The economic and social costs of visual impairment and blindness in India

Purpose: To provide a current estimate of the economic and social costs (or welfare costs) of visual impairment and blindness in India. Methods: Using evidence from the recently conducted Blindness and Visual Impairment Survey across India, the Lancet Global Health Commission on Global Eye Health and other sources, we developed an economic model that estimates the costs of reduced employment, elevated mortality risk, education loss for children, productivity loss in employment, welfare loss for the unemployed, and caregiver costs associated with moderate and severe visual impairment (MSVI) and blindness. Probabilistic sensitivity analyses were also conducted by varying key parameters simultaneously. Results: The costs of MSVI and blindness in India in 2019 are estimated at INR 1,158 billion (range: INR 947–1,427 billion) or $54.4 billion at purchasing power parity exchange rates (range:$44.5–67.0 billion), accounting for all six cost streams. The largest cost was for the loss of employment, whereas the the second largest cost was for caregiver time. A more conservative estimate focusing only on employment loss and elevated mortality risk yielded a cost of INR 504 billion (range: INR 348–621 billion) or $23.7 billion (range:$16.3–29.2 billion). Conclusion: Poor eye health imposes a non‑trivial recurring cost to the Indian economy equivalent to 0.47% to 0.70% of GDP in the primary scenario, a substantial constraint on the country’s growth aspirations. Furthermore, the absolute costs of poor eye health will increase over time as India ages and becomes wealthier unless further progress is made in reducing the prevalence of MSVI and blindness

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

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

Generating evidence for planning eye care service delivery in an urban underprivileged population setting in Pune, Western India.

PURPOSE: To estimate prevalence of blindness, diabetic retinopathy and causes of blindness through rapid assessment of avoidable blindness (RAAB) survey in Pune, India to develop an evidence base for planning urban eye care services. METHODS: 'Rapid assessment of avoidable blindness and diabetic retinopathy' methodology was used. Compact segment sampling was used in each of the 60 selected electoral wards identified through cluster selection module of the RAAB software using probability proportionate to size method. Persons >50 years of age were enumerated from selected segments to achieve cumulative target of 60/day by two teams. Participants underwent presenting and pinhole visual acuity (VA) testing in each eye. A torch light examination and direct ophthalmoscopy established cause of visual impairment/blindness if present. Data were entered into and analysed using RAAB software. RESULTS: The response rate was 89.5% (3221/3600), and 55.3% were women. Results of only RAAB module are presented in this paper. Age-standardised and sex-standardised prevalence of blindness was 1.3% (95% CI 0.9 to 1.8). Cataract was the most common cause of blindness (45.7%) followed by overall posterior segment disorders (39.1%). Cataract surgical outcome was good (VA>6/18) or very good (VA>6/12) in 805/1190 (67.6%) cases. Cataract surgical coverage was 96.7%. 'Need not felt' (36.6%) and 'cost' (31.7%) were the most common barriers for cataract surgery. CONCLUSION: Prevalence of blindness is showing declining trend in urban India. Cataract remains a major cause of blindness followed by posterior segment disorders. Social marketing, and referral linkages between community and service providers were planned after this survey

Estimating the magnitude of diabetes mellitus and diabetic retinopathy in an older age urban population in Pune, western India

Objective To estimate magnitude of diabetes mellitus (DM) and diabetic retinopathy (DR) in a high risk population in Pune, western India. Methods DR module in rapid assessment of avoidable blindness (RAAB) survey methodology was used. Sample size of 3527 was calculated based on estimates from previous studies in India. A certified RAAB trainer conducted a training of survey teams. Random cluster sampling with probability proportionate to size was adapted to select 60 clusters consisting of 60 individuals each. Two teams visited door to door until they finished visiting 60 persons each day. Visual acuity testing, torch light examination, red glow test were carried out to determine persons with visual impairment and its cause. Every participant then underwent a random blood sugar level testing. All diabetics (known and newly detected) underwent dilated retina evaluation with indirect ophthalmoscopy to determine their DR status. Data were entered into RAAB6 software and descriptive statistics generated. Results Response rate was 89.5 % (3221/3600), females (55.3%). The prevalence of DM in the sample was (706/3221) 21.9 %(95 CI 20.1 to 23.7). Prevalence of DR was 14.3 % (95% CI 11.7 to 16.9). Most diabetics (401/579, 69.3%) never had an eye examination for DR in the past. Cataract was the principal cause of blindness (50 % cases) among diabetics. Conclusion DM affects over fifth of persons above 50 years of age in western India. Nearly seventh of the diabetics have DR, but coverage of screening is poor in Pune

Prevalence and determinants of xerophthalmia in preschool children in urban slums, Pune, India--a preliminary assessment.

PURPOSE: International and national programs to control vitamin A deficiency disorders (VADD) among children in developing countries are reducing the magnitude but VADD still occurs in deprived populations. The purpose of the study was to estimate the prevalence of and identify risk factors for xerophthalmia in children aged 6-71 months living in slums in Pune, India in 2003. METHODS: Children were enrolled into a cross sectional study from randomly selected Anganwadis (kindergartens) in selected slums using proportional to size sampling. Parents/caregivers were interviewed by social workers about night blindness, risk factors for VADD at individual and household levels, intake of vitamin A rich foods, and history of vitamin A supplementation. Children were examined for signs of xerophthalmia by an ophthalmologist. Risk factors for xerophthalmia were explored using univariate and multivariate regression analysis. RESULTS: 1,589 children were examined (response rate 80.2%) 22 of whom had xerophthalmia, prevalence 1.32% (95% confidence interval [CI] 0.76-1.88%). There were no gender differences. Independent risk factors for xerophthalmia were having an illiterate mother [Odds ratio [OR]15.4 (95% CI 4.4-64.1)] and lack of a safe water supply [OR 6.11, 95% CI 2.5-5.1)]. Only 11.3 and 13.3% of children in different slums had taken vitamin A supplements. CONCLUSIONS: Xerophthalmia was at a level of public health significance in children living in slums in Pune. This study highlights the importance of female education and indicates that vitamin A supplementation and other approaches to control need to be improved in children living in deprived areas like urban slums

Spontaneous resorption of sub-retinal cortical lens material

We report a rare case of retained sub-retinal cortical material, which underwent spontaneous resorption. Patient presented with a left eye traumatic retinal detachment with a large retinal tear and posteriorly dislocated cataractous lens. Vitrectomy, lensectomy, silicone oil injection, and endolaser were performed. A good visual result was achieved. The report draws attention to this condition and highlights possible technique for minimizing risk of this complication in similar cases

Prevalence and causes of avoidable blindness and severe visual impairment in a tribal district of Maharashtra, India

Background : We present the outcomes of a survey conducted in Nandurbar, a tribal district of Maharashtra, India. It was based on "Rapid Assessment for Avoidable Blindness" methodology and conducted in 2009 in Nandurbar, a tribal district of Maharashtra, India. Materials and Methods : We examined persons of 50 years and older ages. Ophthalmic assistants noted the distant vision [best corrected vision (BCV) and as presented]. Ophthalmologist examined eyes of persons with vision less than 6/18. The principal cause of impairment in each eye and the most "preventable" or "treatable" cause were assigned. We calculated the prevalence rates of bilateral blindness, severe visual impairment (SVI), and moderate visual impairment (MVI). Result : We examined 2,005/2,300 persons (response rate 87.2%). The prevalence of blindness, SVI, and MVI for the BCV was 1.63% (95% CI 1.11-2.15), 5.93% (95% CI 4.96-6.90), and 14.6% (95% CI 13.2-16.1), respectively. The prevalence of blindness, SVI, and MVI for the presented vision was 1.87% (1.32-2.42), 6.72% (95% CI 5.70-7.74), and 19% (95% CI 17.4-20.6), respectively. Unoperated cataract was responsible for 77% of different visual disabilities. The coverage of existing cataract surgery service was 9.4%. Lack of knowledge about cataract surgery was the main cause of unoperated cataract among 41% of interviewed participants with cataract and SVI. Conclusion : Unoperated cataract was the main curable cause of visual disabilities in tribal population of India. Increasing awareness and offering cataract surgeries at affordable cost in the district would reduce visual disabilities

Social determinants of diabetic retinopathy and impact of sight-threatening diabetic retinopathy: A study from Pune, India

Purpose: Diabetes-related retinopathy is the leading cause of blindness in India. The study was carried out with the purpose of studying the association of sight-threatening diabetic retinopathy (STDR) with socioeconomic factors and demonstrating the impact of STDR on the affected individual. Methods: A mixed methods (quantitative and qualitative) research design was used. The study participants were divided into two groups for quantitative analysis. The control group consisted of non–sight-threatening diabetic retinopathy, whereas the study group consisted of sight-threatening diabetic retinopathy. Apart from demographics, data on comorbidities, type and duration of diabetes mellitus (DM), health insurance status, and socioeconomic data were collected from each individual. A statistical test (Chi-square) was performed to study the association between socioeconomic (SE) classes and STDR. For the qualitative part, a few people were chosen. Face-to-face interviews were conducted in depth. Results: A total of 207 individuals, were recruited, of which 69 had STDR and the remaining 138 had non-STDR. The incidence of STDR was high among patients with lower socioeconomic class (SEC) (upper lower and lower), and univariate analysis revealed a strong association between STDR and SEC, the presence of comorbidities, presence of health insurance, type and duration of DM, and P value <0.05. SEC, in contrast, emerged as an independent risk factor for STDR in multivariate analysis. STDR had a devastating effect on all patients interviewed. The financial impact was most likely the most severe. Conclusion: People with lower SEC are more likely to suffer from STDR-related vision loss. The impact of such vision loss on individuals is multifaceted, including a negative impact on social and work life, psychological well-being, and, most importantly, a significant financial impact