Assessing the reliability of tele-refraction for real time consultation with a remote optometrist.

INTRODUCTION: Uncorrected refractive errors pose a significant challenge globally, particularly in remote regions of low-middle income countries where access to optometric care is often limited. Telerefraction, which involves refraction by a trained technician followed by real-time consultation with remote optometrist, is a promising approach for such remote settings. This study aimed to evaluate the accuracy of this model. METHODS: This prospective study, conducted in New Delhi, compared tele-refraction to in-person examinations. Trained technicians used a simple device, Click-check, to perform objective refraction and a tele-refraction platform to enter the findings of objective refraction. Final prescription was made after consulting a remote optometrist on that platform. Masked face-to-face optometrists served as the gold standard. The study involved refraction in 222 patients and 428 eyes. RESULTS: Tele-refraction demonstrated a strong agreement with in-person optometry, achieving 84.6% in spherical correction and 81% conformity in spherical equivalent. The mean difference of spherical equivalent between the two arms was only 0.11 D. The consultation with a remote optometrist improved conformity of spherical equivalent by 14.8% over objective refraction. 82 percent eyes matched in best corrected visual acuity and 92 percent were within 0.1 logMAR difference. For cylindrical axis, 74% eye were within acceptable 10 degrees of difference. The mismatch amongst the individual trained technicians, in terms of difference between the tele-refraction arm and the face-to face optometrist arm was found to be significant for cylindrical axis and not for spherical power and spherical equivalent. CONCLUSION: Our study found tele-refraction by a trained technician comparable to refraction done by face-to-face optometrist. Tele-refraction, coupled with remote optometrist guidance can address the optometry resource gap in underserved areas. Thus, this model offers a transformative approach to enhancing the accessibility and quality of eye care services, which can significantly contribute to our efforts in achieving the global targets set by the World Health Organization for effective refractive error coverage. More standardized training for these technicians on ClickCheckTM for detecting the cylindrical axis with better accuracy, can improve this model further.

Visual Acuity Screening in North Indian Schools: Testing Accuracy and Cost of Alternate Screening Models.

PURPOSE: Our study compares the sensitivity, specificity and cost of visual acuity screening as performed by all class teachers (ACTs), selected teachers (STs) and vision technicians (VTs) in north Indian schools. METHODS: Prospective cluster randomized control studies are conducted in schools in a rural block and an urban-slum of north India. Consenting schools, with a minimum of 800 students aged 6 to 17 years, within a defined study region in both locations, were randomised into three arms: ACTs, STs or VTs. Teachers were trained to test visual acuity. Reduced vision was defined as unable to read equivalent of 20/30. Optometrists, who were masked to results of initial screening, examined all children. Costs were measured for all three arms. RESULTS: The number of students screened were 3410 in 9 ACT schools, 2999 in 9 ST schools and 3071 in 11 VT schools. Vision deficit was found in 214 (6.3%), 349 (11.6%) and 207 (6.7%), (p < .001) children in the ACT, ST and VT arms, respectively. The positive predictive value of VT screening for vision deficit (81.2%) was significantly higher than that of ACTs (42.5%) and STs (30.1%), (p < .001). VTs had significantly higher sensitivity of 93.3% and specificity of 98.7%, compared to ACTs (36.0% and 96.1%) and STs (44.3% and 91.2%). The cost of screening children with actual visual deficit by ACTs, STs and VTs, was found to be $9.35, $5.79 and $2.82 per child, respectively. CONCLUSION: Greater accuracy and lower cost favours school visual acuity screening by visual technicians in this setting, when they are available.

Door-to-door Screening as a New Model Augmenting School Eye Screening: Reaching Out to School Age Children in the Midst of a Pandemic.

PURPOSE: Explore door-to-door eye screening in India as a model to reach school age children in need of eye care, especially during school closures due to the Covid-19 pandemic. METHODS: Children between 5 and 18 years were screened in an urban-slum of Delhi from September 2020 to March 2021. Screening included capturing ocular complaints, visual acuity and conducting a torchlight examination. Children with any eye-related complaints, gross abnormality or a LogMAR acuity of more than 0.2 in either eye were referred to the nearby vision centre. Data were disaggregated by gender and age group. Reporting after referral and proportion of true positives referrals were used to assess the model. RESULTS: 32,857 children were screened. 55% were boys. Only 917 children (2.8%) had previous eye examinations. 1814 (5.5%) children were referred. Overall compliance rate amongst those referred was 59% (1070 of 1814) and compliance was significantly higher (72%) amongst those referred with poor vision as compared to those with only ocular morbidities (38%). Overall compliance was significantly higher amongst older age group (64% vs 50%) and amongst girls than boys (61% vs 56%). 3.9% children were detected with refractive error (RE) and 2.5% with uncorrected RE which was significantly higher in girls and in older age group. Of 1070 children reporting after referral, 85% had confirmed diagnosis for RE or other ocular pathology. CONCLUSION: Door-to-door screening had good referral compliance and positive predictive value. We recommend this model as a supplement to school screening especially in regions with low enrolment and high absenteeism in schools.

Comparison of eyecare utilization at two service delivery levels during the COVID-19 pandemic as a measure of their impact: A multicentric retrospective analysis across four North Indian high-volume eyecare organizations.

Purpose: The purpose of this study was to assess the performance of the tertiary centers (TCS) and vision centers (VCs) of the four organizations participating in this research, once the lockdown was lifted, and to compare it with the performance during the same period of the previous year. Methods: This was a cross-sectional study assessing eyecare utilization in the first 2 months after resumption of services post the lockdown in 2020 and comparing that across the same time period in 2019. Anonymized data containing basic demographic details, proportions of patient visits and their reasons, as well as referral information was collected. The drop percentage method was used, and P values were calculated using paired t-tests. Results: Four TCs and 60 VCs were included. Overall, outpatient attendance dipped 51.2% at TCs and 27.5% at VCs, across the 2 years. At both levels of care delivery, the percentage drop in females was more than that in males; however, the overall drop at VCs was less than that at TCs, for both sexes. Eyecare utilization in pediatric populations dropped significantly more than in adult populations, across the overall sample. There was no significant change in referrals for refractive error as a proportion of total outpatients, although there was a significant decline in the same for cataract and specialty treatment. Conclusion: VCs are valuable and successful model for eyecare delivery especially in the continued aftermath of the COVID-19 pandemic.

Assessment of COVID-19-related awareness, knowledge, prevention practices and challenges faced by truck drivers in major transport cities of India: a cross-sectional survey.

OBJECTIVES: To assess COVID-19-related awareness and knowledge among truck drivers across India and report prevention practices followed, and challenges faced, by them during the COVID-19 lockdown. DESIGN: Cross-sectional study. SETTING: Delhi, Kanpur, Kolkata and Bangalore from July to September 2020. PARTICIPANTS: Data were collected in Hindi using a structured questionnaire via telephonic interviews. Minimum 200 drivers were included from each location. OUTCOME MEASURES: Sociodemographic profile, awareness regarding COVID-19, knowledge regarding infection sources, disease spread and vulnerable populations, prevention practices followed and challenges faced. Information sources were also assessed. RESULTS: Fisher's exact test and Analysis of variance (ANOVA) test were used to check for significant differences across proportions. P value less than 0.05 was considered significant. Overall, 1246 drivers were included, with 72% response rate. Of 1246 drivers, 65% were 30-50 years of age. A majority correctly answered knowledge questions regarding communicability (95%) and fatality (66%). Fifty per cent drivers were aware of treatability of the disease, while only 43% and 24% correctly reported all signs and symptoms and routes of transmission, respectively. No driver was aware of all high-risk populations. Overall Knowledge Score is significantly associated with region. Mobile phones were the primary source of information across all regions. Over two-third drivers follow all prevention practices regularly, which differed significantly across regions. Following standard prevention practices was positively correlated with higher knowledge scores and was significantly correlated with mask use. Worry about the disease was common. Less than 40% drivers received full payment for work during this period, while 25% drivers were unable to return home due to the pandemic. Seven per cent and 26% drivers had either limited or no access to food and health services, respectively. CONCLUSIONS: Awareness activities and employer provisioned social security/health insurance might safeguard this vulnerable population till the pandemic fully abates as well as in similar situations in the future.

Correction: Effect of Door-to-Door Screening and Awareness Generation Activities in the Catchment Areas of Vision Centers on Service Use: Protocol for a Randomized Experimental Study.

[This corrects the article DOI: 10.2196/31951.].

Strategies for cataract and uncorrected refractive error case finding in India: Costs and cost-effectiveness at scale.

Background: India has the largest number of individuals suffering from visual impairment and blindness in the world. Recent surveys indicate that demand-based factors prevent more than 80% of people from seeking appropriate eye services, suggesting the need to scale up cost-effective case finding strategies. We assessed total costs and cost-effectiveness of multiple strategies to identify and encourage people to initiate corrective eye services. Methods: Using administrative and financial data from six Indian eye health providers, we conduct a retrospective micro-costing analysis of five case finding interventions that covered 1·4 million people served at primary eye care facilities (vision centers), 330,000 children screened at school, 310,000 people screened at eye camps and 290,000 people screened via door-to-door campaigns over one year. For four interventions, we estimate total provider costs, provider costs attributable to case finding and treatment initiation for uncorrected refractive error (URE) and cataracts, and the societal cost per DALY averted. We also estimate provider costs of deploying teleophthalmology capability within vision centers. Point estimates were calculated from provided data with confidence intervals determined by varying parameters probabilistically across 10,000 Monte Carlo simulations. Findings: Case finding and treatment initiation costs are lowest for eye camps (URE: $8·0 per case, 95% CI: 3·4-14·4; cataracts: $13·7 per case, 95% CI: 5·6-27·0) and vision centers (URE: $10·8 per case, 95% CI: 8·0-14·4; cataracts: $11·9 per case, 95% CI: 8·8-15·9). Door-to-door screening is as cost-effective for identifying and encouraging surgery for cataracts albeit with large uncertainty ($11·3 per case, 95% CI: 2·2 to 56·2), and more costly for initiating spectacles for URE ($25·8 per case, 95% CI: 24·1 to 30·7). School screening has the highest case finding and treatment initiation costs for URE ($29·3 per case, 95% CI: 15·5 to 49·6) due to the lower prevalence of eye problems in school aged children. The annualized cost of operating a vision center, excluding procurement of spectacles, is estimated at $11,707 (95% CI: 8,722-15,492). Adding teleophthalmology capability increases annualized costs by $1,271 per facility (95% CI: 181 to 3,340). Compared to baseline care, eye camps have an incremental cost-effectiveness ratio (ICER) of $143 per DALY (95% CI: 93-251). Vision centers have an ICER of $262 per DALY (95% CI: 175-431) and were able to reach substantially more patients than any other strategy. Interpretation: Policy makers are expected to consider cost-effective case finding strategies when budgeting for eye health in India. Screening camps and vision centers are the most cost-effective strategies for identifying and encouraging individuals to undertake corrective eye services, with vision centers likely to be most cost-effective at greater scale. Investment in eye health continues to be very cost-effective in India. Funding: The study was funded by the Seva Foundation.

Effect of Door-to-Door Screening and Awareness Generation Activities in the Catchment Areas of Vision Centers on Service Use: Protocol for a Randomized Experimental Study.

BACKGROUND: A vision center (VC) is a significant eye care service model to strengthen primary eye care services. VCs have been set up at the block level, covering a population of 150,000-250,000 in rural areas in North India. Inadequate use by rural communities is a major challenge to sustainability of these VCs. This not only reduces the community's vision improvement potential but also impacts self-sustainability and limits expansion of services in rural areas. The current literature reports a lack of awareness regarding eye diseases and the need for care, social stigmas, low priority being given to eye problems, prevailing gender discrimination, cost, and dependence on caregivers as factors preventing the use of primary eye care. OBJECTIVE: Our organization is planning an awareness-cum-engagement intervention-door-to-door basic eye checkup and visual acuity screening in VCs coverage areas-to connect with the community and improve the rational use of VCs. METHODS: In this randomized, parallel-group experimental study, we will select 2 VCs each for the intervention arm and the control arm from among poor, low-performing VCs (ie, walk-in of ≤10 patients/day) in our 2 operational regions (Vrindavan, Mathura District, and Mohammadi, Kheri District) of Uttar Pradesh. Intervention will include door-to-door screening and awareness generation in 8-12 villages surrounding the VCs, and control VCs will follow existing practices of awareness generation through community activities and health talks. Data will be collected from each VC for 4 months of intervention. Primary outcomes will be an increase in the number of walk-in patients, spectacle advise and uptake, referral and uptake for cataract and specialty surgery, and operational expenses. Secondary outcomes will be uptake of refraction correction and referrals for cataract and other eye conditions. Differences in the number of walk-in patients, referrals, uptake of services, and cost involved will be analyzed. RESULTS: Background work involved planning of interventions and selection of VCs has been completed. Participant recruitment has begun and is currently in progress. CONCLUSIONS: Through this study, we will analyze whether our door-to-door intervention is effective in increasing the number of visits to a VC and, thus, overall sustainability. We will also study the cost-effectiveness of this intervention to recommend its scalability. TRIAL REGISTRATION: ClinicalTrials.gov NCT04800718; https://clinicaltrials.gov/ct2/show/NCT04800718. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/31951.

A multicentric cross-sectional study measuring the equity of cataract surgical services in three high-volume eyecare organizations in North India: Equitable cataract surgical rate as a new indicator.

PURPOSE: Cataract remains the leading cause of blindness and visual impairment in most low-and middle-income countries, with the greatest burden borne by women. To achieve Global Action Plan targets, cataract programs must target people, especially women, with maximum need. This study examines whether cataract surgical programs in three major north Indian eyecare institutions are equitable and describes a refined indicator for reporting equity. METHODS: Retrospective one-year cross-sectional study of cataract surgery utilization using routine administrative data from three north Indian eyecare institutions. Patient data were categorized by paying category, sex, and preoperative visual acuity. Comparisons were made between payment categories and sexes. RESULTS: Out of the total number of patients operated, 86,230 were in the non-paying category and 56,738 in the paying category. Overall, 8.2% were blind, 21.1% were severely visual impaired (SVI) or worse, and 86.1% were moderate visual impaired (MVI) or worse. Non-paying patients had a significantly higher proportion of poorer visual categories compared to paying patients [(blind, 9.7% vs. 5.8%; SVI or worse, 24.6% vs. 15.8%; and MVI or worse, 89.1% vs. 81.6%, respectively, (P < 0.001)]. Women had significantly higher proportion of poorer visual categories than men [(blind, 8.9% vs. 7.4%, SVI or worse, 21.9% vs. 20.3% and MVI or worse 87.6 vs. 84.7%) (P < 0.001)]. CONCLUSION: The institutions primarily provided surgery to patients with maximum need: too poor to pay, low visual acuity, and women. Similar data from all service providers of a region can help estimate the proposed "equitable cataract surgical rate": the proportion of patients operated with maximum need among those operated in a year. This can be used for targeting people in need.

ROP screening and treatment in four district-level special newborn care units in India: a cross-sectional study of screening and treatment rates.

Objective: Blindness from retinopathy of prematurity (ROP) in middle-income countries is generally due to absence of screening or inadequate screening. The objective of this study was to assess uptake of services in an ROP programme in four district-level special newborn care units in India. Design: Cross-sectional study. Setting: All four neonatal units of a state in India where model programme for ROP had been introduced. Patients: Infants eligible for screening and treatment of ROP between March and May 2017. Intervention: Data on sex, birth weight and gestational age of eligible infants were collected and medical records reviewed for follow-up. Main outcome measures: Proportion of eligible infants screened and for those screened, age at first screening, completion of screening, diagnosis and treatment received if indicated. The characteristics of infants screened and not screened were compared. Results: 137 (18%) of the 751 infants eligible for screening were screened at least once, with no statistically significant difference by sex. The mean birth weight and gestational age of those screened were significantly lower than those not screened. Among those screened, 43% underwent first screening later than recommended and 44% had incomplete follow-up. Fourteen infants (11% of those screened) were diagnosed with ROP. Five were advised laser treatment and all complied. Conclusion: Uptake, completion and timing of first screening was suboptimal. Some planned interventions including training of nursing staff, use of integrated data-management software and providing material for parent counselling, which have been initiated, need to be fully implemented to improve uptake of ROP screening services.

Out-of-School Vision Screening in North India: Estimating the Magnitude of Need.

Purpose : Few studies have examined the extent to which school-based vision screening is sufficient to achieve universal coverage among school-aged children in India. Method : A rural administrative region ('Block') was examined. Government records provided the total population of the rural Block, the proportion of school-aged children, and school authorities in the Block provided the number of enrolled students. Absenteeism was measured directly by visiting a representative sample of the schools. The proportion of the school age population found in school was assessed using the indicator, Effective Coverage (EC): the proportion of children attending school divided by the total population of school-aged children in the region. Results : In the rural block, the proportion of children actually enrolled in school was 52% of the school-aged population, with 68% of them attending school. Therefore, EC was 35% (68% of the 52% enrolled). Conclusion : Population coverage by school vision screening would be unacceptably low in a rural setting in northern India. Out-of-school vision screening programs are needed in these rural settings to achieve universal coverage.

Are high-efficiency particulate air (HEPA) filters and laminar air flow necessary in operating rooms to control acute post-operative endophthalmitis?

Purpose: To compare the five-year incidence of acute post-operative endophthalmitis following cataract surgery, between centers with and without laminar air flow and high-efficiency particulate air (HEPA) filters in operating rooms. Methods: Retrospective analysis of medical records of patients operated in a single network of a tertiary and four secondary hospitals across north India. Cases of endophthalmitis were identified from the records between January 2013 and June 2018. Protocols and consumables were standardized across all hospitals. The only infrastructural difference being the presence of laminar air flow and high energy particulate air filters in operating rooms of the tertiary center. The type of surgery, along with the demographic and socio-economic details, were captured and analyzed, using z-test for proportions and logistic regression. Results: Out of 88,297 cataract surgeries conducted, 36 cases of endophthalmitis were reported. The incidence of endophthalmitis across the network was estimated to be 0.041%, (95% CI: 0.027 to 0.054). There was no statistically significant difference between the incidence of POE at the tertiary (0.042%) and secondary centers (0.039%). Certain risk factors for high endophthalmitis incidence were identified, namely patients undergoing small incision cataract surgery and belonging to lower socio-economic status. However, for both factors the difference was not statistically significant. Conclusion: The five-year incidence of acute post-operative endophthalmitis in our network was found comparable to the best reported in literature. Incidence at secondary centers, without laminar air flow and high energy particulate air filters was found comparable to that in the tertiary center having these facilities.

Status of Oxygen Monitoring in Four Selected Special Care Newborn Units in India.

OBJECTIVES: To investigate the status of oxygen monitoring in Special Newborn Care Units. METHODS: Observations were made and records reviewed of infants on oxygen in all four Special Newborn Care Units of a state delivering a model program for retinopathy of prematurity. Multiple choice questions were administered to nurses, semi-structured interviews conducted with pediatricians, ophthalmologists and senior nurses. RESULTS: All units had more than 100% occupancy. The number of functioning pulse oximeters was 73% of that recommended. None of the units had air-oxygen blenders. The upper oxygen saturation alarm was set accurately only for 1 out of 18 babies receiving oxygen and none of the infants had continuous saturation monitoring. 84% of nurses did not know optimal oxygen saturation targets. Most interviewees attributed suboptimal care to overcrowding. CONCLUSION: Compressed air, air-oxygen blenders, sufficient functioning pulse oximeters, rational admission policies and training of nurses are needed to improve oxygen related practices.

Primary eye care in India - The vision center model.

The World Health Organization (WHO) Global Action Plan (GAP) 2014-19 emphasize providing Comprehensive Eye Care (CEC) using the health system approach to achieve Universal Eye Health Coverage (UEHC). An important aspect of CEC is Primary Eye Care (PEC). The scope of PEC varies significantly with primary health workers providing PEC in most parts of the developing world, whereas in developed nations PEC is provided by specialized personnel such as optometrists. This article focuses on delivery of PEC models in India, specifically through the vision center (VC) approach. VCs are part of a larger eye care network and provide PEC in remote rural areas of the country. The authors describe the how PEC is delivered in more than 300 VCs operated by six mentor hospitals in India under the Global Sight Initiative (GSI). Key factors compared include: The role of leadership; human resource planning, including recruitment and retention; service delivery; leveraging technology for planning and reaching key populations; financial sustainability; supply chain management; and quality and monitoring. It also discusses issues to be considered to strengthen VCs as we move ahead towards our collective goal of achieving UEHC and eliminating avoidable blindness.

Costs, cost-effectiveness and detection rate of glaucoma screening in cataract camps in urban India: A study protocol.

India has an estimated 12 million people affected with glaucoma; however, no organised screening programme exists. Cases are usually detected opportunistically. This study documents the protocol for detecting glaucoma in suspects in cataract camps conducted by Shroff Charity Eye Hospital in North India. We report a prospective study design from patients attending cataract camps where glaucoma screening will be integrated. The eligible population for glaucoma screening is non-cataract patients. Patients will undergo glaucoma screening by a trained optometrist using a pre-determined glaucoma screening algorithm. Specific diagnostic cut-off points will be used to identify glaucoma suspects. Suspected patients will be referred to the main hospital for confirmatory diagnosis and treatment. This group will be compared to a cohort of patients arriving from cataract camps conducted by the institute in similar areas and undergoing examination in the hospital. The third arm of the study includes patients arriving directly to the hospital for the first time. Cost data will be captured from both the screening components of cataract-only and glaucoma screening-integrated camps for screening invitation and screening costs. For all three arms, examination and treatment costs will be captured using bottom-up costing methods at the hospital. Detection rates will be calculated by dividing the number of new cases identified during the study by total number of cases examined. Median, average and range of costs across the three arms will be calculated for cost comparisons. Finally, cost-effectiveness analysis will be conducted comparing cost per case detected across the three arms . This is the first such study conducted in India. The study protocol will be useful for researchers and practitioners for conducting similar economic evaluation studies in their context. The protocol publication will be a good step to ensure transparency of methods of reporting of economic evaluation studies in LMICs.