Prevalence and causes of visual impairment in Dongaria indigenous (tribal) community. Tribal Odisha eye disease study # 12

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.

Visual impairment and blindness due to retinitis pigmentosa in India: 15-year follow-up of the Andhra Pradesh Eye Disease Study cohort

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.

The economic and social costs of visual impairment and blindness in India

Purpose: To provide a current estimate of the economic and social costs (or welfare costs) of visual impairment and blindness in India. Methods: Using evidence from the recently conducted Blindness and Visual Impairment Survey across India, the Lancet Global Health Commission on Global Eye Health and other sources, we developed an economic model that estimates the costs of reduced employment, elevated mortality risk, education loss for children, productivity loss in employment, welfare loss for the unemployed, and caregiver costs associated with moderate and severe visual impairment (MSVI) and blindness. Probabilistic sensitivity analyses were also conducted by varying key parameters simultaneously. Results: The costs of MSVI and blindness in India in 2019 are estimated at INR 1,158 billion (range: INR 947–1,427 billion) or $54.4 billion at purchasing power parity exchange rates (range: $44.5–67.0 billion), accounting for all six cost streams. The largest cost was for the loss of employment, whereas the the second largest cost was for caregiver time. A more conservative estimate focusing only on employment loss and elevated mortality risk yielded a cost of INR 504 billion (range: INR 348–621 billion) or $23.7 billion (range: $16.3–29.2 billion). Conclusion: Poor eye health imposes a non?trivial recurring cost to the Indian economy equivalent to 0.47% to 0.70% of GDP in the primary scenario, a substantial constraint on the country’s growth aspirations. Furthermore, the absolute costs of poor eye health will increase over time as India ages and becomes wealthier unless further progress is made in reducing the prevalence of MSVI and blindness

Visual impairment and refractive errors in school children in Andhra Pradesh, India

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 <6/12 was found in 1.72% (95% confidence interval [CI]: 1.61–1.83). The prevalence of refractive error (corrected and uncorrected) was 2.38% (95% CI: 2.26–2.51) and myopia was 2.17% (95% CI: 2.05–2.29). In multivariable analysis, older children, those in urban schools, private schools, and children with a disability had an increased risk of VI and myopia. Additionally, the risk of myopia was higher among girls than boys. Of those referred and reached SC/TC, 73.64% were due to avoidable causes. Conclusion: Childhood VI prevalence was 1.72% in this region. Uncorrected refractive error (URE) was the major cause of VI in children. Older age, schools in urban locations, private schools, and the presence of disability were associated with the risk of VI among children

Awareness of cataract and glaucoma in two rural districts of Telangana, India

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.

Tribal Odisha Eye Disease Study (TOES). Report # 10. Disability inclusive eye health survey in a tribal district (Rayagada) in Odisha, India

Purpose: To estimate seeing and other disabilities in a population cohort in a tribal district, Rayagada, in the Indian state of Orissa. Methods: A door?to?door survey was conducted to identify the disabilities. The vision was measured at the residence of the subject, and other disabilities were documented from the history obtained from the subject/household/neighbor. All people with seeing disabilities were reexamined in the community eye center (primary or secondary), and required treatment was given at no cost to the patients. People with other disabilities were transported to the public health facility for appropriate care and disability certification. The results were compared with the 2011 national census data. Results: A total of 147,699 people were enumerated, and 106,339 (72%) were examined over one year period, 2016–17. In this cohort, 47.3% (n = 50,320) were male and 27.5% (n = 29,215) were 40 years or older. We recorded systemic disease in 0.6% (n = 689) people; hypertension was two times higher than diabetes mellitus. Disability was identified in 2.8% (n = 3022). Common disabilities were seeing (46.7%; n = 1411), hearing (36.8%; n = 1112), mobility (10.4%; n = 315), and mental retardation (3.2%; n = 98). Dual sensory disability (seeing and hearing) was seen in 6.4% (n = 251), and it was higher in the older age group. Seeing and hearing disabilities were higher than the 2011 state (P =< 0.001) and national (P =< 0.001) disability census. Conclusion: The first population?based survey in Rayagada, Odisha (India) in 2017 showed a higher proportion of people with seeing and hearing disabilities. It calls for an appropriate service strategy.

Changing trends in the prevalence of visual impairment, uncorrected refractive errors and use of spectacles in Mahbubnagar district in South India.

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 <20/20 in APEDS and <20/40 in RARE. VI was defined as presenting VA <20/40 in the better eye. URE was defined as presenting VA <20/40 and improving to ≥20/40 with a pinhole. Statistical Analysis Used: Performed using Statistical Package for Social Sciences (SPSS). Chi square tests and t‑test were used. Results and Conclusions: The results from a RARE survey with 3,095 subjects were compared with an APEDS dataset that had 1,232 subjects in the same age group of 15-49 years. The prevalence of VI has decreased from 9.5% (95% CI, 7.7-11.1) in APEDS to 2.7% (95% CI, 2.1-3.3) in RARE. Similarly, the prevalence of URE in the better eye decreased from 5.8% (95% CI, 4.5-7.1) to 2.3% (95% CI, 1.8- 2.8). The usage of spectacles increased from 6.6% (95% CI, 5.2-8.0) to 9.7% (95% CI, 8.7-10.7). There is a decreasing trend in the prevalence of VI and URE in Mahbubnagar district in Andhra Pradesh over a decade.

Visual outcomes of bilateral congenital and developmental cataracts in young children in south India and causes of poor outcome.

Context: Bilateral pediatric cataracts are important cause of visual impairment in children. Aim: To study the outcome of bilateral pediatric cataract surgery in young children. Setting and Design: Retrospective case series in a tertiary center. Materials and Methods: Records of pediatric cataracts operated between January 2001 and December 2003, with a minimum follow-up of 3 months, were reviewed retrospectively. Statistical Methods: Independent sample t-test, Fisher's exact test, and logistic regression using SPSS (Statistical Package for Social Science, Chicago, USA) version 12. Results: 215/257 (83.7%) patients had a minimum follow-up of 3 months. The mean age of presentation to the hospital was 53 months (range: 0-168 months). Congenital cataract was present in 107 patients (58.2%) and developmental cataract in 77 patients (41.8%). The mean age at surgery was 55.2 months (range: 1-168 months). Out of 430 eyes, 269 (62.6%) had an intraocular lens implanted. The mean duration of follow-up was 13.1 months (range: 3-38 months). Pre-operatively, 102 patients (47.3%) had visual acuity <6/60, in the better eye, compared to 37 patients (17.2%) post-operatively (P < 0.001). Eighty-five patients (39.5%) had visual acuity >6/18. The most common early post-operative complication was fibrinous uveitis in 57 eyes (13.3%) and the most common delayed post-operative complication was posterior capsular opacification in 118 eyes (27.4%). The most important prognostic factor for poor outcome was congenital cataract (odds ratio [OR]: 26.3; 95% confidence interval [CI], 4.4-158.5) and total cataract (OR: 4.8; 95% CI, 1.3-17). Conclusion: Nearly half of the eyes had visual acuity>6/18. The outcome was poorer in congenital cataracts, especially those operated after >1 year of age.

Changing trends in the prevalence of blindness and visual impairment in a rural district of India: Systematic observations over a decade.

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 11th 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.

The challenges in improving outcome of cataract surgery in low and middle income countries.

Cataract is the leading cause of blindness globally and surgery is the only known measure to deal with it effectively. Providing high quality cataract surgical services is critical if patients with cataract are to have their sight restored. A key focus of surgery is the outcome of the procedure. In cataract surgery this is measured predominantly, using visual acuity. Population- and hospital-based studies have revealed that the visual outcome of cataract surgery in many low and middle income settings is frequently sub-optimal, often failing to reach the recommended standards set by the World Health Organization (WHO). Another way of measuring outcome of cataract surgery is to ask patients for their views on whether surgery has changed the functioning of their eyes and their quality of life. There are different tools available to capture patient views and now, these patient-reported outcomes are becoming more widely used. This paper discusses the visual outcome of cataract surgery and frames the outcome of surgery within the context of the surgical service, suggesting that the process and outcome of care cannot be separated. It also discusses the components of patient-reported outcome tools and describes some available tools in more detail. Finally, it describes a hierarchy of challenges that need to be addressed before a high quality cataract surgical service can be achieved.

Integrated model of primary and secondary eye care for underserved rural areas: The L V Prasad Eye Institute experience.

Blindness is a major global public health problem and recent estimates from World Health Organization (WHO) showed that in India there were 62 million visually impaired, of whom 8 million are blind. The Andhra Pradesh Eye Disease Study (APEDS) provided a comprehensive estimate for prevalence and causes of blindness for the state of Andhra Pradesh (AP). It also highlighted that uptake of services was also an issue, predominantly among lower socio-economic groups, women, and rural populations. On the basis of this analysis, L V Prasad Eye Institute (LVPEI) developed a pyramidal model of eye care delivery. This article describes the LVPEI eye care delivery model. The article discusses infrastructure development, human resource development, and service delivery (including prevention and promotion) in the context of primary and secondary care service delivery in rural areas. The article also alludes to opportunities for research at these levels of service delivery and the amenability of the evidence generated at these levels of the LVPEI eye health pyramid for advocacy and policy planning. In addition, management issues related to the sustainability of service delivery in rural areas are discussed. The article highlights the key factors required for the success of the LVPEI rural service delivery model and discusses challenges that need to be overcome to replicate the model. The article concludes by noting the potential to convert these challenges into opportunities by integrating certain aspects of the existing healthcare system into the model. Examples include screening of diabetes and diabetic retinopathy in order to promote higher community participation. The results of such integration can serve as evidence for advocacy and policy.

Best practice eye care models.

Since the launching of Global Initiative, VISION 2020 “the Right to Sight” many innovative, practical and unique comprehensive eye care services provision models have evolved targeting the underserved populations in different parts of the World. At places the rapid assessment of the burden of eye diseases in confined areas or utilizing the key informants for identification of eye diseases in the communities are promoted for better planning and evidence based advocacy for getting / allocation of resources for eye care. Similarly for detection and management of diabetes related blindness, retinopathy of prematurity and avoidable blindness at primary level, the major obstacles are confronted in reaching to them in a cost effective manner and then management of the identified patients accordingly. In this regard, the concept of tele-ophthalmology model sounds to be the best solution. Whereas other models on comprehensive eye care services provision have been emphasizing on surgical output through innovative scales of economy that generate income for the program and ensure its sustainability, while guaranteeing treatment of the poorest of the poor.

Role of buccal corridor in smile esthetics and its correlation with underlying skeletal and dental structures.

Purpose: This study was designed to evaluate the buccal corridor in smile esthetics and to correlate it with underlying hard tissues. Materials and Methods: Posed smiling frontal photographs, digital posterior-anterior (PA) cephalograms, and study models of 25 males and 25 females in age range of 18-25 years were taken. Photographs were evaluated for smile esthetics by eight orthodontists, eight plastic surgeons, eight beauticians and eight lay people to group them into three groups with least attractive, average and attractive smile and buccal corridor width was measured. Digital PA cephalograms were transferred on Nemo-tech software for frontal facial analysis. Intercanine and intermolar widths were measured on upper study model with the help of a digital calliper. Results: The buccal corridor width was least in attractive smile group and maximum in least attractive smile group. The buccal corridor width had a negligible correlation with hard tissues and a mild to moderate inverse correlation with intercanine and intermolar widths within the groups. Conclusion: As the amount of buccal corridor display was increased, smiling images were scored less attractive by the evaluators. The buccal corridor is not influenced by underlying skeletal hard tissues but have mild to moderate inverse correlation with the intercanine and intermolar width.

Comparison of patient satisfaction with services of Vision Centers in rural areas of Andhra Pradesh, India.

Aim: To compare the satisfaction of patients with the services of Vision Center services (primary eye care) in large village (s) and small village (s) in rural settings in Andhra Pradesh state, India. Materials and Methods: We have administered standard questionnaires to randomly selected patients to assess patient satisfaction when assessing Vision Center Services. We used the Chi-square (P <0.05) to explore differences in satisfaction of patients with Vision Center services located in the large village (s) and small village (s) rural settings. Results: Vision Center patients at the large village (s) expressed higher levels of satisfaction (median 78%) than patients treated at the Vision Center at small village (s) (median 69%). The difference was statistically significant (Chi square P value ranging from <0.001 to 0.03) for all the items except two – ‘easy to identify vision center location’ and ‘spectacles dispensing time’ as compared to other (privately run optometry) facilities (Chi square P value=0.498 and 0.993 respectively). The location of the Vision Center, convenience of journey, ophthalmic technician’s behavior with patients, are some of the most important factors that determined the patient perception about Vision Center services. Conclusion: The overall satisfaction levels of the Vision Center experience at 78% and 69% were good. However, continual improvement is to be made in service time, staff performance, cost and quality of vision care, especially at more remote primary eye Care Centers.

Two years follow-up outcome of verteporfin therapy for subfoveal choroidal neovascularization in pathologic myopia in Indian eyes.

Context: In India, refractive errors are a major cause of treatable blindness. Population surveys in southern India have shown prevalence of high myopia to be 4.32-4.54%. Photodynamic therapy (PDT) for choroidal neovascularization (CNV) caused by pathologic myopia is beneficial. Aims: To report the 24 months outcome of PDT with verteporfin for subfoveal CNV caused by pathologic myopia in Indian eyes Settings and Design: Prospective case series Materials and Methods: Review of prospectively collected data of Indian patients with pathologic myopia and subfoveal CNV treated with verteporfin therapy between 2001 and 2005 using standard regimen for PDT. Statistical Analysis Used: Wilcoxon signed rank test was used to see the difference in the mean letter acuity at intervals compared to baseline. Kaplan Meier Survival analysis was done to estimate the success rate of verteporfin therapy for CNV caused by pathologic myopia. Results: Fifteen patients (15 eyes) treated with standard fluence PDT and who had completed 24 months follow-up were analyzed. The mean spherical equivalent was -13.36 +/- 5.88 diopter. Five out of 15 eyes in six months, three out of 15 eyes at 12 months and four eyes out of 15 at 24 months had improved vision by > 10 letters. The mean number of treatment session was 2.2 in two years. Conclusions: PDT with verteporfin for subfoveal CNV caused by pathologic myopia in Indian eyes is effective.

Combination therapy of intravitreal triamcinolone and photodynamic therapy with verteporfin for subfoveal choroidal neovascularization.

AIM: To evaluate the six months follow-up outcome of combined intravitreal triamcinolone acetonide (IVTA) and photodynamic therapy (PDT) for subfoveal choroidal neovascularization compared to PDT alone. STUDY DESIGN: Prospective interventional pilot study. MATERIALS AND METHODS: Patients with six months follow-up of IVTA following PDT (Group I, eight eyes) and PDT alone (Group II, eight eyes) were included. Four mg/ 0.1 ml of IVTA was injected 7-10 days following PDT. The patients were reevaluated every month for the first two months and every three months thereafter in both the groups. RESULTS: Group I: The mean age was 65.8+/-11.8 years (range: 47-79 years). Five patients were male. The total treatment sessions in six months were 11 (mean: 1.36). At six months, one eye had >or= 10 letters gain and three eyes had > 10 letters loss. Four eyes had stable vision. Two eyes (25%) developed increased intraocular pressure (>40 mmHg) during follow-up. Group II: The mean age was 58.7+/-11.7 years (range: 46-76 years). Five patients were male. The total treatment sessions in six months were 17 (mean: 2.13). At six months, six eyes had >or= 10 letters gain and none had > 10 letters loss. Two eyes had stable vision. CONCLUSION: The mean number of treatment sessions following combination therapy of IVTA (4 mg) and PDT appears relatively less (1.36 at six months) compared to PDT alone (mean: 2.13). (P =0.02).