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Meeting the Need for Corrective Spectacles in Visually Impaired

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Meeting the Need for Corrective Spectacles in Visually Impaired Clinical science Br J Ophthalmol: first published as 10.1136/bjophthalmol-2018-312262 on 2 October 2018. Downloaded from Meeting the need for corrective spectacles in visually impaired Chinese school children: the potential of ready-made spectacles Zhuoting Zhu,1 Leon B Ellwein,2 Sean K Wang,3 Jialiang Zhao,4 Mingguang He1,5 ► Additional material is ABSTRact Refractive error correction has been a priority published online only. To view Purpose To assess the potential of ready-made for the WHO’s Vision 2020: The Right to Sight please visit the journal online (spherical) spectacles (RMS) in meeting the need for global campaign to eliminate global visual impair- (http:// dx. doi. org/ 10. 1136/ 6 bjophthalmol- 2018- 312262). refractive correction in visually impaired children in ment and blindness. Although the treatment of China. URE with spectacles is straightforward, high costs 1 State Key Laboratory of Methods Eligible children aged 5–17 years were and poor access to refractive services limit universal Ophthalmology, Zhongshan correction. School-based screenings and spectacles Ophthalmic Center, Sun Yat-sen identified from the three study sites in China. Distance University, Guangzhou, China visual acuity was measured with a retroilluminated distribution programmes have become increasingly 7 2National Eye Institute, National logarithm of the minimum angle of resolution chart with common in recent years, some of which have used Institutes of Health, Bethesda, tumbling E optotypes. Cycloplegic autorefraction was ready-made spectacles (RMS) that provide equal Maryland, USA spherical correction in each eye8–10 and can be 3Harvard Medical School, performed on all children using a handheld autorefractor. Boston, Massachusetts, USA If uncorrected visual acuity (UCVA) was ≤20/40 in either made in bulk at low costs. 4Chinese Academy of Medical eye, best corrected visual acuity was measured with In practice, the main limitations excluding RMS Sciences, Peking Union Medical subjective refractive error. as a suitable option for refraction correction are College Hospital, Beijing, China 5 Results A total of 13 702 children were enumerated the extents of astigmatism and anisometropia. Department of Surgery, Centre Studies have postulated that RMS could meet the for Eye Research Australia; from the three studies, with 12 334 (90.0%) having Ophthalmology, University of both reliable visual acuity measurements and successful needs of 66%–89% of adults requiring refractive 11–13 Melbourne, Melbourne, Victoria, cycloplegia. Among the 12 334 study children, the correction with acceptability in visual function, 9 10 Australia prevalence of UCVA ≤20/40 in the better seeing eye patient satisfaction and continued use. However, was 16.4% (95% CI 15.0% to 17.8%), with 91.1% little information is available regarding the poten- Correspondence to (1843) of these improving by ≥3 lines of visual acuity tial percentage of children with refractive error Dr Mingguang He, Zhongshan who could benefit from RMS. Among the studies Ophthalmic Center, People’s with refractive correction. Prevalence was 12.7% (95% Republic of China, Guangzhou CI 11.5% to 13.9%) for UCVA <20/50 with 97.4% that have been performed examining RMS in chil- 510060, China; mingguanghe@ (1521) improving by ≥3 lines, and 9.38% (95% CI dren, the criteria for suitability of RMS have varied, gmail. com and Professor 8.39% to 19.4%) for UCVA ≤20/63 with 98.4% (1138) ranging from astigmatism less than 0.75 to 1.25 Jialiang Zhao, Chinese Academy dioptres (D) and anisometropia less than 0.50 to of Medical Sciences, Peking improving by ≥3 lines. Depending on the severity of 9–14 Union Medical College Hospital, visual impairment, 62.8%–64.0% of children could 2.00 D. The extent to which anisometropia and http://bjo.bmj.com/ Beijing, China; 13501132676@ astigmatism are tolerated also differed considerably be accommodated with RMS if not correcting for 15 163. com astigmatism of ≤0.75 dioptres and anisometropia of among individuals. To date, there are no reliable ≤0.50 spherical equivalent dioptres. Approximately estimates of the acceptability of RMS in meeting the Received 16 March 2018 need for refractive spectacles under different levels Revised 8 August 2018 87% of children could be accommodated with RMS if Accepted 30 August 2018 astigmatism and anisometropia limits were increased to of anisometropia and astigmatism. ≤1.25 and ≤1.50 dioptres, respectively. This article used cross-sectional data from three on September 30, 2021 by guest. Protected copyright. Conclusions RMS could substantially alleviate visual study sites in China to examine the suitability of RMS for meeting the need for spectacles in visually morbidity in two-thirds or more of visually impaired impaired children aged 5–17 years. schoolchildren in China. This cost-effective approach to refractive correction might also be useful in low/middle- income countries with poor access to optometric services. METHODS Study population This cross-sectional study used population-based data from two of the original eight survey sites © Author(s) (or their INTRODUCTION of the Refractive Error Study in Children (RESC) employer(s)) 2018. Re-use Visual impairment poses substantial public health study: Shunyi District,16 a semirural area outside permitted under CC BY-NC. No issues in children. According to the World Health of Beijing in northern China, and Guangzhou,17 commercial re-use. See rights Organization (WHO), approximately 19 million a large metropolis in southern China; as well as and permissions. Published 18 by BMJ. children aged 5–15 years suffer from visual impair- school-based data from rural Yangxi County. For ment, with nearly 12.8 million cases attributable Shunyi and Guangzhou, the study sampling frames To cite: Zhu Z, Ellwein LB, to uncorrected refractive error (URE)1 and half were constructed using geographically defined clus- Wang SK, et al. 2 Br J Ophthalmol Epub ahead of them residing in China. The global economic ters based on local register census data. For Yangxi of print: [please include Day burden of URE has been estimated to be $269 County, stratified cluster sampling frames were Month Year]. doi:10.1136/ billion,3 with a disproportionate impact on individ- constructed through enumeration of grade-specific bjophthalmol-2018-312262 uals living in low/middle-income countries.4 5 classes within 17 county schools. The RESC surveys Zhu Z, et al. Br J Ophthalmol 2018;0:1–6. doi:10.1136/bjophthalmol-2018-312262 1 Clinical science Br J Ophthalmol: first published as 10.1136/bjophthalmol-2018-312262 on 2 October 2018. Downloaded from were conducted in children aged 5–15 years with different ethnic calculated as the ratio of the number of children within accept- origins and environments using a standardised study protocol. able limits to the total number of visually impaired children The Yangxi County study investigated refractive error and visual needing refractive correction. impairment in children aged 13–17 years using the standardised Statistical analyses were performed using Stata Statistical RESC protocol. Details of the RESC and Yangxi County enumer- Software (Stata V.12.0, StataCorp, College Station, TX). CI ation methods have been described elsewhere.16–18 and p values (significant at the 0.05 level) for prevalence esti- The RESC and Yangxi County studies adhered to the tenets mates and regression models were calculated with adjustment of the Declaration of Helsinki. A guardian for each child was for clustering effects associated with the sampling design based informed of the study details and asked to provide signed, on a ratio (deff) comparing the actual variance estimate with informed consent. that obtained through simple random sampling. (Using the Stata svyset command, study sites were declared as strata and clus- Visual acuity and cycloplegic refraction ters as primary sampling units, and estimation commands were Distance visual acuity was measured at 4 m using a retroillumi- adjusted for clustering effects with the Stata svy: prefix.) nated logarithm of the minimum angle of resolution chart with five tumbling E optotypes on each line (Precision Vision, La RESUltS Salle, Illinois, USA), ranging from −0.30 to 1.00. Cycloplegia Study population was induced with two drops of 1% cyclopentolate, administered A total of 13 702 children were enumerated (Shunyi: 6134, 5 min apart, with a third drop administered after 20 min. Cyclo- Guangzhou: 5053 and Yangxi: 2515), with 12 641 (92.3%) plegia and pupil dilation were evaluated after an additional 15 having reliable visual acuity measurements in one or both eyes min. Cycloplegia was recorded as being present if pupils were and an ocular examination. Successful cycloplegic refraction dilated over 6 mm or light reflex was absent. Cycloplegic autore- in both eyes was not available for 307 of the examined chil- fraction was performed on all children using a handheld autore- dren, leaving a total of 12 334 (90.0%) children in the study fractor (ARK-30, Nidek). If uncorrected visual acuity (UCVA) population. was ≤20/40 in either eye, best corrected visual acuity (BCVA) Demographic characteristics of the study population within was measured with subjective refraction. each of the three study sites are shown in online supplementary table 1. Shunyi and Guangzhou, with children aged 5–15 years, Data analysis comprised 47.5% and 35.0% of the total study sample, respec- The prevalence of uncorrected visual impairment was calculated tively. Yangxi, with children aged 13–17 years, comprised 17.5% using three levels of severity in the better seeing eye: ≤20/40, of the study sample. ≤20/50 and ≤20/63. The association of age, gender and study site with each of the three levels of vision impairment was inves- tigated with multiple logistic regression. Vision impairment The need for corrective spectacles was separately defined The prevalence of UCVA in the better seeing eye by age across as either ≥2 or ≥3 lines of visual acuity improvement in the all three sites is shown in table 1.
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