Non-mydriatic fundus photography as an alternative to indirect ophthalmoscopy for screening of diabetic retinopathy in community settings: a comparative pilot study in rural and tribal India.

OBJECTIVES: The impending and increasing prevalence of diabetic retinopathy (DR) in India has necessitated a need for affordable and valid community outreach screening programme for DR, especially in rural and far to reach indigenous local communities. The present study is a pilot study aimed to compare non-mydriatic fundus photography with indirect ophthalmoscopy for its utilisation as a feasible and logistically convenient screening modality for DR in an older age, rural, tribal population in Western India. DESIGN AND SETTING: This community-based, cross-sectional, prospective population study was a part of a module using Rapid Assessment of Avoidable Blindness and DR methodology in 8340 sampled participants with ≥50 years age. In this study, the diabetics identified were screened for DR using two methods: non-mydriatic fundus photography on the field by trained professionals, that were then graded by a retina specialist at the base hospital and indirect ophthalmoscopy by expert ophthalmologists in the field with masking of each other's findings for its utility and comparison. RESULTS: The prevalence of DR, sight threatening DR and maculopathy using indirect ophthalmoscopy was found to be 12.1%, 2.1% and 6.6%, respectively. A fair agreement (κ=0.48 for DR and 0.59 for maculopathy) was observed between both the detection methods. The sensitivity and specificity of fundus photographic evaluation compared with indirect ophthalmoscopy were found to be 54.8% and 92.1% (for DR), 60.7% and 90.8% (for any DR) and 84.2% and 94.8% (for only maculopathy), respectively. CONCLUSION: Non-mydriatic fundus photography has the potential to identify DR (any retinopathy or maculopathy) in community settings in Indian population. Its utility as an affordable and logistically convenient cum practical modality is demonstrable. The sensitivity of this screening modality can be further increased by investing in better resolution cameras, capturing quality images and training and validation of imagers. TRIAL REGISTRATION NUMBER: CTRI/2020/01/023025; Clinical Trial Registry, India (CTRI).

Compliance of spectacle wear among school children.

Purpose: In India, school eye screening is an important component of the National Programme for the Control of Blindness providing spectacles free of cost to children from primary section. The primary aim of this study was to know the compliance of wearing spectacles provided during school screening program and to find out reasons for noncompliance. The secondary aim of this study was to get information regarding the types of modifications required in the school eye screening program to improve the compliance level. Methods: It was a cross-sectional follow-up study involving school children of age group 10-16 years, class 5-9 from different parts of the country. Public or private schools were randomly selected based on their distance from the base hospitals/partner organizations. Data were collected by standard format directly from the students after informed written consent from school principal or class teacher. Results: The utilization of spectacles was found to be only 29.8% (n = 289) within 2 years of receiving the spectacles. Thirty-five percent (n = 108) students were using spectacles with less than 0.75 D. Appearance of the frame was a deciding factor. It was observed that the frames provided by the DBCS were especially not liked by the children. Twenty-five percent (n = 79) children were found to be wearing adult frames. Conclusion: Less than a third of the students were compliant with their spectacle prescription in this study. To improve the compliance, children should not be prescribed spectacles for nonsignificant refractive errors, should be given choices for frames and quality of work being conducted under school screening program needs a review.

Rapid Assessment of Avoidable Blindness and Willingness to Pay for Cataract Surgery in Tribal Region of Surat District of Gujarat State, India.

AIM: To estimate prevalence and causes of avoidable blindness among people ≥50 years and to assess willingness to pay (WTP) for cataract surgery in tribal region of south Gujarat, India. METHODS: A cross-sectional population based survey was conducted with 44 randomly selected clusters each having 50 people aged ≥50 years selected by probability proportional to size of sampling. Adults identified with cataract causing visual loss (<6/18) in any eye were interviewed to assess their WTP for surgery. RESULTS: Total of 2137 examined out of 2200 people enumerated (response rate 97.1%). The prevalence of blindness (Presenting Visual Acuity (PVA)<3/60 in better eye) was 2.23% (95% CI: 2.95%-1.51%). Cataract was main cause of blindness (67.3%) followed by corneal scarring (8.2%). Major barrier to cataract surgery cited by bilaterally blind people was lack of escort to the surgical facility (34.3%). Cataract surgical coverage (CSC) was 84.9% (eyes) and 92% (persons). Of the 492 people interviewed to assess WTP for their surgery, only 36.4% people were willing to pay. CONCLUSION: The tribal population has a high poverty profile in India. Within this group, cataract remains the main treatable cause of blindness despite a high CSC. Assessment of barriers suggested that a well-coordinated outreach programme with free transport facilities to the surgical facility is required along with strategies to improve accessibility and prioritising cataract blind in the community. One-third of people were willing to pay for their surgeries implying that cross subsidization or tier system could be feasible for eye care programme sustainability.

Effectiveness of health education and monetary incentive on uptake of diabetic retinopathy screening at a community health center in South Gujarat, India.

Purpose: The effectiveness of Accredited Social Health Activists (ASHAs) with and without monetary incentive in uptake of diabetic retinopathy (DR) screening at community health center (CHC) was compared in South Gujarat, India. Methods: In this non-randomized controlled trial, ASHAs were incentivized to refer people with diabetes mellitus (PwDM) from their respective villages for DR screening after people were sensitized to DM and DR. The minimum sample size was 63 people in each arm. Results: Of 162, 50.6% were females, 80.2% were literate, 56.2% were >50 years, 54.3% had increased random blood sugar (RBS), and 59.9% had diabetes for 5 years. The percentage of screening was significantly higher [relative risk (RR) = 4.37, 95% confidence interval (CI) 2.79, 6.84] in ASHA incentive group and health education (HE) group (RR = 3.67, 95% CI 2.35, 5.75) compared with baseline. Providing incentive to ASHAs was not found to be of extra advantage (RR = 1.19, 95% CI 0.89, 1.57). The likelihood of uptake of screening was higher among uncontrolled PwDM, poor literacy, and higher duration of diabetes in incentive phase (P < 0.001) compared with HE. The results show that age (P = 0.017), education (P = 0.015) and level of RBS (P = 0.001) of those referred were significantly associated with incentives to ASHAs. Conclusion: ASHAs can be used effectively to refer known PwDM for DR screening especially when DR screening program is introduced in population with low awareness and poor accessibility. When incentives are planned, additional burden on resources should be kept in mind before adapting this model of care.