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Global estimates indicate that more than 2.3 billion people in the world suffer from poor vision due to refractive error; of which 670 million people are considered visually impaired because they do not have access to corrective treatment. Refractive errors, if uncorrected, results in an impaired quality of life for millions of people worldwide, irrespective of their age, sex and ethnicity. Over the past decade, a series of studies using a survey methodology, referred to as Refractive Error Study in Children (RESC), were performed in populations with different ethnic origins and cultural settings. These studies confirmed that the prevalence of uncorrected refractive errors is considerably high for children in low-and-middle-income countries. Furthermore, uncorrected refractive error has been noted to have extensive social and economic impacts, such as limiting educational and employment opportunities of economically active persons, healthy individuals and communities. The key public health challenges presented by uncorrected refractive errors, the leading cause of vision impairment across the world, require urgent attention. To address these issues, it is critical to focus on the development of human resources and sustainable methods of service delivery. This paper discusses three core pillars to addressing the challenges posed by uncorrected refractive errors: Human Resource (HR) Development, Service Development and Social Entrepreneurship. [ABSTRACT FROM AUTHOR]

Objective To estimate the potential global economic productivity loss associated with the existing burden of visual impairment from uncorrected refractive error (URE). Methods Conservative assumptions and national population, epidemiological and economic data were used to estimate the purchasing power parity-adjusted gross domestic product (PPP-adjusted GDP) loss for all individuals with impaired vision and blindness, and for individuals with normal sight who provide them with informal care. Findings An estimated 158.1 million cases of visual impairment resulted from uncorrected or undercorrected refractive error in 2007; of these, 8.7 million were blind. We estimated the global economic productivity loss in international dollars (I$) associated with this burden at I$ 427.7 billion before, and I$ 268.8 billion after, adjustment for country-specific labour force participation and employment rates. With the same adjustment, but assuming no economic productivity for individuals aged >= 50 years, we estimated the potential productivity loss at I$ 121.4 billion. Conclusion Even under the most conservative assumptions, the total estimated productivity loss, in $I, associated with visual impairment from URE is approximately a thousand times greater than the global number of cases. The cost of scaling up existing refractive services to meet this burden is unknown, but if each affected individual were to be provided with appropriate eyeglasses for less than I$ 1000, a net economic gain may be attainable. Copyright © 2009 World Health Organization [ABSTRACT FROM AUTHOR]

This study explored the potential of telemedicine integration into the eye health ecosystem with an aim of scaling effective refractive error coverage in Kenya. This exploratory study was conducted telephonically and through online interviews with key opinion leaders, ophthalmologists, optometrists, ophthalmic clinical officers, optical technicians and beneficiaries of the optical technician's services in rural areas. A telemedicine workflow was developed and validated based on the comments from the key opinion leaders using the Delphi technique. Quantitative and qualitative data were analysed using SPSS and NVivo Software respectively. All of the key opinion leaders agreed that telemedicine is relevant in the eye health ecosystem and recognition of primary vision technicians is critical for effective telemedicine integration. The reasons for the need of telemedicine integration were categorized into; good relationship, organized refractive error service delivery, convenience and availability and cost reduction. The possible factors influencing integration of telemedicine identified were categorized into cost, unwillingness, dominance, perception, lack of technical team, policies and network coverage. The limited human resources in the eye health ecosystem in developing countries cannot effectively deliver refractive error services to the growing population. Hence, integration of telemedicine and establishment of policies recognizing telemedicine are desirable to strengthen task shifting and scale effective refractive error coverage., (© 2024. The Author(s).)

Introduction: Even though the burden of uncorrected refractive error could potentially be addressed through innovative and cost-effective approaches, integration of the services into the National Health Services (NHS) is desirable. However, minimal information exists on the current situation warranting the need for evidence about the integration of refractive error service provided by optometrists into the national health services in Kenya., Methods: A situation analysis of the Kenyan refractive error services provided by optometrists within the NHS was undertaken based on access to service delivery, service coverage, and human resource. A strengths, weaknesses, opportunities, and threats analysis was undertaken based on the existent evidence to identify the core factors that could potentially facilitate or hinder the integration of refractive error services provided by optometrists within the National Health Services. The proportion of optometrists to be integrated in the NHS was estimated based on the minimum ratios recommended by the World Health Organization., Results: A section of tertiary and secondary healthcare facilities in Kenya have specific services to address refractive errors within the NHS with most facilities lacking such services. Treatment of refractive error occurs at the level of eye care general services. There are 11,547 health facilities offering primary care services in Kenya. However, none of them offers refractive error services and only a section of facilities offering county health referral services provides eye care services which is limited to refraction without provision of spectacles. The existing workforce comprises of ophthalmologists, optometrists and ophthalmic clinical officers, together with nurses and other general paramedical assistants. Optometrists, ophthalmologists and ophthalmic clinical officers are allowed to undertake refraction. However, optometrists majorly practices in the private sector. Centralization of eye care services in urban areas, weak referral systems, and a shortage in the workforce per population was observed., Conclusions: The Kenyan NHS should advocate for primary care and reorient the current hospital-based delivery approach for refractive error services. This is attributed to the fact that provision of refractive error services at primary care remains effective and efficient and could translate to early detection of other ocular conditions. The existing human resources in the eye health ecosystem in Kenya should maximize their efforts towards addressing uncorrected refractive error and optometrists should be integrated into the NHS., (© 2024. The Author(s).)

Background: In developing countries such as Kenya, minimal attention has been directed towards population based studies on uncorrected refractive error (URE). However, the absence of population based studies, warrants utilization of other avenues to showcase to the stakeholders in eye health the worth of addressing URE. Hence this study estimated the lost productivity to the Gross Domestic Product (GDP) as a result of URE and the national cost required to address visual impairment from URE in Kenya., Methods: The lost productivity to the GDP for the population aged 16-60 years was calculated. Thereafter the productivity loss of the caregivers of severe visual impaired individuals was computed as a product of the average annual productivity for each caregiver and a 5% productivity loss due to visual impairment. The productivity benefit of correcting refractive error was estimated based on the minimum wage for individuals aged between 16-60 years with URE. Estimation of the national cost of addressing URE was based on spectacle provision cost, cost of training functional clinical refractionists and the cost of establishing vision centres. A cost benefit analysis was undertaken based on the national cost estimates and a factor of 3.5 times., Results: The estimated lost productivity to the GDP due to URE in in Kenya is approximately US$ 671,455,575 -US$ 1,044,486,450 annually for population aged between 16-60 years. The productivity loss of caregivers for the severe visually impaired is approximately US$ 13,882,899 annually. Approximately US$ 246,750,000 is required to provide corrective devices, US$ 413,280- US$ 108,262,300 to train clinical refractionists and US$ 39,800,000 to establish vision centres. The productivity benefit of correcting visual impairment is approximately US$ 41,126,400 annually. Finally, a cost benefit analysis showed a return of US$ 378,918,050 for human resources, US$ 863,625,000 for corrective devices and US$ 139,300,000 for establishment of vision centres., Conclusion: The magnitude of productivity loss due to URE in Kenya is significant warranting prioritization of refractive error services by the government and all stakeholders since any investment directed towards addressing URE has the potential to contribute a positive return., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Muma et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Uncorrected refractive error has predominantly been delivered through commercial entrepreneurship in Kenya. However, to achieve the 2030 IN SIGHT, integration of other forms of entrepreneurship such as the social entrepreneurship is desirable to supplement the efforts of the dominant commercial entrepreneurship. Therefore, this study intended to undertake a SWOT analysis of the current models used by social enterprises in scaling effective refractive error coverage to achieve the 2030 IN SIGHT in Kenya. A review of the seven national strategic plans for eye health in Kenya was undertaken to get a glimpse on the efforts directed towards uncorrected refractive error in achieving the 2030 IN SIGHT. The review was inclined towards assessing the efforts directed by the strategic plans towards scaling human resource, spectacle provision and refraction points. A SWOT analysis was undertaken based on the financial, impact and the approach report for each model. A key informant interview was conducted with a representative and three to five members of the social enterprise about the model. Thereafter, the modified SWOT analysis based on the review and the interview was presented to the representatives of the social enterprises. Purposive sampling was used to identify seven models used by social enterprises in the delivery of refractive error services in Kenya. Finally, the recommendations were presented to key opinion leaders for an input through a Delphi technique. Out of the seven national strategic plans for eye health reviewed, only the strategic plan 2020-2025 intends to establish optical units within 15 different counties in Kenya. Of the seven models currently utilized by social enterprises, only the Kenya Society for the Blind has integrated the telemedicine concept. On application of mHealth, all of the social enterprises models tend to embrace the approach for screening activities. None of the models has a strengthened referral pathway utilizing telereferral and telemedicine. Out of all the models, only Operation Eyesight Universal, Fred Hollow Foundation and Peek Acuity do not depend on sales of subsidized spectacles for sustainability. Every model has the capacity to propel the delivery of refractive error services depending on its comprehensiveness. However, for the 2030 IN SIGHT to be achieved, models prioritizing human resource through telemedicine integration, service provision across all sectors, awareness creation and enhancing cost efficiency are desirable., (© 2024. The Author(s).)

Background: Developing countries such as Kenya still experience challenges around human resource to deliver refractive error services. However, given the burden of uncorrected refractive error, adoption of innovative and cost effective approaches is desirable. Hence this study intended to develop a task shifting framework integrated with telemedicine to potentially scale refractive error services., Methods: This was an exploratory study conducted in four phases as follows: a scoping review of the scope of practice for ophthalmic workers in Kenya, an interview with key opinion leaders on the need for integration of public health approaches such as the vision corridors within the eye health ecosystem in Kenya and their knowledge on task shifting, and finally development and validation of a proposed task shifting framework through a Delphi technique. Purposive sampling was used to recruit key opinion leaders and data was collected via telephonic interviews. The qualitative data was analyzed thematically using NVivo Software, Version 11., Results: The scoping review showed that only optometrists, ophthalmologists and ophthalmic clinical officers are allowed to undertake refraction in Kenya. All of the key opinion leaders (100%) were aware of task shifting and agreed that it is suitable for adoption within the eye health ecosystem in Kenya. All of the key opinion leaders (100%) agreed that skills development for healthcare workers without prior training on eye health supervised by optometrists through telemedicine is desirable. Notwithstanding, all of the key opinion leaders (100%) agreed that integration of public health approaches such as the vision corridors across all levels of healthcare delivery channels and development of a self-assessment visual acuity tool is desirable. Finally all of the key opinion leaders (100%) agreed that task shifting is relevant for adoption within the eye health ecosystem in Kenya. The developed framework prioritized partnership, advocacy, skills development, establishment and equipping of refraction points. The proposed framework advocated for a telemedicine between professionals with conventional training and those with skills development., Conclusion: Task shifting integrated with telemedicine could cost effectively scale refractive error service delivery. However, internal and external factors may hinder the success warranting the need for a multi-faceted interventions and a connection between planning and training to scale the uptake., (© 2024. The Author(s).)

Purpose: Knowledge, positive attitude and good preventive practices are keys to successful myopia control, but information on these is lacking in Africa. This study determined the KAP on myopia in Ghana., Methods: This was a population-based cross-sectional survey conducted among adults (aged 18 years and older) living across 16 regions of Ghana between May and October 2021. Data on socio-demographic factors (sex, age, gender, level of education, working status, type of employment, monthly income, and region of residence), respondents' awareness, and knowledge, attitude and preventive practices (KAP) about myopia were collected. Composite and mean scores were calculated from eleven knowledge (total score = 61), eight attitude (48), and nine preventive practice items (33). Differences in mean scores were assessed using one-way analysis of variance (ANOVA) and standardized coefficients (β) with 95% confidence intervals (CI), using multiple linear regression to determine the associations between the dependent (KAP) and demographic variables., Results: Of the 1,919 participants, mean age was 37.4 ± 13.4 years, 42.3% were aged 18-30 years, 52.6% were men, 55.8% had completed tertiary education, and 49.2% had either heard about myopia, or accurately defined myopia as short sightedness. The mean KAP scores were 22.9 ± 23.7, 33.9 ± 5.4, and 22.3 ± 2.8, respectively and varied significantly with many of the demographic variables particularly with age group, region, marital status, and type of employment. Multiple linear regression analyses revealed significant associations between region of residence and knowledge (β =-0.54, 95%CI:-0.87, -0.23, p < 0.001), attitude (β =-0.24, 95%CI:-0.35,-0.14, p < 0.001) and preventive practices (β = 0.07, 95%CI: 0.01, 0.12, p = 0.015). Preventive practices were also associated with type of employment (self-employed vs employee: β = 0.25, 95%CI: 0.15, 4.91, p < 0.05). Knowledge scores were significantly higher in those who lived in the Greater Accra (39.5 ± 18.5) and Eastern regions (39.1 ± 17.5) and lower among those who lived in the Upper West region (6.4 ± 15.6). Government employees and those with tertiary education had significantly higher mean knowledge scores compared with non-government employees (β = 4.56, 95%CI 1.22, 7.89, p = 0.007), and those with primary/no education (β = 18.35, 95%CI: 14.42, 22.27, p < 0.001)., Conclusion: Ghanaian participants had adequate knowledge of myopia but showed poor attitude and low preventive practices, which varied significantly between regions and were modified by socio-demographic factors. Further research into how education can be used to stimulate Ghanaians' engagement in preventive practices is needed., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Background: Despite being easily corrected with eyeglasses, over two-thirds of the world's child population presents with vision impairment (VI) due to uncorrected refractive errors. While systematic reviews have shown that VI can significantly impact children's depression and anxiety, none have reviewed the existing literature on the association between spectacle correction and well-being. This review aims to address this knowledge gap., Main Outcome Measures: The main outcome measures were i) cognitive and education well-being which included mathematics and english literacy, reading fluency, school function, academic performance and grades; ii) psychological and mental health well-being which included physical anxiety, learning anxiety and mental health test scores and iii) quality of life., Methods: We searched eight databases for articles published between 1999 to 2021 that assessed the associations between spectacle correction and children's (0 to 18 years) well-being. There were no restrictions on language or geographic location. Two reviewers independently screened all publications using validated quality checklists. The findings of the review were analysed using narrative synthesis. [PROSPERO CRD42020196847]., Results: Of 692 records found in the databases, six randomised control trials, one cohort, one cross-sectional and one qualitative study (N = 9, 1.3%) were eligible for analysis. Data were collected from 25 522 children, 20 parents and 25 teachers across the nine studies. Seven were rated as good quality (67 to 100% of quality criteria fulfilled), and two were satisfactory (33 to 66% of quality criteria fulfilled). Spectacle correction was found to improve children's educational well-being (n = 4 very strong evidence; n = 2 strong evidence), quality of life (n = 1, very strong evidence) and decrease anxiety and increase mental health scores (n = 1, strong evidence)., Conclusion: Evidence suggests that spectacle correction improves children's cognitive and educational well-being, psychological well-being, mental health, and quality of life. More research is needed, given the paucity of published literature and the focus on only three aspects of well-being., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Background: Ghana and Nigeria are the two countries in Africa that currently run the Doctor of Optometry (OD) program in sub-Saharan Africa (SSA). Optometrists in these countries are licensed to provide glaucoma care. Despite the clinically relevant practice guidelines for glaucoma, there is no data on the practice patterns for glaucoma eye care in SSA, a region with the highest prevalence of glaucoma. This study aimed to profile glaucoma diagnosis adherence to practice guidelines among optometrists in two neighbouring anglophone countries (Nigeria and Ghana)., Methods: A web-based cross-sectional survey of practising optometrists was conducted in both countries. Each country data was weighted to reflect the total number of licensed and practising optometrists at the time of this survey. Descriptive analyses were performed against demography and practice factors using survey commands to adjust for sampling weights when estimating confidence intervals (CI) around prevalence estimates. Simple and multiple logistic regression analyses were performed to identify factors associated with glaucoma diagnosis., Results: A total of 493 optometrists (238, 48.3% and 255, 51.7%) from Ghana and Nigeria respectively, responded to the survey-the first to document and compare the glaucoma diagnostic criteria between optometrists in Ghana and Nigeria. More Ghanaian than Nigerian optometrists diagnosed glaucoma and over 90% in both countries reported that they frequently performed either tonometry, visual field testing, or fundus examination during glaucoma diagnosis. Ghanaian optometrists were significantly more likely to diagnose glaucoma than Nigerian optometrists (adjusted odd ratio, AOR = 6.15, 95%CI:1.63-23.15, P = .007). Optometrists who have practiced for more than 10 years (AOR = 7.04; 95%CI:1.74-28.47, P = .006) and private practice optometrists (AOR = 3.33; 95%CI:1.13-9.83, P = .03) were more likely to diagnose glaucoma., Conclusions: The study provides information for evaluating glaucoma assessment for optometrists in both countries. Optometrists in both countries are reasonably well-equipped to diagnose glaucoma and are practicing at an adequate level, but with room for improvement., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Purpose: There remains a lack of information on the perception and adoption of myopia control strategies among African eye care practitioners (ECPs). This study provides an African perspective to similar previous studies conducted in other parts of the world., Methods: A self-administered survey in English and French was distributed to ECPs across Africa. The items on the questionnaire assessed their level of concern about the increasing prevalence of paediatric myopia, perceived efficacy, opinions on, and adoption of various myopia management modalities., Results: Responses were obtained from 330 ECPs working in 23 African countries. Respondents were highly concerned about the increasing prevalence of paediatric myopia in their clinic (median 8/10) and perceived approved myopia control soft contact lenses as the most effective at slowing myopia progression (mean perceived reduction in myopia progression ± SD; 53.9 ± 27.1%), followed by single vision spectacles (53.1 ± 30.9%), and orthokeratology (52.8 ± 28.0%). Multifocal soft contact lenses (40.4 ± 25.8%) and pharmaceutical agents such as topical atropine drops (39.5 ± 27.1%) were perceived as least effective in slowing myopia progression. Although ECPs reported being aware of various myopia control strategies, they still mainly prescribed single vision spectacles to a large proportion (64.3 ± 29.9%) of young progressing myopes. Nearly one-third (27%) of ECPs who prescribed single vision lenses stated they were concerned about the cost implications to patients. Other reported concerns included safety of, and inadequate information about myopia control options., Conclusions: African ECPs continue to prescribe single vision lenses for progressing myopes despite being aware of the various myopia control options. Practitioners' perceptions of the efficacy of several modalities to slow myopia progression do not align with the current best evidence. Clear practice guidelines and continuing education on myopia control are warranted to inform and guide the management of myopic patients in Africa., (Copyright © 2022 British Contact Lens Association. Published by Elsevier Ltd. All rights reserved.)

Background: 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., Methods: 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., Findings: 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)., Interpretation: 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., Funding: WHO, Sightsavers, The Fred Hollows Foundation, Fondation Thea, Brien Holden Vision Institute, Lions Clubs International Foundation., Competing Interests: Declaration of interests JR reports university position funding by Buchanan Charitable Foundation, New Zealand. KSN reports employment by OneSight EssilorLuxottica Foundation. JMF reports research grants from Lions SightFirst & Conselho Nacional de Desenvolvimento Científico e Tecnológico, Brazil. Tecnológico, Brazil. ​RV reports the Los Angeles Latino Eye Study research grant from the National Eye Institute, where he participates on a Data Monitoring Board or Advisory Board. The remaining authors declare no competing interests. The remaining authors declare no competing interests., (Copyright © 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Purpose: Increased prevalence of myopia is a major public health challenge worldwide, including in Africa. While previous studies have shown an increasing prevalence in Africa, there is no collective review of evidence on the magnitude of myopia in African school children. Hence, this study reviews the evidence and provides a meta-analysis of the prevalence of myopia in African school children., Methods: This review was conducted using the 2020 Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Five computerized bibliographic databases, PUBMED, Scopus, Web of Science, ProQuest, and Africa Index Medicus were searched for published studies on the prevalence of myopia in Africa from 1 January 2000 to 18 August 2021. Studies were assessed for methodological quality. Data were gathered by gender, age and refraction technique and standardized to the definition of myopia as refractive error ≥ 0.50 diopter. A meta-analysis was conducted to estimate the prevalence. Significant heterogeneity was detected among the various studies (I2 >50%), hence a random effect model was used, and sensitivity analysis was performed to examine the effects of outliers., Results: We included data from 24 quality assessed studies, covering 36,395 African children. The overall crude prevalence of myopia over the last two decades is 4.7% (95% CI, 3.9-5.7) in African children. Although the prevalence of myopia was slightly higher in females (5.3%, 95%CI: 4.1, 6.5) than in males (3.7%, 95% CI, 2.6-4.7; p = 0.297) and higher in older [12-18 years 5.1% (95% CI, 3.8-6.3) than younger children (aged 5-11 years, 3.4%, 95% CI, 2.5-4.4; p = 0.091), the differences were not significant. There was a significantly lower prevalence of myopia with cycloplegic compared with non-cycloplegic refraction [4.2%, 95%CI: 3.3, 5.1 versus 6.4%, 95%CI: 4.4, 8.4; p = 0.046]., Conclusions: Our results showed that myopia affects about one in twenty African schoolchildren, and it is overestimated in non-cycloplegic refraction. Clinical interventions to reduce the prevalence of myopia in the region should target females, and school children who are aged 12-18 years., Competing Interests: The authors have declared that no competing interests exist.

The South African family physician (FP) is an expert generalist who has a number of roles to strengthen the district health system. A research study on FPs in district hospitals has previously demonstrated an impact; however, more evidence on impact in primary health care (PHC) is needed. By serving as a consultant for the PHC team, the FP may improve access to care, capacitate team members, enhance comprehensiveness of care, and improve coordination and continuity of care. This report narrates the story of how one of the FPs at a rural district hospital recorded his experience of being a consultant to the PHC team and was able to self-audit the experience. A self-designed audit tool analysed 1000 patient consultations with the FP and enabled a reflection on the coronavirus disease 2019 (COVID-19)-related changes to the consultant role. There was a clear need for FPs to consult patients with complex multi-morbidity and multifaceted psychosocial aspects to their illness, in consultation with their team members. Patients were referred to them by medical officers, other specialists, family medicine registrars, allied healthcare professionals and nurse practitioners. The FP's ability to strengthen the PHC service outside the district hospital may be enhanced by creating more FP posts at a subdistrict level to support high-quality, team-based primary care in line with the PHC policy directions.

Purpose: To assess the influence of distance and near visual impairment on self-reported near visual functioning (VF) in a multinational study., Design: Population-based cross-sectional study., Participants: Participants aged 35 years or older were selected randomly with cluster sampling at 7 sites: rural sites in Nepal (Kaski) and India (Madurai), a semirural site in China (Shunyi), semiurban sites in South Africa (Durban) and Niger (Dosso), and urban sites in the United States (Los Angeles) and China (Guangzhou)., Methods: Binocular presenting distance and near visual acuity (VA) were measured with a logarithm of the minimum angle of resolution tumbling E chart at 4 m and 40 cm, respectively. A 12-item near VF questionnaire interview was administered by trained local interviewers, with responses scored from 100 to 0 as visual disability increased. Multiple linear regression was used to investigate the association of age, gender, education, and VA with overall eyesight, difficulty with activities, and social functioning subscale scores., Main Outcome Measures: Visual functioning subscale scores., Results: The study sample consisted of 6851 questionnaire respondents. The VF subscale scores decreased significantly with worse distance and near VA, and even mildly impaired VA could result in reduced VF. Lower VF subscale scores were associated with older age at 4 sites, female gender at 3 sites, and greater education at 2 sites. The influence of near VA was greater than distance VA at 3 sites, and at 1 site, distance VA was more influential than near VA. With study site included in the regression modeling, lower scores for the overall eyesight subscale (compared with the Shunyi reference site) were found in Guangzhou, Kaski, and Durban; lower difficulty in activities scores were found in Kaski and Durban, but better scores were found in Guangzhou and Madurai; and social functioning scores were lower in Kaski, Durban, and Dosso., Conclusions: Along the entire VA spectrum, lower levels of distance and near VA led to significant reductions in VF subscale scores, with wide variation both within and between study sites. The impact of near vision on VF should receive greater emphasis with further investigation in various socioeconomic and cultural settings., (Copyright © 2020 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Background: To assess the psychometric properties of the QIRC questionnaire and use it as an outcome measure in spectacle wearers attending an eye clinic in Malawi., Methods: Participants who had uncorrected distance visual acuity of below 6/18 and improved to 6/9 or better with spectacles on both eyes were included in the study. The participants self-administered the Chichewa version of the QIRC questionnaire that was translated and culturally adapted for Malawian settings. Psychometric evaluation of the QIRC responses was carried out using the WinSteps software (Version 3.92.1; Winsteps, Chicago, IL) by applying the Andrich rating scale model of the Rasch analysis., Results: One hundred and forty-three participants (mean age ± standard deviation, 27.64 ± 2.91; age range; 16 to 39 years; male, 51.7%) completed the QIRC. The Chichewa QIRC had satisfactory psychometric properties (Ordered response categories, Person separation index, 1.93; Item separation index, 3.42; Targeting 0.70) including excellent Rasch-model fit statistics (Infit and Outfit MnSq < 1.30 for all items). The QIRC score was not significantly associated with sex, age, magnitude of refractive error, occupation and status of previous spectacle wear (p> 0.05 for all). The QIRC scores negatively correlated with uncorrected visual acuity (in logMAR) in the better eye (spearman's rho=-0.34, p < 0.001)., Conclusion: The translated and culturally adapted version of the QIRC Questionnaire had satisfactory psychometric properties to measure the refractive error-specific quality of life in Malawi. It performed well as an outcome measure of spectacle wear., (© 2020 The College of Medicine and the Medical Association of Malawi.)

Background: Uncorrected refractive error (URE) is a major cause of vision impairment among children that impacts negatively on their lives including distresses. We aim to understand the disability-related distress among vision-impaired children due to URE in rural and semi-rural South Africa using qualitative techniques., Methods: Structured focus groups of children (aged 5-12 years old) with normal vision and vision impairment due to URE from four schools in Pinetown, KwaZulu Natal, South Africa, were performed (four mixed-gender group discussions and eight single gender group discussions). We recruited the study participants after the children underwent standardised vision screening. Criterion sampling was used when selecting study participants. The interviews were transcribed to identify meaning units and broken down to condensed meaning units, which were then grouped into megathemes. Themes were then generated., Results: Thirteen children with normal vision and 63 children with vision impairment due to URE participated in the twelve focus group discussions with 36 boys (47%) and 40 girls (53%). Twelve themes were generated. The megathemes were Loss of Self Confidence (number of themes (n) = 3), Loss of self-worth (n = 3), Loss of interconnection/ interaction with community (n = 2), Humiliation (n = 2) and Discrimination (n = 2)., Conclusions: We found that vision impairment due to URE can cause distress in different domains in children's life and further grouped them into different themes. The themes will be used for the development of a tool to assess disability-related distress among children with vision impairment due to URE. We also recommend that distresses caused by URE should be taken into consideration when designing eye care programmes for children., Competing Interests: The authors have declared that no competing interests exist.

Purpose: We estimated the potential global economic productivity loss resulting from vision impairment (VI) and blindness as a result of uncorrected myopia and myopic macular degeneration (MMD) in 2015., Clinical Relevance: Understanding the economic burden of VI associated with myopia is critical to addressing myopia as an increasingly prevalent public health problem., Methods: We estimated the number of people with myopia and MMD corresponding to critical visual acuity thresholds. Spectacle correction coverage was analyzed against country-level variables from the year of data collection; variation in spectacle correction was described best by a model based on a human development index, with adjustments for urbanization and age. Spectacle correction and myopia data were combined to estimate the number of people with each level of VI resulting from uncorrected myopia. We then applied disability weights, labor force participation rates, employment rates, and gross domestic product per capita to estimate the potential productivity lost among individuals with each level and type of VI resulting from myopia in 2015 in United States dollars (US$). An estimate of care-associated productivity loss also was included., Results: People with myopia are less likely to have adequate optical correction if they are older and live in a rural area of a less developed country. The global potential productivity loss associated with the burden of VI in 2015 was estimated at US$244 billion (95% confidence interval [CI], US$49 billion-US$697 billion) from uncorrected myopia and US$6 billion (95% CI, US$2 billion-US$17 billion) from MMD. Our estimates suggest that the Southeast Asia, South Asia, and East Asia Global Burden of Disease regions bear the greatest potential burden as a proportion of their economic activity, whereas East Asia bears the greatest potential burden in absolute terms., Conclusions: Even under conservative assumptions, the potential productivity loss associated with VI and blindness resulting from uncorrected myopia is substantially greater than the cost of correcting myopia., (Copyright © 2018 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Background:  Global estimates suggest there are almost 19 million visually impaired children worldwide, most of whom reside in poor countries, with the major cause being treatable., Aim:  To determine the barriers to accessing childhood eye care services and to develop an eye care plan for children in South Darfur State, Sudan., Setting:  The study took place in South Darfur State, Sudan., Methods:  The classical Delphi technique was used to build consensus on a list of statements, which were generated based on the themes established by the experts, as well as on an extensive literature review., Results:  Response rates ranged from 90% in the first round (n = 18), 100% in the second round (n = 18) to 89% in the third and final round (n = 16). The total number of statements recommended by the Delphi panellists for development of the paediatric eye care plan, was 60 based on a consensus level of 80% agreement or more. The expert's consensus on the following key elements for promotion and improvement of child eye care: The main barriers to accessing child eye care were high poverty rate, unavailability of child eye services and a lack of community awareness. The challenges facing visually impaired children were an absence of paediatric ophthalmologists, low vision and orthoptic services., Conclusion:  The main barriers to accessing child eye care services were financial, clinical access and lack of knowledge. There should be greater collaboration between the Ministries of Health, Education and non-governmental organisations (NGOs), to work together in addressing these barriers.

Topic: Presbyopia prevalence and spectacle-correction coverage were estimated by systematic review and meta-analysis of epidemiologic evidence, then modeled to expand to country, region, and global estimates., Clinical Relevance: Understanding presbyopia epidemiologic factors and correction coverage is critical to overcoming the burden of vision impairment (VI) from uncorrected presbyopia., Methods: We performed systematic reviews of presbyopia prevalence and spectacle-correction coverage. Accepted presbyopia prevalence data were gathered into 5-year age groups from 0 to 90 years or older and meta-analyzed within World Health Organization global burden of disease regions. We developed a model based on amplitude of accommodation adjusted for myopia rates to match the regionally meta-analyzed presbyopia prevalence. Presbyopia spectacle-correction coverage was analyzed against country-level variables from the year of data collection; variation in correction coverage was described best by a model based on the Human Development Index, Gini coefficient, and health expenditure, with adjustments for age and urbanization. We used the models to estimate presbyopia prevalence and spectacle-correction coverage in each age group in urban and rural areas of every country in the world, and combined with population data to estimate the number of people with near VI., Results: We estimate there were 1.8 billion people (prevalence, 25%; 95% confidence interval [CI], 1.7-2.0 billion [23%-27%]) globally with presbyopia in 2015, 826 million (95% CI, 686-960 million) of whom had near VI because they had no, or inadequate, vision correction. Global unmet need for presbyopia correction in 2015 is estimated to be 45% (95% CI, 41%-49%). People with presbyopia are more likely to have adequate optical correction if they live in an urban area of a more developed country with higher health expenditure and lower inequality., Conclusions: There is a significant burden of VI from uncorrected presbyopia, with the greatest burden in rural areas of low-resource countries., (Copyright © 2018 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Purpose: We used systematic review and meta-analysis to identify and assimilate evidence quantifying blindness and visual impairment (VI) associated with myopic macular degeneration (MMD), then derived models to predict global patterns. The models were used to estimate the global prevalence of blindness and VI associated with MMD from 2000 to 2050., Methods: The systematic review identified 17 papers with prevalence data for MMD VI fitting our inclusion criteria. Data from six papers with age-specific data were scaled to relative age-dependent risk and meta-analysed at VI and blindness levels. We analysed variance in all MMD VI and blindness data as a proportion of high myopia against variables from the place and year of data collection, with a model based on health expenditure providing the best correlation. We used this model to estimate the prevalence and number of people with MMD VI in each country in each decade., Results: We included data from 17 studies comprising 137 514 participants. We estimated 10.0 million people had VI from MMD in 2015 (prevalence 0.13%, 95% CI 5.5 to 23.7 million, 0.07% to 0.34%), 3.3 million of whom were blind (0.04%, 1.8 to 7.8 million, 0.03% to 0.10%). We estimate that by 2050, without changing current interventions, VI from MMD will grow to 55.7 million people (0.57%, 29.0 to 119.7 million, 0.33% to 1.11%), 18.5 million of whom will be blind (0.19%, 9.6 to 39.7 million, 0.11% to 0.37%)., Conclusion: The burden of MMD blindness and VI will rise significantly without efforts to reduce the development and progression of myopia and improve the management of MMD., Competing Interests: Competing interests: The authors have no relevant proprietary interests. TRF: consultant for Brien Holden Vision Institute. MJ: no financial disclosures. KSN: no financial disclosures. PS: no financial disclosures. TN: no financial disclosures. SMH: no financial disclosures. TYW: consultant and on advisory boards for Allergan, Bayer and Novartis. SR: consultant for Brien Holden Vision Institute and previously worked for Thea Pharmaceuticals (2008-2010)., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background: Population-based studies involving refractive error in South Africa are few because they are expensive to conduct and require a high level of expertise. Rapid assessment of refractive error (RARE) is a relatively less resource-intensive method designed to assess the magnitude of uncorrected refractive error (URE), spectacle coverage and barriers to access of services. This information is useful for designing and implementing programs as well as for policy development., Purpose: The purpose of this study was to determine the prevalence of uncorrected refractive error and spectacle coverage and to explore the barriers to uptake of refractive services in persons 15 to 35 years old in the eThekwini municipality, Durban, South Africa., Methods: A cross-sectional epidemiological study was conducted using the RARE protocol. A total of 1,543 participants were enumerated and 1,516 were examined. Uncorrected refractive error was defined as presenting visual acuity less than 6/12 that could be corrected to 6/12 or better using a pinhole. Spectacle coverage was defined as the proportion of need that was already met with spectacle correction., Results: The prevalence of age and sex adjusted URE was 1.5% (95 per cent CI: 0.7 -2.3). Odds for uncorrected refractive error in women were 0.5 (95 per cent CI: 0.3-0.9) lower compared to men. There was a statistically significant association between uncorrected refractive error and respondents 15 to 24 years old (p < 0.001). The spectacle coverage (6/12 cut-off) was 51.4 per cent (95 per cent CI: 28.1-74.7). The prevalence of spectacle use among participants was 3.8 per cent., Conclusions: The low prevalence of uncorrected refractive error found in this study agrees with previous studies that indicate that despite uncorrected refractive error being the most common cause of visual impairment and the second most common cause of blindness worldwide, its prevalence is relatively low in South Africans., (© 2016 Optometry Australia.)

Purpose: Myopia is a common cause of vision loss, with uncorrected myopia the leading cause of distance vision impairment globally. Individual studies show variations in the prevalence of myopia and high myopia between regions and ethnic groups, and there continues to be uncertainty regarding increasing prevalence of myopia., Design: Systematic review and meta-analysis., Methods: We performed a systematic review and meta-analysis of the prevalence of myopia and high myopia and estimated temporal trends from 2000 to 2050 using data published since 1995. The primary data were gathered into 5-year age groups from 0 to ≥100, in urban or rural populations in each country, standardized to definitions of myopia of -0.50 diopter (D) or less and of high myopia of -5.00 D or less, projected to the year 2010, then meta-analyzed within Global Burden of Disease (GBD) regions. Any urban or rural age group that lacked data in a GBD region took data from the most similar region. The prevalence data were combined with urbanization data and population data from United Nations Population Department (UNPD) to estimate the prevalence of myopia and high myopia in each country of the world. These estimates were combined with myopia change estimates over time derived from regression analysis of published evidence to project to each decade from 2000 through 2050., Results: We included data from 145 studies covering 2.1 million participants. We estimated 1406 million people with myopia (22.9% of the world population; 95% confidence interval [CI], 932-1932 million [15.2%-31.5%]) and 163 million people with high myopia (2.7% of the world population; 95% CI, 86-387 million [1.4%-6.3%]) in 2000. We predict by 2050 there will be 4758 million people with myopia (49.8% of the world population; 3620-6056 million [95% CI, 43.4%-55.7%]) and 938 million people with high myopia (9.8% of the world population; 479-2104 million [95% CI, 5.7%-19.4%])., Conclusions: Myopia and high myopia estimates from 2000 to 2050 suggest significant increases in prevalences globally, with implications for planning services, including managing and preventing myopia-related ocular complications and vision loss among almost 1 billion people with high myopia., (Copyright © 2016 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Purpose: To determine the prevalence and types of refractive errors in persons aged 35 years and older in the Inanda, Ntuzuma, and KwaMashu (INK) area of Durban, KwaZulu-Natal Province, South Africa., Methods: Refractive error data were obtained by autorefraction (Retinomax K-Plus; Nikon, Tokyo, Japan), retinoscopy, and subjective refraction. Refractive error was defined using spherical equivalents as myopia (<-0.5D) and hyperopia (>+0.5D). Astigmatism was defined as cylinder equal to or greater than -0.5D in either eye., Results: Participants' ages ranged from 35 to 90 years, with a mean of 53.05 ± 11.4 years. Women comprised 75% of the subjects. The prevalence of refractive error was 57.3%, with myopia 11.4%, hyperopia 37.7%, and astigmatism 25.7%. Myopia and astigmatism were significantly more prevalent in men (p < 0.01), whereas hyperopia was more prevalent in women (p < 0.01). Hyperopia was significantly associated with education (p < 0.01), whereas myopia and astigmatism were not (p = 0.09 and p = 0.15, respectively)., Conclusions: Approximately 57.3% of the population 35 years and older in the INK area of Durban were affected by refractive errors, with myopia, hyperopia, and astigmatism being significantly associated with sex. This study suggests that there is a need for interventions to alleviate refractive error in the INK area as well as in other communities affected by the lack of access to affordable services.

The purpose of this systematic review was to estimate worldwide the number of people with moderate and severe visual impairment (MSVI; presenting visual acuity <6/18, ≥3/60) or blindness (presenting visual acuity <3/60) due to uncorrected refractive error (URE), to estimate trends in prevalence from 1990 to 2010, and to analyze regional differences. The review focuses on uncorrected refractive error which is now the most common cause of avoidable visual impairment globally. : The systematic review of 14,908 relevant manuscripts from 1990 to 2010 using Medline, Embase, and WHOLIS yielded 243 high-quality, population-based cross-sectional studies which informed a meta-analysis of trends by region. The results showed that in 2010, 6.8 million (95% confidence interval [CI]: 4.7-8.8 million) people were blind (7.9% increase from 1990) and 101.2 million (95% CI: 87.88-125.5 million) vision impaired due to URE (15% increase since 1990), while the global population increased by 30% (1990-2010). The all-age age-standardized prevalence of URE blindness decreased 33% from 0.2% (95% CI: 0.1-0.2%) in 1990 to 0.1% (95% CI: 0.1-0.1%) in 2010, whereas the prevalence of URE MSVI decreased 25% from 2.1% (95% CI: 1.6-2.4%) in 1990 to 1.5% (95% CI: 1.3-1.9%) in 2010. In 2010, URE contributed 20.9% (95% CI: 15.2-25.9%) of all blindness and 52.9% (95% CI: 47.2-57.3%) of all MSVI worldwide. The contribution of URE to all MSVI ranged from 44.2 to 48.1% in all regions except in South Asia which was at 65.4% (95% CI: 62-72%). : We conclude that in 2010, uncorrected refractive error continues as the leading cause of vision impairment and the second leading cause of blindness worldwide, affecting a total of 108 million people or 1 in 90 persons.

Purpose: This study was designed to understand the profiles of the patients who attended and chose to purchase spectacles from the public sector eye clinics in KwaZulu Natal, South Africa. Furthermore, we wished to explore patients' perceptions of the spectacle frames on offer and to understand the motivation of the patients in selecting their spectacle frames., Methods: This descriptive study consented 674 patients from seven eye clinics in KwaZulu Natal. Each was interviewed using a questionnaire containing open-ended, close-ended questions and questions with a Likert-scale response., Results: Females comprised 68.4% of the study population. The majority of participants had not completed secondary school or had no schooling (78.9%), were unemployed (70.9%), and earned less than R2000 per month or did not have any form of income (89.2%). Of the 670 who chose to buy spectacles from the eye clinics, 79.4% indicated that this was convenient (79.4%) and 23.0% said that they were motivated in their decision because they liked the available frames. More than 95% of participants rated the design, quality, and price as good to excellent. Factors influencing their decisions included design, recommendations from staff, and quality. Those who bought the spectacles from the budget range were prepared to pay more for the next pair of spectacles, whereas almost all reported that they would return to the same eye clinic for their next pair of spectacles and that they would recommend relatives and friends to the clinic., Conclusions: The results from the study indicate that there is high acceptance by patients of the range of spectacles offered in public sector eye clinics with specific suggestions to improve it. Increased understanding of the perceptions and motivations in spectacle choice will help inform planning and procurement decisions in supplying the needs of the patients and broadening the patient base.

Background: The Global Burden of Disease, Injuries, and Risk Factor study 2013 (GBD 2013) is the first of a series of annual updates of the GBD. Risk factor quantification, particularly of modifiable risk factors, can help to identify emerging threats to population health and opportunities for prevention. The GBD 2013 provides a timely opportunity to update the comparative risk assessment with new data for exposure, relative risks, and evidence on the appropriate counterfactual risk distribution., Methods: Attributable deaths, years of life lost, years lived with disability, and disability-adjusted life-years (DALYs) have been estimated for 79 risks or clusters of risks using the GBD 2010 methods. Risk-outcome pairs meeting explicit evidence criteria were assessed for 188 countries for the period 1990-2013 by age and sex using three inputs: risk exposure, relative risks, and the theoretical minimum risk exposure level (TMREL). Risks are organised into a hierarchy with blocks of behavioural, environmental and occupational, and metabolic risks at the first level of the hierarchy. The next level in the hierarchy includes nine clusters of related risks and two individual risks, with more detail provided at levels 3 and 4 of the hierarchy. Compared with GBD 2010, six new risk factors have been added: handwashing practices, occupational exposure to trichloroethylene, childhood wasting, childhood stunting, unsafe sex, and low glomerular filtration rate. For most risks, data for exposure were synthesised with a Bayesian meta-regression method, DisMod-MR 2.0, or spatial-temporal Gaussian process regression. Relative risks were based on meta-regressions of published cohort and intervention studies. Attributable burden for clusters of risks and all risks combined took into account evidence on the mediation of some risks such as high body-mass index (BMI) through other risks such as high systolic blood pressure and high cholesterol., Findings: All risks combined account for 57·2% (95% uncertainty interval [UI] 55·8-58·5) of deaths and 41·6% (40·1-43·0) of DALYs. Risks quantified account for 87·9% (86·5-89·3) of cardiovascular disease DALYs, ranging to a low of 0% for neonatal disorders and neglected tropical diseases and malaria. In terms of global DALYs in 2013, six risks or clusters of risks each caused more than 5% of DALYs: dietary risks accounting for 11·3 million deaths and 241·4 million DALYs, high systolic blood pressure for 10·4 million deaths and 208·1 million DALYs, child and maternal malnutrition for 1·7 million deaths and 176·9 million DALYs, tobacco smoke for 6·1 million deaths and 143·5 million DALYs, air pollution for 5·5 million deaths and 141·5 million DALYs, and high BMI for 4·4 million deaths and 134·0 million DALYs. Risk factor patterns vary across regions and countries and with time. In sub-Saharan Africa, the leading risk factors are child and maternal malnutrition, unsafe sex, and unsafe water, sanitation, and handwashing. In women, in nearly all countries in the Americas, north Africa, and the Middle East, and in many other high-income countries, high BMI is the leading risk factor, with high systolic blood pressure as the leading risk in most of Central and Eastern Europe and south and east Asia. For men, high systolic blood pressure or tobacco use are the leading risks in nearly all high-income countries, in north Africa and the Middle East, Europe, and Asia. For men and women, unsafe sex is the leading risk in a corridor from Kenya to South Africa., Interpretation: Behavioural, environmental and occupational, and metabolic risks can explain half of global mortality and more than one-third of global DALYs providing many opportunities for prevention. Of the larger risks, the attributable burden of high BMI has increased in the past 23 years. In view of the prominence of behavioural risk factors, behavioural and social science research on interventions for these risks should be strengthened. Many prevention and primary care policy options are available now to act on key risks., Funding: Bill & Melinda Gates Foundation., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Importance: The number of urban migrants in China is 300 million and is increasing rapidly in response to government policies. Urban migrants have poor access to health care, but little is known about rates of correction of refractive error among migrant children. This is of particular significance in light of recent evidence demonstrating the educational impact of providing children with spectacles., Objective: To measure prevalence of spectacle need and ownership among Chinese migrant children., Design, Setting, and Participants: Population-based, cross-sectional study among children who failed vision testing (uncorrected visual acuity ≤6/12 in either eye) between September 15 and 30, 2013, at 94 randomly selected primary schools in predominantly migrant communities in Shanghai, Suzhou, and Wuxi, China., Main Outcomes and Measures: Refractive error by cycloplegic refraction; spectacle ownership, defined as producing glasses at school, having been told to bring them; and needing glasses, defined as uncorrected visual acuity of 6/12 or less correctable to greater than 6/12 in either eye, with myopia of -0.5 diopters (D) or less, hyperopia of +2.0 D or greater, or astigmatism of 0.75 D or greater in both eyes., Results: Among 4409 children, 4376 (99.3%) completed vision screening (mean [SD] age, 11.0 [0.81] years; 55.3% boys; 4225 [96.5%] migrant and 151 [3.5%] local). Among 1204 children failing vision testing (total, 27.5%; 1147 migrant children [27.1%] vs 57 local children [37.7%]; P = .003), 850 (70.6%) completed refraction. Spectacle ownership in migrant children needing glasses (147 of 640 children [23.0%]) was less than among local children (12 of 34 children [35.3%]) (odds ratio = 0.55; 95% CI, 0.32-0.95; P = .03). Having uncorrected visual acuity less than 6/18 in both eyes was associated positively with baseline spectacle ownership (odds ratio = 5.73; 95% CI, 3.81-8.62; P < .001), but parental education and family wealth were not., Conclusions and Relevance: Among urban migrant children, there was a high prevalence of need for spectacles and a very low rate of spectacle ownership. Spectacle distribution programs are needed specifically targeting migrant children.

Background: The Global Burden of Disease Study 2013 (GBD 2013) aims to bring together all available epidemiological data using a coherent measurement framework, standardised estimation methods, and transparent data sources to enable comparisons of health loss over time and across causes, age-sex groups, and countries. The GBD can be used to generate summary measures such as disability-adjusted life-years (DALYs) and healthy life expectancy (HALE) that make possible comparative assessments of broad epidemiological patterns across countries and time. These summary measures can also be used to quantify the component of variation in epidemiology that is related to sociodemographic development., Methods: We used the published GBD 2013 data for age-specific mortality, years of life lost due to premature mortality (YLLs), and years lived with disability (YLDs) to calculate DALYs and HALE for 1990, 1995, 2000, 2005, 2010, and 2013 for 188 countries. We calculated HALE using the Sullivan method; 95% uncertainty intervals (UIs) represent uncertainty in age-specific death rates and YLDs per person for each country, age, sex, and year. We estimated DALYs for 306 causes for each country as the sum of YLLs and YLDs; 95% UIs represent uncertainty in YLL and YLD rates. We quantified patterns of the epidemiological transition with a composite indicator of sociodemographic status, which we constructed from income per person, average years of schooling after age 15 years, and the total fertility rate and mean age of the population. We applied hierarchical regression to DALY rates by cause across countries to decompose variance related to the sociodemographic status variable, country, and time., Findings: Worldwide, from 1990 to 2013, life expectancy at birth rose by 6·2 years (95% UI 5·6-6·6), from 65·3 years (65·0-65·6) in 1990 to 71·5 years (71·0-71·9) in 2013, HALE at birth rose by 5·4 years (4·9-5·8), from 56·9 years (54·5-59·1) to 62·3 years (59·7-64·8), total DALYs fell by 3·6% (0·3-7·4), and age-standardised DALY rates per 100 000 people fell by 26·7% (24·6-29·1). For communicable, maternal, neonatal, and nutritional disorders, global DALY numbers, crude rates, and age-standardised rates have all declined between 1990 and 2013, whereas for non-communicable diseases, global DALYs have been increasing, DALY rates have remained nearly constant, and age-standardised DALY rates declined during the same period. From 2005 to 2013, the number of DALYs increased for most specific non-communicable diseases, including cardiovascular diseases and neoplasms, in addition to dengue, food-borne trematodes, and leishmaniasis; DALYs decreased for nearly all other causes. By 2013, the five leading causes of DALYs were ischaemic heart disease, lower respiratory infections, cerebrovascular disease, low back and neck pain, and road injuries. Sociodemographic status explained more than 50% of the variance between countries and over time for diarrhoea, lower respiratory infections, and other common infectious diseases; maternal disorders; neonatal disorders; nutritional deficiencies; other communicable, maternal, neonatal, and nutritional diseases; musculoskeletal disorders; and other non-communicable diseases. However, sociodemographic status explained less than 10% of the variance in DALY rates for cardiovascular diseases; chronic respiratory diseases; cirrhosis; diabetes, urogenital, blood, and endocrine diseases; unintentional injuries; and self-harm and interpersonal violence. Predictably, increased sociodemographic status was associated with a shift in burden from YLLs to YLDs, driven by declines in YLLs and increases in YLDs from musculoskeletal disorders, neurological disorders, and mental and substance use disorders. In most country-specific estimates, the increase in life expectancy was greater than that in HALE. Leading causes of DALYs are highly variable across countries., Interpretation: Global health is improving. Population growth and ageing have driven up numbers of DALYs, but crude rates have remained relatively constant, showing that progress in health does not mean fewer demands on health systems. The notion of an epidemiological transition--in which increasing sociodemographic status brings structured change in disease burden--is useful, but there is tremendous variation in burden of disease that is not associated with sociodemographic status. This further underscores the need for country-specific assessments of DALYs and HALE to appropriately inform health policy decisions and attendant actions., Funding: Bill & Melinda Gates Foundation., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Purpose: The onset of presbyopia in middle adulthood results in potential losses in productivity among otherwise healthy adults if uncorrected or undercorrected. The economic burden could be significant in lower-income countries, where up to 94% of cases may be uncorrected or undercorrected. This study estimates the global burden of potential productivity lost because of uncorrected functional presbyopia., Design: Population data from the US Census Bureau were combined with the estimated presbyopia prevalence, age of onset, employment rate, gross domestic product (GDP) per capita in current US dollars, and near vision impairment disability weights from the Global Burden of Disease 2010 study to estimate the global loss of productivity from uncorrected and undercorrected presbyopia in each country in 2011. To allow comparison with earlier work, we also calculated the loss with the conservative assumption that the contribution to productivity extends only up to 50 years of age., Participants: The economic modeling did not require the use of subjects., Methods: We estimated the number of cases of uncorrected or undercorrected presbyopia in each country among the working-age population. The number of working-age cases was multiplied by the labor force participation rate, the employment rate, a disability weight, and the GDP per capita to estimate the potential loss of GDP due to presbyopia., Main Outcome Measures: The outcome being measured is the lost productivity in 2011 US dollars resulting from uncorrected or undercorrected presbyopia., Results: There were an estimated 1.272 billion cases of presbyopia worldwide in 2011. A total of 244 million cases, uncorrected or undercorrected among people aged <50 years, were associated with a potential productivity loss of US $11.023 billion (0.016% of global GDP). If all those people aged <65 years are assumed to be productive, the potential productivity loss would be US $25.367 billion or 0.037% of global GDP. Correcting presbyopia to the level achieved in Europe would reduce the burden to US $1.390 billion (0.002% of global GDP)., Conclusions: Even with conservative assumptions regarding the productive population, presbyopia is a significant burden on productivity, and correction would have a significant impact on productivity in lower-income countries.

Background: Blindness and visual impairment are very common in African countries and are often loosely linked to inadequate resources. We designed this study to assess clinical visual and ocular characteristics of children in three integrated schools in Malawi, so that students needing low vision services or those with correctable refractive error will be identified., Methods: We included 95 students, who underwent a detailed optometric examination. The assessment included distance visual acuity measurement in logMAR notation, near visual acuity, oculo-motor assessment, pupillary assessment and anterior as well as posterior segment evaluation. Non-cycloplegic refraction was done in all the participants., Results: Mean age of students was 13.84 ±4.61 years. Almost 90 per cent of students had presenting visual acuity worse than logMAR 0.54. Visual acuity improved significantly after refractive correction by more than two logMAR lines in 31.8 per cent (p < 0.0001). Refractive error was very common (36.5 per cent) and the most common causes of visual impairment were lenticular (21.2 per cent), corneal (20.0 per cent) and albinism (15.3 per cent). One-tenth (10.5 per cent) of the students were wrongly enrolled in the schools, even though they did not have visual impairment. The compliance to spectacles wear was very poor (37 per cent). An adequate refractive correction improved visual acuity in more than a third (36.5 per cent) of the students. Students benefited from spectacle magnifiers (18.8 per cent), handheld magnifiers (4.7 per cent) and telescopes (5.9 per cent). Mobility canes were advised for 36.5 per cent of the students., Conclusion: Nine out of ten students in three integrated schools in Malawi had visual impairment and 41 per cent had low vision. Inappropriate placement in the integrated schools and poor spectacle compliance are very common. Well accepted optical and non-optical devices could improve visual performance in visually disabled children, for which public awareness and parental education is important., (© 2015 The Authors. Clinical and Experimental Optometry © 2015 Optometry Australia.)

Background: Vision impairment, resulting in vision difficulties, is a leading cause of disability, and hence one of the key barriers for people to access education and employment, which may force them into poverty., Objectives: The objective of this study was to determine the prevalence of self-reported vision difficulties as an indicator of vision impairment in economically disadvantaged regions in South Africa, and to examine the relationship between self-reported vision difficulties and socio-economic markers of poverty, namely, income, education and health service needs., Methods: A cross-sectional study was conducted in economically disadvantaged districts to collect data from households on poverty and health, including vision difficulty. As visual acuity measurements were not conducted, the researchers used the term vision difficulty as an indicator of vision impairment. Data were collected from 27 districts (74 901 respondents). Logistic regression analysis and chi-square tests were used to determine bivariate relationships between variables and self-reported vision difficulty. Kernel density estimators were used for age, categorised by self-reported and not reported vision difficulty., Results: Prevalence of self-reported vision difficulty was 11.2% (95% CI, 8.7% - 13.7%). More women (12.7%) compared to men (9.5%) self-reported vision difficulty ( p < 0.01). Self-reported vision difficulty was higher (14.2%) for respondents that do not spend any money. A statistically significant relationship was found between the highest level of education and self-reporting of vision difficulty; as completed highest level of education increased, self-reporting of vision difficulty became lower ( p < 0.01). A significantly higher prevalence of self-reported vision difficulty was found in respondents who are employed ( p < 0.01), 17% (95% CI: 12.8% - 21.1%)., Conclusion: The evidence from this study suggests associations between socio-economic factors and vision difficulties that have a two-fold relationship (some factors such as education, and access to eye health services are associated with vision difficulty whilst vision difficulty may trap people in their current poverty or deepen their poverty status). The results are thus indicative of the need for further research in South Africa., Competing Interests: The authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article.

Background: In Tanzania, the prevalence of refractive error and presbyopia have not been comprehensively assessed, limiting appropriate planning and implementation of delivery of vision care. This study sought to determine the prevalence of refractive error and presbyopia, spectacle coverage and the barriers to uptake of refractive services in people aged 15 years and older in the Kahama district of Tanzania., Methods: A cross-sectional community-based survey was conducted using 54 randomly selected clusters. Respondents 15 years and older were interviewed and underwent standardised clinical eye examinations. Uncorrected refractive error (URE) was defined as presenting vision worse than 6/12 that could be corrected to better than 6/12 using a pinhole. Spectacle coverage was defined as the proportion of need that was met (those that improved from unaided vision with their own spectacle correction)., Results: A total of 3,230 subjects (99.75 per cent of 3,240 eligible) participated in the study with 57.2 per cent males and the median age of participants was 35 years (inter-quartile range, 24 to 49). The prevalence of visual impairment was 10.4 per cent (95% CI 9.4 to 11.4) and was lower in those who had completed their primary school education (odds ratio (OR) 0.54, 95% CI: 0.40 to 0.72) and highest in subjects 40 years and older (OR 3.17, 95% CI: 2.14 to 4.70) and farmers (OR 8.57 95% CI: 2.27 to 32.43). Refractive error prevalence was 7.5 per cent (95% CI: 6.65 to 8.54) and this was highest in participants over 40 years (OR 1.60, 95% CI: 1.14 to 2.25) and in students (OR 3.64, 95% CI: 1.35 to 9.86). Prevalence of presbyopia was 46.5 per cent (773/1,663, 95% CI: 44.34 to 48.75). Spectacle coverage for refractive error and presbyopia was 1.69% (95% CI: 0 to 3.29) and 0.42% (95% CI: 0 to 1.26), respectively., Conclusion: Uncorrected refractive error is a public health challenge in the Kahama district and sustainable service delivery and health promotion efforts are needed., (© 2014 The Authors. Clinical and Experimental Optometry © 2014 Optometrists Association Australia.)

Background: The Millennium Declaration in 2000 brought special global attention to HIV, tuberculosis, and malaria through the formulation of Millennium Development Goal (MDG) 6. The Global Burden of Disease 2013 study provides a consistent and comprehensive approach to disease estimation for between 1990 and 2013, and an opportunity to assess whether accelerated progress has occured since the Millennium Declaration., Methods: To estimate incidence and mortality for HIV, we used the UNAIDS Spectrum model appropriately modified based on a systematic review of available studies of mortality with and without antiretroviral therapy (ART). For concentrated epidemics, we calibrated Spectrum models to fit vital registration data corrected for misclassification of HIV deaths. In generalised epidemics, we minimised a loss function to select epidemic curves most consistent with prevalence data and demographic data for all-cause mortality. We analysed counterfactual scenarios for HIV to assess years of life saved through prevention of mother-to-child transmission (PMTCT) and ART. For tuberculosis, we analysed vital registration and verbal autopsy data to estimate mortality using cause of death ensemble modelling. We analysed data for corrected case-notifications, expert opinions on the case-detection rate, prevalence surveys, and estimated cause-specific mortality using Bayesian meta-regression to generate consistent trends in all parameters. We analysed malaria mortality and incidence using an updated cause of death database, a systematic analysis of verbal autopsy validation studies for malaria, and recent studies (2010-13) of incidence, drug resistance, and coverage of insecticide-treated bednets., Findings: Globally in 2013, there were 1·8 million new HIV infections (95% uncertainty interval 1·7 million to 2·1 million), 29·2 million prevalent HIV cases (28·1 to 31·7), and 1·3 million HIV deaths (1·3 to 1·5). At the peak of the epidemic in 2005, HIV caused 1·7 million deaths (1·6 million to 1·9 million). Concentrated epidemics in Latin America and eastern Europe are substantially smaller than previously estimated. Through interventions including PMTCT and ART, 19·1 million life-years (16·6 million to 21·5 million) have been saved, 70·3% (65·4 to 76·1) in developing countries. From 2000 to 2011, the ratio of development assistance for health for HIV to years of life saved through intervention was US$4498 in developing countries. Including in HIV-positive individuals, all-form tuberculosis incidence was 7·5 million (7·4 million to 7·7 million), prevalence was 11·9 million (11·6 million to 12·2 million), and number of deaths was 1·4 million (1·3 million to 1·5 million) in 2013. In the same year and in only individuals who were HIV-negative, all-form tuberculosis incidence was 7·1 million (6·9 million to 7·3 million), prevalence was 11·2 million (10·8 million to 11·6 million), and number of deaths was 1·3 million (1·2 million to 1·4 million). Annualised rates of change (ARC) for incidence, prevalence, and death became negative after 2000. Tuberculosis in HIV-negative individuals disproportionately occurs in men and boys (versus women and girls); 64·0% of cases (63·6 to 64·3) and 64·7% of deaths (60·8 to 70·3). Globally, malaria cases and deaths grew rapidly from 1990 reaching a peak of 232 million cases (143 million to 387 million) in 2003 and 1·2 million deaths (1·1 million to 1·4 million) in 2004. Since 2004, child deaths from malaria in sub-Saharan Africa have decreased by 31·5% (15·7 to 44·1). Outside of Africa, malaria mortality has been steadily decreasing since 1990., Interpretation: Our estimates of the number of people living with HIV are 18·7% smaller than UNAIDS's estimates in 2012. The number of people living with malaria is larger than estimated by WHO. The number of people living with HIV, tuberculosis, or malaria have all decreased since 2000. At the global level, upward trends for malaria and HIV deaths have been reversed and declines in tuberculosis deaths have accelerated. 101 countries (74 of which are developing) still have increasing HIV incidence. Substantial progress since the Millennium Declaration is an encouraging sign of the effect of global action., Funding: Bill & Melinda Gates Foundation., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Background: The fifth Millennium Development Goal (MDG 5) established the goal of a 75% reduction in the maternal mortality ratio (MMR; number of maternal deaths per 100,000 livebirths) between 1990 and 2015. We aimed to measure levels and track trends in maternal mortality, the key causes contributing to maternal death, and timing of maternal death with respect to delivery., Methods: We used robust statistical methods including the Cause of Death Ensemble model (CODEm) to analyse a database of data for 7065 site-years and estimate the number of maternal deaths from all causes in 188 countries between 1990 and 2013. We estimated the number of pregnancy-related deaths caused by HIV on the basis of a systematic review of the relative risk of dying during pregnancy for HIV-positive women compared with HIV-negative women. We also estimated the fraction of these deaths aggravated by pregnancy on the basis of a systematic review. To estimate the numbers of maternal deaths due to nine different causes, we identified 61 sources from a systematic review and 943 site-years of vital registration data. We also did a systematic review of reports about the timing of maternal death, identifying 142 sources to use in our analysis. We developed estimates for each country for 1990-2013 using Bayesian meta-regression. We estimated 95% uncertainty intervals (UIs) for all values., Findings: 292,982 (95% UI 261,017-327,792) maternal deaths occurred in 2013, compared with 376,034 (343,483-407,574) in 1990. The global annual rate of change in the MMR was -0·3% (-1·1 to 0·6) from 1990 to 2003, and -2·7% (-3·9 to -1·5) from 2003 to 2013, with evidence of continued acceleration. MMRs reduced consistently in south, east, and southeast Asia between 1990 and 2013, but maternal deaths increased in much of sub-Saharan Africa during the 1990s. 2070 (1290-2866) maternal deaths were related to HIV in 2013, 0·4% (0·2-0·6) of the global total. MMR was highest in the oldest age groups in both 1990 and 2013. In 2013, most deaths occurred intrapartum or postpartum. Causes varied by region and between 1990 and 2013. We recorded substantial variation in the MMR by country in 2013, from 956·8 (685·1-1262·8) in South Sudan to 2·4 (1·6-3·6) in Iceland., Interpretation: Global rates of change suggest that only 16 countries will achieve the MDG 5 target by 2015. Accelerated reductions since the Millennium Declaration in 2000 coincide with increased development assistance for maternal, newborn, and child health. Setting of targets and associated interventions for after 2015 will need careful consideration of regions that are making slow progress, such as west and central Africa., Funding: Bill & Melinda Gates Foundation., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Background: Remarkable financial and political efforts have been focused on the reduction of child mortality during the past few decades. Timely measurements of levels and trends in under-5 mortality are important to assess progress towards the Millennium Development Goal 4 (MDG 4) target of reduction of child mortality by two thirds from 1990 to 2015, and to identify models of success., Methods: We generated updated estimates of child mortality in early neonatal (age 0-6 days), late neonatal (7-28 days), postneonatal (29-364 days), childhood (1-4 years), and under-5 (0-4 years) age groups for 188 countries from 1970 to 2013, with more than 29,000 survey, census, vital registration, and sample registration datapoints. We used Gaussian process regression with adjustments for bias and non-sampling error to synthesise the data for under-5 mortality for each country, and a separate model to estimate mortality for more detailed age groups. We used explanatory mixed effects regression models to assess the association between under-5 mortality and income per person, maternal education, HIV child death rates, secular shifts, and other factors. To quantify the contribution of these different factors and birth numbers to the change in numbers of deaths in under-5 age groups from 1990 to 2013, we used Shapley decomposition. We used estimated rates of change between 2000 and 2013 to construct under-5 mortality rate scenarios out to 2030., Findings: We estimated that 6·3 million (95% UI 6·0-6·6) children under-5 died in 2013, a 64% reduction from 17·6 million (17·1-18·1) in 1970. In 2013, child mortality rates ranged from 152·5 per 1000 livebirths (130·6-177·4) in Guinea-Bissau to 2·3 (1·8-2·9) per 1000 in Singapore. The annualised rates of change from 1990 to 2013 ranged from -6·8% to 0·1%. 99 of 188 countries, including 43 of 48 countries in sub-Saharan Africa, had faster decreases in child mortality during 2000-13 than during 1990-2000. In 2013, neonatal deaths accounted for 41·6% of under-5 deaths compared with 37·4% in 1990. Compared with 1990, in 2013, rising numbers of births, especially in sub-Saharan Africa, led to 1·4 million more child deaths, and rising income per person and maternal education led to 0·9 million and 2·2 million fewer deaths, respectively. Changes in secular trends led to 4·2 million fewer deaths. Unexplained factors accounted for only -1% of the change in child deaths. In 30 developing countries, decreases since 2000 have been faster than predicted attributable to income, education, and secular shift alone., Interpretation: Only 27 developing countries are expected to achieve MDG 4. Decreases since 2000 in under-5 mortality rates are accelerating in many developing countries, especially in sub-Saharan Africa. The Millennium Declaration and increased development assistance for health might have been a factor in faster decreases in some developing countries. Without further accelerated progress, many countries in west and central Africa will still have high levels of under-5 mortality in 2030., Funding: Bill & Melinda Gates Foundation, US Agency for International Development., (Copyright © 2014 Elsevier Ltd. All rights reserved.)