Publications by authors named "Allen Foster"

126 Publications

Sex, gender, and retinoblastoma: analysis of 4351 patients from 153 countries.

Eye (Lond) 2021 Jul 16. Epub 2021 Jul 16.

International Centre for Eye Helath, London School of Hygiene & Tropical Medicine, London, UK.

Objective: To investigate in a large global sample of patients with retinoblastoma whether sex predilection exists for this childhood eye cancer.

Methods: A cross-sectional analysis including 4351 treatment-naive retinoblastoma patients from 153 countries who presented to 278 treatment centers across the world in 2017. The sex ratio (male/female) in the sample was compared to the sex ratio at birth by means of a two-sided proportions test at global level, country economic grouping, continent, and for selected countries.

Results: For the entire sample, the mean retinoblastoma sex ratio, 1.20, was higher than the weighted global sex ratio at birth, 1.07 (p < 0.001). Analysis at economic grouping, continent, and country-level demonstrated differences in the sex ratio in the sample compared to the ratio at birth in lower-middle-income countries (n = 1940), 1.23 vs. 1.07 (p = 0.019); Asia (n = 2276), 1.28 vs. 1.06 (p < 0.001); and India (n = 558), 1.52 vs. 1.11 (p = 0.008). Sensitivity analysis, excluding data from India, showed that differences remained significant for the remaining sample (χ = 6.925, corrected p = 0.025) and for Asia (χ = 5.084, corrected p = 0.036). Excluding data from Asia, differences for the remaining sample were nonsignificant (χ = 2.205, p = 0.14).

Conclusions: No proof of sex predilection in retinoblastoma was found in the present study, which is estimated to include over half of new retinoblastoma patients worldwide in 2017. A high male to female ratio in Asian countries, India in specific, which may have had an impact on global-level analysis, is likely due to gender discrimination in access to care in these countries, rather than a biological difference between sexes.
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http://dx.doi.org/10.1038/s41433-021-01675-yDOI Listing
July 2021

Estimating Need for Glasses and Hearing Aids in The Gambia: Results from a National Survey and Comparison of Clinical Impairment and Self-Report Assessment Approaches.

Int J Environ Res Public Health 2021 06 10;18(12). Epub 2021 Jun 10.

International Centre for Evidence in Disability, London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK.

Few estimates are available of the need for assistive devices (ADs) in African settings. This study aimed to estimate population-level need for glasses and hearing aids in The Gambia based on (1) clinical impairment assessment, and (2) self-reported AD awareness, and explore the relationship between the two methods. The Gambia 2019 National Eye Health Survey is a nationally representative population-based sample of 9188 adults aged 35+ years. Participants underwent standardised clinical vision assessments including the need for glasses (distance and near). Approximately 25% of the sample underwent clinical assessment of hearing and hearing aid need. Data were also collected on self-reported awareness, need and access barriers to vision and hearing ADs. Overall, 5.6% of the study population needed distance glasses (95% CI 5.0-6.3), 45.9% (95% CI 44.2-47.5) needed near glasses and 25.5% (95% CI 22.2-29.2) needed hearing aids. Coverage for each AD was very low (<4%). The agreement between self-report and clinical impairment assessment for AD need was poor. In conclusion, there is high prevalence and very low coverage for distance glasses, near glasses and hearing aids in The Gambia. Self-report measures alone will not provide an accurate estimate of AD need.
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http://dx.doi.org/10.3390/ijerph18126302DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8296105PMC
June 2021

Cataract Surgical Services in Palestine.

Ophthalmic Epidemiol 2021 Jun 13:1-9. Epub 2021 Jun 13.

London School of Hygiene and tropical medicine, London, UK.

: Cataract surgery, quantity and quality, is an indicator of ophthalmic care. A comprehensive assessment of cataract surgical services has never been carried out in Palestine, including West Bank, Gaza Strip and East Jerusalem. The objective of this study was to estimate the cataract surgical rate in 2015 to and to explore the modes of payment and referral systems.: A cross-sectional study conducted between June and August 2016. Medical Directors from Cataract Surgical Centres in Palestine were interviewed using a structured questionnaire to extract data on cataract output and surgical techniques. Additionally, data were collected on modes of payment for cataract services. The cataract surgical rate was calculated by dividing the total cataract output in 2015 by the estimated population of Palestine in millions.: In 2015, 9908 cataract surgeries were carried out in 22 centres. The cataract surgical rate was 2,117 operations per million population. Phacoemulsification was the most common technique (73.4%), however in government centres 67% were performed by extracapsular cataract extraction.In the Gaza Strip, 56.6% of cataract surgeries were operated at government centres, and 42.8% were operated at NGO centres while in West Bank, only 12% of cataract surgeries were operated at government centres, with two-thirds of cataracts diagnosed at governmental centres being referred to private and NGO centres. Seventy eight percent of cataract surgeries were funded by insurance, of which the government insurance scheme contributed 65%.: The cataract surgical rate in Palestine falls short of the required WHO target. The majority of cataract surgeries are funded by insurance.
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http://dx.doi.org/10.1080/09286586.2021.1923755DOI Listing
June 2021

A Systematic Review of the Proportion of Blindness in the Population 50 Years and Older from Total Population-Based Surveys of Blindness and Visual Impairment.

Ophthalmic Epidemiol 2021 May 4:1-7. Epub 2021 May 4.

Clinical Research Department, International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, UK.

Epidemiological data is essential for planning; however, all-age population-based surveys are resource intensive. Rapid Assessment of Cataract Surgical Services methodology was developed in India in 1995 and subsequently promoted by the World Health Organisation for use worldwide. The commonly used Rapid Assessment of Avoidable Blindness (RAAB) evolved from this in 2005, constraining surveys to populations aged 50 or more based on the report 'The Epidemiology of Blindness in Nepal' (SEVA, 1988), where 78.7% of blindness occurred in people aged 50+. The purpose of this study is to examine whether more recent total-population-based surveys continue to find a similar proportion of blindness in the population aged 50+.A systematic literature review identified all population-based surveys of blindness published 1996-2017. Data extraction was undertaken by two independent researchers and compared.The proportions of blindness (presenting visual acuity (PVA) <3/60) and moderate/severe visual impairment (MSVI) (PVA <6/18-3/60) from total population-based surveys in people aged 50+ ranged from 90% (Mali, 1996) to 45.8% (South Korea, 2015); the mean proportions across all surveys were 73.1% (95% CI, 60.4-85.8%) for blindness, and 73.8% (95% CI, 54.8-92.8) for MSVI. No trend over time or association with GDP was identified.This systematic literature review supports the rationale for constraining surveys to the population aged 50+ as this will greatly reduce sample size but still include a high proportion of total cases of blindness; paucity of total population-based surveys highlights the ongoing need for RAAB in service planning internationally.
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http://dx.doi.org/10.1080/09286586.2021.1918176DOI Listing
May 2021

Lag Time between Onset of First Symptom and Treatment of Retinoblastoma: An International Collaborative Study of 692 Patients from 10 Countries.

Cancers (Basel) 2021 Apr 19;13(8). Epub 2021 Apr 19.

Department of Ophthalmology, University of Washington, Seattle, WA 98195, USA.

Background: The relationship between lag time and outcomes in retinoblastoma (RB) is unclear. In this study, we aimed to study the effect of lag time between onset of symptoms and diagnosis of retinoblastoma (RB) in countries based on their national-income and analyse its effect on the outcomes.

Methods: We performed a prospective study of 692 patients from 11 RB centres in 10 countries from 1 January 2019 to 31 December 2019.

Results: The following factors were significantly different among different countries based on national-income level: age at diagnosis of RB ( = 0.001), distance from home to nearest primary healthcare centre ( = 0.03) and mean lag time between detection of first symptom to visit to RB treatment centre ( = 0.0007). After adjusting for country income, increased lag time between onset of symptoms and diagnosis of RB was associated with higher chances of an advanced tumour at presentation ( < 0.001), higher chances of high-risk histopathology features ( = 0.003), regional lymph node metastasis ( < 0.001), systemic metastasis ( < 0.001) and death ( < 0.001).

Conclusions: There is a significant difference in the lag time between onset of signs and symptoms and referral to an RB treatment centre among countries based on national income resulting in significant differences in the presenting features and clinical outcomes.
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http://dx.doi.org/10.3390/cancers13081956DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8073369PMC
April 2021

Shifting the focus to functioning: essential for achieving Sustainable Development Goal 3, inclusive Universal Health Coverage and supporting COVID-19 survivors.

Glob Health Action 2021 01;14(1):1903214

International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, UK.

If Sustainable Developmental Goal 3 and Universal Health Coverage are to be achieved, functioning is a third health indicator which must be assessed and integrated into global health population-based metrics alongside mortality and morbidity. In this paper, we define functioning according to the International Classification of Functioning, Disability and Health (ICF) and present why functioning is important to measure, especially when considering the need for, and outcome of, rehabilitation and assistive technology. We discuss examples of tools that measure components of functioning through clinical assessment and self-report methodologies, and present the development of a comprehensive population level tool which aligns with the ICF and combines self-report and clinical measurement methods to measure functioning and the need for rehabilitation and AT. Throughout the paper a survivor of Coronavirus 2019 (COVID-19) is given as an example to illustrate functioning according to the ICF and how access to the interventions of rehabilitation and assistive technology might be of benefit to improve and optimise his/her functioning. We argue that the Global Health community must take action and ensure that the measurement of functioning is well established, accepted and integrated as the third health indicator following the COVID-19 pandemic.
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http://dx.doi.org/10.1080/16549716.2021.1903214DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8081312PMC
January 2021

Musculoskeletal impairment among Syrian refugees living in Sultanbeyli, Turkey: prevalence, cause, diagnosis and need for related services and assistive products.

Confl Health 2021 Apr 20;15(1):29. Epub 2021 Apr 20.

International Centre for Evidence in Disability, London School of Hygiene & Tropical Medicine, London, UK.

Background: Epidemiological data on musculoskeletal impairment (MSI) and related service and assistive product (AP) needs for displaced populations are lacking. This study aimed to estimate the prevalence, aetiology, and specific MSI diagnosis and the need for related services and APs among Syrian refugees living in Sultanbeyli, a district in Istanbul, Turkey.

Methods: A population-based survey used probability proportionate to size and compact segment sampling to select 80 clusters ('street') of 50 individuals (aged 2+), for total sample size of approximately 4000 participants. An updated version of the Rapid Assessment of MSI tool (RAM) was used to screen all participants using six questions. Any participant who screened positive underwent a standardised examination by a physiotherapist to assess the presence, aetiology, severity and specific diagnosis of MSI and an assessment of need for related services and APs.

Results: The all-age prevalence of MSI was 12.2% (95% CI 10.8-13.7) and this increased significantly with age to 43.8% in people 50 and older. Over half (51%) of MSI was classified as moderate, 30% as mild and 19% as severe. The war in Syria was identified as the direct cause for 8% of people with MSI. The majority (56%) of MSI diagnoses were acquired non-traumatic causes. There was high unmet need for rehabilitation services; for example, 83% of people with MSI could benefit from physiotherapy but were not receiving this service. Overall, 19% of people with MSI had an unmet need for at least one AP. Apart from availability of walking sticks/canes, coverage was low with less than half the people with MSI who needed APs and services had received them. The most common reasons for not seeking services and APs were 'need not felt', lack of service availability and of awareness of services, and financial barriers.

Conclusions: MSI is common among the Syrian refugee population living in Sultanbeyli District, particularly older adults, however less than half have been able to access relevant services and APs. These findings can inform the planning of health services for migrant populations, including the essential integration of rehabilitation and APs, and increase access to these vital services.
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http://dx.doi.org/10.1186/s13031-021-00362-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8056489PMC
April 2021

ROP screening and treatment in four district-level special newborn care units in India: a cross-sectional study of screening and treatment rates.

BMJ Paediatr Open 2021 10;5(1):e000930. Epub 2021 Mar 10.

Pediatrics, PGIMER, Chandigarh, Chandigarh, India.

Objective: Blindness from retinopathy of prematurity (ROP) in middle-income countries is generally due to absence of screening or inadequate screening. The objective of this study was to assess uptake of services in an ROP programme in four district-level special newborn care units in India.

Design: Cross-sectional study.

Setting: All four neonatal units of a state in India where model programme for ROP had been introduced.

Patients: Infants eligible for screening and treatment of ROP between March and May 2017.

Intervention: Data on sex, birth weight and gestational age of eligible infants were collected and medical records reviewed for follow-up.

Main Outcome Measures: Proportion of eligible infants screened and for those screened, age at first screening, completion of screening, diagnosis and treatment received if indicated. The characteristics of infants screened and not screened were compared.

Results: 137 (18%) of the 751 infants eligible for screening were screened at least once, with no statistically significant difference by sex. The mean birth weight and gestational age of those screened were significantly lower than those not screened. Among those screened, 43% underwent first screening later than recommended and 44% had incomplete follow-up. Fourteen infants (11% of those screened) were diagnosed with ROP. Five were advised laser treatment and all complied.

Conclusion: Uptake, completion and timing of first screening was suboptimal. Some planned interventions including training of nursing staff, use of integrated data-management software and providing material for parent counselling, which have been initiated, need to be fully implemented to improve uptake of ROP screening services.
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http://dx.doi.org/10.1136/bmjpo-2020-000930DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7949437PMC
March 2021

Technical capacities needed to implement the WHO's primary eye care package for Africa: results of a Delphi process.

BMJ Open 2021 03 19;11(3):e042979. Epub 2021 Mar 19.

International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, UK.

Objective: The aim of the study was to establish the technical capacities needed to deliver the WHO African Region's primary eye care package in primary healthcare facilities.

Design: A two-round Delphi exercise was used to obtain expert consensus on the technical complexity of each component of the package and the technical capacities needed to deliver them using Gericke's framework of technical feasibility. The panel comprised nine eyecare experts in primary eyecare in sub-Saharan Africa. In each round panel members used a 4-point Likert scale to indicate their level of agreement. Consensus was predefined as ≥70% agreement on each statement. For round 1, statements on technical complexity were identified through a literature search of primary eyecare in sub-Saharan Africa from January 1980 to April 2018. Statements for which consensus was achieved were included in round 2, and the technical capacities were agreed.

Results: Technical complexity statements were classified into four broad categories: intervention characteristics, delivery characteristics, government capacity requirements and usage characteristics. 34 of the 38 (89%) statements on health promotion and 40 of the 43 (93%) statements on facility case management were considered necessary technical capacities for implementation.

Conclusion: This study establishes the technical capacities needed to implement the WHO Africa Office primary eye care package, which may be generalisable to countries in sub-Saharan Africa.
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http://dx.doi.org/10.1136/bmjopen-2020-042979DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7986885PMC
March 2021

Incidence of Retinoblastoma Has Increased: Results from 40 European Countries.

Ophthalmology 2021 Jan 26. Epub 2021 Jan 26.

International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, United Kingdom; Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Tel-Aviv University, Tel-Aviv, Israel.

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http://dx.doi.org/10.1016/j.ophtha.2021.01.024DOI Listing
January 2021

The simplified trachoma grading system, amended.

Bull World Health Organ 2020 Oct 3;98(10):698-705. Epub 2020 Sep 3.

International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, England.

A simplified grading system for trachoma was published by the World Health Organization (WHO) in 1987. Intended for use by non-specialist personnel working at community level, the system includes five signs, each of which can be present or absent in any eye: (i) trachomatous trichiasis; (ii) corneal opacity; (iii) trachomatous inflammation-follicular; (iv) trachomatous inflammation-intense; and (v) trachomatous scarring. Though neither perfectly sensitive nor perfectly specific for trachoma, these signs have been essential tools for identifying populations that need interventions to eliminate trachoma as a public health problem. In 2018, at WHO's 4th global scientific meeting on trachoma, the definition of one of the signs, trachomatous trichiasis, was amended to exclude trichiasis that affects only the lower eyelid. This paper presents the amended system, updates its presentation, offers notes on its use and identifies areas of ongoing debate.
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http://dx.doi.org/10.2471/BLT.19.248708DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7652564PMC
October 2020

Assistive technology for visual impairment and trainers at schools for the blind in Delhi.

Assist Technol 2021 Jan 19:1-5. Epub 2021 Jan 19.

International Centre for Eye Health, Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK.

The aim of the study was to assess the availability of assistive technology (AT) for visual impairment and trainers in schools for the blind in Delhi. A cross-sectional study was conducted in 22 of the 24 schools in Delhi. The headteacher of each school was asked about availability of 52 ATs divided into writing, reading, math, sciences, sports, mobility, and daily living, using a questionnaire. Information on availability of trainers was also collected. Of the 52 ATs, the most frequently available were Braille slate with stylus and abacus (>90% of schools), followed by Taylor frame, long cane and talking watch (80% to 90% of schools). Only 11 of 52 AT devices were available in 60% or more of the schools. Tactile-based ATs were more available than vision-based ATs. In the 22 schools, 63 trainers for reading & writing were available (80% of posts), 18 for sciences (59%), 25 for math (70%), and 11 for mobility (50% of posts). Except Braille slate and stylus, there is a huge shortage of AT in these schools. The educational needs and performance of students could be helped by developing and using a list of priority Assistive Products for example, the WHO AP list.
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http://dx.doi.org/10.1080/10400435.2020.1839144DOI Listing
January 2021

International travel to obtain medical treatment for primary retinoblastoma: A global cohort study.

Int J Cancer 2021 04 31;148(8):1858-1866. Epub 2020 Oct 31.

International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, UK.

Early diagnosis and treatment of retinoblastoma (Rb), the most common intraocular malignancy, can save both the child's life and vision. However, access to services and hence chances for survival and preserving the eye and its vision vary widely across the globe. Some families have to, or make a choice to, leave their home country to seek planned medical treatment abroad. We aimed to investigate how frequently this cross-border travel occurs and the factors associated with it. A total of 278 Rb centres in 153 countries were recruited to participate in a global cross-sectional analysis of newly diagnosed Rb patients in 2017. Number and proportions of children who travelled from their home country for treatment were analysed by country, continent, socioeconomic stratum and clinical and demographic features. The cohort included 4351 new patients of whom 223 [5.1%, 95% confidence interval 4.5-5.8] were taken across country borders for planned medical treatment. Independently significant predictors of travelling across borders included: being from a country with a smaller population, being from a country classified as low socioeconomic status, having bilateral Rb and having intraocular disease without extraocular spread. The factors that determine international travel for Rb treatment are complex and deserve further investigation. We may need to rethink the way services are delivered in the light of the threat of severe curtailment of international travel from pandemics like corona virus disease 2019.
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http://dx.doi.org/10.1002/ijc.33350DOI Listing
April 2021

Travel burden and clinical presentation of retinoblastoma: analysis of 1024 patients from 43 African countries and 518 patients from 40 European countries.

Br J Ophthalmol 2020 Sep 15. Epub 2020 Sep 15.

Pediatric Oncology Unit, Hospital Universitario y Politécnico La Fe, Valencia, Spain.

Background: The travel distance from home to a treatment centre, which may impact the stage at diagnosis, has not been investigated for retinoblastoma, the most common childhood eye cancer. We aimed to investigate the travel burden and its impact on clinical presentation in a large sample of patients with retinoblastoma from Africa and Europe.

Methods: A cross-sectional analysis including 518 treatment-naïve patients with retinoblastoma residing in 40 European countries and 1024 treatment-naïve patients with retinoblastoma residing in 43 African countries.

Results: Capture rate was 42.2% of expected patients from Africa and 108.8% from Europe. African patients were older (95% CI -12.4 to -5.4, p<0.001), had fewer cases of familial retinoblastoma (95% CI 2.0 to 5.3, p<0.001) and presented with more advanced disease (95% CI 6.0 to 9.8, p<0.001); 43.4% and 15.4% of Africans had extraocular retinoblastoma and distant metastasis at the time of diagnosis, respectively, compared to 2.9% and 1.0% of the Europeans. To reach a retinoblastoma centre, European patients travelled 421.8 km compared to Africans who travelled 185.7 km (p<0.001). On regression analysis, lower-national income level, African residence and older age (p<0.001), but not travel distance (p=0.19), were risk factors for advanced disease.

Conclusions: Fewer than half the expected number of patients with retinoblastoma presented to African referral centres in 2017, suggesting poor awareness or other barriers to access. Despite the relatively shorter distance travelled by African patients, they presented with later-stage disease. Health education about retinoblastoma is needed for carers and health workers in Africa in order to increase capture rate and promote early referral.
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http://dx.doi.org/10.1136/bjophthalmol-2020-316613DOI Listing
September 2020

Feasibility of a cluster randomized controlled trial on the effectiveness of peer-led health education interventions to increase uptake of retinal examination for diabetic retinopathy in Kirinyaga, Kenya: a pilot trial.

Pilot Feasibility Stud 2020 16;6:102. Epub 2020 Jul 16.

London School of Hygiene and Tropical Medicine, London, UK.

Background: People living with diabetes can reduce their risk of vision loss from diabetic retinopathy by attending screening, which enables early detection and timely treatment. The aim of this pilot trial was to assess the feasibility of a full-scale cluster randomized controlled trial of an intervention to increase uptake of retinal examination in this population, as delivered within existing community-based diabetes support groups (DSGs).

Methods: All 16 DSGs in Kirinyaga county were invited to participate in the study. The first two groups recruited took part in the pilot trial. DSG members who met the eligibility criteria were recruited before the groups that were randomized to the two arms. In the intervention group, two peer educators were trained to deliver monthly DSG-based eye health education and individual telephone reminders to attend screening. The control group continued with usual DSG practice which is monthly meetings without eye health education. The recruitment team and outcome assessors were masked to the allocation. We documented the study processes to ascertain the feasibility, acceptability, and potential effectiveness of the intervention. Feasibility was assessed in terms of clarity of study procedures, recruitment and retention rates, level of acceptability, and rates of uptake of eye examination. We set the target feasibility criteria for continuation to the main study to be recruitment of 50 participants in the trial, 80% monthly follow-up rates for individuals, and no attrition of clusters.

Results: Of the 122 DSG members who were assessed for eligibility, 104 were recruited and followed up: 51 (intervention) and 53 (control) arm. The study procedures were well understood and easy to apply. We learnt the DSG meeting days were the best opportunities for recruitment. The study had a high acceptance rate (100% for clusters, 95% for participants) and high follow-up and retention rate (100% of those recruited). All clusters and participants were analysed. We observed that the rate of incidence of eye exam was about 6 times higher in the intervention arm as compared to the control arm. No adverse unexpected events were reported in either arm.

Conclusions: The study is feasible and acceptable in the study population. The results support the development of a full-scale cluster RCT, as the success criteria for the pilot were met.

Trial Registration: Pan African Clinical Trials Registry PACTR201707002430195 Registered on 25 July 2017.
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http://dx.doi.org/10.1186/s40814-020-00644-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7364632PMC
July 2020

Factors influencing the decision-making of carers of children with bilateral cataract in Nepal.

BMJ Open Ophthalmol 2020 6;5(1):e000422. Epub 2020 Apr 6.

Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, International Centre for Eye Health, London, UK.

Objectives: Two hundred thousand children worldwide are blind from cataract. Late presentation for surgery resulting in poor visual outcomes is a problem globally. We aimed to explore the reasons why children are not brought earlier for surgery in Nepal.

Methods And Analysis: Mixed-method study of carers of children with bilateral cataract attending a large non-government eye hospital were administered a proforma. A random sample took part in semistructured interviews and focus group discussions.

Results: Carers of 102 children completed proformas; 10 interviews and 2 focus group discussions were held. 80.4% were Indian, 35.3% of children were female, and their mean age was 58 months (range 4 months to 10 years). Median delay in time between the carer first noticing a problem to presentation was 182 days IQR (60.8-364.8). This was significantly longer for girls (median 304 IQR (91.2-1094.4)) than boys (median 121.6 IQR (30.4-364.8); p=0.02). Cost to access care was a problem for 42 (41.2%) carers. 13 (12.8%) participants were not aware of treatment and 12 (11.8%) were aware but did not seek treatment. The community influenced carer's health-seeking behaviour. Cataract was sometimes described as 'phula', meaning something white seen on the eye.

Conclusion: Fewer girls presented for surgery, and they also had a significantly longer delay to presentation than boys. Carers are influenced by factors at family, community and socio-organisational levels. Approaches to increase timely access, particularly by girls, are required, such as health education using the term phula, which is widely understood.
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http://dx.doi.org/10.1136/bmjophth-2019-000422DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7254144PMC
April 2020

Viral diseases of the eye.

Community Eye Health 2020 30;33(108):65-67. Epub 2020 Mar 30.

Professor, International Centre for Eye Health, London School of Hygiene & Tropical Medicine, UK.

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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7205179PMC
March 2020

Barriers to using assistive technology among students with visual disability in schools for the blind in Delhi, India.

Disabil Rehabil Assist Technol 2020 Mar 27:1-5. Epub 2020 Mar 27.

Department of Clinical Research, International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, UK.

Students with visual loss may benefit from assistive technology (AT) for their educational activities. To understand the barriers faced in using ATs by students who have heard of ATs and reported needing them, but were not using (acquainted students), at schools for the blind in Delhi.: Two hundred and fifty students were selected randomly from ten schools for the blind in Delhi and screened for presenting and pinhole binocular distance vision using a modified 'E' chart and multiple pinhole occluder. Students were divided into two groups; 1/60 or better vision (likely to benefit from vision-based AT) and <1/60 vision, (likely to benefit from tactile/sound-based AT). Awareness of, and need for, ATs was investigated for each student with a questionnaire. Then information on barriers to using AT was obtained from students who knew about AT, felt they needed AT, but were not using them. This information was collected for a total of 42 ATs. The three most requested tactile/sound-based ATs for the 250 students were talking watch, Braille typewriter and audio format. The three most requested vision-based ATs in 69 (27.6%) students who had presenting or pinhole visual acuity less than 6/18 to 1/60 were near optical magnifiers, electronic magnifiers and large keyboard for computer. Non-availability of ATs in schools was the most common perceived barrier (43% of overall responses), followed by economic constraints (20% of responses). Non-availability or limited possession of ATs and financial constraints were the major barriers to use of ATs among students.IMPLICATION FOR REHABILITATIONStudents with visual disability face many challenges in accessing assistive technology for their education learning, especially in low middle-income countries.Non-availability and limited possession of assistive technology by schools for the blind are main barriers in the study.School authorities must recognize their responsibility to ensure assistive technology (academic and non-academic related, visual and non-visual based) are made accessible for their students with adequate quantity.Future studies should focus on all school age children in the community rather than focusing on school going children.
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http://dx.doi.org/10.1080/17483107.2020.1738566DOI Listing
March 2020

Global Retinoblastoma Presentation and Analysis by National Income Level.

JAMA Oncol 2020 05;6(5):685-695

Imam Hussein Cancer Center, Karbala, Iraq.

Importance: Early diagnosis of retinoblastoma, the most common intraocular cancer, can save both a child's life and vision. However, anecdotal evidence suggests that many children across the world are diagnosed late. To our knowledge, the clinical presentation of retinoblastoma has never been assessed on a global scale.

Objectives: To report the retinoblastoma stage at diagnosis in patients across the world during a single year, to investigate associations between clinical variables and national income level, and to investigate risk factors for advanced disease at diagnosis.

Design, Setting, And Participants: A total of 278 retinoblastoma treatment centers were recruited from June 2017 through December 2018 to participate in a cross-sectional analysis of treatment-naive patients with retinoblastoma who were diagnosed in 2017.

Main Outcomes And Measures: Age at presentation, proportion of familial history of retinoblastoma, and tumor stage and metastasis.

Results: The cohort included 4351 new patients from 153 countries; the median age at diagnosis was 30.5 (interquartile range, 18.3-45.9) months, and 1976 patients (45.4%) were female. Most patients (n = 3685 [84.7%]) were from low- and middle-income countries (LMICs). Globally, the most common indication for referral was leukocoria (n = 2638 [62.8%]), followed by strabismus (n = 429 [10.2%]) and proptosis (n = 309 [7.4%]). Patients from high-income countries (HICs) were diagnosed at a median age of 14.1 months, with 656 of 666 (98.5%) patients having intraocular retinoblastoma and 2 (0.3%) having metastasis. Patients from low-income countries were diagnosed at a median age of 30.5 months, with 256 of 521 (49.1%) having extraocular retinoblastoma and 94 of 498 (18.9%) having metastasis. Lower national income level was associated with older presentation age, higher proportion of locally advanced disease and distant metastasis, and smaller proportion of familial history of retinoblastoma. Advanced disease at diagnosis was more common in LMICs even after adjusting for age (odds ratio for low-income countries vs upper-middle-income countries and HICs, 17.92 [95% CI, 12.94-24.80], and for lower-middle-income countries vs upper-middle-income countries and HICs, 5.74 [95% CI, 4.30-7.68]).

Conclusions And Relevance: This study is estimated to have included more than half of all new retinoblastoma cases worldwide in 2017. Children from LMICs, where the main global retinoblastoma burden lies, presented at an older age with more advanced disease and demonstrated a smaller proportion of familial history of retinoblastoma, likely because many do not reach a childbearing age. Given that retinoblastoma is curable, these data are concerning and mandate intervention at national and international levels. Further studies are needed to investigate factors, other than age at presentation, that may be associated with advanced disease in LMICs.
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http://dx.doi.org/10.1001/jamaoncol.2019.6716DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7047856PMC
May 2020

Status of Oxygen Monitoring in Four Selected Special Care Newborn Units in India.

Indian Pediatr 2020 04 5;57(4):317-320. Epub 2020 Feb 5.

Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, India.

Objectives: To investigate the status of oxygen monitoring in Special Newborn Care Units.

Methods: Observations were made and records reviewed of infants on oxygen in all four Special Newborn Care Units of a state delivering a model program for retinopathy of prematurity. Multiple choice questions were administered to nurses, semi-structured interviews conducted with pediatricians, ophthalmologists and senior nurses.

Results: All units had more than 100% occupancy. The number of functioning pulse oximeters was 73% of that recommended. None of the units had air-oxygen blenders. The upper oxygen saturation alarm was set accurately only for 1 out of 18 babies receiving oxygen and none of the infants had continuous saturation monitoring. 84% of nurses did not know optimal oxygen saturation targets. Most interviewees attributed suboptimal care to overcrowding.

Conclusion: Compressed air, air-oxygen blenders, sufficient functioning pulse oximeters, rational admission policies and training of nurses are needed to improve oxygen related practices.
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April 2020

Peer-support to increase uptake of screening for diabetic retinopathy: process evaluation of the DURE cluster randomized trial.

Trop Med Health 2020 6;48. Epub 2020 Jan 6.

1London School of Hygiene and Tropical Medicine, London, England.

Background: There is limited evidence on how implementation of peer support interventions influences effectiveness, particularly for individuals with diabetes. We conducted a cluster randomized controlled trial to compare the effectiveness of a peer-led health education package versus usual care to increase uptake of screening for diabetic retinopathy (DR).

Methods: Our process evaluation used a mixed-method design to investigate the recruitment and retention, reach, dose, fidelity, acceptability, and context of implementation, and was guided by the Consolidated Framework for Implementation Research (CFIR). We reviewed trial documents, conducted semi-structured interviews with key informants ( = 10) and conducted four focus group discussions with participants in both arms of the trial. Three analysts undertook CFIR theory-driven content analysis of the qualitative data. Quantitative data was analyzed to provide descriptive statistics relevant to the objectives of the process evaluation.

Results: The trial had positive implementation outcomes, 100% retention of clusters and 96% retention for participants, 83% adherence to delivery of content of group talks (fidelity), and 78% attendance (reach) to at least 50% (3/6) of the group talks (dose). The data revealed that intervention characteristics, outer setting, inner setting, individual characteristics, and process (all the constructs of CFIR) influenced the implementation. There were more facilitators than barriers to the implementation. Facilitators included the relative advantage of the intervention compared with current practice (intervention characteristics); awareness of the growing prioritization of diabetes in the national health policy framework (outer setting); tension for change due to the realization of the vulnerability to vision loss from DR (inner setting); a strong collective sense of accountability of peer supporters to implement the intervention (individual characteristics); and regular feedback on the progress with implementation (process). Potential barriers included the need to queue at the eye clinic (intervention characteristic), travel inconveniences (inner setting), and socio-political disruption (outer setting).

Conclusions: The intervention was implemented with high retention, reach, fidelity, and dose. The CFIR provided a valuable framework for evaluating contextual factors that influenced implementation and helped to understand what adaptations may be needed during scale up.

Trial Registration: Pan African Clinical Trials Registry: PACTR201707002430195 registered 15 July 2017.
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http://dx.doi.org/10.1186/s41182-019-0188-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6945600PMC
January 2020

Announcing The Lancet Global Health Commission on Global Eye Health.

Lancet Glob Health 2019 12 9;7(12):e1612-e1613. Epub 2019 Oct 9.

International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, UK.

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http://dx.doi.org/10.1016/S2214-109X(19)30450-4DOI Listing
December 2019

Awareness, utilization and barriers in accessing assistive technology among young patients attending a low vision rehabilitation clinic of a tertiary eye care centre in Delhi.

Indian J Ophthalmol 2019 10;67(10):1548-1554

Department of Community Ophthalmology, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India.

Purpose: People with visual disability need assistive technology to improve their body functioning and performance. The purpose of the present study was to understand the awareness, use and barriers in accessing the assistive technology among young patients attending visual rehabilitation clinic of a tertiary eye care hospital in Delhi.

Methods: A cross-sectional study was conducted on consecutively recruited patients registered for the first time in visual rehabilitation clinic of the community ophthalmology department of the tertiary eye centre during June and July 2018. A study tool consisting of 42 assistive technologies was developed. Patients were screened for distance visual acuity both presenting and binocular pinhole vision using an 'E' chart with two optotype (6/18, 6/60).

Results: 85 patients (69.4% male) were enrolled from the VR clinic. 83.5% of the patients had a best corrected binocular vision acuity <6/18 to 1/60. There was good awareness of only 2 of the 42 devices (>67% of the participants): near optical magnifiers, walking long canes. There was moderate awareness of 10 devices (34-66% of the participants) and poor awareness of the rest (<33%). Likewise, participants reported moderate usage of 3 out of the 42 devices and poor usage of the remaining devices. Non-availability of devices was the most frequently reported barrier in the study.

Conclusion: The awareness and utilization of assistive technologies for visual disability was poor in patients attending visual rehabilitation clinic. Hospitals could procure assistive technologies and introduce strategies to improve awareness as well as promote utilization.
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http://dx.doi.org/10.4103/ijo.IJO_197_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6786185PMC
October 2019

Impact of a 10-Year Eye Care Program in Sokoto, Nigeria: Changing Pattern of Prevalence and Causes of Blindness and Visual Impairment.

Middle East Afr J Ophthalmol 2019 Apr-Jun;26(2):101-106. Epub 2019 Aug 26.

Clinical Research Department, International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, United Kingdom.

Background: This study was undertaken to ascertain the current magnitude and causes of blindness and visual impairment in persons aged 50 years and over and to assess the impact of a 10-year eye care program in Sokoto State, Nigeria.

Methods: A rapid assessment of avoidable blindness (RAAB) survey (in persons 50 years and over) was conducted in 2016. Participants were selected in Wurno health zone using a two-stage cluster randomized sampling with probability proportional to size. Operational definitions were based on RAAB and World Health Organization eye examination record definitions. Eye care program documents were reviewed and data from a baseline survey undertaken in 2005 were reanalyzed.

Results: A response of 89.1% (2405 of 2700 participants) was obtained in the 2016 survey. With available correction, the unadjusted prevalence of blindness was 7.7% (95% confidence interval [CI]: 6.4, 8.9). The odds of blindness were 1.8 times higher in females than males (95% CI: 1.3, 2.4; < 0.001). Major causes of blindness were cataract (48.9%) corneal disease (20.1%), glaucoma (10.3%), and uncorrected refractive error/aphakia (8.7%). The age- and sex-adjusted prevalence of blindness has declined from 11.6% (95% CI: 7.4, 17.0) in 2005 to 6.8% (95% CI: 5.6, 8.0%) in 2016.

Conclusion: The blindness prevalence is high, and the major causes are avoidable in the health zone. The findings suggest that investments in the program over the last 10 years might have led to almost a halving in the prevalence of blindness in th e population. However, the small sample size of persons 50+ years from Wurno zone in the 2005 survey necessitate caution when comparing the 2005 and the 2016 surveys.
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http://dx.doi.org/10.4103/meajo.MEAJO_113_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6737780PMC
November 2019

Incidence of Visually Impairing Cataracts Among Older Adults in Kenya.

JAMA Netw Open 2019 06 5;2(6):e196354. Epub 2019 Jun 5.

International Centre for Eye Health, Clinical Research Department, London School of Hygiene & Tropical Medicine, London, United Kingdom.

Importance: Half of all the cases of blindness worldwide are associated with cataract. Cataract disproportionately affects people living in low- and middle-income countries and persons of African descent.

Objective: To estimate the 6-year cumulative incidence of visually impairing cataract in adult participants in the Nakuru Eye Disease Cohort Study in Kenya.

Design, Setting, And Participants: This secondary analysis of the Nakuru Eye Disease Cohort Study was conducted from February 2016 to April 2016. This cohort comprised citizens of Nakuru, Kenya, aged 50 years or older who consented to participate in the initial or baseline survey from January 2007 to November 2008, as well as the follow-up conducted from January 2013 to March 2014. All participants at baseline (n = 4364) and follow-up (n = 2159) underwent ophthalmic examination.

Main Outcomes And Measures: Six-year cumulative incidence of visually impairing cataract, risk factors of incidence, population estimates, and required cataract surgical rates to manage incident visually impairing cataract.

Results: In total, 4364 individuals (with a mean [SD] age of 63.4 [10.5] years and with 2275 women [52.1%]) had complete eye examinations at baseline, and 2159 participants (with a mean [SD] age of 62.5 [9.3] years and with 1140 men [52.8%]) were followed up 6 years later. The 6-year cumulative incidence of visually significant cataract in either eye was 251.9 per 1000 (95% CI, 228.5-276.8), with an increase with age from 128.9 (95% CI, 107.9-153.2) per 1000 for the group aged 50 to 59 years to 624.5 (95% CI, 493.1-739.9) per 1000 for the group aged 80 years or older. This equated to an annual incidence of visually significant cataract of 45.0 per 1000 people aged 50 years or older. Multivariable analysis showed alcohol consumption (risk ratio [RR], 1.4; 95% CI, 1.1-1.8), diabetes (RR, 1.7; 95% CI, 1.3-2.3), educational level, and increasing age (RR, 3.8; 95% CI, 2.6-5.5 for those aged ≥80 years) were associated with incident visually impairing cataract. Extrapolations to all people aged 50 years or older in Kenya indicated that 148 280 (95% CI, 134 510-162 950) individuals might develop new visually impairing cataract in either eye (visual acuity <6/18 in the worse-seeing eye) and that 9540 (95% CI, 6610-13 750) might become cataract blind in both eyes (visual acuity <3/60 in better-seeing eye).

Conclusions And Relevance: Adults in Kenya appeared to have a high incidence of visually impairing cataract, making cataract a priority for blindness prevention programs in the region; surgical interventions and awareness of these services are also required.
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http://dx.doi.org/10.1001/jamanetworkopen.2019.6354DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6604086PMC
June 2019

Mortality during 6 years of follow-up in relation to visual impairment and eye disease: results from a population-based cohort study of people aged 50 years and above in Nakuru, Kenya.

BMJ Open 2019 06 9;9(6):e029700. Epub 2019 Jun 9.

International Centre for Eye Health, Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK.

Objective: To 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 Participants: The 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 Measures: Cumulative incidence of mortality in relation to VI level at baseline.

Results: Of 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 (<6/18 to ≥6/60; risk=28.3%; risk ratio (RR) 1.75, 95% CI 1.28 to 2.40) or severe VI (SVI)/blindness (<6/60; risk=34.9%; RR 1.98, 95% CI 1.04 to 3.80). These associations remained after adjustment for non-communicable disease (NCD) risk factors (mortality: RR 1.56, 95% CI 1.14 to 2.15; SVI/blind: RR 1.46, 95% CI 0.80 to 2.68). Mortality risk was also associated with presence of diabetic retinopathy at baseline (RR 3.18, 95% CI 1.98 to 5.09), cataract (RR 1.26, 95% CI 0.95 to 1.66) and presence of both cataract and VI (RR 1.57, 95% CI 1.24 to 1.98). Mortality risk was higher among people with age-related macular degeneration at baseline (with or without VI), compared with those without (RR 1.42, 95% CI 0.91 to 2.22 and RR 1.34, 95% CI 0.99 to 1.81, respectively).

Conclusions: Visual acuity was related to 6-year mortality risk in this cohort of elderly Kenyan people, potentially because both VI and mortality are related to ageing and risk factors for NCD.
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http://dx.doi.org/10.1136/bmjopen-2019-029700DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6561440PMC
June 2019

Assistive technology for students with visual disability in schools for the blind in Delhi.

Disabil Rehabil Assist Technol 2020 08 23;15(6):663-669. Epub 2019 Apr 23.

Department of Community Ophthalmology, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India.

To understand the awareness and utilization of assistive technology in students at schools for the blind in Delhi. A cross sectional study was conducted among 250 students selected randomly from 10 blind schools in Delhi. Binocular distance presenting and pinhole vision acuity were assessed using Snellen "E" chart and a multiple pinhole occluder. Students were also interviewed using a questionnaire about 42 assistive devices to understand their awareness and use. Male participants were 72.8%. Of the total, 27.6% students had best corrected visual acuity <6/18 to 1/60, and the rest had <1/60 vision. The awareness about tactile and sound-based technology was good among students: Braille books (98%), Braille slate and stylus (99.2%), handheld audio recorders (77.6%) and screen readers (77.2%). Good awareness was reported for abacus (88.8%), walking long canes (94.4%) and smart cane (89.6%), audible balls (96%), Braille chess (82.8%) and talking watch (98%). Among the students with <6/18 to 1/60 vision, the awareness of visual based technology ranged from 0.8% (typoscope) to 43.6% (video magnifiers). Braille technology was used for reading by 96.4% (books) and for writing by 96.8% (Braille slate and stylus) irrespective of visual status. Other devices were poorly used ranging from nil (typoscope) to 55% (screen readers). The use of math and science learning devices was poor (<20%). Walking canes were used by 59% of students whereas 87.2% students used audible ball for games. The results showed that majority of students used tactile based technology irrespective of visual status.Implications for rehabilitationStudents with visual disability need assistive technology for a wide range of activities including academic learning.Students in schools for the blind who have binocular best corrected vision acuity of 1/60 or better should be encouraged to use visual based assistive technology instead of tactile based.Students with binocular best corrected vision acuity less than1/60 should be encouraged to use other available tactile and sound-based assistive technologies as well as Braille books and Braille slate and stylus for their academic activities including maths and sciences.Teachers should be trained in the use of various assistive technologies for reading, writing, maths, sciences, sports, mobility and activities of daily living.
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http://dx.doi.org/10.1080/17483107.2019.1604829DOI Listing
August 2020
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