Elimination of avoidable blindness due to cataract: where do we prioritize and how should we monitor this decade?

BACKGROUND: In the final push toward the elimination of avoidable blindness, cataract occupies a position of eminence for the success of the Right to Sight initiative. AIMS: Review existing situation and assess what monitoring indicators may be useful to chart progress towards attaining the goals of Vision 2020. SETTINGS AND DESIGN: Review of published papers from low and middle income countries since 2000. MATERIALS AND METHODS: Published population-based data on prevalence of cataract blindness/visual impairment were accessed and prevalence of cataract blindness/visual impairment computed, where not reported. Data on prevalence of cataract blindness, cataract surgical coverage at different visual acuity cut offs, surgical outcomes, and prevalence of cataract surgery were analyzed. Scatter plots were used to look at relationships of some variables, with Human Development Index (HDI) rank. Available data on Cataract Surgical Rate (CSR) was plotted against prevalence of cataract surgery reported from surveys. RESULTS: Worse HDI Ranks were associated with higher prevalence of cataract blindness. Most studies showed that a significant proportion of the blind were covered by surgery, while a fifth showed that a significant proportion, were operated before they went blind. A good visual outcome after surgery was positively correlated with higher surgical coverage. CSR was positively correlated with cataract surgical coverage. CONCLUSIONS: Cataract surgical coverage is increasing in most countries at vision <3/60 and visual outcomes after cataract surgery are improving. Establishing population-based surveillance of cataract surgical need and performance is a strong monitoring tool and will help program planners immensely

Protocol for process evaluation of a randomised controlled trial of family-led rehabilitation post stroke (ATTEND) in India

Introduction We are undertaking a randomised controlled trial (fAmily led rehabiliTaTion aftEr stroke in INDia, ATTEND) evaluating training a family carer to enable maximal rehabilitation of patients with stroke-related disability; as a potentially affordable, culturally acceptable and effective intervention for use in India. A process evaluation is needed to understand how and why this complex intervention may be effective, and to capture important barriers and facilitators to its implementation. We describe the protocol for our process evaluation to encourage the development of in-process evaluation methodology and transparency in reporting. Methods and analysis The realist and RE-AIM (Reach, Effectiveness, Adoption, Implementation and Maintenance) frameworks informed the design. Mixed methods include semistructured interviews with health providers, patients and their carers, analysis of quantitative process data describing fidelity and dose of intervention, observations of trial set up and implementation, and the analysis of the cost data from the patients and their families perspective and programme budgets. These qualitative and quantitative data will be analysed iteratively prior to knowing the quantitative outcomes of the trial, and then triangulated with the results from the primary outcome evaluation. Ethics and dissemination The process evaluation has received ethical approval for all sites in India. In low-income and middle-income countries, the available human capital can form an approach to reducing the evidence practice gap, compared with the high cost alternatives available in established market economies. This process evaluation will provide insights into how such a programme can be implemented in practice and brought to scale. Through local stakeholder engagement and dissemination of findings globally we hope to build on patient-centred, cost-effective and sustainable models of stroke rehabilitation. Trial registration number CTRI/2013/04/003557

Family-led rehabilitation after stroke in India: the ATTEND trial, study protocol for a randomized controlled trial

Background: Globally, most strokes occur in low- and middle-income countries, such as India, with many affected people having no or limited access to rehabilitation services. Western models of stroke rehabilitation are often unaffordable in many populations but evidence from systematic reviews of stroke unit care and early supported discharge rehabilitation trials suggest that some components might form the basis of affordable interventions in low-resource settings. We describe the background, history and design of the ATTEND trial, a complex intervention centred on family-led stroke rehabilitation in India.Methods/design: The ATTEND trial aims to test the hypothesis that a family-led caregiver-delivered home-based rehabilitation intervention, designed for the Indian context, will reduce the composite poor outcome of death or dependency at 6 months after stroke, in a multicentre, individually randomized controlled trial with blinded outcome assessment, involving 1200 patients across 14 hospital sites in India.Discussion: The ATTEND trial is testing the effectiveness of a low-cost rehabilitation intervention that could be widely generalizable to other low- and middle-income countries

Statistical analysis plan for the family-led rehabilitation after stroke in India (ATTEND) trial: A multicenter randomized controlled trial of a new model of stroke rehabilitation compared to usual care

Background In low- and middle-income countries, few patients receive organized rehabilitation after stroke, yet the burden of chronic diseases such as stroke is increasing in these countries. Affordable models of effective rehabilitation could have a major impact. The ATTEND trial is evaluating a family-led caregiver delivered rehabilitation program after stroke. Objective To publish the detailed statistical analysis plan for the ATTEND trial prior to trial unblinding. Methods Based upon the published registration and protocol, the blinded steering committee and management team, led by the trial statistician, have developed a statistical analysis plan. The plan has been informed by the chosen outcome measures, the data collection forms and knowledge of key baseline data. Results The resulting statistical analysis plan is consistent with best practice and will allow open and transparent reporting. Conclusions Publication of the trial statistical analysis plan reduces potential bias in trial reporting, and clearly outlines pre-specified analyses

Roles and responsibilities in the secondary level eye care model

In any secondary level eye care clinic, a number of tasks must be completed. In different countries and different settings, different people will carry out these tasks. The manager is responsible for ensuring that all the tasks are covered, that people are carefully selected to perform them, and that staff are supported and managed. The International Centre for Advancement of Rural Eye Care (ICARE), within the L.V. Prasad Eye Institute (LVPEI) in India, has evolved an eye care team to provide secondary level eye care services to a population of 0.5 to 1 million. The ICARE model emphasises that all cadres of clinical and non-clinical personnel are equally important. Below is a description of the range of jobs at secondary level centres. The tertiary centre at LVPEI manages leadership and training for this model

Barriers to accessing eye care services among visually impaired populations in rural Andhra Pradesh, South India

<b>Purpose:</b> To understand the reasons why people in rural south India with visual impairment arising from various ocular diseases do not seek eye care. <b> Materials and Methods:</b> A total of 5,573 persons above the age of 15 were interviewed and examined in the South Indian state of Andhra Pradesh covering the districts of Adilabad, West Godavari and Mahaboobnagar. A pre-tested structured questionnaire on barriers to eye care was administered by trained field investigators. <b> Results:</b> Of the eligible subjects, 1234 (22.1&#x0025;, N=5573)) presented with distant visual acuity &#60; 20/60 or equivalent visual field loss in the better eye. Of these, 898 (72.7&#x0025;, N=1234) subjects had not sought treatment despite noticing a decrease in vision citing personal, economic and social reasons. The analysis also showed that the odds of seeking treatment was significantly higher for literates [odds ratio (OR) 1.91, 95&#x0025; confidence interval (CI) 1.38 to 2.65], for those who would be defined as blind by visual acuity category (OR 1.35, 95&#x0025; CI 0.96 to 1.90) and for those with cataract and other causes of visual impairment (OR 1.50, 95&#x0025; CI 1.11 to 2.03). Barriers to seeking treatment among those who had not sought treatment despite noticing a decrease in vision over the past five years were personal in 52&#x0025; of the respondents, economic in 37&#x0025; and social in 21&#x0025;. <b> Conclusion:</b> Routine planning for eye care services in rural areas of India must address the barriers to eye care perceived by communities to increase the utilization of services

Awareness of glaucoma in the rural population of Southern India

PURPOSE: To explore the awareness of glaucoma amongst the rural population of Andhra Pradesh, India. MATERIALS AND METHODS: A total of 7775 subjects of all ages, representative of the rural population of Andhra Pradesh, participated in the Andhra Pradesh Eye Disease Study. The responses of subjects older than 15 years (n = 5573) who completed a structured questionnaire regarding awareness (heard of glaucoma) and knowledge (understanding of disease) of glaucoma formed the basis of this study. RESULTS: Awareness of glaucoma (n = 18; 0.32&#x0025;) was very poor in this rural population, and females were significantly less aware (p = 0.007). Awareness of glaucoma was also significantly less among illiterate persons (p &lt; 0.0001), and socially backward population (p &lt; 0.0001). Majority of the respondents who were aware of glaucoma (n = 10; 55.6&#x0025;) did not know if visual loss due to glaucoma was permanent or reversible. The major source of awareness of glaucoma in this population was TV/magazines and other media followed by information from a relative or acquaintance suffering from the disease. CONCLUSION: Awareness of glaucoma is very poor in the rural areas of southern India. The data suggest the need for community-based health education programmes to increase the level of awareness and knowledge about glaucoma

Color vision devices for color vision deficiency patients:A systematic review and meta-analysis

Abstract Background and Aims There is insufficient evidence to support that using electronic or optical color vision devices improve color perception with current advanced technology. The purpose of this study is to compare and analyze the different color vision devices available for patients with color vision deficiency (CVD) and evaluate whether these devices improved their color perception. Methods This review included randomized, experimental, comparative studies, as well as narrative reviews, prototype and innovation studies, and translational studies, followed by case‐control and clinical trials with nonsurgical interventions studies, that is, electronic color vision devices, optical devices, and contact lens‐based studies, with standardized inclusion and exclusion criteria. Results The primary outcome studied was the performance of color vision devices, both objective and subjective. Secondary outcomes included the ease of use and accessibility of color vision devices and technology. The grading of recommendation, assessment, development, and evaluation framework was used to develop a systematic approach for consideration and clinical practice recommendation for CVD devices for color‐deficient populations. We incorporated meta‐analysis reports from a total of n = 16 studies that met the criteria which consisted of case‐control studies, prototype and innovation studies, comparative studies, pre‐ and post‐clinical trial studies, case studies, and narrative reviews. Proportion and standard errors, as well as correlations, were calculated from the meta‐analysis for various available color vision devices. Conclusion This review concludes that commercially available color vision devices, such as EnChroma Glasses, Chromagen filters, and EnChroma Cx‐14 do not provide clinically significant evidence that subjective color perception has improved. As a result, recommending these color vision devices to the CVD population may not prove high beneficial/be counterproductive. However, only a few color shades can be perceived differently. This systematic review and analysis will aid future research and development in color vision devices