Use of the Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7) questionnaires for clinical decision-making and psychological referral in ophthalmic care: a multicentre observational study.

OBJECTIVES: The aim of this study was to evaluate the influence of anxiety and depression on clinician decision-making in patients suffering from chronic eye disease in ophthalmological clinical practice. DESIGN AND SETTING: This multicentre observational study, in collaboration with the WHO, included ophthalmologists and their patients affected by chronic eye disease. States of anxiety and depression were screened with specific questionnaires, the Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7), self-administered by patients before the visit. In the present analysis, we report data from three major eye care centres in Italy between 2021 and 2022. PRIMARY AND SECONDARY OUTCOMES: To assess self-reported changes in ophthalmologists' clinical approach (communication style and their clinical-therapeutic strategies) and decisions after knowing questionnaire scores (primary aim), and to analyse the PHQ-9 and GAD-7 scores in patients with chronic eye diseases (secondary aim). RESULTS: 41 ophthalmologists and 359 patients were included. The results from PHQ-9 and GAD-7 scores showed critical depression and anxiety status scores (PHQ-9 ≥5 and GAD-7 ≥10) in 258 patients. In 74% of cases, no actions were taken by the ophthalmologists based on these scores; in 26% of cases, they changed their clinical approach; and in 14% of cases, they referred the patients for psychological/psychiatric evaluation. CONCLUSIONS: States of anxiety and depression affect many patients with chronic eye conditions and need to be detected and managed early to improve patients' well-being. Providing ophthalmologists with knowledge of their patients' psychological conditions can change the clinical management and attitude towards referral for a psychological evaluation. Further studies are needed to expand our knowledge of how to raise awareness among ophthalmologists regarding multimorbidity of patients suffering from chronic eye diseases in order to achieve better clinical outcomes.

Monitoring hearing and vision functions in older adults: rationale and process.

Hearing and vision impairment are highly prevalent in ageing individuals and are significant public health concerns given their meaningful impacts on individuals and society. Yet, many cases of both visual and hearing impairment remain unidentified and thus, unaddressed. This article describes the rationale and process of monitoring for visual and hearing impairment in older adults, by summarising guidance and resources available from the World Health Organisation (WHO) that were developed based upon the best current available evidence. It is recommended that vision screening be offered at least annually to adults aged over 50 years and hearing screening be offered every 5 years to adults aged 50-64 years, and every 1-3 years to adults aged 65 years or older. Both hearing and vision screening can be conducted in community, home or clinical settings by trained health workers with simple equipment. More specifically, vision screening can be conducted with a simple eye chart. Hearing screening can be conducted without specialised equipment by using pure tones set to a fixed level, an automated mobile- or web-based digits-in-noise test, or the whispered voice test. Hearing screening can also be conducted in audiology clinics using pure-tone air conduction threshold testing. There exists WHO guidance to support the monitoring of hearing and vision impairment, which, when warranted, can facilitate referral for comprehensive assessment and prompt appropriate, person-centred interventions to mitigate the negative consequences of hearing and vision impairment.

The Effect of Varied Microperimetric Biofeedback Training in Central Vision Loss: A Randomized Trial.

SIGNIFICANCE: This investigation reports for the first time the effects of different microperimetric biofeedback strategies in visually impaired subjects with central field loss. PURPOSE: This study aimed to evaluate the effects of two MP-3 microperimeter biofeedback strategies on the visual performance of subjects with central vision loss. Moreover, changes between the groups were compared to provide indications of practice with biofeedback stimulation in subjects with central vision loss. METHODS: Using simple randomization, 19 participants were trained according to two different biofeedback stimulation approaches using the MP-3 microperimeter. Patients were assigned to two different groups: subjects trained for 2 days a week (group A) and 3 days a week (group B). The patients in each group were randomized to perform a total of 10 or 15 sessions. RESULTS: Fixation stability increased from 4.5 ± 2.8 to 2.3 ± 2.2° 2 and from 8.2 ± 6.9 to 1.4 ± 1° 2 after 2 and 3 weekly biofeedback training sessions, respectively ( P < .05). Biofeedback training induced a significant improvement of 40.7 and 29.4% in reading speed for groups A and B, respectively ( P < .05). A comparison of two weekly biofeedback training sessions with three weekly biofeedback sessions demonstrated greater fixation stability in group B ( P < .05). CONCLUSIONS: This study concludes that a biofeedback intervention is effective in enhancing oculomotor control in patients with central vision loss. In our study, a more intensive biofeedback strategy seemed to produce significantly better results in terms of functional vision parameters.

Development of the WHO eye care competency framework.

BACKGROUND: The eye care workforce, particularly in lower resource settings, face challenges of limited integration into the health system, limited workforce capacity, mismatch of workforce to population need and poor quality of care. In recognition of these challenges, coupled with a gap in existing tools, provides a strong rationale for the development of the Eye care competency framework (ECCF). METHODS: A mixed methods approach was utilised to develop and validate the ECCF. Content was developed by extracting relevant components of existing frameworks used both within and outside of eye care. A diverse technical working group provided feedback and guidance on the structure, design, and content to create a preliminary draft. Competencies and activities were validated using a modified-Delphi study, and the framework was then piloted at four sites to understand how the tool can be implemented in different settings. RESULTS: The final version of the ECCF included eight outcomes, nine guiding principles, and content of each of the key elements, including the six domains, 22 competencies, 21 activities, 193 behaviours and 234 tasks, and the knowledge and skills that underpin them. 95/112 participants from the six WHO regions completed the modified-Delphi study, yielding an average of 96% agreement across the competencies and activities in the ECCF. The pilot showcased the versatility and flexibility of the ECCF, where each of the four sites had a different experience in implementing the ECCF. All sites found that the ECCF enabled them to identify gaps within their current workforce documentation. CONCLUSIONS: The ECCF was developed using a collaborative approach, reflecting the opinions of participants and stakeholders from all around the world. The comprehensive competencies and activities developed in the ECCF encompass the diverse roles of eye care workers, and thus encourage multi-disciplinary care and better integration into the health system. It is recommended that eye care workforce planners and developers use the ECCF, and adapt it to their context, to support workforce development and focus on the quality and scope of eye care service provision.

Global Trends in Blindness and Vision Impairment Resulting from Corneal Opacity 1984-2020: A Meta-analysis.

TOPIC: We provide global estimates of the prevalence of corneal blindness and vision impairment in adults 40 years of age and older and examine the burden by age, sex, and geographic region from 1984 through 2020. CLINICAL RELEVANCE: Corneal opacities (COs) are among the top 5 causes of blindness worldwide, yet the global prevalence, regional differences, and risk factors are unclear. METHODS: Abstracted data from the published literature and surveys were obtained from the Global Burden of Disease Vision Loss Expert Group. We supplemented this by an independent systematic literature search of several databases. Studies that provided CO vision impairment data based on population-based surveys for those 40 years of age or older were included, for a total of 244. For each of the 4 outcomes of blindness and moderate to severe vision impairment (MSVI) caused by trachomatous and nontrachomatous CO (NTCO), time trends and differences in prevalence by region, age, and sex were evaluated using a Poisson log-linear model with a generalized estimating equation method. Age-standardized estimates of global prevalence of blindness and MSVI were calculated using the 2015 United Nations standard populations. RESULTS: The global prevalence of blindness resulting from NTCO in those 40 years and older was 0.081% (95% confidence interval [CI], 0.049%-0.315%); that of MSVI was 0.130% (95% CI, 0.087%-0.372%). A significant increase with age was found (prevalence rate ratio, 2.15; 95% CI, 1.99-2.32). Latin America and Europe showed the lowest rates, with 2- to 8-fold higher rates of blindness or MSVI in other regions. The global prevalence of blindness resulting from trachomatous CO in those 50 years and older was 0.0094% (95% CI, 0%-0.0693%); that from MSVI was 0.012% (95% CI, 0%-0.0761%). Blindness resulting from trachomatous CO and MSVI increased with age and female sex, and rates were significantly higher in the African regions. A decrease in trachomatous blindness rates over time was found (prevalence rate ratio, 0.91; 95% CI, 0.86-0.96). DISCUSSION: An estimated 5.5 million people worldwide are bilaterally blind or have MSVI resulting from CO, with an additional 6.2 million unilaterally blind. Blindness resulting from trachomatous CO is declining over time, likely because of the massive scaleup of the global trachoma elimination program and overall socioeconomic development. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Toward Universal Eye Health Coverage-Key Outcomes of the World Health Organization Package of Eye Care Interventions: A Systematic Review.

Importance: Despite persistent inequalities in access to eye care services globally, guidance on a set of recommended, evidence-based eye care interventions to support country health care planning has not been available. To overcome this barrier, the World Health Organization (WHO) Package of Eye Care Interventions (PECI) has been developed. Objective: To describe the key outcomes of the PECI development. Evidence Review: A standardized stepwise approach that included the following stages: (1) selection of priority eye conditions by an expert panel after reviewing epidemiological evidence and health facility data; (2) identification of interventions and related evidence for the selected eye conditions from a systematic review of clinical practice guidelines (CPGs); stage 2 included a systematic literature search, screening of title and abstracts (excluding articles that were not relevant CPGs), full-text review to assess disclosure of conflicts of interest and affiliations, quality appraisal, and data extraction; (3) expert review of the evidence extracted in stage 2, identification of missed interventions, and agreement on the inclusion of essential interventions suitable for implementation in low- and middle-income resource settings; and (4) peer review. Findings: Fifteen priority eye conditions were chosen. The literature search identified 3601 articles. Of these, 469 passed title and abstract screening, 151 passed full-text screening, 98 passed quality appraisal, and 87 were selected for data extraction. Little evidence (≤1 CPG identified) was available for pterygium, keratoconus, congenital eyelid disorders, vision rehabilitation, myopic macular degeneration, ptosis, entropion, and ectropion. In stage 3, domain-specific expert groups voted to include 135 interventions (57%) of a potential 235 interventions collated from stage 2. After synthesis across all interventions and eye conditions, 64 interventions (13 health promotion and education, 6 screening and prevention, 38 treatment, and 7 rehabilitation) were included in the PECI. Conclusions and Relevance: This systematic review of CPGs for priority eye conditions, followed by an expert consensus procedure, identified 64 essential, evidence-based, eye care interventions that are required to achieve universal eye health coverage. The review identified some important gaps, including a paucity of high-quality, English-language CPGs, for several eye diseases and a dearth of evidence-based recommendations on eye health promotion and prevention within existing CPGs.

Universal newborn eye screening: a systematic review of the literature and review of international guidelines.

Background: This systematic review assessed the effectiveness of universal screening for newborn eye abnormalities compared with no screening in improving infant vision and health outcomes. Methods: We searched CENTRAL (Cochrane Library), MEDLINE, Embase, Global Health, Global Index Medicus, clinical trials databases, and bibliographies of relevant articles. We included randomized and observational studies of all newborns, regardless of illness or risk factors, that compared universal screening for any eye abnormality by eight weeks of age with no universal screening. Two authors independently selected studies, extracted data, and evaluated the risk of bias. We used GRADE to assess the certainty of evidence. We also reviewed available recommendations on newborn eye screening. Results: Fourteen studies were identified but only three compared universal red reflex screening with no screening. Findings suggest that universal red reflex testing in maternity wards (MWs) may increase the number of newborns with congenital cataracts referred for eye care from MWs or well-baby clinics (WBCs) in the first year of life (risk ratio (RR) = 9.83, 95% confidence interval (CI) = 1.36-71.20; low certainty evidence). However, the effect of screening in WBC is uncertain (RR = 6.62, 95% CI = 0.87-50.09). The effect of MW or WBC screening on referral from any health care facility (MWs, WBCs, paediatrician clinic, other) in the first year is uncertain (MW screening: RR = 1.22, 95% CI = 0.63-2.39; WBC screening: RR = 0.97, 95% CI = 0.46-2.05). However, referral or surgery by 6 weeks of age may be higher with universal MW screening (early referral: RR = 4.61, 95% CI = 1.12-19.01; early surgery: RR = 8.23, 95% CI = 1.13-59.80; low certainty evidence). The effect of WBC screening on early referral and surgery is uncertain (early referral: RR = 1.98, 95% CI = 0.43-9.19; early surgery: RR = 3.97, 95% CI = 0.50-31.33; very low certainty evidence). Universal red reflex testing may increase clinical conjunctivitis (OR = 1.22, 95% CI = 1.01-1.47; low certainty evidence) but the effect on confirmed bacterial conjunctivitis is uncertain (OR = 1.20, 95% CI = 0.76-1.90; very low-certainty evidence). Nine guidelines recommended universal newborn eye screening using red reflex testing. Conclusions: Evidence supports the role of red reflex testing shortly after birth to increase early identification, referral, and surgery for congenital cataracts.

The WHO-ITU MyopiaEd Programme: A Digital Message Programme Targeting Education on Myopia and Its Prevention.

The objective of this paper is to provide an overview of the World Health Organization - International Telecommunication Union MyopiaEd programme - a digital message programme targeting education on myopia and its prevention. The development of the MyopiaEd programme included 4 key steps: (1) Conceptualization and consultation with experts in the field of myopia, mHealth and health behavior change; (2) Creation of SMS message libraries and programme algorithm; (3) Review of the message libraries to ensure relevance to the target audience; and (4) Pre-testing amongst end-user groups to ensure that the design of the programme and the message content were understandable. After reviewing the available evidence and considering input of the experts, the aims, end users and key themes of the programme were finalized. Separate SMS-adapted message libraries were developed, reviewed and pre-tested for four target end-user groups; (1) general population involved in the care of children (2) parents or caregivers of children with myopia; (3) adolescents with myopia; and (4) adults with myopia. The message libraries are part of a comprehensive toolkit, developed through a consultative process with experts in digital health, to support implementation within countries. The development of the MyopiaEd programme aims to provide a basis for Member States and other stakeholders to develop, implement and monitor large-scale mHealth programmes. It is aimed at raising awareness of good eye care behaviors and addressing common reasons for non-compliance to spectacle wear. The next steps will involve adapting and evaluating the MyopiaEd programme in selected settings.

The Association between Vision Impairment and Depression: A Systematic Review of Population-Based Studies.

We conducted a systematic review and meta-analysis to investigate whether depression is associated with vision impairment (VI) in population-based studies in adults. MEDLINE and EMBASE were searched, from inception to June 2020. Studies were included if they provided two-by-two data for calculating the OR of association between VI and depression, or crude and/or an adjusted odds ratio (OR) with a corresponding 95% confidence interval (CI) were reported. The proportion of VI and depression was also extracted. ORs were pooled using random-effect models, proportions were pooled using random intercepts logistic regression models. Overall, 29 articles (31 studies) were included: of those, 18 studies used survey data (622,312 participants), 10 used clinical examination data (69,178 participants), and 3 used administrative databases (48,162,290 participants). The proportion of depression (95%CI) was 0.17 (0.13-0.22) overall and 0.27 (0.21-0.33) in VI subjects. The proportion of VI was 0.10 (0.07-0.16) overall and 0.20 (0.13-0.29) in depressed subjects. The association between VI and depression was direct: crude ORs were 1.89 (1.51-2.37) for survey data, 2.17 (1.76-2.67) for clinical examination data, and 3.34 (1.01-11.11) for administrative databases; adjusted ORs were 1.75 (1.34-2.30), 1.59 (1.22-1.96), and 2.47 (0.97-6.33), respectively. In conclusion, VI and depression are prevalent morbidities and should be actively sought when either is identified, especially in older adults.

Welcoming teleretinography into diabetes integrated care.

Integrated Care (IC) is a perfect fit for people with diabetes. Fundus examination (FE) is a disease marker for diabetologists and identifies potentially blinding complications (Diabetic Retinopathy, DR). In our Diabetes Clinic (DC) in Pescara, Italy, FE is possibly provided with telemedicine in same day as other exams, avoiding it to be a standalone clinical one; images taken with a retinal digital camera are graded by a remote ophthalmologist within a shared Electronic Health Record (EHR), immediately readable by other stakeholders; a dedicated care path to the Eye Clinic, University of Chieti-Pescara is provided for urgent cases. Personnel's worktime shortening allows gaining time for ophthalmologists' eye examinations in outpatient settings and other stakeholders' work in the DC. The need for a DR digital screening system is growing worldwide: our experience confirms the ease of implementation, and the advantage of sharing clinical data with all stakeholders when working within an EHR, aiming to optimize an IC effective system.

Ophthalmologists perceived usefulness of Patient Health Questionnaire (PHQ-9) and Generalized Anxiety Disorder (GAD-7) for evaluating the mental health of patients with chronic eye diseases.

PURPOSE: To evaluate the awareness of ophthalmologists about assessing the mental health of patients and usefulness of the Patient Health Questionnaire (PHQ-9) and Generalized Anxiety Disorder (GAD-7) survey. METHODS: This web-based survey was performed in 2020 at an eye hospital in Saudi Arabia. Participants included ophthalmologists and physicians. Participants were queried on the need to assess mental health of patients, usefulness of the screening tool, and barriers to assessment. Their responses were graded on a Likert scale and Rasch analysis was performed. RESULTS: Of the 100 participants, 72 were aware of assessing mental health of eye patients and 82 expressed about limited skills for such assessment. The median score for perceived usefulness of the PHQ-9 as screening tool to suspect depression was -1.0 (inter quartile range, -1.0: 0.0) [Mean Rasch score = -0.735]. The median score of perceived usefulness for the GAD-7 as screening tool to suspect anxiety was -1.0 (inter quartile range, -1.0: 0.0) [Mean Rasch score = -0.695]. The PHQ-9 related score was significantly correlated to "30-39 years" age group (Kruskal Wallis p = 0.04) and non-Saudi professionals (Mann Whitney p = 0.005). The GAD-7 related score was significantly correlated to non-Saudi professionals (Mann Whitney p = 0.04). The mental health related score was significantly and negatively correlated to the "40-59 years" age group (Kruskal Wallis p = 0.04). CONCLUSIONS: Although awareness of mental health assessment was high, eyecare professionals felt with inadequate training for performing the screening. PHQ-9 seems to be more acceptable to screen for depression than GAD-7 for screening anxiety.

Keeping an eye on eye care: monitoring progress towards effective coverage.

The eye care sector is well positioned to contribute to the advancement of universal health coverage within countries. Given the large unmet need for care associated with cataract and refractive error, coupled with the fact that highly cost-effective interventions exist, we propose that effective cataract surgery coverage (eCSC) and effective refractive error coverage (eREC) serve as ideal indicators to track progress in the uptake and quality of eye care services at the global level, and to monitor progress towards universal health coverage in general. Global targets for 2030 for these two indicators were endorsed by WHO Member States at the 74th World Health Assembly in May, 2021. To develop consensus on the data requirements and methods of calculating eCSC and eREC, WHO convened a series of expert consultations to make recommendations for standardising the definitions and measurement approaches for eCSC and eREC and to identify areas in which future work is required.

Knowledge of patient emotional health status: impact on clinical care in glaucoma and retinal services.

OBJECTIVE: Knowledge of a patient's emotional health status and using patient-centred communication may be key to providing early intervention and referral to appropriate treatment/support services for ophthalmology patients. This study aims to determine if and how ophthalmologists use anxiety and depression scores to determine clinical care of patients with chronic eye disease. METHODS AND ANALYSIS: This cross-sectional study included 10 ophthalmologists and a convenience sample of 100 of their patients (>18 years). The Patient Health Questionnaire (PHQ-9) for depression and the Generalised Anxiety Disorder (GAD-7) tool were administered to patients. Scores from these instruments were provided to ophthalmologists just prior to the clinic visit. After the visit, ophthalmologists were given a questionnaire to assess self-reported change in clinical practice and whether knowledge of scores impacted their communication style, treatment plan and follow-up protocol. RESULTS: Of these patients (mean age=63), 27% reported mild-moderate anxiety or depression as their worst score, while 2% reported suicidal thoughts; 20% reported neither anxiety nor depression. Ophthalmologists' response to patients with mild or worse anxiety or depression was to change clinical approach (28%) and communication style (31%), both metrics increasing with severity of symptoms (Fisher's exact p<0.05). None reported changing their choice of treatment or modifying follow-up protocols; referral to social work/psychiatry services was 60%, 3.7% and 0% for patients with moderately severe or worse, mild-to-moderate, or minimal scores, respectively. CONCLUSION: Providing ophthalmologists with knowledge of the emotional health of their patients may change the clinical approach and referral pattern.

Strengthening the integration of eye care into the health system: methodology for the development of the WHO package of eye care interventions.

OBJECTIVE: To describe the rational for, and the methods that will be employed to develop, the WHO package of eye care interventions (PECI). METHODS AND ANALYSIS: The development of the package will be conducted in four steps: (1) selection of eye conditions (for which interventions will be included in the package) based on epidemiological data on the causes of vision impairment and blindness, prevalence estimates of eye conditions and health facility data; (2) identification of interventions and related evidence for the selected eye conditions from clinical practice guidelines and high-quality systematic reviews by a technical working group; (3) expert agreement on the inclusion of eye care interventions in the package and the description of resources required for the provision of the selected interventions; and (4) peer review. The project will be led by the WHO Vision Programme in collaboration with Cochrane Eyes and Vision. A Technical Advisory Group, comprised of public health and clinical experts in the field, will provide technical input throughout all stages of development. RESULTS: After considering the feedback of Technical Advisory Group members and reviewing-related evidence, a final list of eye conditions for which interventions will be included in the package has been collated. CONCLUSION: The PECI will support Ministries of Health in prioritising, planning, budgeting and integrating eye care interventions into health systems. It is anticipated that the PECI will be available for use in 2021.

Redesigning care for older people to preserve physical and mental capacity: WHO guidelines on community-level interventions in integrated care.

Islene Araujo de Carvalho and coauthors discuss the WHO guidelines on integrated care for older people.

Correction: Assessment of trachoma in suspected endemic areas within 16 provinces in mainland China.

[This corrects the article DOI: 10.1371/journal.pntd.0007130.].

Assessment of trachoma in suspected endemic areas within 16 provinces in mainland China.

BACKGROUND: China used to be among the countries with a high prevalence of trachoma. At the launch of The Global Elimination of Trachoma (GET) 2020 campaign by the World Health Organization (WHO) in 1996, China was placed on the list of countries endemic for trachoma based on historical data. However, empirical observation and routinely collected eye care data were suggesting that trachoma was no longer a public health problem. To determine whether the GET 2020 goals had been met in P. R. China, we conducted a targeted assessment with national scope. METHODOLOGY/PRINCIPAL FINDING: Province assessment teams, trained in WHO Trachoma Rapid Assessment (TRA) methodology and in WHO simplified trachoma grading system, carried out assessments in 16 provinces (among them, 2 provinces conducted pilot assessment). Based on the published literature, including national and international reports, suspected trachoma-endemic areas within each province were identified. Within these areas, trachomatous inflammation- follicular (TF) assessments were carried out in at least 50 grade-one children in primary schools serving villages with the lowest socio-economic development. Trachomatous trichiasis (TT) and corneal opacity (CO) assessments were conducted among persons aged 15 and over in villages within the catchment area of the selected schools. Of 8,259 children examined in 128 primary schools in 97 suspected trachoma endemic areas, only 16 cases of conjunctivitis were graded as TF. 38 cases with TT were found among the 339,013 examined residents in villages surrounding the schools. Among these 97 suspected trachoma endemic areas in only three was the prevalence of TT more than 0.2%. CONCLUSIONS/SIGNIFICANCE: This large study suggested that trachoma was not a public health problem in 16 provinces that had been previously suspected to be endemic. These findings will facilitate planning for elimination of trachoma from PR China.