Understanding patient health-seeking behaviour to optimise the uptake of cataract surgery in rural Kenya, Zambia and Uganda: findings from a multisite qualitative study

Background
Cataract is a major cause of visual impairment globally, affecting 15.2 million people who are blind, and another 78.8 million who have moderate or severe visual impairment. This study was designed to explore factors that influence the uptake of surgery offered to patients with operable cataract in a free-of-charge, community-based eye health programme.

Methods
Focus group discussions and in-depth interviews were conducted with patients and healthcare providers in rural Zambia, Kenya and Uganda during 2018–2019. We identified participants using purposive sampling. Thematic analysis was conducted using a combination of an inductive and deductive team-based approach.

Results
Participants consisted of 131 healthcare providers and 294 patients. Two-thirds of patients had been operated on for cataract. Two major themes emerged: (1) surgery enablers, including a desire to regain control of their lives, the positive testimonies of others, family support, as well as free surgery, medication and food; and (2) barriers to surgery, including cultural and social factors, as well as the inadequacies of the healthcare delivery system.

Conclusions
Cultural, social and health system realities impact decisions made by patients about cataract surgery uptake. This study highlights the importance of demand segmentation and improving the quality of services, based on patients’ expectations and needs, as strategies for increasing cataract surgery uptake.

Vision impairment and traffic safety outcomes in low-income and middle-income countries: a systematic review and meta-analysis

Background
Road traffic injuries are a major public health concern and their prevention requires concerted efforts. We aimed to systematically analyse the current evidence to establish whether any aspects of vision, and particularly interventions to improve vision function, are associated with traffic safety outcomes in low-income and middle-income countries (LMICs).

Methods
We did a systematic review and meta-analysis to assess the association between poor vision and traffic safety outcomes. We searched MEDLINE, Embase, PsycINFO, CINAHL, Web of Science, Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials in the Cochrane Library from database inception to April 2, 2020. We included any interventional or observational studies assessing whether vision is associated with traffic safety outcomes, studies describing prevalence of poor vision among drivers, and adherence to licensure regulations. We excluded studies done in high-income countries. We did a meta-analysis to explore the associations between vision function and traffic safety outcomes and a narrative synthesis to describe the prevalence of vision disorders and adherence to licensure requirements. We used random-effects models with residual maximum likelihood method. The systematic review protocol was registered on PROSPERO, CRD-42020180505.

Findings
We identified 49 (1·8%) eligible articles of 2653 assessed and included 29 (59·2%) in the various data syntheses. 15 394 participants (mean sample size n=530 [SD 824]; mean age of 39·3 years [SD 9·65]; 1167 [7·6%] of 15 279 female) were included. The prevalence of vision impairment among road users ranged from 1·2% to 26·4% (26 studies), colour vision defects from 0·5% to 17·1% (15 studies), and visual field defects from 2·0% to 37·3% (ten studies). A substantial proportion (range 10·6–85·4%) received licences without undergoing mandatory vision testing. The meta-analysis revealed a 46% greater risk of having a road traffic crash among those with central acuity visual impairment (risk ratio [RR] 1·46 [95% CI 1·20–1·78]; p=0·0002, 13 studies) and a greater risk among those with defects in colour vision (RR 1·36 [1·01–1·82]; p=0·041, seven studies) or the visual field (RR 1·36 [1·25–1·48]; p<0·0001, seven studies). The I2 value for overall statistical heterogeneity was 63·4%.

Interpretation
This systematic review shows a positive association between vision impairment and traffic crashes in LMICs. Our findings provide support for mandatory vision function assessment before issuing a driving licence.

Impact of SARS-CoV-2 on Ocular Surface Pathology and Treatment Practices: a Review

Purpose of Review
The ocular surface is a potential site of ocular involvement by SARS-CoV-2 infection. We performed a review of the literature to understand the pathogenesis of SARS-CoV-2 disease manifestations on the ocular surface as well as to elucidate emerging treatment patterns and practice changes during the COVID-19 pandemic.

Recent Findings
The ocular manifestations of SARS-CoV-2 are likely limited to a mild and transient conjunctivitis. Other manifestations have not been validated in larger cohorts. Ocular surface tissue should be considered potentially infectious due to the presence of host receptors on surface tissues. The availability of donor tissue in lower-middle income countries has been greatly impacted by the pandemic and would benefit from further investigation into transmissibility through donor tissue.

Summary
Transmission of SARS-CoV-2 through the ocular surface has yet to be confirmed. The most common ocular manifestation is a mild conjunctivitis. Ocular surface surgeons face specific challenges in the use of donor tissues and aerosolizing procedures and have adapted practice patterns accordingly.

Assessing the Performance of Artificial Intelligence Systems for the Screening of Diabetic Retinopathy: A Systematic Review and Meta-Analysis

Diabetic retinopathy is the most common microvascular complication of diabetes mellitus and one of the leading causes of blindness globally. Due to the progressive nature of the disease, earlier detection and timely treatment can lead to substantial reductions in the incidence of irreversible vision-loss. Artificial intelligence (AI) screening systems have offered clinically acceptable and quicker results in detecting diabetic retinopathy from retinal fundus and optical coherence tomography (OCT) images. Thus, this systematic review and meta-analysis of relevant investigations was performed to document the performance of AI screening systems that were applied to fundus and OCT images of patients from diverse geographic locations including North America, Europe, Africa, Asia, and Australia. A systematic literature search on Medline, Global Health, and PubMed was performed and studies published between October 2015 and January 2020 were included. The search strategy was based on the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines, and AI-based investigations were mandatory for studies inclusion. The abstracts, titles, and full-texts of potentially eligible studies were screened against inclusion and exclusion criteria. Twenty-one studies were included in this systematic review; 18 met inclusion criteria for the meta-analysis. The pooled sensitivity of the evaluated AI screening systems in detecting diabetic retinopathy was 0.93 (95% CI: 0.92-0.94) and the specificity was 0.88 (95% CI: 0.86-0.89). The included studies detailed training and external validation datasets, criteria for diabetic retinopathy case ascertainment, imaging modalities, DR-grading scales, and compared AI results to those of human graders (e.g., ophthalmologists, retinal specialists, trained nurses, and other healthcare providers) as a reference standard. The findings of this study showed that the majority AI screening systems demonstrated clinically acceptable levels of sensitivity and specificity for detecting referable diabetic retinopathy from retinal fundus and OCT photographs. Further improvement depends on the continual development of novel algorithms with large and gradable sets of images for training and validation. If cost-effectiveness ratios can be optimized, AI can become a financially sustainable and clinically effective intervention that can be incorporated into the healthcare systems of low-to-middle income countries (LMICs) and geographically remote locations. Combining screening technologies with treatment interventions such as anti-VEGF therapy, acellular capillary laser treatment, and vitreoretinal surgery can lead to substantial reductions in the incidence of irreversible vision-loss due to proliferative diabetic retinopathy.

Effectiveness of an mHealth system on access to eye health services in Kenya: a cluster-randomised controlled trial

Background
There is limited access to eye health services in many low-income and middle-income populations. We aimed to assess the effectiveness in increasing service utilisation of the Peek Community Eye Health (Peek CEH) system, a smartphone-based referral system comprising decision support algorithms (Peek Community Screening app), SMS reminders, and real-time reporting.

Methods
In this cluster-randomised controlled trial of eye health in Kenya, community unit clusters were defined as one health centre and its catchment population. Clusters were randomly allocated (1:1) to receive Peek CEH and referral (intervention group) or standard care via periodic health centre-based outreach clinics and onward referral (control group). Individuals in the intervention group were assessed at home by screeners and those referred were asked to present for triage assessment in a central location. They received regular SMS reminders. In both groups, community sensitisation was done followed by a triage clinic at the cluster health centre 4 weeks after sensitisation. During triage, individuals in both groups were assessed and treated and, if necessary, referred to a specific hospital. Individuals in the intervention group received further SMS reminders. The primary outcome was the mean attendance rate (the number of people per 10 000 population) at triage of those with confirmed eye conditions, as assessed at 4 weeks after sensitisation in the intention-to-treat population. We estimated the intervention effect using a Student’s t-test on cluster-level rates. This trial is registered with Pan African Clinical Trial Registry, number 201807329096632.

Findings
Between Nov 26, 2018, and June 7, 2019, of the 85 community units in Trans Nzoia County, Kenya, 49 were excluded. We randomly allocated 18 community units each to the intervention group (68 348 individuals) and the control group (60 243 individuals). 9387 individuals from the intervention group and 3070 from the control group attended triage assessment. The mean attendance rate at triage by individuals with eye problems was 1429 (92% CI 1228–1629) in the intervention group and 522 (418–625) in the control group (rate difference 906 per 10 000 [95% CI 689–1124; p<0·0001]).

Interpretation
The Peek CEH system increased primary care attendance by people with eye problems compared with standard approaches, indicating the potential of this mobile health package to increase service uptake and guide appropriate task sharing.

Utilization of eye health services and diabetic retinopathy: a cross-sectional study among persons living with diabetes visiting a tertiary eye care facility in Ghana

Background
There have been a major advance made in screening, early diagnosis, and prompt treatment of Diabetic Retinopathy among Person living with diabetes (PLWD). However, screening services remain a challenge in Low-Middle-Income-Countries where access to eye care professionals is inadequate. This study assesses the utilization of Eye Health Service prevalence (UEHS) among PLWD and associated factors and further quantifies its association with Non-Proliferative Diabetic Retinopathy (NPDR).

Methods
A cross-sectional study design with a random sample of 360 PLWD was conducted at Korle-Bu Teaching Hospital, a National Referral Centre in Ghana from May to July 2019. UEHS and DR were the study outcomes. We adopted Poisson and Probit regression analysis to assess factors associated with UEHS over the past year. We employed pairwise and phi correlation (fourfold correlational analysis) to assess the relationship between UEHS and DR (ordinal and binary respectively). Ordered Logistic and Poisson regression were applied to assess the association between the UEHS and DR. Stata 16.1 was used to perform the analyses and a p-value ≤ 0.05 was deemed significant.

Results
The prevalence of UEHS over the past year and DR was 21.7 %(95 %CI = 17.7–26.2) and 65.0 %(95 %CI = 59.9–69.8 respectively. The prevalence of severe NPDR with Clinically Significant Macular Edema (CSME) was 23.9 %(19.8–28.6). Type of diabetes, increasing age, educational level, mode of payment for healthcare services, marital status, years since diagnosis, and current blood glucose significantly influenced UEHS. There was a negative relationship between DR and UEHS (Pairwise and φ correlation were − 20 and − 15 respectively; p < 0.001). Non-UEHS among PLWD doubles the likelihood of experiencing severe NPDR with CSME compared with UEHS among PLWD [aOR(95 %CI) = 2.05(1.03–4.08)]. Meanwhile, the prevalence of DR among patients per non-UEHS was insignificantly higher [12 %; aPR(95 %CI) = 0.89–1.41)] compared with patients who utilized eye care health service.

Conclusions
Most of the PLWD did not utilize the eye health service even once in a year and that was highly influenced by type of diabetes and increasing age. Type 2 diabetes patients and middle age decreased the likelihood of UEHS. There was a negative relationship between DR and UEHS among PLWD and this doubled the likelihood of experiencing severe NPDR with CSME. Structured health education and screening interventions are key to improving UEHS.

Evaluation of postoperative refractive error correction after cataract surgery

Suboptimal cataract surgery outcomes remain a challenge in most developing countries. In Ghana, about 2 million people have been reported to be blind due to cataract with about 20% new cases being recorded yearly. The aim of this study was to evaluate postoperative correction of refractive errors after cataract surgery in a selected eye hospital in Ashanti Region, Ghana. This was a retrospective study where medical records of patients (aged 40–100) who reported to an eye hospital in Ghana from 2013–2018 were reviewed. Included in the study were patients aged ≥40 years and patients with complete records. Data on patient demographics, type of surgery, intra-ocular lens (PCIOL) power, availability of biometry, postoperative refraction outcomes, pre- and postoperative visual acuity were analyzed. Data of two hundred and thirteen eyes of 190 patients who met the inclusion criteria were analyzed. Descriptive analysis and Chi-square test were carried out to determine the mean, median, standard deviation and relevant associations. The mean ± SD age was 67.21±12.2 years (51.2% were females). Small Incision Cataract Surgery (99.5%) with 100% IOL implants was the main cataract surgery procedure in this study. Pre-operative biometry was performed for 38.9% of all patients on their first eye surgery and 41.5% for second eye surgeries. About 71% eyes in this study were blind (presenting VA<3/60) before surgery; 40.4% had post-operative VA <3/60. Pre-existing ocular comorbidities discovered post- surgery, attributed to suboptimal visual outcomes. More than half (55.3%) of patients did not undergo postoperative refraction due to loss to follow-up. Year of surgery (p = .017), follow up visits< 2months (p < .0001) and discovered comorbidity post-surgery (p = .035) were the factors significantly associated with postoperative refraction. Myopia and compound myopic astigmatism were the dominant refractive error outcomes. The timing of post-operative refraction had a significant effect on postoperative refraction done. These findings indicate a clinically meaningful significance between completion of postoperative care and postoperative refraction done. Consequently, with settings in most developing countries, where less biometry is done, it is appropriate that post-operative refractive services are encouraged and done earlier to enhance the patients’ expectations while increasing cataract surgery patronage.

An assessment of human resource distribution for public eye health services in KwaZulu-Natal, South Africa

Background: The development of human resources for eye health (HReH), aimed at achieving a 25% reduction in visual impairment by the year 2020, was one of the VISION 2020 objectives.

Aim: To assess HReH in the public sector of KwaZulu-Natal (KZN), and its effect on the accessibility of eye care in the province.

Setting: All public eye facilities in KZN.

Methods: A quantitative cross-sectional study using a close-ended questionnaire to assess distribution and outputs of HReH. At the end of the questionnaire, respondents gave general comments on their ability to provide services.

Results: Human resource rates were 0.89 for ophthalmologists, 2.44 for cataract surgeons, 4.8 for optometrists and 4.7 for ophthalmic nurses per 1 million population. Most health facilities had some HReH working in them, albeit none had dispensing opticians. Regression analysis showed that 67.1% of variation in cataract surgery was because of the number of surgeons available. Cataract surgical rates were low with a waiting period of up to 18 months. In addition to the refractive error regression analysis of 33.7%, spectacle supply was low, with a backlog of up to 9 months in some facilities.

Conclusion: Overall, HReH targets as per VISION 2020 and the National Prevention of Blindness have not been met in this region. Dispensing opticians are not employed in any of the province’s health districts. An increase in the eye health workforce is necessary to improve the eye health outcomes for people dependent on public eye facilities.

Time to recovery from cataract and its predictors among eye cataract patients treated with cataract surgery: A retrospective cohort study in Ethiopia

Background
Cataracts is the major global causes of blindness and a vision-affecting disease of the eye. Cataract surgery is a curative and cost-effective intervention. The number of people who undergo cataract surgery has increased rapidly. Hence, this study was aimed to determine predictors and the time of recovery of cataract patients after cataract surgery by using Simi parametric models of survival analysis.

Methods
A retrospective cohort study was conducted from January/01/2015 and January/30/2019. STATA version14.0 statistical software was used for analysis. The Kaplan-Meier survival method and log-rank test curves were applied. Weibull regression was used and adjusted hazard ratio 95% CI with a value of p less than 0.05 was used to identify a significant association.

Results
Two hundred twenty three cataract patients were recovered from cataract, 72.6% (95% CI 69.8%–75.9%). The overall median survival time was 23 weeks (IQR = 16 to 35) with (95% CI, 21%–25%). aged between 16 and 30year (AHR = 1.20 CI; 1.07–2.36), age 31 to 45 (AHR = 1.24 CI; 1.08–1.54), urban dwellers (AHR = 1.59; 95% CI, 1.18–2.14), medium visual acuity (AHR = 4.14 CI; 2.57–6.67), high visual acuity (AHR = 5.23 CI; 3.06–8.93), Secondary cataract (AHR = 2.59 CI; 1.01–3.02), traumatic cataract (AHR = 1.75 CI; 1.01–3.02), extra capsular cataract extraction surgery (AHR = 1.43 CI; 1.07–1.94),and diabetes mellitus (AHR = 0.75, CI; 0.41–0.96) were notably associated with time to recovery.

Conclusion
Time to recovery in the study area was slightly higher as compared with the global cut of time. Cataract patients with comorbidity of DM had lower recovery tim

Task-shifting eye care to ophthalmic community health officers (OCHO) in Sierra Leone: A qualitative study

Background :Preventing visual impairment due to avoidable causes has been a long-standing global priority. Of all blindness in Sierra Leone, 91.5% is estimated to be avoidable and 58.2% treatable, however, there are only 6 ophthalmologists for the whole country. Task-shifting has been suggested as a strategy to address this issue and a training intervention was developed to create a cadre of community-based staff known as Ophthalmic Community Health Officers (OCHOs). This qualitative study aimed to explore the experiences of OCHOs, their relationship with other eye health workers, and how they interact with the wider health system, in order to provide recommendations for the design and delivery of future task-shifting strategies.
Methods Between April and May 2018, we conducted semi-structured interviews with 42 participants including: OCHOs (n=13), traditional ophthalmic staff (n=17)
and other stakeholders from the districts (n=6), training institution staff (n=4) and MOH headquarters (n=2). We identified participants using purposive sampling. Interviews were audio-recorded, transcribed, and thematically analysed. We draw largely on in-depth interviews but complement the analysis with evidence from a
document review.
Results In Sierra Leone, the roll-out of the OCHO programme presented a mixed picture. OCHOs participating in the study expressed a strong commitment to their new role. However, policy changes proposed to clearly demarcate roles and responsibilities and institutionalise the cadre in the civil service were not implemented, resulting in the posting of some staff at an inappropriate level, dissatisfaction with the OCHO certification, and lack of opportunities for advancement and training. These challenges reflect structural weaknesses in the health system that undermine a cohesive implementation of eye health initiatives at the primary health care level in Sierra Leone.
Conclusions: Task-shifting has the potential to improve provision in under-resourced specialities such as eye health. However, the success of this approach will be contingent upon the development of a robust and supportive health policy environment