Strategies to address inequity of uncorrected refractive error in the Western Pacific: A modified Delphi process.

PURPOSE: Uncorrected refractive error is the leading cause of vision impairment globally; however, little attention has been given to equity and access to services. This study aimed to identify and prioritise: (1) strategies to address inequity of access to refractive error services and (2) population groups to target with these strategies in five sub-regions within the Western Pacific. METHODS: We invited eye care professionals to complete a two-round online prioritisation process. In round 1, panellists nominated population groups least able to access refractive error services, and strategies to improve access. Responses were summarised and presented in round 2, where panellists ranked the groups (by extent of difficulty and size) and strategies (in terms of reach, acceptability, sustainability, feasibility and equity). Groups and strategies were scored according to their rank within each sub-region. RESULTS: Seventy five people from 17 countries completed both rounds (55% women). Regional differences were evident. Indigenous peoples were a priority group for improving access in Australasia and Southeast Asia, while East Asia identified refugees and Oceania identified rural/remote people. Across the five sub-regions, reducing out-of-pocket costs was a commonly prioritised strategy for refraction and spectacles. Australasia prioritised improving cultural safety, East Asia prioritised strengthening school eye health programmes and Oceania and Southeast Asia prioritised outreach to rural areas. CONCLUSION: These results provide policy-makers, researchers and funders with a starting point for context-specific actions to improve access to refractive error services, particularly among underserved population groups who may be left behind in existing private sector-dominated models of care.

Profile of ocular trauma in the Solomon Islands.

BACKGROUND: The objective of this study was to characterize the causes of ocular trauma and determine the risk factors for infection and vision loss following ocular trauma in the Solomon Islands. DESIGN: A prospective clinic-based study. PARTICIPANTS: A total of 507 patients with ocular trauma who were reviewed at the National Referral Hospital in Honiara or one of five provincial eye clinics were included. METHODS: An interview-based questionnaire to determine the circumstances of ocular trauma, and an ocular examination to elicit the trauma sustained,infectious sequelae and the visual outcome. MAIN OUTCOME MEASURE: Visual acuity. RESULTS: Males were significantly more likely to have ocular trauma than females (P = 0.01). The major cause of ocular trauma in young boys and girls was being poked by a stick, followed by lime burns in young boys. For both genders, physical violence resulted in most injuries across all adult age groups. Microbial keratitis complicated 4.4% of ocular trauma. Monocular vision impairment (<6/18) occurred in 5.5% of participants and was more likely to occur if female (P = 0.02). CONCLUSIONS: Ocular trauma is a significant cause of visual morbidity in the Solomon Islands. The results from this prospective study provide a basis for planning blindness prevention programmes in the Western Pacific.

Sight-threatening diabetic retinopathy at presentation to screening services in Fiji.

PURPOSE: To report the spectrum of retinopathy at first presentation to photoscreening services, to determine the proportion of patients that present with sight-threatening diabetic retinopathy (STDR), and to raise awareness of the burden of diabetic eye disease in Fiji. METHODS: This retrospective observational cohort study used data from the initial visit of all new patients presenting to the diabetes retinal screening service at the Pacific Eye Institute in Fiji over the 3-month period between July and September 2012. Patients were assessed using a detailed questionnaire regarding diabetes type, duration of disease, medications, complications and co-morbidities, and blood sugar control. Patients subsequently underwent non-mydriatic fundus photography according to Pacific diabetes retinal screening guidelines. Images were graded at the time of acquisition, and data were entered onto a computerized database. For the purposes of this study, information regarding retinopathy grading, visual acuity and patient demographics was used. RESULTS: A total of 522 new patients were screened over the 3-month period. STDR was observed in 27% of patients, with 15% observed to have bilateral STDR. Diabetes control was generally poor. Blindness and visual impairment were observed in 2.7% and 6.7% of the cohort, respectively. CONCLUSION: Severe and advanced diabetic retinopathy was present in this population presenting to screening. This was observed 4 years after the formal expansion of the screening services and reflects the high prevalence of diabetes in the population. The need for increased public awareness and greater resource allocation into diabetes and its complications is emphasized.

Congenital orbital teratoma.

We present a case of mature congenital orbital teratoma managed with lid-sparing exenteration and dermis fat graft. This is a case report on the management of congenital orbital teratoma. A full-term baby was born in Fiji with prolapsed right globe which was surrounded by a nonpulsatile, cystic mass. Clinical and imaging features were consistent with congenital orbital teratoma. Due to limited surgical expertise, the patient was transferred to Adelaide, Australia for further management. The patient underwent a lid-sparing exenteration with frozen section control of the apical margin. A dermis fat graft from the groin was placed beneath the lid skin to provide volume. Histopathology revealed mature tissues from each of the three germ cell layers which confirmed the diagnosis of mature teratoma. We describe the successful use of demis fat graft in socket reconstruction following lid-sparing exenteration for congenital orbital teratoma.

Prevalence and causes of blindness and low vision among adults in Fiji.

BACKGROUND: To estimate the prevalence and causes of blindness and low vision among adults aged ≥40 years in Fiji. DESIGN: Population-based cross-sectional study. PARTICIPANTS: Adults aged ≥40 years in Viti Levu, Fiji. METHOD: A population-based cross-sectional survey used multistage cluster random sampling to identify 34 clusters of 40 people. A cause of vision loss was determined for each eye with presenting vision worse than 6/18. MAIN OUTCOME MEASURES: Blindness (better eye presenting vision worse than 6/60), low vision (better eye presenting vision worse than 6/18, but 6/60 or better). RESULTS: Of 1892 people enumerated, 1381 participated (73.0%). Adjusting sample data for ethnicity, gender, age and domicile, the prevalence of blindness was 2.6% (95% confidence interval 1.7, 3.4) and low vision was 7.2% (95% confidence interval 5.9, 8.6) among adults aged ≥40 years. On multivariate analysis, being ≥70 years was a risk factor for blindness, but ethnicity, gender and urban/rural domicile were not. Being Indo-Fijian, female and older were risk factors for vision impairment (better eye presenting vision worse than 6/18). Cataract was the most common cause of bilateral blindness (71.1%). Among participants with low vision, uncorrected refractive error caused 63.3% and cataract was responsible for 25.0%. CONCLUSION: Strategies that provide accessible cataract and refractive error services producing good quality outcomes will likely have the greatest impact on reducing vision impairment.

The association of diabetes and BMI among Melanesian and Indian Fijians aged ≥ 40 years.

The present study examines the association of diabetes with BMI (kg/m(2)) in Asian-Indian and Melanesian Fijian populations sharing a common environment. A population-based survey was used to investigate the risk of diabetes (defined by glycosylated Hb concentration ≥ 6·5 % among participants who denied previous diagnosis of the disease by a medical practitioner) by sex, ethnicity and strata of BMI in a series of age-adjusted logistic regression models. Ethnicity and BMI interactions were compared using WHO and empirically derived BMI cut-off points. Indians had a greater risk (BMI and age adjusted) of undetected diabetes than Melanesians in both males (OR 2·99, 95 % CI 1·73, 5·17; P < 0·001) and females (OR 2·26, 95 % CI 1·56, 3·28; P < 0·001). BMI ≥ 25 to < 30 and ≥ 30 kg/m(2) conferred a higher risk of diabetes compared with a BMI ≥ 18·5 to < 25 kg/m(2). Risk was higher for males with a BMI ≥ 25 to < 30 kg/m(2) (OR 2·35, 95 % CI 1·24, 4·46; P = 0·007) and BMI ≥ 30 kg/m(2) (OR 6·08, 95 % CI 3·06, 12·07; P < 0·001) than for females with the same BMI (OR 1·85, 95 % CI 1·11, 3·08; P = 0·027 and OR 2·10, 95 % CI 1·28, 3·44; P = 0·002, respectively). However, the threshold that appeared to differentiate higher risk varied by ethnicity and sex. For Melanesians, BMI thresholds suggested were 25 kg/m(2) for males and 32 kg/m(2) for females. For Indo-Fijians, these were 24 and 22 kg/m(2) for males and females, respectively. Disaggregating by ethnicity and sex, and applying specific evidence-based thresholds, may render BMI a more discriminating tool for assessing the risk of developing diabetes among Fiji adults.

Diabetic eye disease among adults in Fiji with previously undiagnosed diabetes.

BACKGROUND: To determine the prevalence and severity of diabetic eye disease among adults aged ≥40 years with unrecognized diabetes in Fiji. DESIGN: Population-based cross-sectional survey using multistage cluster random sampling. PARTICIPANTS: 1381 (=73.0% participation). METHODS: Interview-based questionnaire; visual acuity measured; dilated ocular examination performed; glycosylated haemoglobin (HbA1c) concentration determined. MAIN OUTCOME MEASURES: Prevalence and grade of diabetic retinopathy/maculopathy. RESULTS: Sample prevalence of diabetes was 44.8% (95%CI 42.2-47.5%), with 63.4% (95%CI 59.5-67.1%) previously undiagnosed (384/606). Predictors of undiagnosed compared with previously diagnosed diabetes were female gender (P = 0.001), rural residence (P = 0.049) and not having a relative with known diabetes (P < 0.001). Twenty-two retinae of participants with previously undiagnosed diabetes were unexaminable (predominantly cataract). Of the remaining 746 eyes, 3.5% (95%CI 2.4-5.1%) had diabetic retinopathy/maculopathy, 1 (0.1%) had proliferative retinopathy and 4 (0.5%) had active significant maculopathy. Of eyes with diabetic disease, two (7.7%, 95%CI 1.0-25.3%) had diabetes-related vision impairment (3/60; 6/60). Sixteen previously undiagnosed participants (4.2%, 95%CI 2.5-6.7%) had diabetic disease evident in at least one eye: for four (all Melanesian women aged >50 years), this was vision-threatening (1.0%; 95%CI 0.3-2.8). Mean HbA1c (10.7 ± 2.6%) of participants undiagnosed and with diabetes eye disease was higher (P < 0.001) than that of those undiagnosed and without. CONCLUSIONS: The prevalence of diabetic eye disease was low among this cohort, but where present, severe vision-threatening retinopathy/maculopathy was relatively common. If diabetic eye disease is to be avoided or ameliorated in Fiji, then community awareness of and access to diabetes diagnostic services must improve, particularly for women and rural dwellers.

Population-based study of self-reported ocular trauma in Fiji.

BACKGROUND: To characterize causes, risk factors and outcomes for ocular trauma among adults aged ≥40 years in Fiji. DESIGN: Population-based cross-sectional survey; multistage cluster random sampling. PARTICIPANTS: 1381 (= 73.0% participation); eight provinces on Viti Levu. METHODS: Interview-based questionnaire. Visual acuity measurement. Dilated ocular examination. MAIN OUTCOME MEASURES: Circumstances, management and consequences of self-reported ocular trauma. RESULTS: Of participants, 20.6% recalled ocular trauma: being Melanesian (P < 0.001) and male (P < 0.001) were predictive. Age at injury was ≤15 years for 13.0%: 78.4% occurred at home; 72.4% caused by sharp objects. For injury at >15 years: 38.5% occurred inside the home, most by sharp objects (51.6%) and domestic violence (28.4%); agricultural activities caused 20.6% of injuries; non-agricultural workplace incidents caused 16.2%, with chemicals responsible for 27.5% of these; public alcohol consumption was associated with 13.8% of injuries, mostly by assault (91.2%). Conventional medical services were the primary source of care for 47.2% of injured participants: 61.9% attended on injury day. For trauma: sample prevalence of vision impairment in at least one eye was 1.7% (95% confidence interval 1.1-2.4%), and 0.1% (95% confidence interval 0.02-0.5) for bilateral blindness. Injury at ≤15 years (P = 0.008) and at the workplace (P = 0.044) were predictive of ongoing vision impairment. Of visually impaired eyes, 36% had corneal opacity that may have been caused by relatively minor trauma. CONCLUSIONS: Ophthalmic service strengthening (including minor corneal trauma management) and specific injury prevention strategies (including behaviour change education and advocacy for legislation) are required to decrease the ocular trauma burden in Fiji.

Cataract and its surgery in Fiji.

BACKGROUND: To characterize cataract and its surgery among adults aged ≥40 years in Fiji. DESIGN: Population-based cross-sectional survey using multistage cluster random sampling. PARTICIPANTS: 1381 (= 73.0% participation); eight provinces on Viti Levu. METHODS: Interview-based questionnaire; visual acuity measured; autorefraction; dilated ocular examination. MAIN OUTCOME MEASURES: Prevalence; predictors; surgical outcomes. RESULTS: Being Indian (P = 0.001), elderly (P < 0.001), and previous/current smoker (P = 0.036) were predictive of at least one unoperated vision-impairing or operated cataract. Gender (P = 0.062) and diabetes (P = 0.384) were not. Unoperated cataract (predominantly nucleosclerosis) was the second most frequent (25.0%) cause of low vision (<6/18, ≥6/60) and commonest (71.1%) of blindness (<6/60). Ethnicity-gender-age-domicile adjusted and extrapolating to the Fiji population aged ≥40 years, prevalence of cataract-induced low vision and blindness were each 1.7% (95% confidence interval [CI] 1.0-2.4%). At least one eye of 4.6% and both of 1.8% participants had surgery (86.4% extracapsular). Gender (P = 0.213), age (P = 0.472) and rural/urban domicile (P = 0.895) were not predictors of surgery among those who required it in at least one eye. After intraocular lens surgery: 50.7% had pupillary posterior capsular opacification; mean spherical equivalent was -1.37 ± 1.95D (range, -6.38 to +2.25D); mean cylindrical error was 2.31 ± 1.75D (range, 0.0 to 8.75D); ≥N8 for 39.5%; ≥6/18 for 56.6%; <6/60 for 19.7%, with 2.6% no light perception. Ethnicity-gender-age-domicile adjusted and extrapolating to the Fiji population aged ≥40 years, Cataract Surgical Coverage (Person) was 47.5% (95%CI 29.2-65.8%) at <6/18, and 65.2% (95%CI 37.8-92.6%) at <6/60. CONCLUSIONS: Fiji cataract services and outcomes compare favourably with those of neighbouring Papua New Guinea and Timor Leste.

Diabetic eye disease among adults in Fiji with self-reported diabetes.

BACKGROUND: To characterize diabetic eye disease and its management among adults aged ≥40 years with self-reported diabetes in Fiji. METHODS: During a population-based cross-sectional survey using multistage cluster random sampling, participants reported health information, including whether a doctor had diagnosed diabetes. HbA1c and visual acuity were measured. Diabetic eye disease was assessed using 90-dioptre lens dilated funduscopy. RESULTS: Of those enumerated, 1381 (73.0%) participated, with 222 reporting diabetes. Twenty fundi were not examined (19 due to cataract). Of the remaining 424 eyes, 75.5% had no diabetic disease, 1.2% had proliferative retinopathy, 7.5% had active significant maculopathy and 0.7% had burnt-out/treated disease. By person, 27.2% had retinopathy and/or maculopathy in at least one eye. Mean HbA1c (9.9 ± 2.3%) for this group was significantly higher (P = 0.004) than for those without eye disease. Vision-threat occurred in at least one eye of 11.5%. Diabetes (predominantly maculopathy) caused pinhole acuity <6/18, <6/60 and <3/60 for 3.8%, 1.1% and 0.7% of eyes, respectively. No person was bilaterally blind (<6/60) due to diabetes, but 2.3% (all on oral antiglycaemics alone) were 6/60 bilaterally. Compared with recent diabetes diagnosis, diagnosis >10 years ago was predictive of any (odds ratio [OR] 8.13; 95% confidence interval [CI] 3.28-20.21; P < 0.001) and vision-threatening (OR 5.25; 95% CI 1.71-16.12; P = 0.004) eye disease. Although 80.6% claimed regular general diabetes checkups, only 36.5% recalled previous dilated ocular examination. Four eyes had received laser treatment. CONCLUSION: There was evidence of failure of management of diabetes and its eye complications. Both need to be improved if increasing diabetes-related visual disability is to be avoided.

Diabetic retinopathy in a hospital eye clinic population in Honiara, Solomon Islands.

BACKGROUND: To determine the presence, severity and context of diabetic retinopathy among diabetic adults using hospital eye clinic services in Honiara, Solomon Islands. METHODS: Fifty consecutive known diabetic patients aged ≥20 years were interviewed and underwent Snellen distance vision testing and complete ocular examination, including dilated 90 D funduscopy. Diabetic retinopathy was graded according to the International Clinical Diabetic Retinopathy and Macular Oedema Disease Severity Scales. RESULTS: Participants were predominantly Melanesian (94%). Mean age was 53.6 ± 10.7 years; 42% were female; and 34% were rural dwellers. Diabetes had been diagnosed <5, 5-10 and >10 years ago for 42%, 34% and 24% of participants. However, 54% denied ever having had a dilated fundus examination. Proliferative retinopathy, severe non-proliferative changes and maculopathy were present in 5, 12 and 26 eyes, respectively. For the 32 eyes with pinhole acuity ≤6/12, diabetic eye disease was the cause for 20, with all but one due to maculopathy. Diabetes reduced the pinhole vision of five eyes to ≤6/60. Twenty-four per cent of participants had diabetes-related pinhole vision ≤6/12 in at least one eye. Those diagnosed with diabetes 5-10 and >10 years were 17.5 and 58.8 times more likely to have such an eye compared with those recently (<5 years) diagnosed (extended Mantel-Haenszel χ² = 11.570, P < 0.001). Participants were not well informed about diabetic eye disease. CONCLUSIONS: Diabetic eye disease is now a significant contributor to this clinic's workload. A population-based survey is needed to quantify the problem and inform design and delivery of eye services for this chronic disease.

The prevalence of diabetes among adults aged 40 years and over in Fiji.

AIM: To estimate the prevalence of diabetes among adults aged ≥40 years in Fiji, and determine the demographic characteristics associated with this diagnosis. METHOD: During a population-based survey, participant glycosylated haemoglobin (HbA1c) was determined and physician diagnosis of diabetes self-reported. HbA1c ≥6.5% or claimed previous diagnosis, independent of HbA1c, defined presence of diabetes. Results were extrapolated to the whole population. Predictors of risk for diabetes were investigated using logistic regression models. RESULTS: Of those enumerated, 1381 participated (73.0%). For 1353 with either a history of diabetes or valid HbA1c, prevalence of diabetes was 44.8% (95%CI 42.2-47.5). Adjusting for age and domicile, Indians had significantly higher risk of diabetes than Melanesians among males (OR 2.02, 95%CI 1.37-2.97, p<0.001) and females (OR 1.99, 95%CI 1.44-2.73, p<0.001). Females were at greater risk than males among Melanesians (OR 1.75, 95%CI 1.30-2.36, p<0.001) and Indians (OR 1.94, 95%CI 1.33-2.84, p<0.001). Risk increased with age for both genders and ethnicities, adjusting for ethnicity and domicile, then gender and domicile. The ethnicity-gender-age-domicile adjusted prevalence of diabetes among adults aged ≥40 years in Fiji was 41.0% (95%CI 38.4-43.6): 99,000 people. CONCLUSION: As identified in 1970, diabetes continues to be a substantial population health problem in Fiji.

Evaluation of the first 5 years of a national eye health programme in Vanuatu.

PURPOSE: To evaluate against its objectives the achievements of the first 5 years of a national eye health programme in Vanuatu. METHODS: Programme clinical activity data were collated from surgical logs, clinic and outreach reports, and patient register books. Cataract surgical outcomes were retrieved from monitoring software. Programme annual reports provided information about management, infrastructure improvements, equipment supplied, repaired or replaced, the supply and use of consumables, and human resource development and deployment. Costs were determined from project budgets and acquittals. RESULTS: The programme promoted eye health, including through the integration of eye care into existing health services; established adequate facilities, at referral hospitals, provincial hospitals and rural health clinics, with equipment and manpower to provide eye care appropriate to the location; established a primary eye care programme; strengthened cataract services, although its effect on any cataract backlog is unknown; developed a diabetic eye disease diagnosis and treatment service, but its reach and effectiveness are unknown; provided accessible comprehensive eye care, but its effect on the prevalence of vision impairment is unknown; and established medical records and data collection systems, but these need more attention. DISCUSSION: This programme achieved much. However, the evaluation highlighted the limitations of inadequate project design and that, without addressing further human resource development and the Ministry of Health's wavering financial commitment, there are potential risks to ongoing services. That revenue generating capacity was not incorporated into this programme may prove to be a flaw that will limit ongoing access to eye care, especially in rural areas.

The prevalence and severity of diabetic retinopathy, associated risk factors and vision loss in patients registered with type 2 diabetes in Luganville, Vanuatu.

AIM: To determine the prevalence and severity of diabetic retinopathy in patients with type 2 diabetes in Luganville, the second largest town in Vanuatu. Additionally, to investigate risk factors for retinopathy and the effect of retinopathy on visual acuity (VA) within this group. METHOD: All 83 registered patients with type 2 diabetes in Luganville, a town of 13 121 people, were invited for an interview and anthropometric measurements. A questionnaire including assessment of hypertension and glycaemic control, which are known risk factors for diabetic retinopathy, was administered. This sample accounted for approximately 1.07% of Luganville's adult population. Presenting VA was measured. The retina was photographed with a non-mydriatic fundus camera and images later independently graded for the extent of retinopathy. RESULTS: 68 (82%) of the 83 patients attended. The mean (SD) age was 54 (11) years and 31 (46%) were male. Diabetic retinopathy was present in 36 (52.9%) of the sample. Sight-threatening retinopathy requiring urgent referral was present in 15 (22.1%) patients. Presenting VA was worse than 6/12 in the better eye in n = 32 (47%) and in up to half of these cases the principal cause was retinopathy. In addition, four people had uniocular blindness resulting from diabetes. The mean body mass index was lower in those patients with diabetes with retinopathy than in those without (p = 0.010), but there were no other significant differences between the two groups and, specifically, no difference in the frequency of retinopathy risk factors. 42 (61.8%) patients had hypertension (>or=135/85 mm Hg) or were taking antihypertensive therapy. CONCLUSIONS: The prevalence of registered patients with diabetes in Luganville's adult population was 1.07%. Diabetic retinopathy was highly prevalent in the sample (in 36, 52.9%), and in 15 (22.1%) there was a significant threat to sight, with up to 25% of the sample possibly already affected by decreased VA or blindness resulting from diabetes-related eye disease. Retinopathy risk factors were also prevalent. A diabetes screening programme with baseline ophthalmic assessment and follow-up are urgently needed to enable timely intervention and treatment.