Public Health

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Burton MJ, Ramke J, Marques AP, Bourne RRA, Congdon N, Jones I, Ah Tong BAM, Arunga S, Bachani D, Bascaran C, Bastawrous A, Blanchet K, Braithwaite T, Buchan JC, Cairns J, Cama A, Chagunda M, Chuluunkhuu C, Cooper A, Crofts-Lawrence J, Dean WH, Denniston AK, Ehrlich JR, Emerson PM, Evans JR, Frick KD, Friedman DS, Furtado JM, Gichangi MM, Gichuhi S, Gilbert SS, Gurung R, Habtamu E, Holland P, Jonas JB, Keane PA, Keay L, Khanna RC, Khaw PT, Kuper H, Kyari F, Lansingh VC, Mactaggart I, Mafwiri MM, Mathenge W, McCormick I, Morjaria P, Mowatt L, Muirhead D, Murthy GVS, Mwangi N, Patel DB, Peto T, Qureshi BM, Salomão SR, Sarah V, Shilio BR, Solomon AW, Swenor BK, Taylor HR, Wang N, Webson A, West SK, Wong TY, Wormald R, Yasmin S, Yusufu M, Silva JC, Resnikoff S, Ravilla T, Gilbert CE, Foster A, Faal HB. The Lancet Global Health Commission on Global Eye Health: vision beyond 2020. Lancet Glob Health 2021;9(4):e489-e551.
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Chen T, Jin L, Zhu W, Wang C, Zhang G, Wang X, Wang J, Yang K, Cochrane GM, Lamoureux EL, Friedman DS, Gilbert S, Lansingh VC, Resnikoff S, Zhao J, Xiao B, He M, Congdon N. Knowledge, attitudes and eye health-seeking behaviours in a population-based sample of people with diabetes in rural China. Br J Ophthalmol 2021;105(6):806-811.Abstract
AIMS: To assess knowledge of diabetes and acceptance of eye care among people with diabetes in rural China, to improve service uptake. METHODS: Population-based study of people in Guangdong, China, with glycosylated haemoglobin A1c≥6.5% and/or known history of diabetes. Between August and November 2014, participants answered a questionnaire (based on Delphi process/previous focus groups) on medical history, demographic characteristics, self-rated health and vision, knowledge about diabetes and diabetic retinopathy, quality of local healthcare, barriers to treatment, likely acceptance of eye exams and treatment, and interventions rated most likely to improve service uptake. Presenting visual acuity was assessed, fundus photography performed and images graded by trained graders. Potential predictors of accepting care were evaluated and confounders adjusted for using logistic regression. RESULTS: A total of 562 people (9.6% (256/5825), mean age 66.2±9.84 years, 207 (36.8%) men) had diabetes, 118 (22.3%) previously diagnosed. 'Very likely' or 'likely' acceptance of laser treatment (140/530=26.4%) was lower than for eye exams (317/530=59.8%, p<0.001). Predictors of accepting both exams and laser included younger age (p<.001) and prior awareness of diabetes diagnosis (p=0.004 and p=0.035, respectively). The leading barrier to receiving diabetes treatment was unawareness of diagnosis (409/454, 97.2%), while interventions rated most likely to improve acceptance of eye exams included reimbursement of travel costs (387/562, 73.0%), video or other health education (359/562, 67.7%) and phone call reminders (346/562, 65.3%). CONCLUSIONS: Improving diagnosis of diabetes, along with incentives, education and communication strategies, is most likely to enhance poor acceptance of diabetic eye care in this setting.
Collins ME, Guo X, Mudie LI, Slavin RE, Madden N, Chang D, Owoeye J, Repka MX, Friedman DS. Baseline vision results from the Baltimore Reading and Eye Disease Study. Can J Ophthalmol 2022;57(1):29-35.Abstract
OBJECTIVE: We describe the Baltimore Reading and Eye Disease Study, report baseline ocular findings, and explore the feasibility of eye examinations in the school setting. DESIGN: Prospective, school-based cohort study. PARTICIPANTS: Students in second and third grades. METHODS: Baseline eye examinations, including near and distance presenting visual acuity (VA), stereopsis, ocular alignment, dilated retinal examination, and cycloplegic refraction, were performed in 12 Baltimore public schools during the 2014-15 school year. MAIN OUTCOME MEASURES: Presenting VA, prevalence of refractive error, and other ocular findings. RESULTS: Among the 1054 eligible students, 321 participated. There were 271 (84.4%) African American and 186 (57.9%) female students; mean age was 7.9 ± 0.8 years. Cycloplegia was achieved in 308. The mean presenting distance and near VA was 0.1 ± 0.2 logMAR (range -0.1 to 1.5) and 0.1 ± 0.2 logMAR (range 0.0-1.6) in the better-seeing eye, respectively. The most common ocular findings were +1.00 diopter (D) or greater hyperopia (34.7%), -0.50 D or greater myopia (29.5%), 1.00 D or greater astigmatism (23.4%), and convergence insufficiency (7.2%). Thirty-seven (11.5%) children needed referral to an eye care provider; 10% of students required glasses full-time. CONCLUSIONS: Whereas the majority of second and third grade students in this study have good VA and minimal refractive error, 1 in 9 have an ocular finding necessitating further evaluation. It was feasible to conduct cycloplegic eye examinations in the school setting.
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Deiner MS, Seitzman GD, Kaur G, McLeod SD, Chodosh J, Lietman TM, Porco TC. Sustained Reductions in Online Search Interest for Communicable Eye and Other Conditions During the COVID-19 Pandemic: Infodemiology Study. JMIR Infodemiology 2022;2(1):e31732.Abstract
Background: In a prior study at the start of the pandemic, we reported reduced numbers of Google searches for the term "conjunctivitis" in the United States in March and April 2020 compared with prior years. As one explanation, we conjectured that reduced information-seeking may have resulted from social distancing reducing contagious conjunctivitis cases. Here, after 1 year of continued implementation of social distancing, we asked if there have been persistent reductions in searches for "conjunctivitis," and similarly for other communicable disease terms, compared to control terms. Objective: The aim of this study was to determine if reduction in searches in the United States for terms related to conjunctivitis and other common communicable diseases occurred in the spring-winter season of the COVID-19 pandemic, and to compare this outcome to searches for terms representing noncommunicable conditions, COVID-19, and to seasonality. Methods: Weekly relative search frequency volume data from Google Trends for 68 search terms in English for the United States were obtained for the weeks of March 2011 through February 2021. Terms were classified a priori as 16 terms related to COVID-19, 29 terms representing communicable conditions, and 23 terms representing control noncommunicable conditions. To reduce bias, all analyses were performed while masked to term names, classifications, and locations. To test for the significance of changes during the pandemic, we detrended and compared postpandemic values to those expected based on prepandemic trends, per season, computing one- and two-sided P values. We then compared these P values between term groups using Wilcoxon rank-sum and Fisher exact tests to assess if non-COVID-19 terms representing communicable diseases were more likely to show significant reductions in searches in 2020-2021 than terms not representing such diseases. We also assessed any relationship between a term's seasonality and a reduced search trend for the term in 2020-2021 seasons. P values were subjected to false discovery rate correction prior to reporting. Data were then unmasked. Results: Terms representing conjunctivitis and other communicable conditions showed a sustained reduced search trend in the first 4 seasons of the 2020-2021 COVID-19 pandemic compared to prior years. In comparison, the search for noncommunicable condition terms was significantly less reduced (Wilcoxon and Fisher exact tests, P<.001; summer, autumn, winter). A significant correlation was also found between reduced search for a term in 2020-2021 and seasonality of that term (Theil-Sen, P<.001; summer, autumn, winter). Searches for COVID-19-related conditions were significantly elevated compared to those in prior years, and searches for influenza-related terms were significantly lower than those for prior years in winter 2020-2021 (P<.001). Conclusions: We demonstrate the low-cost and unbiased use of online search data to study how a wide range of conditions may be affected by large-scale interventions or events such as social distancing during the COVID-19 pandemic. Our findings support emerging clinical evidence implicating social distancing and the COVID-19 pandemic in the reduction of communicable disease and on ocular conditions.
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Guo X, Nguyen AM, Vongsachang H, Kretz AM, Mukherjee RM, Neitzel AJ, Shakarchi AF, Friedman DS, Repka MX, Collins ME. Refractive Error Findings in Students Who Failed School-based Vision Screening. Ophthalmic Epidemiol 2021;:1-9.Abstract
PURPOSE: To report refractive error findings in Baltimore City schoolchildren who failed school-based vision screenings. METHODS: In this cross-sectional analysis, students pre-kindergarten through 8th grade who failed screenings during school years 2016-2019 received an eye examination, including non-cycloplegic autorefraction and visual acuity (VA) measurements. Refractive error was identified when there was at least: -0.50 diopter (D) spherical equivalent (SE) myopia, +0.50D SE hyperopia, 1.00D astigmatism, or 1.00D anisometropia in either eye. Generalized estimating equation models were used to identify factors associated with clinically significant refractive error, defined as decreased VA and more severe refractive error. RESULTS: Of 7520 students who failed screening, 6627 (88%) were analyzed. Clinically significant refractive error and any refractive error were found in 2352 (35.5%) and 5952 (89.8%) students, respectively. Mild myopia (45%, -0.50 D to <-3.00 D SE) and low astigmatism (47%, 1.00 D to <3.00 D cylinder) were the most prevalent types of refractive error. Proportions of students with myopia increased with higher grade levels (Ptrend<0.001). Myopia and astigmatism were more common in black and Latinx. Risk factors for clinically significant refractive error included higher grades (odds ratios [OR] ranged from 1.30 to 2.19 compared with 1st grade, P < .05) and Latinx ethnicity (OR = 1.31, 95%CI: 1.08-1.59). CONCLUSION: A Baltimore school-based vision program identified a substantial number of students with refractive error in a high-poverty urban community. Over 1/3 students who failed vision screening had clinically significant refractive error, with black and Latinx students at higher risk of having myopia and astigmatism.
Guo X, Shakarchi AF, Block SS, Friedman DS, Repka MX, Collins ME. Non-Cycloplegic Compared with Cycloplegic Refraction in a Chicago School-aged Population. Ophthalmology 2022;Abstract
PURPOSE: To evaluate differences between autorefraction measurements with and without cycloplegia among school-aged individuals and to explore factors associated with significant differences. DESIGN: Cross-sectional, retrospective study PARTICIPANTS: Individuals between 3 and 22 years, evaluated at the Illinois College of Optometry Princeton Vision Clinic (PVC) from September 2016 through June 2019, who had same day non-cycloplegic and cycloplegic autorefractions of their right eyes. METHODS: Demographic information including age, sex, and race/ethnicity were collected during the eye exam. Autorefraction was performed before and after cycloplegia. Myopia defined as at least -0.50 diopters (D) spherical equivalent (SE), hyperopia as at least +0.50D SE, and astigmatism of at least 1.00D cylinder were determined using both non-cycloplegic and cycloplegic autorefractions. Factors associated with at least 1.00D more myopic SE or at least 0.75D cylindrical difference by non-cycloplegic autorefraction was assessed using logistic regression models. MAIN OUTCOME MEASURES: Differences between non-cycloplegic and cycloplegic autorefraction measures RESULTS: The mean age was 10.8±4.0 years for the 11119 individuals; 52.4% were females. The mean SE refraction was -0.87±2.11D for non-cycloplegic and -0.23±2.31D for cycloplegic refraction, with non-cycloplegic SE measuring 0.65±1.04D more myopic. After adjusting for demographic factors and refractive error, individuals with ≥1.00D more myopic SE refraction by non-cycloplegic autorefraction (25.9%) were more likely to be <5 years of age (odds ratio [OR]=1.45, 95% confidence interval [CI]: 1.18 to 1.79) and 5 to <10 years (OR=1.32, 95%CI: 1.18 to 1.48) compared with those 10 to <15 years. This ≥1.00D more myopic SE difference was more likely to be observed in Hispanics (OR=1.23, 95%CI: 1.10 to 1.36) and individuals with hyperopia (ORs range: 1.56 to 5.64). Individuals with ≥ 0.75D cylindrical difference (5.1%) between refractions were more likely to be <5 years of age, male, and have mild/moderate/high myopia, or moderate/high hyperopia. CONCLUSIONS: Three quarters of school-aged individuals had less than 1D myopic SE difference using non-cycloplegic compared to cycloplegic autorefraction. Understanding measurement differences obtained for refractive error and associated factors may provide useful information for future studies or programs involving refraction in school-aged children.
Guo X, Friedman DS, Repka MX, Collins ME. Visual acuity and refractive findings in children prescribed glasses from a school-based vision program. J AAPOS 2021;Abstract
PURPOSE: We report visual acuity improvement and refractive profiles in children prescribed glasses by a school-based vision program (SBVP) in Baltimore, Maryland. METHODS: In this cross-sectional analysis, pre-kindergarten through 8th grade students who failed vision screening underwent an eye examination. Students prescribed glasses are included. Visual acuity improvement was the difference between presenting and best-corrected visual acuity based on noncycloplegic manifest refraction. Clinically significant refractive error (CSRE) was defined as ≥0.75 D myopia, ≥2.00 D hyperopia without strabismus, ≥1.00 D hyperopia with esodeviation, or ≥1.50 D astigmatism AND presenting visual acuity ≤20/40 or ≥2-line difference with the better-seeing eye ≤20/30. Characteristics associated with greater visual acuity improvement were explored. RESULTS: Of the 4,972 students, mean age was 9.4 ± 2.7 years; 77% were black, and 18% were Hispanic. Myopia, hyperopia, astigmatism, and CSRE were found in 65%, 24%, 60%, and 46% students, respectively. In the better-seeing eyes, 70% gained ≥2 lines. Of students with CSRE, improvement of at least 5 lines in the worse-seeing eye increased from 30.9% in pre-kindergarten and kindergarten to 77.3% in 7th and 8th grade (Ptrend < 0.001). Students with CSRE had a higher rate of gaining at least 2 lines' improvement in their worse-seeing eyes compared with those without (98.7% vs 80.6%). Older students as well as blacks and Hispanics were more likely to have improvement of at least 2 lines. CONCLUSIONS: Most students prescribed glasses from our SBVP had clinically significant visual deficits corrected.
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Halawa OA, Kolli A, Oh G, Mitchell WG, Glynn RJ, Kim DH, Friedman DS, Zebardast N. Racial and Socioeconomic Differences in Eye Care Utilization among Medicare Beneficiaries with Glaucoma. Ophthalmology 2022;129(4):397-405.Abstract
PURPOSE: Evaluate differences in eye care utilization among patients with glaucoma by race and socioeconomic status (SES). DESIGN: Retrospective cohort study. PARTICIPANTS: Representative 5% sample of Medicare beneficiaries aged > 65 years with continuous part A/B enrollment between January 1, 2014, and July 1, 2014, at least 1 diagnosis code for glaucoma within that period, and a glaucoma diagnosis in the Chronic Conditions Warehouse before January 1, 2014. METHODS: The following race/ethnicity categories were defined in our cohort: non-Hispanic White, Black/African American, Hispanic, and Asian/Pacific Islander. Low SES was defined as having 2 or more enrollment-based low-income indicators (dual eligibility for Medicare/Medicaid, Part D limited income subsidies, and eligibility for Part A and B State buy-in). Negative binomial regression analyses were carried out to compare relative rate ratios (RRs) of eye care utilization among racial groups stratified by low and non-low SES. MAIN OUTCOME MEASURES: Measured from July 1, 2014, to December 31, 2016: eye examinations and eye care-related office visits; eye care-related inpatient and emergency department (ED) encounters; eye care-related nursing home and home-visit encounters; visual field and retinal nerve fiber OCT tests; glaucoma lasers and surgeries. RESULTS: Among 78 526 participants with glaucoma, mean age was 79.1 years (standard deviation, 7.9 years), 60.9% were female, 78.4% were non-Hispanic White, and 13.8% met enrollment-based criteria for low-SES. Compared with White beneficiaries, Blacks had lower counts of outpatient visits (RR, 0.92; 95% confidence interval [CI], 0.90-0.93), visual field (VF) tests (RR, 0.92; 95% CI, 0.90-0.94), but more inpatient/ED encounters (RR, 2.42; 95% CI, 1.55-3.78) and surgeries (RR, 1.14; 95% CI, 1.03-1.27). Hispanics had fewer outpatient visits (RR, 0.97; 95% CI, 0.95-0.98) and retinal nerve fiber layer (RNFL) OCT tests (RR, 0.89; 95% CI, 0.86-0.93), but more inpatient/ED encounters (RR, 2.32; 95% CI, 1.18-4.57) and selective laser trabeculoplasty (SLT) (RR, 1.25; 95% CI, 1.11-1.42) versus non-Hispanic Whites. In the non-low SES group, Black versus White disparities persisted in outpatient visits (RR, 0.93; 95% CI, 0.92-0.95), VF (RR, 0.96; 95% CI, 0.94-0.98), RNFL OCT (RR, 0.81; 95% CI, 0.78-0.83), and inpatient/ED encounters (RR, 2.57; 95% CI, 1.55-4.26). CONCLUSIONS: Disparities were found in eye care utilization among Black and Hispanic patients with glaucoma. These differences persisted among Blacks after stratification by SES, suggesting that systemic racism may be an independent driver in this population.
Hu A, Gu SZ, Friedman DS, Cao K, Wang N. Six-Year Incidence and Causes of Low Vision and Blindness in a Rural Chinese Adult Population: The Handan Eye Study. Ophthalmic Epidemiol 2021;28(2):160-168.Abstract
PURPOSE: To determine the six-year incidence, risk factors, and causes of visual impairment in a Chinese population. METHODS: This was a population-based study of eye disease in Chinese adults in a rural district of Handan in China. 6,830 individuals were invited to participate in 2006 and 5,394 returned for follow-up in 2012. All participants underwent standardized eye examinations. Visual impairment was defined according to WHO criteria. The incidence of visual impairment was age- and gender-standardized to the 2010 China Census. Multivariable logistic regression analysis was used to determine risk factors for visual impairment. RESULTS: The leading causes of visual impairment were cataract and refractive error. Based on (PVA), the six-year incidence rates of low vision and blindness were 5.2% and 0.5%, respectively. Incidence of low vision was associated with older age ( < .001), less education ( < .001), diabetes ( < .05), and lower BMI ( < .001). The incidence of blindness was associated with diabetes ( < .05). Based on (BCVA), the six-year incidence rates of low vision and blindness were 0.8% and 0.1%, respectively. Incidence of low vision was associated with older age ( < .001) and lower BMI ( < .05). None of these factors were associated with the incidence of blindness. CONCLUSION: In Handan, the incidence of visual impairment was high and associated with older age, less education, diabetes, and lower BMI. The majority of cases were due to unoperated cataract and uncorrected refractive error, reflecting the need for improved eye care in this region.
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Keel S, Evans JR, Block S, Bourne R, Calonge M, Cheng C-Y, Friedman DS, Furtado JM, Khanna RC, Mathenge W, Mariotti S, Matoto E, Müller A, Rabiu MM, Rasengane T, Zhao J, Wormald R, Cieza A. Strengthening the integration of eye care into the health system: methodology for the development of the WHO package of eye care interventions. BMJ Open Ophthalmol 2020;5(1):e000533.Abstract
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.
Kempen JH, Abashawl A, Suga HK, Nigussie Difabachew M, Kempen CJ, Tesfaye Debele M, Menkir AA, Assefa MT, Asfaw EH, Habtegabriel LB, Sitotaw Addisie Y, Nilles EJ, Longenecker JC. SARS-CoV-2 Serosurvey in Addis Ababa, Ethiopia. Am J Trop Med Hyg 2020;103(5):2022-2023.Abstract
In a serosurvey of asymptomatic people from the general population recruited from a clinical laboratory in May 2020 in Addis Ababa, Ethiopia, three of 99 persons tested positive for SARS-CoV-2 IgG (3.0%, 95% binomial exact confidence interval: 0.6-8.6%). Taking into account pretest probability and the sampling scheme, the range of plausible population prevalence values was approximately 1.0-8.4%. These results suggest that a larger number of people have been infected than the counts detected by surveillance to date; nevertheless, the results suggest the large majority of the general population in Addis Ababa currently is susceptible to COVID-19.
Kolomeyer NN, Katz LJ, Hark LA, Wahl M, Gajwani P, Aziz K, Myers JS, Friedman DS. Lessons Learned From 2 Large Community-based Glaucoma Screening Studies. J Glaucoma 2021;30(10):875-877.Abstract
Community-based screening programs have had limited success in preventing vision loss from glaucoma due to overall low prevalence of glaucoma, screening limitations, and barriers to follow-up appointments. This editorial highlights lessons learned from 2 large prospective trials: the Philadelphia Telemedicine Glaucoma Detection and Follow-up Study and the Screening To Prevent Glaucoma Study. While some lessons are specific to ophthalmology, many lessons are applicable to screening for asymptomatic diseases in underserved, vulnerable communities.
Kretz AM, Vongsachang H, Friedman DS, Callan J, Wahl M, Mukherjee RM, Neitzel A, Collins ME. Stakeholders' Perceptions of a School-Based Eye Care Programme in Baltimore, MD. Ophthalmic Epidemiol 2021;:1-10.Abstract
PURPOSE: To explore stakeholders' perceptions of a school-based vision programme (SBVP). METHODS: We conducted 20 focus groups with 105 parents and teachers at schools in Baltimore, MD, that participated in a SBVP. Facilitators used a semi-structured interview guide to discuss participants' perceptions of the SBVP. Focus groups were audio-recorded, transcribed, and coded using inductive thematic analysis. RESULTS: Participant perceptions fell into three categories: benefits of school-based eye care, limitations of school-based eye care, and observation of impact. The majority of participants had positive comments about the programme; benefits included convenience (location, time, and cost), the comprehensive nature of the programme, the quality of the eyeglasses and ability to receive replacements, and a positive screening/exam experience. Limitations of programme impact were related to communication and organisation, the time to receive the glasses, missed instructional time, and uncertainty about screenings. Observations of impact included academic and classroom improvements, as well as visual and other health improvements. CONCLUSION: Parents and teachers reported mostly positive perceptions regarding the SBVP. Their appreciation for the convenience underscores that location, cost, time, and comprehensive services are crucial aspects for implementing a successful programme. To maximize impact, programs must also implement robust communication campaigns that integrate into the schools' workflow to help parents and teachers stay engaged in the process from start to finish.
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Marmamula S, Barrenakala NR, Challa R, Kumbham TR, Modepalli SB, Yellapragada R, Bhakki M, Khanna RC, Friedman DS. Prevalence and risk factors for visual impairment among elderly residents in 'homes for the aged' in India: the Hyderabad Ocular Morbidity in Elderly Study (HOMES). Br J Ophthalmol 2021;105(1):32-36.Abstract
BACKGROUND/AIM: To investigate the prevalence, causes and risk factors of visual impairment (VI) among the elderly in 'home for the aged' in Hyderabad, India. METHODS: Individuals aged ≥60 years were recruited from 41 'homes for the aged'. All participants had complete eye examinations including presenting visual acuity, refraction, slit-lamp examination, intraocular pressure measurement and fundus imaging by trained clinicians. VI was defined as presenting visual acuity worse than 6/18 in the better eye. Multivariate logistic regression was used to determine the risk factors associated with VI. RESULTS: 1512 elderly residents from 41 homes for the aged were enumerated, of whom 1182 (78.1%) were examined. The mean age of examined participants was 75.0 years (SD 8.8 years; range: 60-108 years); 35.4% of those examined were men. The prevalence of VI was 30.1% (95% CI 27.5 to 32.8). The leading cause of VI was cataract (46.3%, n=165), followed by uncorrected refractive error (27.0%, n=96), posterior capsular opacification (14.9%, n=53) and posterior segment disease (6.5%, n=23). Overall, 88.2% of the VI was either treatable or correctable. In multiple logistic regression, those aged 80 years and older (OR: 1.7, p<0.01), living in 'free' homes (OR: 1.5, p<0.01) and who were immobile/bedridden (OR: 3.02, p<0.01) had significantly higher odds of VI. Gender was not associated with VI. CONCLUSIONS: VI was common and largely avoidable in residents of 'homes for the aged' in Hyderabad, India. Screening for vision loss in 'homes for aged' and the provision of appropriate services should become routine practice to achieve the goal of healthy ageing in India.
Marmamula S, Barrenkala NR, Challa R, Kumbham TR, Modepalli SB, Yellapragada R, Bhakki M, Friedman DS, Khanna RC. Falls and visual impairment among elderly residents in 'homes for the aged' in India. Sci Rep 2020;10(1):13389.Abstract
We evaluated the prevalence of falls and their association with visual impairment (VI) in elderly residents in 'homes for the aged' in Hyderabad, India. Participants aged ≥ 60 years were recruited from 41 homes, and a comprehensive eye examination was conducted. Interviews were conducted to collect personal and demographic information, systemic health status, fear of falling, depression, and history of falls in the last year. VI categories included low vision (presenting visual acuity worse than 6/18 to 3/60) and blindness (presenting visual acuity worse than 3/60). The data of 1,074 participants were analysed. The mean age was 74.4 years (standard deviation:8.7 years); 63.9% were women, 19.4% had no formal education, 28.1% were diabetic and 56.9% were hypertensive. The annual prevalence of falls was 29.1% (95% CI: 26.4-32.0). Multivariable analysis showed those with VI had significantly higher odds of falls (Odds Ratio:1.47; p = 0.043). The prevalence of falls was higher among those with VI due to uncorrected refractive errors. We found a very high prevalence of falls in elderly individuals living in 'homes for the aged' in Hyderabad, India. Addressing VI can result in fewer falls and contribute to healthy aging in India.
Marmamula S, Mitchell W, Zebardast N, Locascio J, Barrenkala NR, Kumbham TR, Modepalli SB, Khanna RC, Friedman DS. Impact of Vision Loss on Visual Function Among Elderly Residents in the "Home for the Aged" in India: The Hyderabad Ocular Morbidity in Elderly Study. Transl Vis Sci Technol 2020;9(13):11.Abstract
Purpose: The purpose of this study was to report the association between visual impairment (VI) and self-reported visual difficulty among the elderly in residential care using the Indian Vision Functioning Questionnaire (IND-VFQ-33) psychometrically validated questionnaire. Methods: Participants aged ≥ 60 years were recruited from 41 homes in Hyderabad in South India. All participants underwent detailed eye examination and interviews. Self-reported visual function was assessed using the IND-VFQ-33 questionnaire. Factor Analysis and Item Response Theory (IRT) models were used for analysis. Multivariable regression models were used to investigate associations between derived global difficulty scores versus severity and causes of VI. Presenting visual acuity worse than 6/18 in the better eye was considered as VI. Results: In total, 867 elderly participants completed the INDVFQ-33. Two latent traits ("daily activities" and "visual symptoms") were identified on factor analysis, each with uniquely loading questions. Participants with VI reported significantly higher daily activities difficulty (6 points higher) and visual symptoms difficulty (1.7 points higher) than those without VI ( < 0.05). Those with cataract reported the highest daily activities and visual symptoms difficulty (7.6 points and 2.2 points higher, respectively, < 0.05). Greater severity of VI was associated with increased self-reported difficulty for both factors, and for all causes of VI. Conclusions: We present a psychometrically validated visual questionnaire particularly suited to older adults in residential homes. We show a significant association between cause/severity of VI and difficulty with daily activities and visual symptoms after adjusting for sociodemographic and medical factors. Translational Relevance: Understanding the impact of vision loss on visual functions in the elderly will help in planning and resource allocation for developing early intervention programs for the elderly.
Marmamula S, Barrenkala NR, Khanna RC, Challa R, Bhakki M, Kumbham TR, Modepalli SB, Yellapragada R, Friedman DS. Near vision impairment among the elderly in residential care-the Hyderabad Ocular Morbidity in Elderly Study (HOMES). Eye (Lond) 2021;35(8):2310-2315.Abstract
BACKGROUND/OBJECTIVE: To report on the prevalence and risk factors for near vision impairment (NVI) among the elderly in residential care in Telangana State in India. METHODS: Individuals aged ≥60 years were recruited from 41 'home for the aged' centres in Hyderabad, India. All participants had complete eye examinations including presenting and best-corrected visual acuity assessment for distance and near. NVI was defined as binocular presenting near vision worse than N8 (6/15) among those who had a normal presenting distance visual acuity of 6/18 in the better eye. RESULTS: Of the 826 participants, the mean age was 74.4 years (standard deviation-8.4 years), 525 (63.6%) were women, 715 (86.6%) had at least school education. The prevalence of NVI was 51.2% (95% CI: 47.7-54.7) based on presenting vision. On applying multiple logistic regression analysis, the odds of NVI were higher in 80 years and older age (OR: 2.17; 95% CI: 3.44-13.6). Those with school education (OR: 0.58: 95% CI: 0.36-0.94) and higher education (OR: 0.38; 95% CI: 0.21-0.69) had lower odds for NVI. Similarly, those with self-reported diabetes (OR: 0.69; 95% CI: 0.49-0.97), those using spectacles (OR: 0.09; 95% CI: 0.05-0.16), and those who had undergone cataract surgery (OR: 0.51; 95% CI: 0.36-0.74) had lower odds for NVI. CONCLUSIONS: NVI was common among the elderly in residential care in homes for the aged in Hyderabad, India. As most of this NVI is correctable, a routine screening programme and dispensing of spectacles can be undertaken to address this vision loss.
Milante RR, Guo X, Neitzel AJ, Kretz AM, Mukherjee RM, Friedman DS, Repka MX, Collins ME. Analysis of vision screening failures in a school-based vision program (2016-19). J AAPOS 2021;Abstract
BACKGROUND: Vision screenings of a school-based program were conducted in state-mandated grades (pre-kindergarten [pre-K] or kindergarten [K], 1st and 8th grade), and nonmandated grades (2nd to 7th). METHODS: During school years 2016-19, 51,593 pre-K to 8th grade students from 123 Baltimore City Public Schools underwent vision screenings, with 85% of the schools qualifying for Free and Reduced Price Meals. Assessments included distance visual acuity, Spot photoscreening, stereopsis, and cover testing. Screening failures were analyzed by grade using aggregate data. Failure rates for mandated and nonmandated grades were compared using a logistic regression model, and visual acuity distributions were analyzed using individual data. RESULTS: Over the 3-year period, 17,414 (34%) of students failed vision screening. Failure rates by grade ranged from 28% to 38%. Children in kindergarten and 3rd grade and higher were statistically more likely to fail screening than those in 1st grade. Reduced visual acuity was the most common reason for failure (91%). Failure rates were significantly higher in nonmandated grades than in state-mandated testing grades (34.7% vs 32.5% [P < 0.001]). Mean visual acuity of all students who failed vision screening was 20/50 in the worse-seeing eye and was 20/40 in the better-seeing eye. CONCLUSIONS: One-third of students failed vision screening. High screening failure rates across all grades suggest that screening in select grade levels, as currently mandated in Maryland schools, is inadequate for detecting vision problems in the low-income communities served by this program.
Mitchell W, Bhatia R, Zebardast N. Retrospective cross-sectional analysis of the changes in marijuana use in the USA, 2005-2018. BMJ Open 2020;10(7):e037905.Abstract
OBJECTIVES: Understanding trends of marijuana use in the USA throughout a period of particularly high adoption of marijuana-legalisation, and understanding demographics most at risk of use, is important in evolving healthcare policy and intervention. This study analyses the demographic-specific changes in the prevalence of marijuana use in the USA between 2005 and 2018. DESIGN, SETTING AND PARTICIPANTS: A 14-year retrospective cross-sectional analysis of the National Health and Nutrition Examination Survey database, a publicly available biennially collected national survey, weighted to represent the entire US population. A total of 35 212 adults between 18 and 69 years old participated in the seven-cycles of surveys analysed (2005-2018). PRIMARY OUTCOME MEASURED: Lifetime use, first use before 18 years old, and past-year use of marijuana. RESULTS: The majority of adults reported ever using marijuana. While the overall prevalence of lifetime marijuana use remained stable (p=0.53), past-year use increased significantly between 2005 and 2018 (p<0.001) with highest rate of past-year use among younger age groups (p<0.001), males (p<0.001) and those with income below poverty level (p<0.001). Past-year use was the most common among non-Hispanic blacks, and less common among Hispanic/Mexican populations (p<0.002). Trends in past-year use increased among all age categories, males/females, all ethnicities, those with high school education/above, and those at all income levels (p<0.01 for all). CONCLUSIONS: While lifetime marijuana use remained stable, past-year use significantly increased between 2005 and 2018. While past-year use remained the most common in younger age groups, males, non-Hispanic blacks and those with lower income; increasing trends in past-year use were significant for all age, sex, race and income categories, and for those with high school education/above. With high adoption of marijuana-legalisation laws during this period, our results suggest an associated increase in past-year marijuana use.An accurate understanding of those most at risk can help to inform decisions of healthcare policy-makers and professionals, and facilitate a safe transition of changing marijuana legalisation and use in the USA.
Mitchell W, Marmamula S, Zebardast N, Ng W, Locascio JJ, Kumbam T, Brahmanandam S, Barrenkala NR. Psychometric validation techniques applied to the IND-VFQ-33 visual function questionnaire: the Hyderabad ocular morbidity in the elderly study (HOMES). BMC Med Res Methodol 2021;21(1):26.Abstract
BACKGROUND: Over 2 billion people suffer from vision impairment or blindness globally, and access to validated visual measurement tools in imperative in accurately describing and managing the burden of eye disease. The present study applies contemporary psychometric validation techniques to the widely used 33-item Indian Visual Function Questionnaire (IND-VFQ-33). METHODS: We first estimated the polychoric correlation between each pair of items. Next, an unrotated and oblique Promax rotated factor analysis, item response theory (IRT, using a graded response model (GRM)), and differential item functioning (DIF) testing were applied to the IND-VFQ-33. We subsequently propose a validated IND-VFQ-33 questionnaire after psychometric testing, data reduction, and adjustment. RESULTS: Exploratory unrotated factor analysis identified two factors; one with a particularly high eigenvalue (18.1) and a second with a lower eigenvalue still above our threshold (1.1). A subsequent oblique Promax factor rotation was undertaken for a 2-factor solution, revealing two moderately correlated factors (+ 0.68) with clinically discrete item loadings onto either Factor 1 (21 items; collectively labelled "daily activities") or Factor 2 (5 items; collectively labelled "bright lights"). IRT confirmed high item discrimination for all remaining items with good separation between difficulty thresholds. We found significant DIF on depression for six items in Factor 1 (all uniform DIF, except item 21 (non-uniform DIF) with no substantive difference in beta thresholds for any item and no substantive difference in expected individual or sum score, by depression at baseline. For Factor 2, only one item demonstrated significant uniform DIF on gender, similarly without major differences in beta thresholds or expected total score between gender at baseline. Consequently, no further item recalibration or reduction was undertaken after IRT and DIF analysis. CONCLUSION: Applying IRT and DIF validation techniques to the IND-VFQ-33 identified 2 discrete factors with 26 uniquely-loading items, clinically representative of difficulty performing daily activities and experiencing difficulty due to bright lights/glare respectively. The proposed modified scale may be useful in evaluating symptomatic disease progression or response to treatment in an Indian population.

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