A Population-Based Cross-Sectional Study of Visual Impairment in West Godavari and Krishna Districts in Andhra Pradesh: Akividu Visual Impairment Study (AVIS).

PURPOSE: To report the prevalence and causes of visual impairment (VI) among those aged ≥40 years in West Godavari and Krishna districts in Andhra Pradesh, India. METHODS: Trained teams visited the households in the selected clusters and conducted eye examinations. Presenting visual acuity (PVA) was assessed for distance and near. Torchlight examination was conducted to assess the anterior segment. Non-mydriatic retinal images were also obtained. VI was defined as PVA worse than 6/18 in the better eye. It included Moderate VI (PVA worse than 6/18 to 6/60), Severe VI (PVA worse than 6/60 to 3/60) and Blindness (PVA worse than 3/60). Multiple logistic regression analysis was conducted to assess the risk factors for VI. RESULTS: In total, 2587/3000 (86.2%) participants were examined. Of this, 1406 (54.4%) were women and 1224 (47.3%) had no education. The age- and gender-adjusted prevalence of VI was 12.8% (95% CI: 11.5-14.1). Compared to the 40-49-year age group, the odds of having VI among those aged 50-59 years, 60-69 years and ≥70 years were 2.93 (95% CI: 1.91-4.52), 6.53 (95% CI: 4.31-9.91) and 17.45 (95% CI: 11.50-26.46), respectively. Those respondents who had no education had a higher odds (OR: 1.73; 95% CI: 1.34-2.23) of VI compared to those who were educated. Cataract (62.4%) and uncorrected refractive errors (29.8%) were the leading causes of VI. Over 90% of the VI was due to avoidable causes. CONCLUSION: VI is a major public health challenge in Andhra Pradesh. Over 90% of this burden is avoidable and can be eliminated by low-cost interventions such as spectacles and cataract surgery.

Population-based assessment of prevalence of spectacle use and effective spectacle coverage for distance vision in Andhra Pradesh, India - Akividu Visual Impairment Study.

CLINICAL RELEVANCE: Effective spectacle coverage is a useful indicator to assess the coverage of refraction services in a given region. We found a low coverage in the Akividu region suggesting a need to develop effective refraction services. BACKGROUND: To assess the prevalence of spectacle use and effective spectacle coverage for distance vision among people aged 40 years and older in the Indian state of Andhra Pradesh. METHODS: A population-based cross-sectional survey was carried out in the Akividu region in West Godavari and Krishna districts. The study teams visited selected households and conducted eye examinations in the selected clusters. A structured questionnaire was used to collect information on spectacle use. 'Met Need' was defined as unaided VA worse than 6/12 but improved to 6/12 or better with their current spectacles. 'Unmet Need' was defined as unaided VA worse than 6/12 but improved to 6/12 with pinhole, among those not using spectacles. The 'Under-met Need' was defined as aided VA worse than 6/12 but improving with pinhole to 6/12 or better. Based on these definitions, Effective Refractive Error Coverage (e-REC) is calculated as: e-REC (%) s = ((met need)/(met need + under-met need + unmet need)) X100. RESULTS: Of 3,000 enumerated from 60 clusters, 2,587 (86.2%) participants were examined. The prevalence of current spectacle use was 43.1% (95% CI:41.2-45.0). The e-REC was 37.4%. It was also lower in men compared to women and among those without any education. Participants who had cataract surgery in either eye had similar e-REC compared to those who were not operated. CONCLUSION: Though spectacle use was found to be high, there is a still large unmet need for refractive correction for distance. Effective service delivery models to provide refraction and spectacle dispensing services are needed to achieve universal eye health coverage in the region.

Near-vision impairment and effective near-vision spectacle coverage in two districts in Telangana, India: a population-based cross-sectional study.

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.

Prevalence of disabilities and non-communicable diseases in an elderly population in the Telangana state, India: a population-based cross-sectional study.

OBJECTIVES: To assess the prevalence of disabilities (vision, hearing, mobility, cognitive, self-care and communication) and non-communicable diseases (NCDs) among the elderly population in two districts in Telangana, India. DESIGN: Population-based cross-sectional study using a cluster random sampling method to select the study clusters. SETTING: Elderly population in Khammam and Warangal districts were recruited. Detailed interviews were conducted by trained community health workers. Personal and demographic information such as age, gender, level of education and a self-report of NCDs was collected. The Washington Disability Questionnaire was administered to assess the presence of disabilities. PARTICIPANTS: 1821 participants aged ≥60 years, 54.5% were women, and 73.3% had no education. PRIMARY OUTCOME MEASURE: Prevalence of disabilities and NCDs. RESULTS: Overall, the prevalence of at least disability was 20.3% (95% CI 16.3 to 24.9). The prevalence of self- reported disabilities were: seeing (5.9%; 95% CI 4.4 to 7.8), mobility (12.8%; 95% CI 9.7 to 16.8), hearing (3.6%; 95% CI 2.7 to 4.8), cognition (4.8%; 95% CI 3.5 to 6.7), self-care (3.3%; 95% CI 2.3 to 4.7) and communication (1.8%; 95% CI 1.2 to 2.6). Overall, the prevalence of at least one NCD was 34.2% (95% CI 30.9 to 37.7). Hypertension was the most common systemic condition (25.4%; 95% CI 22.4 to 28.7), followed by diabetes (9.0%; 95% CI 7.3 to 11.0), and body pains (muscle-skeletal) (9.9%; 95% CI 8.1 to 12.2). CONCLUSION: Every fifth elderly person in the districts of Khammam and Warangal in Telangana had at least one self-reported disability. Besides, a third of the elderly had at least one NCD. There is a definite need to develop comprehensive public health strategies to address disabilities and NCDs in Telangana.

Prevalence and risk factors for visual impairment among elderly residents in 'homes for the aged' in India: the Hyderabad Ocular Morbidity in Elderly Study (HOMES).

BACKGROUND/AIM: To investigate the prevalence, causes and risk factors of visual impairment (VI) among the elderly in 'home for the aged' in Hyderabad, India. METHODS: Individuals aged ≥60 years were recruited from 41 'homes for the aged'. All participants had complete eye examinations including presenting visual acuity, refraction, slit-lamp examination, intraocular pressure measurement and fundus imaging by trained clinicians. VI was defined as presenting visual acuity worse than 6/18 in the better eye. Multivariate logistic regression was used to determine the risk factors associated with VI. RESULTS: 1512 elderly residents from 41 homes for the aged were enumerated, of whom 1182 (78.1%) were examined. The mean age of examined participants was 75.0 years (SD 8.8 years; range: 60-108 years); 35.4% of those examined were men. The prevalence of VI was 30.1% (95% CI 27.5 to 32.8). The leading cause of VI was cataract (46.3%, n=165), followed by uncorrected refractive error (27.0%, n=96), posterior capsular opacification (14.9%, n=53) and posterior segment disease (6.5%, n=23). Overall, 88.2% of the VI was either treatable or correctable. In multiple logistic regression, those aged 80 years and older (OR: 1.7, p<0.01), living in 'free' homes (OR: 1.5, p<0.01) and who were immobile/bedridden (OR: 3.02, p<0.01) had significantly higher odds of VI. Gender was not associated with VI. CONCLUSIONS: VI was common and largely avoidable in residents of 'homes for the aged' in Hyderabad, India. Screening for vision loss in 'homes for aged' and the provision of appropriate services should become routine practice to achieve the goal of healthy ageing in India.

Visual outcomes after cataract surgery among the elderly residents in the 'homes for the aged' in South India: the Hyderabad Ocular Morbidity in Elderly Study.

BACKGROUND/AIM: To report visual outcomes and factors associated with good visual outcomes after cataract surgery among the elderly residents in 'homes for the aged' in Hyderabad, India. METHODS: Individuals aged ≥60 years were recruited from 41 'homes for the aged'. All participants had a detailed eye examinations including visual acuity (VA) assessment , refraction, slit-lamp examination and fundus imaging by trained professionals. A detailed history of cataract surgery was recorded. Multivariate logistic regression was used to determine the factors associated with good visual outcomes after cataract surgery which was defined as presenting VA of 6/18 or better in the operated eye. Visual impairment (VI) is defined as presenting VA worse than 6/18 in the operated eye. RESULTS: 1215 eyes of 703 individuals had cataract surgery. The mean age of these participants was 77.5 years (SD: 8.2 years; range: 60-108 years), 66.8% were women, 29.9% reported diabetes and 61% reported hypertension. 406/1215 (33.4%; 95% CI 30.8 to 36.1) eyes had VI after cataract surgery. Posterior capsular opacification (31.8%; n=129) was the leading cause of VI followed by uncorrected refractive error (24.1%; n=98). The prevalence of good outcomes was 66.6% (95% CI 63.8 to 69.2). On applying multivariable analysis, younger age, self-reported hypertension, independent mobility, surgery in a non-government (as opposed to private) hospital and undergoing paid surgery were associated with good outcomes. CONCLUSIONS: One-third of the eyes of elderly individuals living in homes for the aged that had previously undergone cataract surgery had VI. Regular eye examinations with the provision of laser capsulotomy and appropriate refractive correction can substantially improve their vision.

Near vision impairment among the elderly in residential care-the Hyderabad Ocular Morbidity in Elderly Study (HOMES).

BACKGROUND/OBJECTIVE: To report on the prevalence and risk factors for near vision impairment (NVI) among the elderly in residential care in Telangana State in India. METHODS: Individuals aged ≥60 years were recruited from 41 'home for the aged' centres in Hyderabad, India. All participants had complete eye examinations including presenting and best-corrected visual acuity assessment for distance and near. NVI was defined as binocular presenting near vision worse than N8 (6/15) among those who had a normal presenting distance visual acuity of 6/18 in the better eye. RESULTS: Of the 826 participants, the mean age was 74.4 years (standard deviation-8.4 years), 525 (63.6%) were women, 715 (86.6%) had at least school education. The prevalence of NVI was 51.2% (95% CI: 47.7-54.7) based on presenting vision. On applying multiple logistic regression analysis, the odds of NVI were higher in 80 years and older age (OR: 2.17; 95% CI: 3.44-13.6). Those with school education (OR: 0.58: 95% CI: 0.36-0.94) and higher education (OR: 0.38; 95% CI: 0.21-0.69) had lower odds for NVI. Similarly, those with self-reported diabetes (OR: 0.69; 95% CI: 0.49-0.97), those using spectacles (OR: 0.09; 95% CI: 0.05-0.16), and those who had undergone cataract surgery (OR: 0.51; 95% CI: 0.36-0.74) had lower odds for NVI. CONCLUSIONS: NVI was common among the elderly in residential care in homes for the aged in Hyderabad, India. As most of this NVI is correctable, a routine screening programme and dispensing of spectacles can be undertaken to address this vision loss.

Population-based Assessment of Vision Impairment in the Elderly Population in Telangana State in India - Policy Implications for Eye Health Programmes.

PURPOSE: To investigate the prevalence, causes and risk factors for vision impairment (VI) among the elderly population in Telangana State, India. METHODS: A population-based cross-sectional study were conducted in four districts. All participants had eye examinations including visual acuity assessment for distance and near, anterior segment examination and non-mydriatic fundus imaging by trained personnel. VI was defined as presenting visual acuity worse than 6/18 in the better eye. Individuals aged ≥60 years were considered as elderly. RESULTS: In total, 11,238/12,150 (92.5%) individuals aged ≥40 years were examined. Of this, the dataset of 3,640 individuals (32.4%) elderly participants was used for analysis. Among the 3,640 participants, 53.1% were women and 78.1% had no education. The mean age of the participants was 67.8 years (standard deviation: 7 years; range: 60 to 102 years). The age and gender-adjusted prevalence of VI was 32.1% (95% CI: 29.5-34.8). On multivariable analysis, the odds of VI was significantly higher in older age groups, and among those with no education. Gender and district of residence were not associated with the prevalence of VI. Cataract (54.8%) was the leading cause of VI followed by uncorrected refractive errors (37.6%). CONCLUSIONS AND RELEVANCE: VI was common and largely avoidable in the elderly population in Telangana state in India. Elderly centric eye care including screening for vision loss, provision of cataract surgery and spectacles can be used as strategies to address VI in the elderly.

Falls and visual impairment among elderly residents in 'homes for the aged' in India.

We evaluated the prevalence of falls and their association with visual impairment (VI) in elderly residents in 'homes for the aged' in Hyderabad, India. Participants aged ≥ 60 years were recruited from 41 homes, and a comprehensive eye examination was conducted. Interviews were conducted to collect personal and demographic information, systemic health status, fear of falling, depression, and history of falls in the last year. VI categories included low vision (presenting visual acuity worse than 6/18 to 3/60) and blindness (presenting visual acuity worse than 3/60). The data of 1,074 participants were analysed. The mean age was 74.4 years (standard deviation:8.7 years); 63.9% were women, 19.4% had no formal education, 28.1% were diabetic and 56.9% were hypertensive. The annual prevalence of falls was 29.1% (95% CI: 26.4-32.0). Multivariable analysis showed those with VI had significantly higher odds of falls (Odds Ratio:1.47; p = 0.043). The prevalence of falls was higher among those with VI due to uncorrected refractive errors. We found a very high prevalence of falls in elderly individuals living in 'homes for the aged' in Hyderabad, India. Addressing VI can result in fewer falls and contribute to healthy aging in India.

Uncorrected refractive errors for distance among the residents in 'homes for the aged' in South India-The Hyderabad Ocular Morbidity in Elderly Study (HOMES).

PURPOSE: To investigate the prevalence and risk factors of Uncorrected Refractive Errors (URE) for distance in elderly residents in 'homes for the aged' in Hyderabad, India. METHODS: Individuals aged ≥60 years and residing in 'homes for the aged' in Hyderabad, India for a minimum of 1 month and providing consent for participation were recruited. All participants underwent visual acuity assessment, refraction, slit lamp biomicroscopy, intraocular pressure measurement, fundus examination, and retinal imaging. Monocular presenting visual acuity was recorded using a logMAR chart. Objective and subjective refraction were performed, and best-corrected visual acuity was recorded. URE was defined as presenting visual acuity worse than 6/12 but improving to 6/12 or better with refraction. Univariable and multivariable logistic regression analyses were used to assess the risk factors associated with URE. RESULTS: In total, 1 513 elderly participants were enumerated from 41 homes of which 1 182 participants (78.1%) were examined. The mean age of participants was 75.0 years (standard deviation 8.8 years; range: 60-108 years). 35.4% of those examined were men and 20.3% had no formal education. The prevalence of URE was 13.5% (95% CI: 11.5-15.5; n = 159). On applying multiple logistic regression analysis, compared to those living in private homes, the odds of URE were significantly higher among the elderly living in the aided homes (OR: 1.65; 95% CI: 1.11-2.43) and free homes (OR: 1.67; 95% CI: 1.00-2.80). As compared to those who reported having an eye examination in the last 3 years, the odds of URE were higher among those who never had an eye examination in the last three years (OR: 1.51; 95% CI: 1.07-2.14). Similarly, those who had unilateral cataract surgery (OR: 1.80; 95% CI: 1.10-2.93) or bilateral cataract surgery (1.69; 95% CI: 1.10-2.56) had higher odds of URE compared to those elderly who were not operated for cataract. Gender, self-report of diabetes, and education were not associated with URE. CONCLUSIONS: A large burden of URE was found among the residents in the 'homes for the aged' in Hyderabad, India which could be addressed with a pair of glasses. Over 40% of the residents never had an eye examination in the last three years, which indicates poor utilisation of eye care services by the elderly. Regular eye examinations and provision of spectacles are needed to address needless URE for distance among the elderly in residential care in India.

Temporal trends in the prevalence of spectacle use and spectacle coverage in India.

BACKGROUND: This study aims to assess the temporal trends in the prevalence of spectacle use and spectacle coverage for refractive errors in population-based studies conducted during 2011-2012 and 2017 among those aged ≥ 40 years in the state of Telangana, India. An intervention in the form of 10 vision centres and a secondary centre was established in one district (Khammam) after the 2011-2012 study and another district (Warangal) was left to secular trends. METHODS: In both the studies, multi-stage cluster random sampling methodology was used to select the participants. In addition to a clinical examination, a questionnaire was used for collecting information on current and previous use of spectacles, type of spectacles and details of the spectacle providers. The same questionnaire was used in both the studies. RESULTS: In total, 2,485 participants were examined in the 2011-2012 study and 2,711 participants were examined in the 2017 study in Khammam. Similarly, 2,438 and 2,646 participants were examined in Warangal in the two studies, respectively. In Khammam, the age and gender-adjusted prevalence of current spectacle use increased from 30.0 per cent (95% CI 28.2-31.9) to 34.8 per cent (95% CI 33.0-36.6) in the 2011-2012 and 2017 studies, respectively (p < 0.01). However, in the Warangal district, the age and gender-adjusted prevalence of current spectacle use declined from 32.8 per cent (95% CI 31.0-34.7) to 27.6 per cent (95% CI 25.9-29.3) during the 2011-2012 and 2017 studies, respectively (p < 0.01). In Khammam, the spectacle coverage increased from 26.9 per cent to 35.6 per cent, but it declined from 43.8 per cent to 35.7 per cent in Warangal between the studies in 2011-2012 and 2017. CONCLUSIONS: An increase in spectacle use and coverage was observed in Khammam where the secondary centre and vision centres were established, compared to Warangal where there was no such intervention. The results suggest a positive impact of the intervention in the Khammam district and suggest replication of the model to address the burden of uncorrected refractive errors.

Hyderabad Ocular Morbidity in Elderly Study (HOMES) - Rationale, Study Design and Methodology.

Purpose: To describe the study design, interobserver variability of the questionnaires and clinical procedures of Hyderabad Ocular Morbidity in Elderly Study (HOMES) designed to, (a) to investigate the prevalence, causes and risk factors for visual impairment, and (b) to assess the impact of dispensing spectacles and cataract surgery on visual functions, fear of falls (FOF) and depression among the elderly in India.Methods: Individuals aged ≥60 years are considered elderly. The non-clinical protocol was administered by two trained investigators and included collection of personal, sociodemographic information, ocular and systemic history, Indian Visual Function Questionnaire (IND-VFQ33), Patient Health Questionnaire (PHQ9), Mini-Mental State Examination (MMSE) questionnaire, Hearing Handicap Inventory for the Elderly Screening (HHIE), Short Falls Efficacy Scale (SFES) questionnaire. The eye examination was conducted by a trained optometrist and vision technicians in clinics set-up in the homes and included visual acuity (VA) assessment for distance and near, anterior segment examination and fundus examination, and imaging. The reliability assessments were carried out among 138 participants.Result: The intraclass correlation (ICC) coefficients for MMSE, PHQ9, HHIE, SFES was 0.73 (95% CI: 0.62-0.81), 0.67 (95% CI: 0.54-0.77), 0.63 (95% CI: 0.48-0.74) and 0.70 (95% CI: 0.58-0.79) respectively. The ICC for INDVFQ domains ranged from 0.66 (95% CI: 0.55-0.74) for Psychosocial Impact to 0.88 (95% CI: 0.84-0.91) for activity limitation. The ICC for VA was 0.94 (95% CI: 0.92-0.96).Conclusion: All questionnaires demonstrated acceptable reliability and can be applied in the main study. HOMES is expected to provide data that will help plan strategies to contribute towards 'healthy aging' in India.

Temporal trends in the prevalence and causes of visual impairment in the South Indian state of Telangana: a population-based cross-sectional study.

OBJECTIVES: To investigate the temporal trends in the prevalence and causes of visual impairment (VI) in South India. DESIGN: Population-based cross-sectional studies conducted during the years 2011-2012 and 2017 using identical study methods and in geographical locations are compared. The L V Prasad Eye Institute established services in Khammam and not in Warangal district after the 2011-2012 study. SETTING: Khammam and Warangal districts in Telangana, India. PARTICIPANTS: In total, 5357 participants aged ≥40 years were examined from two districts in the 2011-2012 study and 4923 participants were examined in the 2017 study. MAIN OUTCOME MEASURES: Age-adjusted and gender-adjusted temporal trends in the prevalence and causes of VI.Blindness and moderate VI (MVI) were defined as presenting visual acuity worse than 6/60 and 6/18-6/60 in the better eye, respectively. VI included MVI and blindness. RESULTS: Nearly 2500 participants were examined in each location in both the 2011-2012 and 2017 studies. In Khammam district, overall VI declined by 2.5% from 15.5% to 13.0% (p<0.001). While there was no significant change in MVI (p=0.566), blindness declined by 3.0% from 5.4% to 2.4% (p<0.001). In Warangal district, the overall VI remained unchanged (p=0.60). While MVI increased by 3% from 9.3% to 12.3% (p=0.001), blindness declined by 3.5% from 6.5% to 3.0% (p<0.001). While MVI due to cataract increased in both districts, there was a significant decline in MVI due to refractive errors in Khammam. CONCLUSION: There was a significant decline in VI in Khammam district but not in Warangal district. The differential trends in prevalence and causes of VI can be explained by the availability and uptake of eye care services in these two districts.