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Objective To report the relationship between visual impairment (VI) and cognitive impairment (CI) among the older population living in residential care homes in Hyderabad, India.Study design Cross-sectional study.Setting 41 homes for the aged centres in the Hyderabad region.Participants 965 participants aged ≥60 years from homes for the aged centres.Primary outcome measures Visual impairment and cognitive impairment.Methods The Hindi mini-Mental Status Examination (HMSE) questionnaire was used to assess the cognitive function. The final HMSE score was calculated after excluding vision-dependent tasks (HMSE-VI). A detailed eye examination was conducted, including visual acuity (VA) measurement for distance and near vision, using a standard logarithm of the minimum angle of resolution chart under good illumination. CI was defined as having a HMSE-VI score of ≤17. VI was defined as presenting VA worse than 6/12 in the better-seeing eye. Near VI (NVI) was defined as binocular presenting near vision worse than N8 and distance VA of 6/18 or better in the better-seeing eye. Multiple logistic regression was done to assess the association between VI and CI.Results The mean age (±SD) was 74.3 (±8.3) years (range: 60–97 years). There were 612 (63.4%) women, and 593 (61.5%) had a school education. In total, 260 (26.9%; 95% confidence intervals: 24.2 to 29.9) participants had CI. The prevalence of CI among those with VI was 40.5% compared with 14.6% among those without VI (p

Objective To determine the prevalence, causes and risk factors associated with visual impairment (VI) in the Nirmal district of Telangana, India, using extended Rapid Assessment of Visual Impairment (RAVI) methodology.Design Cross-sectional study.Setting Community setting.Participants Participants aged ≥16 years were enumerated from 90 randomly selected clusters and 4629/5400 (85.7%) participants were examined. Presenting visual acuity (VA) was assessed using a Snellen chart with E optotypes at a 6 m distance. Near vision was assessed binocularly using an N notation chart with tumbling E optotypes at a 40 cm distance. An anterior segment examination done followed by distance direct ophthalmoscopy at 50 cm. Non-mydriatic fundus images were obtained. VI was defined as presenting VA worse than 6/12 in the better eye. The prevalence of VI in the current study was compared with a RAVI study conducted in 2014 to assess the trends in VI among those aged ≥40 years.Primary outcome Prevalence, causes and risk factors for VI.Results Among those examined, 55% were women, 53% had at least school-level education, 2.3% self-reported diabetes and 8.7% self-reported hypertension. The prevalence of VI was 8.81% (95% CI 8.01% to 9.67%). Overall, uncorrected refractive errors (49.5%) were the leading cause of VI, followed by cataracts (40.2%) and posterior segment diseases (4.9%). Among those aged ≥40 years, the prevalence of VI declined by 19.3% compared with the 2014 baseline study (from 20.2% to 16.3%; p

Objective To report the prevalence and risk factors for the fear of falling (FOF) among older individuals living in residential care facilities in India.Design Cross-sectional study.Setting Homes for the aged centres in Hyderabad, India.Participants The study included individuals aged ≥60 years from homes for the aged centres. The participants underwent a comprehensive eye examination in make-shift clinics setup in homes. Trained investigators collected the personal and demographic information of the participants and administered the Patient Health Questionnaire-9 and Hearing Handicap Inventory for Elderly questionnaire in the vernacular language. FOF was assessed using the Short Falls Efficacy Scale. The presence of hearing and visual impairment in the same individual was considered dual sensory impairment (DSI). A multiple logistic regression analysis was done to assess the factors associated with FOF.Primary outcome measure FOF.Results In total, 867 participants were included from 41 homes for the aged centres in the analyses. The mean (±SD) age of the participants was 74.2 (±8.3) years (range 60–96 years). The prevalence of FOF was 56.1% (95% CI 52.7% to 59.4%; n=486). The multivariate analysis showed that those with DSI had eleven times higher odds of reporting FOF than those with no impairment (OR 11.14; 95% CI 3.15 to 41.4.) Similarly, those with moderate depression had seven times higher odds (OR 6.85; 95% CI 3.70 to 12.70), and those with severe depression had eight times higher odds (OR 8.13; 95% CI 3.50 to 18.90) of reporting FOF. A history of falls in the last year was also associated with increased odds for FOF (OR 1.52; 95% CI 1.03 to 2.26).Conclusion FOF is common among older individuals in residential care in India. Depression, falling in the previous year and DSI were strongly associated with FOF. A cross-disciplinary approach may be required to address FOF among the older people in residential care in India.

Purpose: The World Report on Vision highlights that health information systems (HIS) should collect information on the determinants of eye conditions and vision impairment (VI) as a step toward integrated people-centered eye care (IPEC). Thus, this retrospective study aims to elucidate VI trends across age and gender of the patients who visited our centres in southern and eastern India. Methods: Electronic medical records of all new patients who visited the network were included. VI was defined as visual acuity less than 6/12; unilateral VI was based on the worse presenting eye (the other eye being normal), and bilateral VI was based on the better eye. “Total VI” includes both unilateral and bilateral VI. Results: The records of 7,31,307 patients from January to December 2019 were extracted. Males were 54%. The mean age was 40 years (SD: 19.16 years). The majority of patients (46.54%) visited a primary care centre. Centres in Andhra Pradesh saw the largest number of patients (46%). Approximately 65% of all patients presented had no VI in either eye. Total VI was 23.5% at the primary-centre level and approximately 45% at other levels, the highest being in Odisha. More females accessed care at primary and secondary centres (46.6%) than at higher levels of care (44%). Odisha had the lowest number of females accessing care (43.01%). Conclusion: Non-visually impairing conditions form an important reason for patients visiting our eye care facilities. Strategies focusing on improving access to eye care for females should be planned at all levels, especially in Odisha.

Primary congenital glaucoma (PCG) occurs in children due to developmental abnormalities in the trabecular meshwork and anterior chamber angle. Previous studies have implicated rare variants in CYP1B1, LTBP2, and TEK and their interactions with MYOC, FOXC1, and PRSS56 in the genetic complexity and clinical heterogeneity of PCG. Given that some of the gene-encoded proteins are localized in the centrosomes (MYOC) and perform ciliary functions (TEK), we explored the involvement of a core centrosomal protein, CEP164, which is responsible for ocular development and regulation of intraocular pressure. Deep sequencing of CEP164 in a PCG cohort devoid of homozygous mutations in candidate genes (n = 298) and controls (n = 1757) revealed CEP164 rare pathogenic variants in 16 cases (5.36%). Co-occurrences of heterozygous alleles of CEP164 with other genes were seen in four cases (1.34%), and a physical interaction was noted for CEP164 and CYP1B1 in HEK293 cells. Cases of co-harboring alleles of the CEP164 and other genes had a poor prognosis compared with those with a single copy of the CEP164 allele. We also screened INPP5E, which synergistically interacts with CEP164, and observed a lower frequency of pathogenic variants (0.67%). Our data suggest the potential involvements of CEP164 and INPP5E and the yet unexplored cilia-centrosomal functions in PCG pathogenesis.

Abstract Timely identification of individuals “at-risk” for myopia progression is the leading requisite for myopia practice as it aids in the decision of appropriate management. This study aimed to develop ‘myopia progression risk assessment score’ (MPRAS) based on multiple risk factors (10) to determine whether a myope is “at-risk” or “low-risk” for myopia progression. Two risk-score models (model-1: non-weightage, model-2: weightage) were developed. Ability of MPRAS to diagnose individual “at-risk” for myopia progression was compared against decision of five clinicians in 149 myopes, aged 6–29 years. Using model-1 (no-weightage), further 7 sub-models were created with varying number of risk factors in decreasing step-wise manner (1a: 10 factors to 1g: 4 factors). In random eye analysis for model-1, the highest Youden’s J-index (0.63–0.65) led to the MPRAS cut-off score of 41.50–43.50 for 5 clinicians with a sensitivity ranging from 78 to 85% and specificity ranging from 79 to 87%. For this cut-off score, the mean area under the curve (AUC) between clinicians and the MPRAS model ranged from 0.89 to 0.90. Model-2 (weighted for few risk-factors) provided similar sensitivity, specificity, and AUC. Sub-model analysis revealed greater AUC with high sensitivity (89%) and specificity (94%) in model-1g that has 4 risk factors compared to other sub-models (1a–1f). All the MPRAS models showed good agreement with the clinician’s decision in identifying individuals “at-risk” for myopia progression.

AimTo investigate the barriers to the uptake of referral services from secondary care centers (SC) to a higher-level tertiary care center (TC) in Southern India.MethodsA cross-sectional study was conducted in the Mahabubnagar district of Telangana, India, between February 1, 2018 to January 31, 2019 and all those referred from SC to TC between January 1, 2013 to December 30, 2016 were identified for interview. Based on inclusion criteria, of the 960 participants identified, 681 (70.9%) participated in the study. A validated study questionnaire was administered to all participants. Information collected were the demographic details, details related to their referral and barriers to referral. The participants that presented at TC were considered compliant and who did not, were non-compliant. Reasons for non-compliance was also collected.ResultsThe mean age those interviewed was 46.1 years (SD: 17.3 years) and 429 (63%) were males and 252 (37%) were females. Overall, 516 (75.8%) were compliant, and 165 (24.2%) were non-compliant. The major factors for non-compliance were economic (16.4%) and attitudinal (44.2%) barriers. Within the attitudinal barrier category, the most prevalent individual attitudinal barriers were 'too busy to go to the eye center for treatment (16.4%)'and 'able to manage routine daily activities with current vision (12.1%)'. The multivariable analysis showed that the non-compliant participants had only visited the SC once prior to the referral (odds ratio: 2.82; 95% CI: 1.43-5.57) (p = 0.003).ConclusionsParticipants with only one SC visit, were less likely to comply with referrals and the major barriers to compliance were economical and attitudinal. It is important to address these specific barriers to provide proper counseling to participants during referrals.

Purpose: Undetected vision impairment (VI) could negatively affect the overall development in children. School vision screening program is a viable and cost-effective approach for the early identification and management of VI. Aim: This study aims to estimate the prevalence of VI, its risk factors, and ocular morbidity among school children in Telangana, South India. Methods: Children aged 4–15 years attending schools in the study area were screened in this study. The vision screenings were performed in schools by trained community eye health workers using 6/12 tumbling E optotypes. Children who failed the test and/or presented with other eye conditions were referred to vision centers or secondary and tertiary eye care centers. A comprehensive eye examination was conducted in these centers, including cycloplegic refraction and fundus examination. Results: A total of 774,184 children, with a mean age of 9.4 ± 3.27 years, were screened. Overall, 51.49% (N = 398,596) were male. In total, 4.33% [N = 33,528; 95% confidence interval (CI): 4.29–4.38] required referral services, while 1.16% (N = 9,002) had a presenting visual acuity of < 6/12. Multivariate analysis showed a high risk of VI among older children [Adj. odds ratio (OR): 5.75; 95% CI: 5.18–6.38], those with disabilities (Adj. OR: 5.12; 95% CI: 4.14–6.33), female gender (Adj. OR: 1.29; 95% CI: 1.24 - 1.35), and those residing in the urban areas (Adj. OR: 2.87; 95% CI: 2.42–3.39). The main cause of VI was uncorrected refractive errors (74.14%). Conclusion: The prevalence of VI among school children was 1.16% in Telangana, South India, and refractive error was the leading cause of VI among this population. Increasing age, urban location, female gender and other disabilities increase the risk of VI among children.

Purpose: To document the spectrum and magnitude of eye disorders and visual impairment in the Dongaria—a Particularly Vulnerable Tribal Group in the Rayagada district of Odisha, India. Methods: A door-to-door screening protocol included a record of basic health parameters, visual acuity for distance, and near and flashlight examination of the eyes. Spectacles were dispensed to those who improved; those who failed the screening were referred to fixed (primary and secondary) eye care centers. Results: We examined 89% (n = 9872/11,085) of people who consented for screening. The mean age was 25.5 ± 18.8 years; 55% (n = 5391) were female; 13.8% (n = 1361) were under-five children, and 39% (n = 3884) were 6 to 16 years. 86% (n = 8515) were illiterate. 12.4% (n = 1224) were visually impaired, of which 9.9% had early moderate VI, and 2.5% had severe VI and blindness. Uncorrected refractive error was detected in 7.5% (n = 744) and cataracts in 7.6% (n = 754); among the adults, 41.5% (n = 924/2227) had presbyopia. In children, 20% (n = 790) had vitamin A deficiency, 17% (n = 234) had global acute malnutrition, and 18% (n = 244) were stunted for their age. Almost two-thirds (62%, n = 6144) confirmed habitual intake of alcohol, and 4% (n = 389) of adults had essential hypertension. Following the screening, 43.5% (n = 837) of referred patients reported to the fixed centers, and 55% (134/243) of people advised underwent cataract surgery. Spectacles were dispensed to 1496 individuals. Conclusion: Visual impairment and malnutrition are high in Dongaria indigenous community. Permanent health facilities and advocacy would improve this community's health and health-seeking behavior.

Purpose: To assess the incidence, visual impairment, and blindness due to retinitis pigmentosa (RP) in a rural southern Indian cohort. Methods: This is a population-based longitudinal cohort study of participants with RP from the Andhra Pradesh Eye Disease Study (APEDS) cohorts I and III, respectively. The study included participants with RP of APEDS I who were followed until APEDS III. Their demographic data along with ocular features, fundus photographs, and visual fields (Humphrey) were collected. Descriptive statistics using mean ± standard deviation with interquartile range (IQR) were calculated. The main outcome measures were RP incidence, visual impairment, and blindness as per the World Health Organization (WHO) definitions. Results: At baseline (APEDS I), 7771 participants residing in three rural areas were examined. There were nine participants with RP with a mean age at baseline of 47.33 ± 10.89 years (IQR: 39–55). There was a male preponderance (6:3), and the mean best-corrected visual acuity (BCVA) of 18 eyes from nine participants with RP was 1.2 ± 0.72 logarithm of minimum angle of resolution (logMAR; IQR: 0.7–1.6). Over a mean follow-up duration of 15 years, 5395/7771 (69.4%) were re-examined, which included seven RP participants from APEDS 1. Additionally, two new participants with RP were identified; so, the overall incidence was 370/ million in 15 years (24.7/million per year). The mean BCVA of 14 eyes of seven participants with RP who were re-examined in APEDS III was 2.17 ± 0.56 logMAR (IQR: 1.8–2.6), and five of these seven participants with RP developed incident blindness during the follow-up period. Conclusion: RP is a prevalent disease in southern India that warrants appropriate strategies to prevent this condition.

Abstract We report prevalence and risk factors for multimorbidity and multi-disability among elderly people in residential care in the Hyderabad region in South India. In total, 1182 elderly (aged ≥ 60) participants were examined in 41 homes for the aged centres. Detailed interviews were conducted by trained personnel to collect personal and demographic information. A questionnaire was used to assess the history of non-communicable diseases and Washington Disability Questionnaire (WDQ) was administered to assess disabilities. The mean age of the participants was 75.0 years (SD 8.8 years; range: 60–108 years), 35.4% were men, 20.3% had no formal education, 60.7% had school education and 19% had higher education. The prevalence of multimorbidity was 37.6% (95% CI: 34.8–40.4). Prevalence of multi-disability was 23.6% (95% CI: 21.2–26.3; n = 270). In total, 857 (72.5%) participants reported using at least one medication for NCDs. Over a third of the elderly in residential care had multimorbidity, and a quarter of them had multi-disability. A holistic health care system that comprises health and wellness coupled with rehabilitation to address disabilities is needed to achieve healthy aging in elderly in homes for the aged in India.

Purpose: To report the barriers for seeking eye care among the elderly population aged ≥60 years with avoidable vision impairment (VI) in the South Indian state of Telangana. Methods: A total of 3640 participants aged ≥60 years were recruited using cluster-random sampling. Demographic information, including presenting visual acuity, was measured using the standard Rapid Assessment of Visual Impairment (RAVI) protocol. “Avoidable VI” was considered if the VI was due to cataract or uncorrected refractive error (URE). A detailed interview was conducted using a validated questionnaire to report the barriers for not seeking eye care. Data were analyzed using the Stata statistical software version 14. Results: Prevalence of avoidable VI was 30.2% (95% CI: 28.02–31.06; n = 1102). Among those who noticed decreased vision (n = 1074), only 392 participants (36.4%) reported that they felt the need for seeking eye care. The major barriers for not seeking eye care were: cannot afford the consultation fee and services (42.0%) and no escort (25.7%). Overall, the personal barriers (57.9%) were the major reason for not seeking care, followed by economic barriers (42.0%). No significant difference was reported in barriers between the participants with unilateral and bilateral VI (>0.05). Conclusion: Overall, among the elderly people, personal and economic barriers were the major reason for not seeking eye care. Health care providers and policymakers should focus on newer models of eye care delivery to ensure better accessibility and uptake of care by the elderly people.

Purpose: Addressing childhood vision impairment (VI) is one of the main goals of the World Health Organization's (WHO) combating blindness strategies. The primary aim of this study was to estimate the prevalence of VI, causes, and its risk factors in school children in Krishna district, Andhra Pradesh, India. Methods: Children aged 4–15 years were screened in schools using the 6/12 Snellen optotype by trained community eye health workers, and those who failed the test and those reported or found to have obvious eye conditions were referred to primary (VC), secondary (SC), or tertiary (TC) care centre appropriately, where they underwent a complete eye examination including cycloplegic refraction and fundus examination. Results: A total of 56,988 children were screened, of whom 51.18% were boys. The mean age was 9.69 ± 3.26 years (4–15 years). Overall, 2,802/56,988 (4.92%) children were referred to a VC, of which 632/56,988 (1.11%) required referral to SC/TC. PVA of

Purpose: To determine the level of awareness of cataract and glaucoma and identify the determinants of awareness in two rural districts of Telangana, India. Methods: A population-based cross-sectional study was conducted using the rapid assessment of visual impairment (RAVI) methodology in Khammam and Warangal districts. A validated questionnaire was administered to participants aged 40 years and above to assess the level of awareness of cataract and glaucoma. Results: The awareness questionnaire was administered to 3273 participants of whom 1433 (43.8%) were men, 1985 (60.6%) of them had no education, and 1645 (50.3%) were from Khammam district. In total, 2539/3273 (77.6%; 95% confidence intervals (CI): 76.1– 79.0%) participants reported awareness of cataract. Awareness of cataract was higher in Khammam compared to that in Warangal (84.4% versus 70.6%; P < 0.01). Only 41/3273 (1.25%, 95% CI: 0.90–1.69%) participants were aware of glaucoma. Awareness of glaucoma was also higher in Khammam (1.88% versus 0.61%; P < 0.01). Younger age groups, men, any level of education, and residing in Khammam were factors associated with awareness of cataract. Only having any level of education and residing in Khammam were associated with awareness of glaucoma. Conclusion: Awareness of cataract was high, but awareness of glaucoma was very poor. There is a need to spread awareness about these potentially blinding conditions. Moving forward, this can be a critical step in developing a preventive eye care strategy to achieve universal eye health in India.

Abstract To report the prevalence of depression and its association with combined visual (VI) and hearing impairment (HI) in the elderly in residential care in India. Participants aged ≥ 60 years were recruited from 41 homes. Data on personal and sociodemographic information were obtained. Visual acuity was measured using the logMAR chart. Patient Health Questionnaire (PHQ-9) was used to assess depression, and the Hearing Handicap Inventory for the Elderly Screening (HHIE) was administered to assess hearing status. Data of all 867 eligible elderly participants were analysed. The mean age of the participants was 74.2 years (standard deviation: 8.2 years) and included 537 (61.9%) women and 117 (13.5%) participants who had no education. The prevalence of depression was 60.0% (95% CI: 45.2–73.4) in the elderly with combined VI and HI compared to 20.9% (95% CI:14.4–28.8) among those with VI only and 37.8% (95% CI: 26.6–46.5) among those with HI only. On multiple logistic regression analyses, depression was approximately 5 times higher among the participants with DSI after adjusting for other covariates. Six out of ten elderly with combined HI and VI had depression highlighting the need for screening and referral when elderly present with combined vision and hearing loss.

Abstract Background Over 2 billion people suffer from vision impairment or blindness globally, and access to validated visual measurement tools in imperative in accurately describing and managing the burden of eye disease. The present study applies contemporary psychometric validation techniques to the widely used 33-item Indian Visual Function Questionnaire (IND-VFQ-33). Methods We first estimated the polychoric correlation between each pair of items. Next, an unrotated and oblique Promax rotated factor analysis, item response theory (IRT, using a graded response model (GRM)), and differential item functioning (DIF) testing were applied to the IND-VFQ-33. We subsequently propose a validated IND-VFQ-33 questionnaire after psychometric testing, data reduction, and adjustment. Results Exploratory unrotated factor analysis identified two factors; one with a particularly high eigenvalue (18.1) and a second with a lower eigenvalue still above our threshold (1.1). A subsequent oblique Promax factor rotation was undertaken for a 2-factor solution, revealing two moderately correlated factors (+ 0.68) with clinically discrete item loadings onto either Factor 1 (21 items; collectively labelled “daily activities”) or Factor 2 (5 items; collectively labelled “bright lights”). IRT confirmed high item discrimination for all remaining items with good separation between difficulty thresholds. We found significant DIF on depression for six items in Factor 1 (all uniform DIF, except item 21 (non-uniform DIF) with no substantive difference in beta thresholds for any item and no substantive difference in expected individual or sum score, by depression at baseline. For Factor 2, only one item demonstrated significant uniform DIF on gender, similarly without major differences in beta thresholds or expected total score between gender at baseline. Consequently, no further item recalibration or reduction was undertaken after IRT and DIF analysis. Conclusion Applying IRT and DIF validation techniques to the IND-VFQ-33 identified 2 discrete factors with 26 uniquely-loading items, clinically representative of difficulty performing daily activities and experiencing difficulty due to bright lights/glare respectively. The proposed modified scale may be useful in evaluating symptomatic disease progression or response to treatment in an Indian population.

Purpose: Screening preschool children for vision-related disorders poses a challenge. This study is designed to determine the agreement and diagnostic accuracy of the spot vision screener (SVS) in screening preschool children compared to screening procedure by vision technicians (VT). Methods: This study was conducted as a part of the ongoing study titled “Initiative for Screening Children for Refractive Errors and other Eye Health Needs (I-SCREEN).” Children from 33 Anganwadis (preschools) in two districts, Adilabad district of Telangana and Krishna district of Andhra Pradesh, in South India, underwent eye health screening by a VT and by a trained community eye health workers (CEHW) using the SVS. Findings were compared for agreement and diagnostic accuracy of assessment. Results: A total of 976 preschool children were screened by the VT and separately by the CEHW using the SVS in Adilabad (15 schools) and Krishna (18 schools) districts. The overall mean age of these children was 2.5 years (SD ± 1.3 years). There were 48 (4.9%) referrals by VT compared to 105 (10.8%) referrals by CEHW using SVS. The overall sensitivity of SVS was 91.7% (95% CI: 80%–97.7%) and the specificity was 93.4% (95% CI: 91.6%–94.9%). Positive predictive value was 41.9% (95% CI: 32.3%–51.9%) and negative predictive value was 99.5% (95% CI: 98.8%–99.9%) with a moderate agreement (0.54; 95% CI 0.49–0.64) between VT screening and screening with SVS. Conclusion: The SVS showed good diagnostic accuracy and agreement in screening for possible vision-related disorders in preschool children.

Purpose: The aim of this study was to report on the impact of COVID-19 “Unlock-I” on Network of Eye Centers in Southern India. Methods: Our eye health pyramid model has a network of eye care centers in four Indian states. The network constitutes a center of excellence (CoE) at the apex followed by tertiary care centers (TC) located in urban areas, secondary care centers (SC), and primary care vision centers (VC) at the base located in rural areas. We collected data on patients seen between June 2019 and June 2020, which included age, gender, total patients seen (new or follow-up), and socioeconomic status (paying and nonpaying). A comparative study was done between the data for outpatients and surgeries performed pre-COVID-19 and during Unlock-I in COVID-19 period. Results: There was a 36.71% reduction in the overall outpatients seen in June 2020 (n = 83,161) compared to June 2019 (n = 131,395). The reduction was variable across different levels of the pyramid with the highest reduction in CoE (54.18%), followed by TCs (40.37%), SCs (30.49%) and VCs (18.85%). Similar pattern was seen for new paying patients with the highest reduction in CoE (54.22%), followed by TCs (25.86%) and SCs (4.9%). A 43.67% reduction was noted in the surgeries performed in June 2020 (n = 6,168), compared to June 2019 (n = 10,950). Reduction in paying services was highest in CoE (47.52%), followed by TCs (15.17%) and SCs (4.87%). There was no significant change in the uptake of services by gender in the network. Conclusion: Highest reduction in patient footfalls during “Unlock-1” was noted in urban centers. Going forward, there is a need to develop strategies to provide eye care closer to the doorsteps.

Summary: Background: We undertook a Grand Challenges in Global Eye Health prioritisation exercise to identify the key issues that must be addressed to improve eye health in the context of an ageing population, to eliminate persistent inequities in health-care access, and to mitigate widespread resource limitations. Methods: Drawing on methods used in previous Grand Challenges studies, we used a multi-step recruitment strategy to assemble a diverse panel of individuals from a range of disciplines relevant to global eye health from all regions globally to participate in a three-round, online, Delphi-like, prioritisation process to nominate and rank challenges in global eye health. Through this process, we developed both global and regional priority lists. Findings: Between Sept 1 and Dec 12, 2019, 470 individuals complete round 1 of the process, of whom 336 completed all three rounds (round 2 between Feb 26 and March 18, 2020, and round 3 between April 2 and April 25, 2020) 156 (46%) of 336 were women, 180 (54%) were men. The proportion of participants who worked in each region ranged from 104 (31%) in sub-Saharan Africa to 21 (6%) in central Europe, eastern Europe, and in central Asia. Of 85 unique challenges identified after round 1, 16 challenges were prioritised at the global level; six focused on detection and treatment of conditions (cataract, refractive error, glaucoma, diabetic retinopathy, services for children and screening for early detection), two focused on addressing shortages in human resource capacity, five on other health service and policy factors (including strengthening policies, integration, health information systems, and budget allocation), and three on improving access to care and promoting equity. Interpretation: This list of Grand Challenges serves as a starting point for immediate action by funders to guide investment in research and innovation in eye health. It challenges researchers, clinicians, and policy makers to build collaborations to address specific challenges. Funding: The Queen Elizabeth Diamond Jubilee Trust, Moorfields Eye Charity, National Institute for Health Research Moorfields Biomedical Research Centre, Wellcome Trust, Sightsavers, The Fred Hollows Foundation, The Seva Foundation, British Council for the Prevention of Blindness, and Christian Blind Mission. Translations: For the French, Spanish, Chinese, Portuguese, Arabic and Persian translations of the abstract see Supplementary Materials section.

Objectives To investigate the prevalence of near-vision impairment (NVI) and effective spectacle coverage for near vision in those aged ≥40 years in Khammam and Warangal district in Telangana, India.Design A population-based cross-sectional study.Setting Khammam and Warangal district in Telangana, India.Participants Of 6000 people enumerated, 5357 were examined (89%). 4526 participants without distance vision impairment were included in the analysis.Main outcome measures The study teams visited selected households and conducted eye examinations. NVI was defined as binocular presenting near vision worse than N6. ‘Unmet need’ was deemed to be present if the unaided near vision was worse than N6 and improved to N6 with near correction among the participants who did not have spectacles for near vision. ‘Met need’ was deemed to be present when unaided near vision was worse than N6 but improving to N6 with their spectacles. The ‘undermet need’ was deemed to be present when aided near vision was worse than N6 but improved to N6 with correction. Based on these definitions, e-near-vision coverage (%) is calculated as follows: e-NVC (%)=met need/(met need+undermet need+unmet need) × 100.Results The mean age was 53.5 years (SD: 10.8 years), 2534/4526 (55.8%) were women, 1819/4526 (41.8%) had at least primary school education and 2368/4526 (52.3%) were from the Khammam district. The prevalence of NVI was 55.8% (95% CI 72.5 to 75.1; n=3343). Overall, the e-NVC (%) was 31.8%. It was 40.0% in Khammam and 23.2% in Warangal.Conclusion NVI is common in Khammam and Warangal districts in Telangana with inadequate effective near-vision coverage. Effective service delivery models are needed to reach out and provide services to address NVI to achieve universal eye health coverage in the region.

AIM: To report on the utilization of eye care services and its associated factors among those with unilateral visual impairment (VI) in a rural South Indian population. METHODS: A population based cross-sectional study was conducted in three districts (Adilabad, Mahbubnagar and West Godavari) in the state of Andhra Pradesh, India. A detailed interview and a comprehensive eye examination were conducted. Those with unilateral VI were asked questions about noticing any change in vision and on utilization of eye care services. The most important reason reported by the participant for not utilizing the services was used for the analysis. Multiple logistic regression models were used to examine the association between noticing a change in vision and socio-demographic variables such as age, gender, education and area of residence, severity and causes of VI. RESULTS: Among the 4456 participants aged ≥16y who were administered the questionnaire, 53.2% were women, and 54.7% had no education. Of the 489 (11%; 95% CI: 10.1-11.9) people with unilateral VI, 399 (81.6%) participants reported noticing a change in their vision over the last five years but only 136 (34.1%) participants had sought eye care consultation. Those who had any education (OR: 1.9; 95% CI: 1.1-3.2), had blindness (OR: 2.7; 95% CI: 1.4-5.2), and cataract (OR: 2.1; 95% CI: 1.0-4.3) as a cause of unilateral VI were more like to seek eye care consultations. The most commonly reported reasons for not seeking eye care services were “do not have money for eye checkup” in 30.7% of the participants followed by “do not have a serious problem” (30.0%). CONCLUSION: A large proportion of rural population though noticed a change in their vision did not seek eye care due to financial and person-related reasons. Eye care service providers need to address these barriers to enhance the uptake of eye care services among those with unilateral VI.

Context: Uncorrected refractive errors are the leading cause of visual impairment. Aims: To assess the prevalence and patterns of spectacles use among those aged ≥40 years in the South Indian state of Telangana. Settings and Design: This was a population-based, cross-sectional study, in which 6150 people were enumerated from 123 clusters in the two districts of Telangana state (Adilabad and Mahbubnagar) using a two-stage cluster random sampling methodology. Materials and Methods: Participants were visited in their households and presenting visual acuity (VA) was assessed in all cases followed by pinhole VA if presenting VA was worse than 6/12. A questionnaire was used to collect information on the current and previous spectacles use, type of spectacles, and details of the spectacles provider. Statistical Analysis Used: Stata statistical software version 12. Results: Among 5881 participants examined, 53.7% were women, and 82% had no formal education. The prevalence of current spectacles use was 28.8% (95% confidence interval: 27.6–30.0). On applying multiple logistic regression analysis, spectacles use was significantly associated with older age groups, female gender, higher levels of education, and residing in Adilabad district. Bifocals were the most commonly used type of spectacles (56.3%), and private eye clinics (70.3%) were the leading service providers. The spectacles coverage was 53.6%. Conclusions: We reported on prevalence and patterns of spectacles use using a large representative sample and a high response rate. More than half of those who may benefit from spectacles were using them, suggestive of a reasonable primary eye care coverage in the two districts studied.

AIM: To report the prevalence and causes of unilateral visual impairment (UVI) in rural population of all ages in rural Andhra Pradesh, India. METHODS: A population-based cross sectional study using a multi-stage cluster sampling methodology was carried out in West Godavari, Adilabad and Mahbubnagar districts in south India. A comprehensive eye examination that included presenting and best corrected visual acuity and dilated fundus examination was conducted by trained professionals. UVI is defined as presenting visual acuity ＜6/18 in one eye but ≥6/18 in other eye. Multiple logistic regression analysis was used to test association of UVI with socio-demographic risk factors. RESULTS: Data were analyzed for 6634/7771 participants after excluding those with bilateral visual impairment. The mean age of the participants was 27.4y (standard deviation: 17.9y), 51.9% were women and 49.1% were educated. The prevalence of UVI was 7.8% (95% CI: 7.2%-8.5%). Uncorrected refractive error (60.8%), cataract (17.4%) and retinal causes (6.6%) were the leading causes of UVI. On multiple logistic regression analyses, older age, not having education, living in well-off district had significantly higher odds of being associated with UVI. UVI was not associated with gender. CONCLUSION: UVI is common in rural south India. Most of it is due to cataract and refractive errors, both of which can be addressed at primary and secondary levels of eye care. Burden of UVI should also be considered in planning eye care services.

Background/Aim: The Andhra Pradesh Eye disease Study (APEDS) was a conventional cross-sectional study conducted in four locations during 1996-2000. Ten years later, a Rapid Assessment of Refractive Errors (RARE) survey was conducted in one of the geographical regions. The prevalence of visual impairment (VI), uncorrected refractive error (URE), spectacles use obtained from both the surveys was compared. Settings and Design: Rural settings; cross-sectional studies. Materials and Methods: In both the surveys, distance visual acuity (VA) was assessed using a logMAR chart. Pinhole VA was assessed if presenting VA was

To assess the visual outcomes after cataract surgery among urban and rural population aged ≥40 years in the South India state of Andhra Pradesh.A population based cross-sectional study was conducted in which 7800 subjects were sampled from two rural and one urban location. Visual Acuity was assessed and eye examination were performed by trained personnel. A questionnaire was used to collect personal and demographic information, and history of cataract surgery. Blindness and moderate Visual Impairment (MVI) was defined as presenting VA

Reliable information is required for the planning and management of eye care services. While classical research methods provide reliable estimates, they are prohibitively expensive and resource intensive. Rapid assessment (RA) methods are indispensable tools in situations where data are needed quickly and where time- or cost-related factors prohibit the use of classical epidemiological surveys. These methods have been developed and field tested, and can be applied across almost the entire gamut of health care. The 1990s witnessed the emergence of RA methods in eye care for cataract, onchocerciasis, and trachoma and, more recently, the main causes of avoidable blindness and visual impairment. The important features of RA methods include the use of local resources, simplified sampling methodology, and a simple examination protocol/data collection method that can be performed by locally available personnel. The analysis is quick and easy to interpret. The entire process is inexpensive, so the survey may be repeated once every 5-10 years to assess the changing trends in disease burden. RA survey methods are typically linked with an intervention. This article provides an overview of the RA methods commonly used in eye care, and emphasizes the selection of appropriate methods based on the local need and context.

Context : Globally, limited data are available on changing trends of blindness from a single region. Aims : To report the changing trends in the prevalence of blindness, visual impairment (VI), and visual outcomes of cataract surgery in a rural district of Andhra Pradesh, India, over period of one decade. Settings and Design : Rural setting; cross-sectional study. Materials and Methods : Using a validated Rapid Assessment of Cataract Surgical Services (RACSS) method, population-based, cross-sectional survey was done in a rural district in the state of Andhra Pradesh, India. Two-stage sampling procedure was used to select participants ≥50 years of age. Further, a comparative analysis was done with participants ≥50 years from the previously concluded Andhra Pradesh Eye Disease Study (APEDS) study, who belonged to the same district. Statistical Analysis : Done using 11 th version of Stata. Results : Using RACSS, 2160/2300 (93.9%) participants were examined as compared with the APEDS dataset (n=521). Age and sex adjusted prevalence of blindness in RACSS and APEDS was 8% (95% CI, 6.9-9.1%) and 11% (95% CI, 8.3-13.7%), while that of VI was 13.6% (95% CI, 12.2-15.1%) and 40.3% (95% CI, 36.1-44.5%), respectively. Cataract was the major cause of blindness in both the studies. There was a significant reduction in blindness following cataract surgery as observed through RACSS (17.3%; 95% CI, 13.5-21.8%) compared with APEDS (34%; 95% CI, 20.9-49.3%). Conclusion : There was a significant reduction in prevalence of blindness and VI in this rural district of India over a decade.

PURPOSE: To explore the awareness of glaucoma amongst the rural population of Andhra Pradesh, India. MATERIALS AND METHODS: A total of 7775 subjects of all ages, representative of the rural population of Andhra Pradesh, participated in the Andhra Pradesh Eye Disease Study. The responses of subjects older than 15 years (n = 5573) who completed a structured questionnaire regarding awareness (heard of glaucoma) and knowledge (understanding of disease) of glaucoma formed the basis of this study. RESULTS: Awareness of glaucoma (n = 18; 0.32%) was very poor in this rural population, and females were significantly less aware (p = 0.007). Awareness of glaucoma was also significantly less among illiterate persons (p < 0.0001), and socially backward population (p < 0.0001). Majority of the respondents who were aware of glaucoma (n = 10; 55.6%) did not know if visual loss due to glaucoma was permanent or reversible. The major source of awareness of glaucoma in this population was TV/magazines and other media followed by information from a relative or acquaintance suffering from the disease. CONCLUSION: Awareness of glaucoma is very poor in the rural areas of southern India. The data suggest the need for community-based health education programmes to increase the level of awareness and knowledge about glaucoma.

This study assessed the use of spectacles and its demographic associations in a sample representative of the population of the Indian state of Andhra Pradesh. A total of 11,786 subjects of all ages were sampled from 94 clusters in one urban and three rural study areas of Andhra Pradesh using stratified, random, cluster, systematic sampling. The eligible subjects underwent detailed interview and eye examination including dilated examination of the posterior segment. The data on the use of spectacles were analysed for subjects> 15 years of age. A total of 7,432 subjects> 15 years of age participated in the study of whom 1,030 (13.8%) had a refractive error of spherical equivalent + 3.00 Diopter or worse. The prevalence of current use of spectacles in those with spherical equivalent + 3.00 Diopter or worse, who were likely to be visually impaired without refractive correction, was 34.2% (95% confidence interval 30.3-38%) and of previous use of spectacles was 12.3% (95% confidence interval 10.3-14.3%). The odds of using spectacles currently were significantly higher for those with any level of education, those living in the urban area, and for those with aphakia or psuedophakia as compared with natural refractive error. Among those who had used spectacles previously, 43.8% had discontinued because they felt that either the prescription was incorrect or that the spectacles were uncomfortable, suggesting poor quality of refractive services, and another 19.6% had lost the pair and could not afford to buy another pair. These data suggest that the use of spectacles in this population by those with refractive error was not optimal. Two-thirds of those with spherical equivalent + 3.00 Diopter or worse were not using spectacles. Of those who had discontinued the use of spectacles, a significant proportion did so for reasons related to poor quality of refractive services. Strategies such as vision screening programmes and eye health promotion need to be implemented, the quality of refractive services monitored and the cost of spectacles regulated, if the substantial burden of visual impairment due to refractive error in this population is to be reduced

PURPOSE: To assess the prevalence and causes of visual impairment in urban and rural population aged ≥ 40 years in the South India state of Andhra Pradesh. METHODS: A population based cross-sectional study was conducted in which 7800 subjects were sampled from two rural and an urban locations. Visual Acuity (VA) was assessed using a tumbling E chart and eye examinations were performed by trained vision technicians. A questionnaire was used to collect personal and demographic information and previous consultation to eye care providers. Blindness and moderate Visual Impairment (VI) was defined as presenting VA

PURPOSE: To assess the prevalence and causes of visual impairment in weaving communities in Prakasam district in South India state of Andhra Pradesh. METHODS: Using Rapid Assessment of Visual Impairment (RAVI) methodology, a population based cross-sectional study was conducted. A two-stage sampling strategy was used to select 3000 participants aged ≥40 years. Visual Acuity (VA) was assessed using a tumbling E chart and ocular examinations were performed by trained Para medical ophthalmic personnel. A questionnaire was used to collect personal and demographic information. Blindness and moderate Visual Impairment (VI) was defined as presenting VA

Aim To assess the barriers to the uptake of refraction services in the age group of 15–49 years in rural Andhra Pradesh, India.Methods A population-based cross-sectional study was conducted using cluster random sampling to enumerate 3300 individuals from 55 clusters. A validated questionnaire was used to elicit information on barriers to utilisation of services among individuals with uncorrected refractive error (presenting visual acuity 35 years with binocular distance visual acuity of ≥6/12).Results 3095 (94%) were available for examination. Those with uncorrected refractive errors cited affordability as the main barrier to the uptake of eye-care services. Among people with uncorrected presbyopia, lack of ‘felt need’ was the leading barrier.Conclusion The barriers that were ‘relatively easy to change’ were reported by those with uncorrected refractive errors in contrast to ‘difficult to change’ barriers reported by those with uncorrected presbyopia. Together, the data on prevalence and an understanding of the barriers for the uptake of services are critical to the planning of refractive error services.