Approaches for delivery of refractive and optical care services in community and primary care settings.

BACKGROUND: Uncorrected refractive error is a leading cause of vision impairment which, in most cases, can be managed with the appropriate spectacle correction. In 2021, the World Health Assembly endorsed a global target of a 40-percentage-point increase in effective coverage of refractive error by 2030. To achieve this global target, equitable access to refractive and optical services within community and primary care settings needs to be strengthened. This review will inform the development of technical guidance to support improvements in the testing and correction of refractive error among World Health Organization (WHO) member states. OBJECTIVES: To determine the range of approaches for delivery of refractive and optical care services in community and primary care settings, and the methods employed for their evaluation. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase and Global Health databases, grey literature, and annual reports and websites of relevant organizations involved in eye-care delivery from January 2002 to November 2022 to identify approaches for refractive and optical service delivery. SELECTION CRITERIA: We included observational and interventional studies, reviews, and reports from relevant organizations related to delivering refractive services and optical services for preschool and school-aged children and adults in community and primary care settings published between January 2002 and November 2022. We searched for studies and reports published within the last 20 years because vision impairment due to uncorrected refractive error has only recently become a public health and eye health priority, therefore we did not expect to find much relevant literature until after 2002. DATA COLLECTION AND ANALYSIS: Two review authors screened titles, abstracts and full texts, and extracted data. We resolved any discrepancies through discussion. We synthesized data, and presented results as tables, figures, and case studies. This project was led by the World Health Organization (WHO) Vision and Eye Care Programme. MAIN RESULTS: We identified 175 studies from searches of databases and grey literature, 146 records from company reports, and 81 records from website searches of relevant organizations that matched our inclusion criteria. Delivery approaches for refractive and optical services in community care included school-based, pharmacy, and outreach models, whereas primary care approaches comprised vision centre, health centre, and a combination of vision or health centre and door-to-door delivery. In community care, school-based and outreach approaches were predominant, while in primary care, a vision-centre approach was mainly used. In the WHO African region, the school-based and outreach approaches were mainly reported while, in the Americas, the outreach approach was mostly used. Very few approaches for service delivery were reported in the WHO Eastern Mediterranean region. Prominent gaps exist in the evaluation of the approaches, and few studies attempted to evaluate the approaches for delivery of refractive and optical care services. AUTHORS' CONCLUSIONS: We comprehensively describe a range of approaches for delivery of refractive and optical services in community and primary care. Further evaluation of their effectiveness will better inform the application of these service-delivery approaches. The study outcomes will help guide WHO member states in strengthening refractive and optical services at community and primary care levels. FUNDING: This scoping review was supported by the Vision and Eye care Programme, World Health Organization and ATscale Global Partnership. REGISTRATION: The protocol of this scoping review was published in the Open Source Framework.

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.

TFOS Lifestyle Report: Impact of environmental conditions on the ocular surface.

Environmental risk factors that have an impact on the ocular surface were reviewed and associations with age and sex, race/ethnicity, geographical area, seasonality, prevalence and possible interactions between risk factors are reviewed. Environmental factors can be (a) climate-related: temperature, humidity, wind speed, altitude, dew point, ultraviolet light, and allergen or (b) outdoor and indoor pollution: gases, particulate matter, and other sources of airborne pollutants. Temperature affects ocular surface homeostasis directly and indirectly, precipitating ocular surface diseases and/or symptoms, including trachoma. Humidity is negatively associated with dry eye disease. There is little data on wind speed and dewpoint. High altitude and ultraviolet light exposure are associated with pterygium, ocular surface degenerations and neoplastic disease. Pollution is associated with dry eye disease and conjunctivitis. Primary Sjögren syndrome is associated with exposure to chemical solvents. Living within a potential zone of active volcanic eruption is associated with eye irritation. Indoor pollution, "sick" building or house can also be associated with eye irritation. Most ocular surface conditions are multifactorial, and several environmental factors may contribute to specific diseases. A systematic review was conducted to answer the following research question: "What are the associations between outdoor environment pollution and signs or symptoms of dry eye disease in humans?" Dry eye disease is associated with air pollution (from NO2) and soil pollution (from chromium), but not from air pollution from CO or PM10. Future research should adequately account for confounders, follow up over time, and report results separately for ocular surface findings, including signs and symptoms.

Indicators for Assessing the Quality of Refractive Error Care.

SIGNIFICANCE: Quality refractive error care is essential for reducing vision impairment. Quality indicators and standardized approaches for assessing the quality of refractive error care need to be established. PURPOSE: This study aimed to develop a set of indicators for assessing the quality of refractive error care and test their applicability in a real-world setting using unannounced standardized patients (USPs). METHODS: Patient outcomes and three quality of refractive error care (Q.REC) indicators (1, optimally prescribed spectacles; 2, adequately prescribed spectacles; 3, vector dioptric distance) were developed using existing literature, refraction training standards, and consulting educators. Twenty-one USPs with various refractive errors were trained to visit optical stores across Vietnam to have a refraction, observe techniques, and order spectacles. Spectacles were assessed against each Q.REC indicator and tested for associations with vision and comfort. RESULTS: Overall, 44.1% (184/417) of spectacles provided good vision and comfort. Of the spectacles that met Q.REC indicators 1 and 2, 62.5 and 54.9%, respectively, provided both good vision and comfort. Optimally prescribed spectacles (indicator 1) were significantly more likely to provide good vision and comfort independently compared with spectacles that did not meet any indicator (good vision: 94.6 vs. 85.0%, P = .01; comfortable: 66.1 vs. 36.3%, P < .01). Adequately prescribed spectacles (indicator 2) were more likely to provide good comfort compared with spectacles not meeting any indicator (57.7 vs. 36.3%, P < .01); however, vision outcomes were not significantly different (85.9 vs. 85.0%, P = .90). Good vision was associated with a lower mean vector dioptric distance (P < .01) but not with comfort (P = .52). CONCLUSIONS: The optimally prescribed spectacles indicator is a promising approach for assessing the quality of refractive error care without additional assessments of vision and comfort. Using USPs is a practical approach and could be used as a standardized method for evaluating the quality of refractive error care.

3-D printed spectacles: potential, challenges and the future.

Three-dimensional (3-D) printing offers the potential to custom-produce a wide range of manufactured objects and improve manufacturing processes. The additive manufacturing process involves material (resin, metal, ceramics or biological cells) being deposited layer upon layer, which is fused to create a 3-D object. While 3-D printing has been readily available in the aerospace and automotive industries, and is being used increasingly in the medical field, its potential for optometry and ophthalmic optics has rarely been discussed in depth. 3-D printing of spectacles has the potential to provide customised experiences, to cater for those who do not fit standardised frames or for those with irregular prescriptions, and to reduce delivery times and inventory with the opportunity of increasing access to underserved populations. Here we review available 3-D printing technologies, and the current 3-D printed spectacle market, including testing three commercially available spectacle frames to assess compliance with ISO:12870 standards. The article then explores the challenges faced and environmental impact of implementing 3-D printing of spectacles.

The situation of low vision services in Papua New Guinea: an exploratory study.

BACKGROUND: The aim of this study was to investigate the current situation of low vision services and barriers to low vision service delivery in Papua New Guinea (PNG). METHODS: An exploratory study was undertaken to assess the situation of available services, human resources, training, equipment and assistive devices, supportive policies, needs of people with low vision and community attitudes toward people with low vision. In-depth interviews with 50 key informants were conducted in-country. Key informants included eye-care practitioners (n = 13), special education teachers (n = 10), community-based rehabilitation workers (n = 3), other stakeholders providing disability-related services (n = 8), and people with low vision (n = 14) and their family members (n = 2). Interview transcripts were analysed inductively and deductively using thematic analysis. RESULTS: Barriers were identified at systems and community levels. The barriers at the systems level were: low vision not a priority area for eye care and rehabilitation programs, limited availability of low vision services, trained personnel and low vision devices; low vision not included in training programs of eye-care practitioners and lack of awareness of available referral services among service providers. The barriers identified at the community level were lack of awareness of services, distance, costs and limited transport to access services and negative community attitudes. CONCLUSION: This study has identified barriers from the perspectives of different stakeholders, including service providers and people with low vision and their families. Knowledge of these barriers can now guide the development of future low vision services in PNG.

Experiences of vision impairment in Papua New Guinea: implications for blindness prevention programs.

INTRODUCTION: A person's capability to access services and achieve good eye health is influenced by their behaviours, perceptions, beliefs and experiences. As evidence from Papua New Guinea (PNG) about people's lived experience with vision impairment is limited, the purpose of the present study was to better understand the beliefs, perceptions and emotional responses to vision impairment in PNG. METHODS: A qualitative study, using both purposive and convenience sampling, was undertaken to explore common beliefs and perceptions about vision impairment, as well as the emotional responses to vision impairment. In-depth interviews were undertaken with 51 adults from five provinces representing culturally and geographically diverse regions of PNG. Grounded theory was used to elicit key themes from interview data. RESULTS: Participants described activities of everyday life impacted by vision impairment and the related worry, sadness and social exclusion. Common beliefs about the causes of vision impairment were environmental stressors (sun, dust, dirt and smoke), ageing and sorcery. CONCLUSIONS: Findings provide insight into the unique social context in PNG and identify a number of programmatic and policy implications, such as the need for preventative eye health information and services, addressing persisting beliefs in sorcery when developing health information packages, and the importance of coordinating with counselling and well-being services for people experiencing vision impairment.

Perceptions of Eye Health and Eye Health Services among Adults Attending Outreach Eye Care Clinics in Papua New Guinea.

PURPOSE: To determine how people attending outreach eye care clinics in Papua New Guinea (PNG) perceive eye health and eye health services. METHODS: An interview-based questionnaire was administrated to a convenience sample of 614 adult participants across four provinces and perceptions of eye health and eye health services were recorded. Presenting and near visual acuity were measured and cause of visual impairment (VI) determined. RESULTS: In this sample, 113/614 participants (18.4%) presented with distance VI, 16 (2.6%) with distance blindness, and 221 (47.6%) with near VI. Older participants and those with near VI were more likely to indicate that it is hard to have an eye examination due to travel time, lack of transport and transport costs. Female participants and those from underserved areas were more likely to report shame and fear of jealousy from others when asked about their attitudes towards spectacles. Participants reporting that they were willing to pay higher amounts for testing and spectacles/treatment also reported higher education levels, higher household incomes and were more likely to be male. A quarter of participants (25.9%) indicated that they did not like having an eye examination because their reading and writing was poor. CONCLUSIONS: People attending outreach eye care clinics in PNG reported finding it difficult to attend eye health services due to transport difficulties and anticipated high costs. Negative attitudes towards spectacles were also prevalent, and negative perceptions appeared more frequently among older participants and those with less education.