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Abstract Few metrics exist to describe phenotypic diversity within ophthalmic imaging datasets, with researchers often using ethnicity as a surrogate marker for biological variability. We derived a continuous, measured metric, the retinal pigment score (RPS), that quantifies the degree of pigmentation from a colour fundus photograph of the eye. RPS was validated using two large epidemiological studies with demographic and genetic data (UK Biobank and EPIC-Norfolk Study) and reproduced in a Tanzanian, an Australian, and a Chinese dataset. A genome-wide association study (GWAS) of RPS from UK Biobank identified 20 loci with known associations with skin, iris and hair pigmentation, of which eight were replicated in the EPIC-Norfolk cohort. There was a strong association between RPS and ethnicity, however, there was substantial overlap between each ethnicity and the respective distributions of RPS scores. RPS decouples traditional demographic variables from clinical imaging characteristics. RPS may serve as a useful metric to quantify the diversity of the training, validation, and testing datasets used in the development of AI algorithms to ensure adequate inclusion and explainability of the model performance, critical in evaluating all currently deployed AI models. The code to derive RPS is publicly available at: https://github.com/uw-biomedical-ml/retinal-pigmentation-score .

Introduction Only 30%–50% of people referred to clinics during community-based eye screening are able to access care in Botswana, India, Kenya and Nepal. The access rate is even lower for certain population groups. This platform trial aims to test multiple, iterative, low-risk public health interventions and simple service modifications with a series of individual randomised controlled trials (RCT) conducted in each country, with the aim of increasing the proportion of people attending.Methods and analysis We will set up a platform trial in each country to govern the running of a series of pragmatic, adaptive, embedded, parallel, multiarm, superiority RCTs to test a series of service modifications suggested by intended service users. The aim is to identify serial marginal gains that cumulatively result in large improvements to equity and access. The primary outcome will be the probability of accessing treatment among the population group with the worst access at baseline. We will calculate Bayesian posterior probabilities of clinic attendance in each arm every 72 hours. Each RCT will continually recruit participants until the following default stopping rules have been met: >95% probability that one arm is best; >95% probability that the difference between the best arm and the arms remaining in the trial is

Background Our research team conducted phenomenological interviews in Kenya with people who were not able to access community eye health services, aiming to explore the barriers and ideas for potential service modifications. We conducted an embedded study that compared in-person and telephone interview modalities in terms of time requirements, costs, and data richness. Methods A team of six interviewers conducted 31 in-person interviews and 31 telephone interviews using the same recruitment strategy, topic guide, and analytic matrix for each interview. We compared the mean duration; mean number of themes reported by each participant; total number of themes reported; interviewer rating of perceived richness; interviewer rating of perceived ease of building rapport; number of days taken by the team to complete all interviews; and all costs associated with conducting the interviews in each modality. Results In-person interviews were 44% more expensive and took 60% longer to complete than our telephone interviews (requiring 5 days and 3 days respectively). The average in-person interview lasted 110 seconds longer than the average telephone interview ( p = .05) and generated more words and themes. However, the full set of interviews from both approaches identified similar numbers of barriers ( p = .14) and the same number of solutions ( p = .03). Interviewers universally felt that the in-person approach was associated with better rapport and higher quality data ( p = .01). Triangulation of themes revealed good agreement, with 88% of all solutions occurring in both sets of interviews, and no areas of thematic dissonance. Conclusions The in-person approach required more time and financial resources, but generated more words and themes per person, and was perceived to afford richer data by interviewers. However, this additional richness did not translate into a greater number of themes that our team can act upon to improve services.

Introduction Access to care varies by sociodemographic group, with some groups facing higher barriers to care than others. This study will use novel methods to explore barriers and potential solutions as perceived by members of the population groups who are least able to access care. We aim to use rapid yet robust mixed methods that allow us to identify generalisable findings within each programme and testable service modifications to improve equitable access to care; delivering non-tokenistic findings within a matter of weeks.Methods and analysis This is a multiphased exploratory sequential mixed methods study. We will use the same approach in four different screening programmes, in Botswana, India, Kenya and Nepal. First, we will conduct interviews with people purposively selected from the sociodemographic subgroups with the lowest odds of accessing care within each programme. We will explore their perceptions of barriers and potential service modifications that could boost attendance at eye clinics among people from these ‘left-behind’ groups. We will use a deductive analytic matrix to facilitate the rapid analysis of qualitative data. Space will be made for the inductive identification of themes that are not necessarily captured in the framework. Sample size will be determined by thematic saturation. Next, we will conduct a survey with a representative sample of non-attenders from the same left-behind groups, asking them to rank each suggested service modification by likely impact. Finally, we will convene a multistakeholder workshop to assess each service modification based on ranking, likely impact, feasibility, cost and potential risks. The most promising service modifications will be implemented and evaluated in a follow-on randomised controlled trial, the methods for which will be reported elsewhere.Ethics and dissemination This project has been approved by independent research ethics committees in Botswana, Kenya, India, Nepal and the UK. We will disseminate our findings through local community advisory boards, national eye screening meetings, in peer-reviewed journals and at conferences.

Objective The aim of this study was to assess the prevalence of diabetic retinopathy (DR) and retina screening coverage among people with diabetes in the catchment area of a high-volume eye care organisation in north India.Design A population-based cross-sectional study using Rapid Assessment of Avoidable Blindness survey, including the DR module.Setting A customised rural district in the catchment of Dr Shroff’s Charity Eye Hospital in Uttar Pradesh in north India.Participants 4095 people of age 50 years and above were enrolled using a two-staged cluster sampling, 3867 (94.4%) participated; 2167 (52.9%) were women. 3803 of 4095 (92.9%) participants were assessed for diabetes. People with already diagnosed diabetes and anyone with a random blood glucose ≥200 mg/dL were offered dilated fundus examination.Primary and secondary outcomes Primary and secondary outcomes were the prevalence of DR and screening coverage for DR, respectively.Results The prevalence of diabetes was 7.0% (95% CI 5.9% to 8.0%). 50.2% of all people with diabetes were newly detected. The prevalence of any DR among people with diabetes who consented to dilated pupillary examination was 22.8% (51 of 224), (95% CI 18.2% to 27.3%). 5.8% (13/224) of people with diabetes were found to have sight-threatening DR and only 15.4% (2/13) had received treatment. 84.8% of people with previously diagnosed diabetes had never had their eyes tested for DR; this was significantly higher in women (90.2% vs 76.0%, respectively, p10 years and poor glycaemic control (OR of 1.8 and 1.6, respectively), but this was not found to be statistically significant.Conclusion The prevalence of DR in this predominantly rural setting was found to be higher than the national average. Coverage of retinal screening and treatment was found to be very low. Working with general health providers to increase detection of people with diabetes and leveraging vision centres to improve DR screening coverage is needed in this region.

Abstract Background Over 80% of blindness in Kenya is due to curable or preventable causes and 7.5 m Kenyans currently need eye services. Embedding sociodemographic data collection into screening programmes could help identify the groups facing systematic barriers to care. We aimed to determine the sociodemographic characteristics that were associated with access among patients diagnosed with an eye problem and referred for treatment in the Vision Impact Programme, currently operating in Meru County. Method We used an embedded, pragmatic, cross-sectional design. A list of sociodemographic questions was developed with input from key stakeholders. The final question set included the following domains: age, gender, religion, marital status, disability, education, occupation, income, housing, assets, and health insurance. These were integrated into an app that is used to screen, refer, and check-in (register) participants within a major eye screening programme. We gathered data from 4,240 people who screened positive and were referred to their local outreach treatment clinic. We used logistic regression to identify which groups were facing the greatest barriers to accessing care. Results A quarter of those screened between April – July 2023 were found to have an eye problem and were referred, however only 46% of these people were able to access care. In our fully adjusted model, at the 0.05 level there were no statistically significant differences in the odds of attendance within the domains of disability, health insurance, housing, income, or religion. Strong evidence (p

Abstract Background The purpose of this study was to quantify how much of the burden of visual impairment (VI) and unmet need in Talagang, identified by Rapid Assessment of Avoidable Blindness (RAAB) survey data, has been addressed by Community Eye Health (CEH) programme efforts. Methods A RAAB survey was carried out in November 2018, with 2,824 participants in Talagang Tehsil, Punjab, Pakistan, aged 50 and over. Census data were used to extrapolate survey data to the population. Alongside this, a CEH programme was launched, consisting of community eye screening, and onward referral to rural health centres, secondary or tertiary ophthalmological services, as required. This health intervention aimed to address the eye care needs surfaced by the initial survey. From 2018 to 2022, 30,383 people aged 50 or over were screened; 14,054 needed referral to further steps of the treatment pathway and more detailed data collection. Programme data were compared to estimates of population unmet needs. Main outcome measures were prevalence of VI, and proportion of need met by CEH Programme, by cause and level of VI. Results Among those aged 50 and over, 51.0% had VI in at least one eye. The leading causes were cataract (46.2%) and uncorrected refractive error (URE) (25.0%). In its first four years, the programme reached an estimated 18.3% of the unmet need from cataract, and 21.1% of URE, equally in both men and women. Conclusions Robustly collected survey and programme data can improve eye health planning, monitoring and evaluation, address inequities, and quantify the resources required for improving eye health. This study quantifies the time required to reach eye health needs at the community level.

Our research team is conducting phenomenological interviews with people who have not been able to access health services in Meru County, Kenya, aiming to explore the barriers they face and their perceptions of how we could modify our community outreach services to improve accessibility. We plan to conduct an embedded study that compares in-person and telephone interview modalities in terms of the richness of the data and the resources required for each modality. This is a qualitative mode comparison study, embedded within a broader project to understand and address the issues that lead to inequitable access to local outreach clinics in Kenya. We will recruit at least 40 people who have been referred to local services but who have not been able to attend. We will conduct in-person interviews with half of these people, and telephone interviews with the other half. We will use random numbers to determine the modality that is used for each participant. All interviews will be conducted in the same month by a team of six research assistants who will use the same topic guide and analytic matrix for each interview. For all interviews conducted in each mode we will record and compare the mean duration; mean number of themes reported by each participant; total number of themes reported; interviewer rating of perceived richness; interviewer rating of perceived ease of building rapport; number of days taken by the team to complete all interviews; and all costs associated with conducting the interviews. The findings will help us to weigh up the relative strengths and weaknesses of each modality for our research context. Given that we are exploring a focused research question in a fairly homogenous population, we anticipate that there may not be a meaningful difference in the number of themes reported.

The Rapid Assessment of Avoidable Blindness (RAAB) is a population-based cross-sectional survey methodology used to collect data on the prevalence of vision impairment and its causes and eye care service indicators among the population 50 years and older. RAAB has been used for over 20 years with modifications to the protocol over time reflected in changing version numbers; this paper describes the latest version of the methodology–RAAB7. RAAB7 is a collaborative project between the International Centre for Eye Health and Peek Vision with guidance from a steering group of global eye health stakeholders. We have fully digitised RAAB, allowing for fast, accurate and secure data collection. A bespoke Android mobile application automatically synchronises data to a secure Amazon Web Services virtual private cloud when devices are online so users can monitor data collection in real-time. Vision is screened using Peek Vision’s digital visual acuity test for mobile devices and uncorrected, corrected and pinhole visual acuity are collected. An optional module on Disability is available. We have rebuilt the RAAB data repository as the end point of RAAB7’s digital data workflow, including a front-end website to access the past 20 years of RAAB surveys worldwide. This website (https://www.raab.world) hosts open access RAAB data to support the advocacy and research efforts of the global eye health community. Active research sub-projects are finalising three new components in 2024-2025: 1) Near vision screening to address data gaps on near vision impairment and effective refractive error coverage; 2) an optional Health Economics module to assess the affordability of eye care services and productivity losses associated with vision impairment; 3) an optional Health Systems data collection module to support RAAB’s primary aim to inform eye health service planning by supporting users to integrate eye care facility data with population data.

Abstract Background Health inequalities are ubiquitous, and as countries seek to expand service coverage, they are at risk of exacerbating existing inequalities unless they adopt equity-focused approaches to service delivery. Main text Our team has developed an equity-focused continuous improvement model that reconciles prioritisation of disadvantaged groups with the expansion of service coverage. Our new approach is based on the foundations of routinely collecting sociodemographic data; identifying left-behind groups; engaging with these service users to elicit barriers and potential solutions; and then rigorously testing these solutions with pragmatic, embedded trials. This paper presents the rationale for the model, a holistic overview of how the different elements fit together, and potential applications. Future work will present findings as the model is operationalised in eye-health programmes in Botswana, India, Kenya, and Nepal. Conclusion There is a real paucity of approaches for operationalising equity. By bringing a series of steps together that force programme managers to focus on groups that are being left behind, we present a model that can be used in any service delivery setting to build equity into routine practice.

Background: The advancement of universal health coverage (UHC) is largely based on identifying and addressing barriers to accessing community health services. Traditional qualitative research approaches provide excellent insights but have unfeasibly high resource requirements for most care providers. Aim: To identify, categorise, and evaluate methods that have been used to identify barriers to and/or solutions for improving access to community-based health services, grounded in engagement with affected communities, excluding approaches that take >14 days. Design & setting: This was a scoping review. Method: Following Joanna Briggs Institute (JBI) guidelines, a search was undertaken using the Cochrane Library, Ovid MEDLINE, Ovid Embase, Ovid Global Health, and Google Scholar. An information specialist designed the search, and dual independent review and data charting were used. Results: In total, 44 studies were included from 30 countries, reporting on 18 different clinical services. Thirty studies used self-described ‘rapid’ approaches; however, the majority of these did not justify what they meant by this term. Nearly half of the studies used mixed- or multi-methods and triangulation to verify early findings. All of the qualitative studies used interviews and/or focus groups, which were often supplemented with observations, document review, and mapping activities. The use of in situ snowball and convenience sampling; community members as data collectors and cultural guides; collaborative summarisation (review of findings with community members and end-users); and deductive framework analysis expedited the research processes. There were no data on costs. Conclusion: There are a wide range of methods that can be used to deliver timely information about barriers to access. The methods employed in the articles reviewed tended to use traditional data collection approaches in innovative ways.

Background Attendance rates for eye clinics are low across low- and middle-income countries (LMICs) and exhibit marked sociodemographic inequalities. We aimed to quantify the association between a range of sociodemographic domains and attendance rates from vision screening in programmes launching in Botswana, India, Kenya and Nepal. Methods We performed a literature review of international guidance on sociodemographic data collection. Once we had identified 13 core candidate domains (age, gender, place of residence, language, ethnicity/tribe/caste, religion, marital status, parent/guardian status, place of birth, education, occupation, income, wealth) we held workshops with researchers, academics, programme implementers, and programme designers in each country to tailor the domains and response options to the national context, basing our survey development on the USAID Demographic and Health Survey model questionnaire and the RAAB7 eye health survey methodology. The draft surveys were reviewed by health economists and piloted with laypeople before being finalised, translated, and back-translated for use in Botswana, Kenya, India, and Nepal. These surveys will be used to assess the distribution of eye disease among different sociodemographic groups, and to track attendance rates between groups in four major eye screening programmes. We gather data from 3,850 people in each country and use logistic regression to identify the groups that experience the worst access to community-based eye care services in each setting. We will use a secure, password protected android-based app to gather sociodemographic information. These data will be stored using state-of-the art security measures, complying with each country’s data management legislation and UK law. Discussion This low-risk, embedded, pragmatic, observational data collection will enable eye screening programme managers to accurately identify which sociodemographic groups are facing the highest systematic barriers to accessing care at any point in time. This information will be used to inform the development of service improvements to improve equity.

Abstract Background Eye conditions in children can have negative consequences on visual functioning and quality of life. There is a lack of data on the magnitude of children with eye conditions who need services for effective planning of school eye health programmes. To address this, the School Eye Health Rapid Assessment (SEHRA) tool is being developed to collect data to support school eye health programme planning. Methods The module, ‘the magnitude and nature of local needs in school children’ is the first of six modules in the SEHRA tool. The module outlines a school-based cluster survey designed to determine the magnitude of eye health needs in children. This paper outlines the survey sampling strategy, and sample size calculations. Results The requirements for the SEHRA survey indicate that in regions where a larger sample size is required, or where fewer schools are recruited to the survey, confidence in the accuracy of the data will be lower. Conclusions The SEHRA survey module ‘the magnitude and nature of local needs in school children’ can be applied in any context. In certain circumstances, the confidence in the survey data will be reduced.

Abstract Background Clinic non-attendance rates are high across the African continent. Emerging evidence suggests that phone-based reminder messages could make a small but important contribution to reducing non-attendance. We will use behavioural economics principles to develop an SMS and voice reminder message to improve attendance rates in a school-based eye screening programme in Botswana. Methods We will test a new theory-informed SMS and voice reminder message in a national school-based eye screening programme in Botswana. The control will be the standard SMS message used to remind parents/guardians to bring their child for ophthalmic assessment. All messages will be sent twice. The primary outcome is attendance for ophthalmic assessment. We will use an automated adaptive approach, starting with a 1:1 allocation ratio. Discussion As far as we are aware, only one other study has used behavioural economics to inform the development of reminder messages to be deployed in an African healthcare setting. Our study will use an adaptive trial design, embedded in a national screening programme. Our approach can be used to trial other forms of reminder message in the future. Trial registration ISRCTN 96528723 . Registered on 5 January 2022.

Objectives Low attendance rates for community health services reflect important barriers that prevent people from receiving the care they need. Services and health systems that seek to advance Universal Health Coverage need to understand and act on these factors. Formal qualitative research is the best way to elicit barriers and identify potential solutions, however traditional approaches take months to complete and can be very expensive. We aim to map the methods that have been used to rapidly elicit barriers to accessing community health services and identify potential solutions.Methods and analysis We will search MEDLINE, Embase, the Cochrane Library and Global Health for empirical studies that use rapid methods (

Objective Monitoring health outcomes disaggregated by socioeconomic position (SEP) is crucial to ensure no one is left behind in efforts to achieve universal health coverage. In eye health planning, rapid population surveys are most commonly implemented; these need an SEP measure that is feasible to collect within the constraints of a streamlined examination protocol. We aimed to assess whether each of four SEP measures identified inequality—an underserved group or socioeconomic gradient—in key eye health outcomes.Design Population-based cross-sectional survey.Participants A subset of 4020 adults 50 years and older from a nationally representative sample of 9188 adults aged 35 years and older in The Gambia.Outcome measures Blindness (presenting visual acuity (PVA)

BackgroundOver one billion people worldwide live with avoidable blindness or vision impairment. Eye Health Programmes tackle this by providing screening, primary eye care, refractive correction, and referral to hospital eye services. One point where patients can be lost in the treatment journey is adherence to hospital referral.ContextPeek Vision's software solutions have been used in Pakistan with the goal of increasing eye health programme coverage and effectiveness. This involved collaboration between health system stakeholders, international partners, local community leaders, social organizers and “Lady Health Workers”.ResultsFrom the beginning of the programmes in November 2018, to the end of December 2021, 393,759 people have been screened, 26% of whom (n = 101,236) needed refractive services or secondary eye care, and so were referred onwards to the triage centers or hospital services. Except for a short period affected heavily by COVID-19 pandemic, the programmes reached an increasing number of people over time: screening coverage improved from 774 people per month to over 28,300 people per month. Gathering and discussing data regularly with stakeholders and implementers has enabled continuous improvement to service delivery. The quality of screening and adherence to hospital visits, gender balance differences and waiting time to hospital visits were also improved. Overall attendance to hospital appointments improved in 2020 compared to 2019 from 45% (95% CI: 42–48%) to 78% (95% CI: 76–80%) in women, and from 48% (95% CI: 45–52%) to 70% (95% CI: 68–73%) in men. These patients also accessed treatment more quickly: 30-day hospital referral adherence improved from 12% in 2019 to 66% in 2020. This approach helped to utilize refractive services more efficiently, reducing false positive referrals to triage from 10.6 to 5.9%. Hospital-based services were also utilized more efficiently, as primary eye care services and refractive services were mainly delivered at the primary healthcare level.DiscussionDespite various challenges, we demonstrate how data-driven decisions can lead to health programme systems changes, including patient counseling and appointment reminders, which can effectively improve adherence to referral, allowing programmes to better meet their community's needs.

Background: Attendance rates for eye clinics are low across low- and middle-income countries (LMICs) and exhibit marked sociodemographic (SD) inequalities. We aimed to quantify the association between a range of SD domains and attendance rates from vision screening in programmes launching in Botswana, Kenya and Nepal. Methods: We will develop a set of sociodemographic questions and introduce them into routine community-based eye screening programmes in Kenya, Botswana and Nepal, targeting children aged 5-18 years and adults. Our study design is a rolling survey, embedded within the Peek screening programme. The sociodemographic questions will be asked of 10% of all those presenting to be screened, and 100% of those identified with an eye problem. We will also collect data on whether people referred to ophthalmic clinic for treatment or further assessment attended, and we will use logistic regression to report odds ratios for this outcome attendance) for each socioeconomic domain in each country. We hypothesise that attendance rates will be lowest among marginalised sociodemographic groups such as older, less educated, less wealthy women. To identify the most appropriate sociodemographic items we will perform a literature review, and then hold workshops with researchers, academics, programme implementers, and programme designers in each country to tailor the domains and response options to the national context. We will report outcome data at 6 and 12 months, identifying the groups facing the highest barriers to access. Discussion: This low-risk, embedded, pragmatic, observational data collection will enable eye screening programme managers to accurately identify which sociodemographic groups are facing the highest systematic barriers to accessing care at any point in time. This information will be used to inform the development of service improvements to improve equity.

Summary: Vision impairment (VI) can have wide ranging economic impact on individuals, households, and health systems. The aim of this systematic review was to describe and summarise the costs associated with VI and its major causes. We searched MEDLINE (16 November 2019), National Health Service Economic Evaluation Database, the Database of Abstracts of Reviews of Effects and the Health Technology Assessment database (12 December 2019) for partial or full economic evaluation studies, published between 1 January 2000 and the search dates, reporting cost data for participants with VI due to an unspecified cause or one of the seven leading causes globally: cataract, uncorrected refractive error, diabetic retinopathy, glaucoma, age-related macular degeneration, corneal opacity, trachoma. The search was repeated on 20 January 2022 to identify studies published since our initial search. Included studies were quality appraised using the British Medical Journal Checklist for economic submissions adapted for cost of illness studies. Results were synthesized in a structured narrative. Of the 138 included studies, 38 reported cost estimates for VI due to an unspecified cause and 100 reported costs for one of the leading causes. These 138 studies provided 155 regional cost estimates. Fourteen studies reported global data; 103/155 (66%) regional estimates were from high-income countries. Costs were most commonly reported using a societal (n = 48) or healthcare system perspective (n = 25). Most studies included only a limited number of cost components. Large variations in methodology and reporting across studies meant cost estimates varied considerably. The average quality assessment score was 78% (range 35–100%); the most common weaknesses were the lack of sensitivity analysis and insufficient disaggregation of costs. There was substantial variation across studies in average treatment costs per patient for most conditions, including refractive error correction (range $12–$201 ppp), cataract surgery (range $54–$3654 ppp), glaucoma (range $351–$1354 ppp) and AMD (range $2209–$7524 ppp). Future cost estimates of the economic burden of VI and its major causes will be improved by the development and adoption of a reference case for eye health. This could then be used in regular studies, particularly in countries with data gaps, including low- and middle-income countries in Asia, Eastern Europe, Oceania, Latin America and sub-Saharan Africa.

Introduction Gathering data on socioeconomic status (SES) is a prerequisite for any health programme that aims to assess and improve the equitable distribution of its outcomes. Many different modalities can be used to collect SES data, ranging from (1) face-to-face elicitation, to (2) telephone-administered questionnaires, to (3) automated text message-based systems. The relative costs and perceived benefits to patients and providers of these different data collection approaches is unknown. This protocol is for a systematic review that aims to compare the resource requirements, performance characteristics, and acceptability to participants and service providers of these three approaches to collect SES data from those enrolled in health programmes.Methods and analysis An information specialist will conduct searches on the Cochrane Library, MEDLINE, Embase, Global Health, ClinicalTrials.gov, the WHO ICTRP and OpenGrey. All databases will be searched from 1999 to present with no language limits used. We will also search Google Scholar and check the reference lists of relevant articles for further potentially eligible studies. Any empirical study design will be eligible if it compares two or more modalities to elicit SES data from the following three; in-person, voice call, or automated phone-based systems. Two reviewers will independently screen titles, abstracts and full-text articles; and complete data extraction. For each study, we will extract data on the modality characteristics, primary outcomes (response rate and equivalence) and secondary outcomes (time, costs and acceptability to patients and providers). We will synthesise findings thematically without meta-analysis.Ethics and dissemination Ethical approval is not required, as our review will include published and publicly accessible data. This review is part of a project to improve equitable access to eye care services in low-ioncome and middle-income countries. However, the findings will be useful to policy-makers and programme managers in a range of health settings and non-health settings. We will publish our findings in a peer-reviewed journal and develop an accessible summary of results for website posting and stakeholder meetings.PROSPERO registration number CRD42021251959.

Summary: Background: We undertook a Grand Challenges in Global Eye Health prioritisation exercise to identify the key issues that must be addressed to improve eye health in the context of an ageing population, to eliminate persistent inequities in health-care access, and to mitigate widespread resource limitations. Methods: Drawing on methods used in previous Grand Challenges studies, we used a multi-step recruitment strategy to assemble a diverse panel of individuals from a range of disciplines relevant to global eye health from all regions globally to participate in a three-round, online, Delphi-like, prioritisation process to nominate and rank challenges in global eye health. Through this process, we developed both global and regional priority lists. Findings: Between Sept 1 and Dec 12, 2019, 470 individuals complete round 1 of the process, of whom 336 completed all three rounds (round 2 between Feb 26 and March 18, 2020, and round 3 between April 2 and April 25, 2020) 156 (46%) of 336 were women, 180 (54%) were men. The proportion of participants who worked in each region ranged from 104 (31%) in sub-Saharan Africa to 21 (6%) in central Europe, eastern Europe, and in central Asia. Of 85 unique challenges identified after round 1, 16 challenges were prioritised at the global level; six focused on detection and treatment of conditions (cataract, refractive error, glaucoma, diabetic retinopathy, services for children and screening for early detection), two focused on addressing shortages in human resource capacity, five on other health service and policy factors (including strengthening policies, integration, health information systems, and budget allocation), and three on improving access to care and promoting equity. Interpretation: This list of Grand Challenges serves as a starting point for immediate action by funders to guide investment in research and innovation in eye health. It challenges researchers, clinicians, and policy makers to build collaborations to address specific challenges. Funding: The Queen Elizabeth Diamond Jubilee Trust, Moorfields Eye Charity, National Institute for Health Research Moorfields Biomedical Research Centre, Wellcome Trust, Sightsavers, The Fred Hollows Foundation, The Seva Foundation, British Council for the Prevention of Blindness, and Christian Blind Mission. Translations: For the French, Spanish, Chinese, Portuguese, Arabic and Persian translations of the abstract see Supplementary Materials section.

Achieving The United Nations sustainable developments goals by 2030 will be a challenge. Researchers around the world are working toward this aim across the breadth of healthcare. Technology, and more especially artificial intelligence, has the ability to propel us forwards and support these goals but requires careful application. Artificial intelligence shows promise within healthcare and there has been fast development in ophthalmology, cardiology, diabetes, and oncology. Healthcare is starting to learn from commercial industry leaders who utilize fast and continuous testing algorithms to gain efficiency and find the optimum solutions. This article provides examples of how commercial industry is benefitting from utilizing AI and improving service delivery. The article then provides a specific example in eye health on how machine learning algorithms can be purposed to drive service delivery in a resource-limited setting by utilizing the novel study designs in response adaptive randomization. We then aim to provide six key considerations for researchers who wish to begin working with AI technology which include collaboration, adopting a fast-fail culture and developing a capacity in ethics and data science.

Two national surveys of vision impairment and blindness were undertaken in The Gambia in 1986 and 1996. These provided data for the inception of The Gambia’s National Eye Health Programme (NEHP) within the Ministry of Health and Social Welfare. There have been important developments in the eye health services provided by the NEHP in the last 20 years. At the same time, the population has also undergone major demographic changes that may have led to substantial changes in the burden of eye disease. We conducted a National Eye Health Survey of vision impairment, blindness and its comorbidities in adults in The Gambia in 2019. We examined a nationally representative population-based sample of adults 35 years and above to permit direct comparison with the data available from the previous surveys. Alongside a comprehensive vision and eye examination, the survey provides nationally representative data on important comorbidities in this population: diabetes, hypertension, obesity, hearing impairment, disability and mental health. Secondly, it estimates access to assistive technologies and eye health services. Thirdly, it is powered to allow a five-year follow up cohort study to measure the incidence and progression of eye disease.

Abstract Background Globally, eye care provision is currently insufficient to meet the requirement for eye care services. Lack of access and awareness are key barriers to specialist services; in addition, specialist services are over-utilised by people with conditions that could be managed in the community or primary care. In combination, these lead to a large unmet need for eye health provision. We have developed a validated smartphone-based screening algorithm (Peek Community Screening App). The application (App) is part of the Peek Community Eye Health system (Peek CEH) that enables Community Volunteers (CV) to make referral decisions about patients with eye problems. It generates referrals, automated short messages service (SMS) notifications to patients or guardians and has a program dashboard for visualising service delivery. We hypothesise that a greater proportion of people with eye problems will be identified using the Peek CEH system and that there will be increased uptake of referrals, compared to those identified and referred using the current community screening approaches. Study design A single masked, cluster randomised controlled trial design will be used. The unit of randomisation will be the ‘community unit’, defined as a dispensary or health centre with its catchment population. The community units will be allocated to receive either the intervention (Peek CEH system) or the current care (periodic health centre-based outreach clinics with onward referral for further treatment). In both arms, a triage clinic will be held at the link health facility four weeks from sensitisation, where attendance will be ascertained. During triage, participants will be assessed and treated and, if necessary, referred onwards to Kitale Eye Unit. Discussion We aim to evaluate a M-health system (Peek CEH) geared towards reducing avoidable blindness through early identification and improved adherence to referral for those with eye problems and reducing demand at secondary care for conditions that can be managed effectively at primary care level. Trial registration The Pan African Clinical Trials Registry (PACTR), 201807329096632. Registered on 8 June 2018.

Summary: 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

Background: Uncorrected refractive errors can be corrected by spectacles which improve visual functioning, academic performance and quality of life. However, spectacle wear can be low due to teasing/bullying, parental disapproval and no perceived benefit.Hypothesis: higher proportion of children with uncorrected refractive errors in the schools allocated to the intervention will wear their spectacles 3–4 months after they are dispensed. Methods: A superiority, cluster-randomised controlled trial was undertaken in 50 government schools in Hyderabad, India using a superiority margin of 20%. Schools were the unit of randomization. Schools were randomized to intervention or a standard school programme. The same clinical procedures were followed in both arms and free spectacles were delivered to schools. Children 11–15 years with a presenting Snellen visual acuity of

Introduction Vision impairment (VI) places a burden on individuals, health systems and society in general. In order to support the case for investing in eye health services, an updated cost of illness study that measures the global impact of VI is necessary. To perform such a study, a systematic review of the literature is needed. Here we outline the protocol for a systematic review to describe and summarise the costs associated with VI and its major causes.Methods and analysis We will systematically search in Medline (Ovid) and the Centre for Reviews and Dissemination database which includes the National Health Service Economics Evaluation Database. No language or geographical restriction will be applied. Additional literature will be identified by reviewing the references in the included studies and by contacting field experts. Grey literature will be considered. The review will include any study published from 1 January 2000 to November 2019 that provides information about costs of illness, burden of disease and/or loss of well-being in participants with VI due to an unspecified cause or due to one of the seven leading causes globally.Two reviewers will independently screen studies and extract relevant data from included studies. Methodological quality of economic studies will be assessed based on the British Medical Journal checklist for economic submissions adapted to costs of illness studies. This protocol has been prepared following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis protocols and has been published prospectively in Open Science Framework.Ethics and dissemination Formal ethical approval is not required, as primary data will not be collected in this review. The findings of this study will be disseminated through peer-reviewed publications, stakeholder meetings and inclusion in the ongoing Lancet Global Health Commission on Global Eye Health.Registration details https://osf.io/9au3w (DOI 10.17605/OSF.IO/6F8VM).

Abstract Background In 2013 five polar explorers attempted to complete the first Trans-Antarctic Winter Traverse (TAWT). This study presents the ophthalmological findings for this group, who overwintered in Antarctica as part of the White Mars Human Science Protocol. Antarctic crews are exposed to extreme cold, chronic hypoxia and altered day-night cycles. Previous studies of Antarctic explorers have focused on the prolonged effect of ultraviolet radiation including the development of ultraviolet keratitis and accelerated cataract formation. This is the first study of its kind to investigate the effect of overwintering in Antarctica on the human eye. Methods Pre and post-expedition clinical observations were made including visual acuity, contrast sensitivity, colour vision, auto-refraction, subjective refraction, retinal examination, retinal autofluoresence and retinal thickness, which were graded for comparison. During the expedition additional observations were made on a monthly basis including LogMAR visual acuity, autorefraction and intraocular pressure. Results No significant differences between pre and post-expedition observations were found, including visual acuity, contrast sensitivity, colour vision, refraction, visual fields, intraocular pressure and retinal examination. There was a small but statistically significant decrease in retinal thickness across all regions of the retina, except for the macular and fovea, in all explorers. Intra-expedition observations remained within normal limits. Conclusion Reassuringly, the human eye remains largely unchanged by exposure to the extreme conditions encountered during the Antarctic winter, however, further research is needed to investigate changes in retinal thickness. This may have implications for scientists who spend prolonged periods of time in the polar regions, as well as those who have prolonged exposure to the extreme cold or chronic hypoxia in other settings.

Abstract Background Uncorrected refractive errors are the commonest cause of visual loss in children despite spectacle correction being highly cost-effective. Many affected children do not benefit from correction as a high proportion do not wear their spectacles. Reasons for non-wear include parental attitudes, overprescribing and children being teased/bullied. Most school programmes do not provide health education for affected children, their peers, teachers or parents. The Portable Eye Examination Kit (Peek) will be used in this study. Peek has applications for measuring visual acuity with software for data entry and sending automated messages to inform providers and parents. Peek also has an application which simulates the visual blur of uncorrected refractive error (SightSim). The hypothesis is that higher proportion of children with uncorrected refractive errors in schools allocated to the Peek educational package will wear their spectacles 3–4 months after they are dispensed, and a higher proportion of children identified with other eye conditions will access services, compared with schools receiving standard school screening. Methods/Design Cluster randomized, double-masked trial of children with and without uncorrected refractive errors or other eye conditions. Government schools in Hyderabad, India will be allocated to intervention (Peek) or comparator (standard programme) arms before vision screening. In the intervention arm Peek will be used for vision screening, SightSim images will be used in classroom teaching and will be taken home by children, and voice messages will be sent to parents of children requiring spectacles or referral. In both arms the same criteria for recruitment, prescribing and dispensing spectacles will be used. After 3–4 months children dispensed spectacles will be followed up to assess spectacle wear, and uptake of referrals will be ascertained. The cost of developing and delivering the Peek package will be assessed. The cost per child wearing their spectacles or accessing services will be compared. Discussion Educating parents, teachers and children about refractive errors and the importance of wearing spectacles has the potential to increase spectacle wear amongst children. Innovative, potentially scalable mobile technology (Peek) will be used to screen, provide health education, track spectacle wear and adherence to follow-up amongst children referred. Trial registration Controlled-Trials.com, ISRCTN78134921 . Registered on 29 June 2016.

ObjectiveTo estimate the association between (1) visual impairment (VI) and (2) eye disease and 6-year mortality risk within a cohort of elderly Kenyan people.Design, setting and participantsThe baseline of the Nakuru Posterior Segment Eye Disease Study was formed from a population-based survey of 4318 participants aged ≥50 years, enrolled in 2007–2008. Ophthalmic and anthropometric examinations were undertaken on all participants at baseline, and a questionnaire was administered, including medical and ophthalmic history. Participants were retraced in 2013–2014 for a second examination. Vital status was recorded for all participants through information from community members. Cumulative incidence of mortality, and its relationship with baseline VI and types of eye disease was estimated. Inverse probability weighting was used to adjust for non-participation.Primary outcome measuresCumulative incidence of mortality in relation to VI level at baseline.ResultsOf the baseline sample, 2170 (50%) were re-examined at follow-up and 407 (10%) were known to have died (adjusted risk of 11.9% over 6 years). Compared to those with normal vision (visual acuity (VA) ≥6/12, risk=9.7%), the 6-year mortality risk was higher among people with VI (

School eye health programmes provide a unique opportunity to positively influence the health of 700 million children globally. The impact of school eye health (SEH) goes far beyond good vision— it encompasses education, social development and economic productivity.

Summary: Background: Childhood visual impairment is a major public health concern that requires effective screening and early intervention. We investigated the effectiveness of Peek school eye health, a smartphone-based sight test and referral system (comprising Peek Acuity test, sight simulation referral cards, and short message service [SMS] reminders), versus standard care (Snellen's Tumbling-E card and written referral). Methods: We initially compared the performance of both the Snellen Tumbling-E card and the Peek Acuity test to a standard backlit EDTRS LogMAR visual acuity test chart. We did a cluster randomised controlled trial to compare the Peek school eye health system with standard school screening care, delivered by school teachers. Schools in Trans Nzoia County, Kenya, were eligible if they did not have an active screening programme already in place. Schools were randomly allocated (1:1) to either the Peek school eye health screening and referral programmes (Peek group) or the standard care screening and referral programme (standard group). In both groups, teachers tested vision of children in years 1–8. Pupils with visual impairment (defined as vision less than 6/12 in either eye) were referred to hospital for treatment. Referred children from the standard group received a written hospital referral letter. Participants and their teachers in the Peek group were shown their simulated sight on a smartphone and given a printout of this simulation with the same hospital details as the standard referral letter to present to their parent or guardian. They also received regular SMS reminders to attend the hospital. The primary outcome was the proportion of referred children who reported to hospital within 8 weeks of referral. Primary analysis was by intention to treat, with the intervention effect estimated using odds ratios. This trial is registered with Pan African Clinical Trial Registry, number PACTR201503001049236. Findings: Sensitivity was similar for the Peek test and the standard test (77% [95% CI 64·8–86·5] vs 75% [63·1–85·2]). Specificity was lower for the Peek test than the standard test (91% [95% CI 89·3–92·1] vs 97·4% [96·6-98·1]). Trial recruitment occurred between March 2, 2015, and March 13, 2015. Of the 295 eligible public primary schools in Trans Nzoia County, 50 schools were randomly selected and assigned to either the Peek group (n=25) or the standard group (n=25). 10 579 children were assessed for visual impairment in the Peek group and 10 284 children in the standard group. Visual impairment was identified in 531 (5%) of 10 579 children in the Peek group and 366 (4%) of 10 284 children in the standard care group. The proportion of pupils identified as having visual impairment who attended their hospital referral was significantly higher in the Peek group (285 [54%] of 531) than in the standard group (82 [22%] of 366; odds ratio 7·35 [95% CI 3·49–15·47]; p

Purpose: To estimate the prevalence and causes of visual impairment (VI), among primary school children in Mekelle, Ethiopia and the feasibility of teachers conducting vision screening in school using a smart phone application:Peek Acuity. Methods: The study was conducted in four schools in Mekelle among children in their final 2 years of primary school (ages 11–15 years). Six teachers were trained in Peek Acuity, inter-observer variation was assessed and all teachers attained acceptable agreement (kappa>0.7) after one or two training sessions. Trained teachers then screened all eligible children for vision impairment in each eye using Peek Acuity. Children with visual acuity less than Log MAR 0.3 in either eye were examined by optometrists to determine the causes of VI. Results: 1137 out of 1197 children participated (95.1%) with a mean age of 13 years. 141 children (12.4, 95% CI 10.5–14.3) had VI (presenting VA

OBJECTIVE:Digital retinal imaging is an established method of screening for diabetic retinopathy (DR). It has been established that currently about 1% of the world's blind or visually impaired is due to DR. However, the increasing prevalence of diabetes mellitus and DR is creating an increased workload on those with expertise in grading retinal images. Safe and reliable automated analysis of retinal images may support screening services worldwide. This study aimed to compare the Iowa Detection Program (IDP) ability to detect diabetic eye diseases (DED) to human grading carried out at Moorfields Reading Centre on the population of Nakuru Study from Kenya. PARTICIPANTS:Retinal images were taken from participants of the Nakuru Eye Disease Study in Kenya in 2007/08 (n = 4,381 participants [NW6 Topcon Digital Retinal Camera]). METHODS:First, human grading was performed for the presence or absence of DR, and for those with DR this was sub-divided in to referable or non-referable DR. The automated IDP software was deployed to identify those with DR and also to categorize the severity of DR. MAIN OUTCOME MEASURES:The primary outcomes were sensitivity, specificity, and positive and negative predictive value of IDP versus the human grader as reference standard. RESULTS:Altogether 3,460 participants were included. 113 had DED, giving a prevalence of 3.3% (95% CI, 2.7-3.9%). Sensitivity of the IDP to detect DED as by the human grading was 91.0% (95% CI, 88.0-93.4%). The IDP ability to detect DED gave an AUC of 0.878 (95% CI 0.850-0.905). It showed a negative predictive value of 98%. The IDP missed no vision threatening retinopathy in any patients and none of the false negative cases met criteria for treatment. CONCLUSIONS:In this epidemiological sample, the IDP's grading was comparable to that of human graders'. It therefore might be feasible to consider inclusion into usual epidemiological grading.

BACKGROUND:Diseases of the posterior segment of the eye, including age-related macular degeneration (AMD), have recently been recognised as the leading or second leading cause of blindness in several African countries. However, prevalence of AMD alone has not been assessed. We hypothesized that AMD is an important cause of visual impairment among elderly people in Nakuru, Kenya, and therefore sought to assess the prevalence and predictors of AMD in a diverse adult Kenyan population. METHODS AND FINDINGS:In a population-based cross-sectional survey in the Nakuru District of Kenya, 100 clusters of 50 people 50 y of age or older were selected by probability-proportional-to-size sampling between 26 January 2007 and 11 November 2008. Households within clusters were selected through compact segment sampling. All participants underwent a standardised interview and comprehensive eye examination, including dilated slit lamp examination by an ophthalmologist and digital retinal photography. Images were graded for the presence and severity of AMD lesions following a modified version of the International Classification and Grading System for Age-Related Maculopathy. Comparison was made between slit lamp biomicroscopy (SLB) and photographic grading. Of 4,381 participants, fundus photographs were gradable for 3,304 persons (75.4%), and SLB was completed for 4,312 (98%). Early and late AMD prevalence were 11.2% and 1.2%, respectively, among participants graded on images. Prevalence of AMD by SLB was 6.7% and 0.7% for early and late AMD, respectively. SLB underdiagnosed AMD relative to photographic grading by a factor of 1.7. After controlling for age, women had a higher prevalence of early AMD than men (odds ratio 1.5; 95% CI, 1.2-1.9). Overall prevalence rose significantly with each decade of age. We estimate that, in Kenya, 283,900 to 362,800 people 50 y and older have early AMD and 25,200 to 50,500 have late AMD, based on population estimates in 2007. CONCLUSIONS:AMD is an important cause of visual impairment and blindness in Kenya. Greater availability of low vision services and ophthalmologist training in diagnosis and treatment of AMD would be appropriate next steps. Please see later in the article for the Editors' Summary.