهاب الجريبي التراكومي؛ و(4) الالتهاب التراكومي الشديد؛ و(5) التندب التراكومي. وبالرغم من أن هذه العلامات لم تكن حساسة للغاية أو محددة للإصابة بالتراكوما، إلا أنها كانت مؤشرات أساسية لتحديد السكان الذين يحتاجون إلى تدخلات طبية للقضاء على التراكوما كمشكلة صحية عامة. في عام 2018، في الاجتماع العلمي العالمي الرابع لمنظمة الصحة العالمية حول التراكوما، تم تعديل تعريف إحدى العلامات، وهو داء الشعرة التراكومي، وذلك لاستبعاد داء الشعرة الذي يصيب الجفن السفلي فقط. تعرض هذه الورقة النظام المعدل، وتقوم بتحديث عرضه التقديمي، وتقدم ملاحظات حول استخدامه، وتحدد مجالات النقاش الدائر.1987 年,世界卫生组织 (WHO) 公布了沙眼简化分级系统。该系统旨在供社区非专业工作人员使用，具备五种体征，其中每个体征都可出现于任一眼睛中，也可能不出现：(I) 沙眼性倒睫；(ii) 角膜混浊； (iii) 沙眼性炎症-滤泡； (iv) 沙眼性剧烈-炎症；以及 (v) 沙眼性疤痕。尽管对沙眼而言，这些体征即非特别敏感，也非专属于沙眼，但其已是确定哪些民众需通过干预消除沙眼这个公共卫生问题的关键。2018 年世卫组织第四届全球沙眼科学会议对沙眼性倒睫的定义进行了修正，排除了仅影响下眼睑的倒睫。本文介绍了修正后的系统，并更新了其介绍，给出了使用说明，并确定了正在讨论中的领域。.В 1987 году Всемирная организация здравоохранения (ВОЗ) опубликовала упрощенную систему оценки трахомы. Предназначенная для использования неспециализированным персоналом, работающим на местном уровне, система включает пять признаков, каждый из которых может присутствовать или отсутствовать в любом глазу: (i) трахоматозный трихиаз; (ii) помутнение роговицы; (iii) трахоматозное воспаление фолликулярное; (iv) трахоматозное воспаление интенсивное; (v) трахоматозное рубцевание. Хотя эти признаки не являются ни абсолютно чувствительными, ни абсолютно специфичными для трахомы, они были важными инструментами для выявления групп населения, которым необходимы вмешательства для устранения трахомы как проблемы общественного здравоохранения. В 2018 году на 4-й Всемирной научной конференции ВОЗ по вопросам трахомы определение одного из признаков, трахоматозного трихиаза, было изменено, чтобы исключить трихиаз, поражающий только нижнее веко. В данном документе приведена измененная система, обновлено ее представление, даны примечания по ее использованию и определены сферы текущих дискуссий.

Background/AimsThe International Council of Ophthalmology (ICO) offers fellowship programmes to help young ophthalmologists, mainly from low-resource countries, improve their practical or research skills in ophthalmology subspecialty areas. Using questionnaires, the objective of the present study was to evaluate how the ICO Fellowship Programme has impacted on improving knowledge, skills and the careers of young ophthalmologists from low-resource countries.MethodsFrom 2001 to 2019 overall 1140 ICO fellowships were awarded. A questionnaire was sent to ICO fellows after the conclusion of their fellowship and another 3 years later. Part 1 contained 26 questions, while Part 2 had 21 questions. The answers were collected through an online platform and analysed descriptively thereafter.Results1101 Part 1 questionnaires had been sent to former fellows, with a return rate of 47% (516 responses) and 829 Part 2 questionnaires with a return rate of 47% (390 responses). Overall, 98.3% strongly or somewhat agreed that knowledge in their subspecialty has improved considerably. Whereas only 19% of them held a lecturer, senior lecturer or head of subspecialty department position prior to the fellowship, 46% of them held such a position 3 years after the fellowship was completed.ConclusionsThe ICO Fellowship Programmes aim to promote the enhancement of eye care delivery and eye health in low-resource countries, the professional development of young leaders and the improvement of eye care. The results of the current study confirm the expectation of such a positive impact. Moreover, almost half of the responding participants have been appointed to a local leadership position in their home country.

IMPORTANCE: Projections of Australia's future burden of vision loss will inform eye health service delivery. BACKGROUND: This study aimed to forecast bilateral vision loss in Australia from 2020 to 2050. DESIGN: Population-based survey. PARTICIPANTS: Indigenous and non-indigenous Australians (n = 4253) aged ≥50 years from the National Eye Health Survey (NEHS, 2015-2016). METHODS: Using the age-and-sex-stratified prevalence of vision loss (better eye visual acuity

Cataract remains the leading cause of blindness in Aboriginal and Torres Strait Islander peoples and is still a major cause of vision loss. The pathway of care to cataract surgery has many potential gaps and barriers. Although there has been a significant increase in services over the last few years, there is still the urgent need to facilitate timely and affordable cataract surgery. Particularly for public surgery there needs to be a significant decrease in waiting times for the clinical assessment of those needing surgery and for those on a surgical waiting list.

Background/aimsTo estimate 2015 global ophthalmologist data and analyse their relationship to income groups, prevalence rates of blindness and visual impairment and gross domestic product (GDP) per capita.MethodsOnline surveys were emailed to presidents/chairpersons of national societies of ophthalmology and Ministry of Health representatives from all 194 countries to capture the number and density (per million population) of ophthalmologists, the number/density performing cataract surgery and refraction, and annual ophthalmologist population growth trends. Correlations between these data and income group, GDP per capita and prevalence rates of blindness and visual impairment were analysed.ResultsIn 2015, there were an estimated 232 866 ophthalmologists in 194 countries. Income was positively associated with ophthalmologist density (a mean 3.7 per million population in low-income countries vs a mean 76.2 in high-income countries). Most countries reported positive growth (94/156; 60.3%). There was a weak, inverse correlation between the prevalence of blindness and the ophthalmologist density. There were weak, positive correlations between the density of ophthalmologists performing cataract surgery and GDP per capita and the prevalence of blindness, as well as between GDP per capita and the density of ophthalmologists doing refractions.ConclusionsAlthough the estimated global ophthalmologist workforce appears to be growing, the appropriate distribution of the eye care workforce and the development of comprehensive eye care delivery systems are needed to ensure that eye care needs are universally met.

Purpose To report establishment of the Magrabi ICO Cameroon Eye Institute at Yaounde, Cameroon, as an ophthalmology subspecialty patient care and training center in Central Africa. Design Perspective. Methods Assessment of unpublished and published material. Results To improve, preserve and restore eye health and vision in a region with world-high prevalence of functional vision impairment and blindness, the Africa Eye Foundation established the Magrabi ICO Cameroon Eye Institute as an ophthalmology subspecialty patient care center for all in need and a training center for ophthalmologists, ophthalmology subspecialists, and allied personnel. In 2017, the year of its inauguration and the first year of operation, the Magrabi ICO Cameroon Eye Institute provided ophthalmology subspecialty care to more than 25 000 patients and surgery for pediatric and adult cataract, glaucoma, retinal disease, oculoplastic disorders, and other vision-threatening conditions. Outreach programs extended care to an additional 2500 individuals in rural communities and 7 training courses were conducted for ophthalmologists and allied personnel. Conclusion Through ophthalmology subspecialty patient care and the training of ophthalmologists and allied personnel, Magrabi ICO Cameroon Eye Institute is acting to enhance vision and the quality of life for individuals and families in all segments of society.

Potential environmental sources of oxidative damage to the lens and retina are cigarette smoke and sunlight exposure. Ultraviolet radiation, specifically UV-B in the range 290 to 320 nm, has been implicated in the development of age-related cataract. Research in laboratory animals and with cadaver lenses has shown that UVB is absorbed by the lens and that cataract can be induced by the introduction of UV-B radiation. Investigators from the Chesapeake Bay Watermen Study revealed that recent sunlight exposure was strongly related to geographic atrophy, suggesting that the normal mechanisms of retinal photooxidative repair may decrease with age. The role of solar UV radiation in the development of climatic droplet keratopathy, ocular melanoma, pinguecela and carcinoma in situ was reviewed recently by a WHO task group. The epidemiologic data support a role for sunlight in the development of cataract and pterygium, and possibly AMD, but more data are needed.

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.

Neglected Tropical Diseases (NTDs) are a diverse set of communicable diseases that are usually prevalent in tropical and subtropical areas of 149 countries [1]. One in five people worldwide is at risk of NTDs. These diseases generally affect the poorest—approximately 1.6 billion people living in the most marginalized communities. In addition to the deaths they cause, NTDs also cause substantial disability, stigma, and loss of livelihood [2]. People living in poverty without adequate sanitation and in close contact with infectious vectors, domestic animals, and livestock are those worst affected (Fig. 13.1).

To ensure universal eye care coverage of a country’s population, good evidence of the need for services is required. This evidence comes from quality data on the prevalence and causes of vision impairment and blindness. These data are used to plan eye care services and to monitor and evaluate the outcomes of services and coverage of the needs.

Objective To present the prevalence of self-reported diabetes in Indigenous and non-Indigenous participants in the National Eye Health Survey. Research Design and Methods 3098 non-Indigenous Australians aged 50–98 years and 1738 Indigenous Australians aged 40–92 years were examined in 30 randomly selected sites, stratified by remoteness. A history of diabetes was obtained using an interviewer-administered questionnaire. Results 13.91% (431/3098) of non-Indigenous Australians and 37.11% (645/1738) of Indigenous Australians had self-reported diabetes. The age-adjusted prevalence of self-reported diabetes for non-Indigenous and Indigenous Australians was 11.49% and 43.77%, respectively (p

Background In the Solomon Islands and Vanuatu, the sign trachomatous inflammation—follicular (TF) is common, but ocular infection with Chlamydia trachomatis is not. It is therefore debatable whether azithromycin mass drug administration (MDA), the recommended antibiotic treatment strategy for trachoma’s elimination as a public health problem, is necessary in this setting. We set out to estimate what proportion of adolescents were at risk of progression of trachomatous scarring. Methods A cross-sectional survey was undertaken of all children aged 10–14 years resident in communities identified as high-TF clusters during previous population-based mapping. Graders examined children for clinical evidence of trachomatous scarring, pannus, and Herbert’s pits (HPs) or limbal follicles in both eyes. A dried blood spot was collected from each child and tested for antibodies to C. trachomatis. Results A total of 492 children in 24 villages of the Solomon Islands and Vanuatu were examined. In total, 35/492 (7%) of children had limbal signs (pannus and/or HPs) plus any conjunctival scarring. And 9/492 (2%) had limbal signs and moderate or severe conjunctival scarring; 22% of children were anti-Pgp3 seropositive. Conclusions Few adolescents here are at risk of future complications from trachoma, supporting the conclusion that further antibiotic MDA is not currently required for trachoma elimination purposes in these settings., In Solomon Islands and Vanuatu communities in which active trachoma prevalence in children was previously high, prevalence of Herbert’s pits or pannus plus conjunctival scarring in 10–14-year-olds is low, suggesting risk of future trachomatous blindness here is also low.

Background: The Vision Loss Expert Group and Global Burden of Disease Study have extensively updated estimates of global vision loss burden in 2020, temporal changeover 3 decades and forecasts for 2050. Methods: A systematic review and meta-analysis was conducted of population-based datasets relevant to vision impairment (VI) from January 1980 to October 2018. Hierarchical models were fitted to estimate 2020 prevalence (with 95% uncertainty intervals, UI) of (1) mild VI (presenting visual acuity [PVA] 6/12). Findings: In 2020, an estimated 43.2 million (95% UI: 37.5-48.2 million; 55% female) people were blind, 295.3 (95% UI 267.0-325.5) million had MSVI, 257.3 (95% UI 232.2-284.7) million had mild VI, and 507.4 million (95% UI 369.3–663.8) were VI from uncorrected presbyopia. Globally among adults aged ≥50 years, age-standardised prevalence of blindness reduced by 29% between 1990 and 2020, while MSVI increased slightly (+2.4%). The number of blind people increased by 50.2% and MSVI by 91.6%. By 2050, we predict 895.5 million people blind/VI. Interpretation: It is encouraging that age-adjusted prevalence of blindness has reduced over the past 3 decades, yet due to population growth progress is not keeping pace with needs. We face enormous challenges in avoiding vision impairment as the global population grows and ages. Funding Statement: Brien Holden Vision Institute. Fondation Thea. Fred Hollows Foundation. Gates Foundation. Sightsavers International. University of Heidelberg. Declaration of Interests: A.M. Bron, Allergan (C) Baush and Lomb (C), Santen (C), Thea (C) - (C) stands for consultant. J Kempen: Consultant (DSMC Chair) for Gilead. Grants and contracts from National Institutes of Health/National Eye Institute; Sight for Souls; and Christoffel Blindenmission. No other authors had conflicts to declare.

OBJECTIVE The goal of this study was to describe the development and validation of an artificial intelligence–based, deep learning algorithm (DLA) for the detection of referable diabetic retinopathy (DR). RESEARCH DESIGN AND METHODS A DLA using a convolutional neural network was developed for automated detection of vision-threatening referable DR (preproliferative DR or worse, diabetic macular edema, or both). The DLA was tested by using a set of 106,244 nonstereoscopic retinal images. A panel of ophthalmologists graded DR severity in retinal photographs included in the development and internal validation data sets (n = 71,043); a reference standard grading was assigned once three graders achieved consistent grading outcomes. For external validation, we tested our DLA using 35,201 images of 14,520 eyes (904 eyes with any DR; 401 eyes with vision-threatening referable DR) from population-based cohorts of Malays, Caucasian Australians, and Indigenous Australians. RESULTS Among the 71,043 retinal images in the training and validation data sets, 12,329 showed vision-threatening referable DR. In the internal validation data set, the area under the curve (AUC), sensitivity, and specificity of the DLA for vision-threatening referable DR were 0.989, 97.0%, and 91.4%, respectively. Testing against the independent, multiethnic data set achieved an AUC, sensitivity, and specificity of 0.955, 92.5%, and 98.5%, respectively. Among false-positive cases, 85.6% were due to a misclassification of mild or moderate DR. Undetected intraretinal microvascular abnormalities accounted for 77.3% of all false-negative cases. CONCLUSIONS This artificial intelligence–based DLA can be used with high accuracy in the detection of vision-threatening referable DR in retinal images. This technology offers potential to increase the efficiency and accessibility of DR screening programs.

Diabetes mellitus (DM) is a global epidemic and affects populations in both developing and developed countries, with differing health care and resource levels. Diabetic retinopathy (DR) is a major complication of DM and a leading cause of vision loss in working middle-aged adults. Vision loss from DR can be prevented with broad-level public health strategies, but these need to be tailored to a country's and population's resource setting. Designing DR screening programs, with appropriate and timely referral to facilities with trained eye care professionals, and using cost-effective treatment for vision-threatening levels of DR can prevent vision loss. The International Council of Ophthalmology Guidelines for Diabetic Eye Care 2017 summarize and offer a comprehensive guide for DR screening, referral and follow-up schedules for DR, and appropriate management of vision-threatening DR, including diabetic macular edema (DME) and proliferative DR, for countries with high- and low- or intermediate-resource settings. The guidelines include updated evidence on screening and referral criteria, the minimum requirements for a screening vision and retinal examination, follow-up care, and management of DR and DME, including laser photocoagulation and appropriate use of intravitreal anti-vascular endothelial growth factor inhibitors and, in specific situations, intravitreal corticosteroids. Recommendations for management of DR in patients during pregnancy and with concomitant cataract also are included. The guidelines offer suggestions for monitoring outcomes and indicators of success at a population level.

The actual numbers of people blind or with poor vision continue to increase despite so excellent progress that is being made in reducing the prevalence or percentage of people affected. More attention is required to provide quality outcomes for cataract surgery, prevent and manage myopia, detect and treat diabetic retinopathy, glaucoma, and age-related macular degeneration (AMD). Although more ophthalmologists are needed to provide this eye care, it is important that ophthalmologists work in effective teams with allied eye health personal to be able to meet the community needs.

AimTo estimate the prevalence of glaucoma in Australia.MethodsThis was a population-based study of 3098 non-Indigenous Australians (50–98 years) and 1738 Indigenous Australians (40–92 years) stratified by remoteness. Each participant underwent a standard examination that included visual field assessment, tonometry and non-mydriatic fundus photography. Two fellowship-trained glaucoma specialists independently assessed relevant case notes (past ocular history, best-corrected visual acuity, frequency doubling technology visual fields, Van Herick grade, intraocular pressure and optic disc-centred photographs) and assigned a diagnosis ranked on a scale of certainty: none, possible, probable or definite glaucoma.ResultsA total of 4792 (99.1%, 3062 non-Indigenous and 1730 Indigenous) participants had retinal photographs in at least one eye that were gradable for glaucoma. The weighted prevalence of glaucoma (definite) in non-Indigenous Australians and Indigenous Australians was 1.5% (95% CI 1.0 to 2.2) and 0.6% (95% CI 0.4 to 1.1), respectively. When definite and probable cases of glaucoma were combined, rates were 3.4% (95% CI 2.7 to 4.3) among non-Indigenous and 1.6% (95% CI 1.1 to 2.3) in Indigenous Australians. Only 52.4% of non-Indigenous Australians and 28.0% of Indigenous Australians with glaucoma self-reported a known history of glaucoma.ConclusionWe estimate that 198 923 non-Indigenous Australians aged 50 years and over and 2139 Indigenous Australians aged 40 years and over have glaucoma. Given the high rates of undiagnosed glaucoma coupled with a significant ageing of the Australian population, improvements in case detection and access to low vision rehabilitation services may be required to cope with the growing burden of glaucoma.

PURPOSE: To describe the prevalence and associations of presenting near vision impairment (NVI) in Indigenous and non-Indigenous Australians. METHODS: A sample of 3098 non-Indigenous Australians (aged 50–98 years) and 1738 Indigenous Australians (aged 40–92 years) living in 30 randomly selected Australian sites were examined as part of the population-based National Eye Health Survey (NEHS). Binocular presenting NVI was defined as near vision worse than N8 (20/50). RESULTS: In total, 4817 participants (99.6% of the total sample, comprising 3084 non-Indigenous Australians and 1733 Indigenous Australians) had complete data on near visual acuity. The overall weighted prevalence of presenting NVI was 21.6% (95% CI: 19.6, 23.8) in non-Indigenous Australians and 34.7% (95% CI: 29.2, 40.8) among Indigenous Australians. In the non-Indigenous population, higher odds of presenting NVI were associated with older age (OR=1.68 per 10 years, P

AimTo assess the visual outcomes of cataract surgery among a national sample of non-Indigenous and Indigenous Australians.MethodsThis was a population-based study of 3098 non-Indigenous Australians (50–98 years) and 1738 Indigenous Australians (40–92 years), stratified by remoteness. A poor postoperative outcome in an eye that had undergone cataract surgery was defined as presenting distance visual acuity (PVA) ResultsThe sampling weight adjusted cataract surgery prevalence was 19.8% (95% CI 17.9 to 22.0) in non-Indigenous Australians and 8.2% (95% CI 6.0 to 9.6) in Indigenous Australians. Among the non-Indigenous population, poor and very poor PVA outcomes were present in 18.1% and 1.9% of eyes, respectively. For Indigenous Australians, these values were 27.8% and 6.3%, respectively. The main causes of poor vision were refractive error (non-Indigenous=41.8%; Indigenous=41.9%) and coincident disease (non-Indigenous=43.3%; Indigenous=40.3%). The eCSC rates in the non-Indigenous and Indigenous populations were 88.5% (95% CI 85.2 to 91.2) and 51.6% (95% CI 42.4 to 60.7), respectively.ConclusionApproximately half of eyes with a poor visual outcome postcataract surgery could be readily avoided through the appropriate refractive correction. The finding of a lower eCSC rate among Indigenous Australians suggests that improvements in access and quality of cataract services may be warranted in order to reduce cataract-related vision loss in the Indigenous population.

Author(s): Ung, Lawson; Acharya, Nisha R; Agarwal, Tushar; Alfonso, Eduardo C; Bagga, Bhupesh; Bispo, Paulo Jm; Burton, Matthew J; Dart, John Kg; Doan, Thuy; Fleiszig, Suzanne Mj; Garg, Prashant; Gilmore, Michael S; Gritz, David C; Hazlett, Linda D; Iovieno, Alfonso; Jhanji, Vishal; Kempen, John H; Lee, Cecilia S; Lietman, Thomas M; Margolis, Todd P; McLeod, Stephen D; Mehta, Jod S; Miller, Darlene; Pearlman, Eric; Prajna, Lalitha; Prajna, N Venkatesh; Seitzman, Gerami D; Shanbhag, Swapna S; Sharma, Namrata; Sharma, Savitri; Srinivasan, Muthiah; Stapleton, Fiona; Tan, Donald Th; Tandon, Radhika; Taylor, Hugh R; Tu, Elmer Y; Tuli, Sonal S; Vajpayee, Rasik B; Van Gelder, Russell N; Watson, Stephanie L; Zegans, Michael E; Chodosh, James

Purpose: To conduct a nationwide survey on the prevalence and causes of vision impairment and blindness in Indigenous and non-Indigenous Australians. \ud Design: Nationwide, cross-sectional, population-based field survey. Participants: Indigenous Australians aged 40 years or older and non-Indigenous Australians aged 50 years or more randomly sampled from all levels of geographic remoteness in Australia. \ud Methods: Multistage random-cluster sampling was used to select 3098 non-Indigenous Australians and 1738 Indigenous Australians from 30 sites across 5 remoteness strata with a response rate of 71.5%. Sociodemographic and health data were collected using an interviewer-administered questionnaire. Trained examiners conducted standardized eye examinations, including visual acuity, perimetry, slit-lamp examination, intraocular pressure, and fundus photography. The prevalence and main causes of bilateral presenting vision loss (visual acuity worse than 6/12 in the better eye) were determined, and risk factor analysis was conducted. \ud Main Outcome Measures: The prevalence and main causes of vision impairment and blindness. \ud Results: The overall prevalence of vision loss in Australia was 6.6% (95% confidence interval [CI], 5.4e7.8). The prevalence of vision loss was 11.2% (95% CI, 9.5e13.1) in Indigenous Australians and 6.5% (95% CI, 5.3e7.9) in non-Indigenous Australians. Vision loss was 2.8 times more prevalent in Indigenous Australians than in non-Indigenous Australians after age and gender adjustment (17.7%, 95% CI, 14.5e21.0 vs. 6.4%, 95% CI, 5.2e7.6, P < 0.001). In non-Indigenous Australians, the leading causes of vision loss were uncorrected refractive error (61.3%), cataract (13.2%), and age-related macular degeneration (10.3%). In Indigenous Australians, the leading causes of vision loss were uncorrected refractive error (60.8%), cataract (20.1%), and diabetic retinopathy (5.2%). In non-Indigenous Australians, increasing age (odds ratio [OR], 1.72 per decade; 95% CI, 1.40e2.10) and having not had an eye examination within the past year (OR, 1.61; 95% CI, 1.06e2.42) were risk factors for vision loss. Risk factors in Indigenous Australians included older age (OR, 1.61 per decade; 95% CI, 1.34e1.95), remoteness (OR, 2.02; 95% CI, 1.23e3.31), gender (OR, 0.60 for men; 95% CI, 0.42e0.84), and diabetes in combination with never having had an eye examination (OR, 14.47; 95% CI, 5.65e37.05). \ud Conclusions: Vision loss is more prevalent in Indigenous Australians than in non-Indigenous Australians, highlighting that improvements in eye healthcare in Indigenous communities are required. The leading causes of vision loss were uncorrected refractive error and cataract, which are readily treatable. Other countries with Indigenous communities may benefit from conducting similar surveys of Indigenous and non-Indigenous populations.

Background To determine the prevalence of vision loss due to ocular trauma in Australia. Methods The National Eye Health Survey (NEHS) is a population-based cross-sectional study that examined 3098 non-Indigenous Australians (aged 50–98 years) and 1738 Indigenous Australians (aged 40–92 years) living in 30 randomly selected sites, stratified by remoteness. An eye was considered to have vision loss due to trauma if the best-corrected visual acuity was worse than 6/12 and the main cause was attributed to ocular trauma. This determination was made by two independent ophthalmologists and any disagreements were adjudicated by a third senior ophthalmologist. Results The sampling weight adjusted prevalence of vision loss due to ocular trauma in non-Indigenous Australians aged 50 years and older and Indigenous Australians aged 40 years and over was 0.24% (95% CI: 0.10, 0.52) and 0.79% (95% CI: 0.56, 1.13), respectively. Trauma was attributed as an underlying cause of bilateral vision loss in one Indigenous participant, with all other cases being monocular. Males displayed a higher prevalence of vision loss from ocular trauma than females in both the non-Indigenous (0.47% vs. 1.25%, p = 0.03) and Indigenous populations (0.12% vs. 0.38%, p = 0.02). After multivariate adjustments, residing in Very Remote geographical areas was associated with higher odds of vision loss from ocular trauma. Conclusions We estimate that 2.4 per 1000 non-Indigenous and 7.9 per 1000 Indigenous Australian adults have monocular vision loss due to a previous severe ocular trauma. Our findings indicate that males, Indigenous Australians and those residing in Very Remote communities may benefit from targeted health promotion to improve awareness of trauma prevention strategies.

Importance National data on eye healthcare service utilisation will inform Australia's eye health policy. Background To investigate the utilisation of eye healthcare services by Australians. Design Cross-sectional survey Participants Indigenous Australians aged 40 years and older and non-Indigenous Australians aged 50 years and older. Methods 1738 Indigenous Australians and 3098 non-Indigenous Australians were recruited from 30 randomly-selected sites, stratified by remoteness. Sociodemographic, ocular history, and eye healthcare service utilisation data were collected, and an eye examination was conducted. Main outcome measures Recentness of eye examinations, types of providers used, and associated risk factors. Results 67.0% of Indigenous Australians and 82.5% of non-Indigenous Australians underwent an eye examination within the previous two years. Indigenous status (p

IMPORTANCE: In Australia, knowledge of the epidemiology of retinal vein occlusion remains scarce because of a paucity of recent population-based data. The National Eye Health Survey (2015-2016) provides an up-to-date estimate of the prevalence of retinal vein occlusion in non-Indigenous and Indigenous Australian adults. BACKGROUND: To determine the prevalence and associations of retinal vein occlusion in a national sample of Indigenous and non-Indigenous Australian adults. DESIGN: Population-based cross-sectional study. PARTICIPANTS: A total of 3098 non-Indigenous Australians (aged 50-98 years) and 1738 Indigenous Australians (aged 40-92 years) living in 30 randomly selected sites, stratified by remoteness. METHODS: Retinal vein occlusions were graded from retinal photographs using standardized protocols and recorded as central retinal vein occlusion or branch retinal vein occlusion. MAIN OUTCOME MEASURE: Prevalence of retinal vein occlusion. RESULTS: In the non-Indigenous population, the sampling weight adjusted prevalence of any retinal vein occlusion was 0.96% (95% confidence interval: 0.59, 1.6), with branch retinal vein occlusion observed in 0.72% (95% confidence interval: 0.41, 1.2) and central retinal vein occlusion in 0.24% (95% confidence interval: 0.13, 0.47). Any retinal vein occlusion was found in 0.91% (95% confidence interval: 0.47, 1.7) of Indigenous Australians aged 40 years and over, with branch retinal vein occlusion observed in 0.83% (95% confidence interval: 0.40, 1.7) and central retinal vein occlusion in 0.07% (95% confidence interval: 0.02, 0.32). Older age (odds ratio = 1.64 per 10 years, P = 0.006) and the presence of self-reported diabetes (odds ratio = 3.24, P = 0.006) were associated with any retinal vein occlusion after multivariable adjustments. Retinal vein occlusion was attributed as the cause of monocular vision loss (

Purpose To determine the prevalence of and factors associated with diabetic retinopathy (DR) among non-Indigenous and Indigenous Australian adults with self-reported diabetes. Design Population-based cross-sectional study. Participants Non-Indigenous Australians (50–98 years of age) and Indigenous Australians (40–92 years of age) with known diabetes. Methods Diabetes was determined based on self-report of previous diagnosis of the disease. Nonmydriatic fundus photographs were obtained of each eye and graded according to the modified Airlie House classification system. Main Outcome Measures Any DR, vision-threatening DR (VTDR), treatment coverage rates (proportion of participants with proliferative DR [PDR], clinically significant macular edema [CSME], or both who had evidence of retinal scatter and focal laser treatment). Results Four hundred thirty-one non-Indigenous Australians (13.9%) and 645 Indigenous Australians (37.1%) self-reported diabetes, of whom 93% (1004/1076) had retinal images that were gradable for DR. The sampling weight-adjusted prevalence of any DR and VTDR among non-Indigenous adults with self-reported diabetes was 28.5% (95% confidence interval [CI], 22.6–35.3) and 4.5% (95% CI, 2.6–7.9), respectively. Among adults 40 years of age and older, the sampling weight-adjusted prevalence of any DR and VTDR was 39.4% (95% CI, 33.1–46.1) and 9.5% (95% CI, 6.8–13.1), respectively. Longer diabetes duration was associated significantly with VTDR in the Indigenous Australian population (odds ratio [OR], 1.08 per 1-year increase; P = 0.005) and non-Indigenous Australian population (OR, 1.05 per 1-year increase; P = 0.03). The treatment coverage of PDR and CSME was 75% (56/75) in Indigenous Australians and 79% (15/19) in non-Indigenous Australians. Diabetic retinopathy was attributed as the main cause of vision loss ( Conclusions Three quarters of non-Indigenous and Indigenous Australian adults with PDR or CSME have received laser treatment. The prevalence of VTDR in Indigenous and non-Indigenous Australians in the present study was lower than that found in previous population-based reports, nevertheless, approximately 1 in 10 Indigenous adults with known diabetes experience VTDR. This highlights that intensified prevention strategies are required to delay or prevent avoidable vision loss resulting from DR in Indigenous Australian communities.

OBJECTIVE: To determine adherence to NHMRC eye examination guidelines for Indigenous and non-Indigenous Australian people with diabetes. DESIGN: Cross-sectional survey using multistage, random cluster sampling. SETTING: Thirty randomly selected geographic sites in the five mainland Australian states and the Northern Territory, stratified by remoteness. PARTICIPANTS: 1738 Indigenous Australians aged 40-92 years and 3098 non-Indigenous Australians aged 50-98 years were recruited and examined between March 2015 and April 2016 according to a standardised protocol that included a questionnaire (administered by an interviewer) and a series of standard eye tests. MAIN OUTCOME MEASURES: Adherence rates to NHMRC eye examination guidelines; factors influencing adherence. RESULTS: Adherence to screening recommendations was significantly greater among non-Indigenous Australians (biennial screening; 77.5%) than Indigenous Australians (annual screening; 52.7%; P

To present the recruitment and testing methodology of the National Eye Health Survey (NEHS), a population-based study that aimed to determine the prevalence and causes of vision impairment and blindness in Australia.Non-Indigenous Australians aged 50 years and older and Indigenous Australians aged 40 years and older were recruited using a door-to-door approach from 30 randomly selected geographical areas, stratified by remoteness. Participants underwent a vision examination, anterior segment assessment, intraocular pressure testing, perimetry, and fundus photography.In total, recruiters approached 23,235 residences, and 11,883 residents were successfully contacted (51.1%). Of these, 6760 (56.9%) were deemed eligible and 5764 agreed to participate (positive response rate = 85.3%). Of those who agreed, 4836 residents attended the examination (4836/6760 = 71.5%). This included 1738 Indigenous Australians (41.1% male) aged 40-92 years (mean ± standard deviation = 55.0 ± 10.0 years) and 3098 non-Indigenous Australians (46.4% male), aged 50-98 years (mean ± standard deviation = 66.6 ± 9.7 years).The NEHS achieved an excellent positive response rate, and the data collected from 4836 Australians will provide the first population-based national estimate of the prevalence of vision impairment and blindness. This data will guide future economic analysis, policy formulation, and eye health service delivery in Australia.