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Purpose: The purpose of this study was to assess the performance of the tertiary centers (TCS) and vision centers (VCs) of the four organizations participating in this research, once the lockdown was lifted, and to compare it with the performance during the same period of the previous year. Methods: This was a cross-sectional study assessing eyecare utilization in the first 2 months after resumption of services post the lockdown in 2020 and comparing that across the same time period in 2019. Anonymized data containing basic demographic details, proportions of patient visits and their reasons, as well as referral information was collected. The drop percentage method was used, and P values were calculated using paired t-tests. Results: Four TCs and 60 VCs were included. Overall, outpatient attendance dipped 51.2% at TCs and 27.5% at VCs, across the 2 years. At both levels of care delivery, the percentage drop in females was more than that in males; however, the overall drop at VCs was less than that at TCs, for both sexes. Eyecare utilization in pediatric populations dropped significantly more than in adult populations, across the overall sample. There was no significant change in referrals for refractive error as a proportion of total outpatients, although there was a significant decline in the same for cataract and specialty treatment. Conclusion: VCs are valuable and successful model for eyecare delivery especially in the continued aftermath of the COVID-19 pandemic.

Summary: 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% CI: 3·4–14·4; cataracts: $13·7 per case, 95% CI: 5·6–27·0) and vision centers (URE: $10·8 per case, 95% CI: 8·0–14·4; cataracts: $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% CI: 2·2 to 56·2), and more costly for initiating spectacles for URE ($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% CI: 15·5 to 49·6) due to the lower prevalence of eye problems in school aged children. The annualized cost of operating a vision center, excluding procurement of spectacles, is estimated at $11,707 (95% CI: 8,722–15,492). Adding teleophthalmology capability increases annualized costs by $1,271 per facility (95% CI: 181 to 3,340). Compared to baseline care, eye camps have an incremental cost-effectiveness ratio (ICER) of $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. Funding: The study was funded by the Seva Foundation.

Purpose: Cataract remains the leading cause of blindness and visual impairment in most low-and middle-income countries, with the greatest burden borne by women. To achieve Global Action Plan targets, cataract programs must target people, especially women, with maximum need. This study examines whether cataract surgical programs in three major north Indian eyecare institutions are equitable and describes a refined indicator for reporting equity. Methods: Retrospective one-year cross-sectional study of cataract surgery utilization using routine administrative data from three north Indian eyecare institutions. Patient data were categorized by paying category, sex, and preoperative visual acuity. Comparisons were made between payment categories and sexes. Results: Out of the total number of patients operated, 86,230 were in the non-paying category and 56,738 in the paying category. Overall, 8.2% were blind, 21.1% were severely visual impaired (SVI) or worse, and 86.1% were moderate visual impaired (MVI) or worse. Non-paying patients had a significantly higher proportion of poorer visual categories compared to paying patients [(blind, 9.7% vs. 5.8%; SVI or worse, 24.6% vs. 15.8%; and MVI or worse, 89.1% vs. 81.6%, respectively, (P < 0.001)]. Women had significantly higher proportion of poorer visual categories than men [(blind, 8.9% vs. 7.4%, SVI or worse, 21.9% vs. 20.3% and MVI or worse 87.6 vs. 84.7%) (P < 0.001)]. Conclusion: The institutions primarily provided surgery to patients with maximum need: too poor to pay, low visual acuity, and women. Similar data from all service providers of a region can help estimate the proposed “equitable cataract surgical rate”: the proportion of patients operated with maximum need among those operated in a year. This can be used for targeting people in need.

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.