First Rapid Assessment of Avoidable Blindness Survey in the Maldives: Prevalence and Causes of Blindness and Cataract Surgery

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1 origial cliical study First Rapid Assessmet of Avoidable Blidess Survey i the Maldives: Prevalece ad Causes of Blidess ad Cataract Surgery Ubeydulla Thoufeeq, MSc,* Taraprasad Das, MD, Has Limburg, PhD, Maharshi Maitra, MD, Lapam Pada, MD, Asim Sil, MD, Joh Trevelya,** ad Yuddha Sapkota, MSc Purpose: A atiowide rapid assessmet of avoidable blidess survey was udertake i the Maldives amog people aged 0 years or more to assess the prevalece ad causes of blidess ad visual impairmet, cataract surgical coverage, cataract surgery outcome, ad barriers to uptake of cataract surgical services. Desig: Prospective populatio-based study. Methods: I the cluster samplig probability proportioate to size method, 3100 participats i 62 clusters across all 20 atolls were erolled through house-to-house visits. They were examied i clusters by a ophthalmologist-led team. Data was recorded i mraab versio 1.2 software o a smartphoe. Results: The age-sex stadardized prevalece of blidess was 2.0 [9 cofidece iterval (CI), ]. Cataract was the leadig cause of blidess (1.4) ad ucorrected refractive error was the leadig cause of visual impairmet (0.9). Blidess was more prevalet i higher age groups ad wome (16.3). Cataract surgical coverage was 86 i cataract blid eyes ad 93. i cataract blid persos. Good visual outcome i cataract operated eyes was 67.9 (presetig) ad 76.6 (best corrected visual acuity). I this study, 48.1 of people had received cataract surgery i eighborig coutries. Importat barriers for ot usig the services were did ot feel the eed (29.7) ad treatmet deferred (). Coclusios: Cataract surgical coverage is good, though early half the people received surgery outside the Maldives. Cataract surgery outcomes are below World Health Orgaizatio stadards. Some barriers could be overcome with additioal huma resources ad traiig to improve cataract surgical outcomes, which could ecourage greater uptake of services withi the coutry. Key Words: Maldives, rapid assessmet of avoidable blidess, blidess, visual impairmet, cataract surgical coverage (Asia-Pac J Ophthalmol 2017;6:0 0) Blidess ad severe visual impairmet remai leadig causes of disability i the world. I 2010, the World Health From the *Health Protectio Agecy, Miistry of Health, Maldives; Iteratioal Agecy for Prevetio of Blidess South East Asia Regioal Office, L V Prasad Eye Istitute, Hyderabad, Idia; L V Prasad Eye Istitute, Hyderabad, Idia; Iteratioal Cetre for Eye Health, Lodo, UK; Netra Niramaya Niketa, Purba Mediipur, West Begal, Idia; L V Prasad Eye Istitute, Bhubaeshwar, Odisha, Idia; **Iteratioal Agecy for the Prevetio of Blidess, Lodo, UK. Received for publicatio July 20, 2017; accepted September 26, Fuded i part by the Lios Clubs Iteratioal Foudatio. The authors have o fudig or coflicts of iterest to declare. Reprits: Yuddha Sapkota, Iteratioal Agecy for Prevetio of Blidess South East Asia Regioal Office, L V Prasad Eye Istitute, Hyderabad 00034, Idia. E mail: ysapkota@iapb.org. Copyright 2017 by Asia Pacific Academy of Ophthalmology ISSN: DOI: /APO Asia-Pacific Joural of Ophthalmology Volume 0, Number 0, Moth 2017 Orgaisatio (WHO) estimated that 28 millio people had visual impairmet, of which 39 millio were blid. Further, 90 of blid people live i developig coutries. 1 Similarly, the Global Burde of Disease (GBD) 2010 data showed that globally, 32.4 millio people [9 cofidece iterval (CI), millio people; 60 wome] were blid, ad 191 millio people (9 CI, millio people; 7 wome) had moderate to severe visual impairmet (MSVI). The age stadardized prevalece of blidess i older adults (0+ years) i South Asia was 4.4 (9 CI, 3..1), ad the MSVI prevalece i older adults was highest i South Asia (23.6; 9 CI, ). 2 The WHO Global Actio Pla (GAP) called o member states to work toward reducig the prevalece of avoidable visual impairmet by 2 by the year The GAP idetifies the rapid assessmet of avoidable blidess (RAAB) as a preferred method to assess the prevalece ad causes of visual impairmet i a specific populatio. Fidigs of RAAB surveys are useful for maagers to develop itervetio programs for cotrol of blidess based o a commuity s eeds. 4 Recetly RAAB studies have bee coducted i Southeast Asia (Thailad, Sri Laka, 6 Nepal 7 ) ad are i progress i Idia, Myamar, ad Idoesia. There has ever bee a prevalece study o eye health i the Maldives. The primary objective of this study was to assess the pricipal causes of blidess ad visual impairmet i the elderly Maldivia populatio. I the absece of baselie data, it would be difficult to assess the impact of eye care services vis-à-vis the WHO global actio pla. Hece the Miistry of Health, Govermet of Maldives agreed to this atiowide blidess prevalece study. materials ad methods Selectio of Study Clusters The islads of the Maldives form 26 atural clusters of islads ad are admiistratively divided ito 20 atolls (admiistrative areas). The atolls are divided ito 198 admiistrative subdistricts ad further divided ito 997 cesus blocks. Of these, 468 blocks have less tha 300 people, 19 blocks have betwee 300 ad 700 people, ad 10 blocks have more tha 700 people. As per the 2014 cesus data, approximately 14.3 of the Maldivia populatio was aged 0 years ad above. A populato uit of 30 people of all ages was thus ecessary to fid 0 people aged 0 years ad older. To create the populatio uit of appropriate sizes, we combied the 2 earest possible cesus blocks o the same islad whe the populatio was less tha 300 people i a give cesus block. The 10 cesus blocks which could ot be joied with aother block o same islad were joied with radomly chose cesus blocks from the earest possible islad. Five cesus blocks with a populatio of 700 or more were segmeted ito 2 populatio uits.

2 Thoufeeq et al Asia-Pacific Joural of Ophthalmology Volume 0, Number 0, Moth 2017 Table 1. Distributio of Study Participats Category Male Female All Erolled Examied Respose Rate Sample Size Usig RAAB computerized software, the sample size was calculated ad the study clusters were chose. I the absece of ay previous prevalece data, we assumed a 4.2 prevalece of blidess i people aged 0 years ad over. With 20 tolerable error, 9 precisio, ad adjustig the cluster desig effect of 1. for the cluster size of 0, the sample size was 3061 (Maldives populatio per 2014 cesus: 341,848). The participats were recruited from 62 study clusters spread over 738 populatio uits of 20 atolls. The coutry was divided ito 3 zoes for data collectio purposes: orth, cetral, ad south. The orth zoe cosisted of 17 clusters i 7 atolls, the cetral zoe cosisted of 27 clusters i 3 atolls, ad the south zoe cosisted of 18 clusters i 10 atolls. The capital city Malé was located i the cetral zoe. Traiig ad Pilot Study There were 2 study teams. Each study team cosisted of 1 ophthalmologist, 1 assistat, 1 cluster commuity worker, ad 1 village guide. The pricipal ivestigator (U.T.) ad the study coordiator (F.S.) supervised both teams. The actual fieldwork was preceded by 4 days of traiig ad a pilot study. The certified RAAB traier (Y.S.) coducted the traiig that bega with a itroductio to the RAAB survey ad methodology, followed by practice of certai examiatio procedures such as the measuremet of visual acuity usig the tumblig E, 8 aterior segmet eye examiatio usig a flashlight, fudus examiatio usig direct ophthalmoscope with mydriasis whe required, ad assigig the pricipal cause of visual impairmet for each eye ad i the perso. Everyoe practiced usig the mraab loaded o a smartphoe ad etered mock data. The pricipal ivestigator practiced dowloadig iformatio set by the data collectio team from the study site as a attachmet. A iterobserver variatio (IOV) test was doe i 1 of the ostudy clusters, ad the task icluded the measuremet of visual acuity ad ocular examiatio i the same group of people by both groups. The traiig cocluded with a pilot study i 1 ostudy cluster to stadardize all examiatio ad data etry procedures. Examiatio ad Data Etry Each cliical team cosisted of 1 ophthalmologist, 1 ophthalmic assistat, ad 1 cluster/village guide. The sequece of idividual examiatio cosisted of the followig: 1) the basic data icludig the study participat s ame, age, sex, ad history regardig the use of distace ad ear spectacles were etered i the software; 2) distace visio was recorded usig the tumblig E chart at 6 m, which was brought to 3 m ad 1 m for those who could ot read the chart; 3) flashlight examiatio of the eye ad adexa was doe; 4) direct ophthalmoscope was used to see the media clarity; ad ) the pupils were dilated if pihole visual acuity was less tha 6/18 uless there were obvious causes such as coreal opacity or cataract. The defiitios of diseases were i lie with the RAAB istructio maual versio.0. 8 Those who had bee operated o for cataract were asked about the duratio of surgery, isertio of itraocular les (IOL) (yes/o), mode of paymet (totally free, partially paid, or fully paid), place of surgery (govermet, private, abroad), ad the surgical settigs (eye camp/improvised settig/hospital settig). Those who had ot had surgery despite havig visual impairmet due to cataract were asked about the barriers (did ot feel the eed, fear of surgery, poor result, caot afford, asked to defer treatmet by provider, uaware of treatmet, o access to treatmet, o oe to accompay them) ad the 2 importat causes i order of priority. I cases where the perso was ot available, was ot able to commuicate, or refused the examiatio, he/she was erolled i the study ad the possible details of visio ad cause of blidess (cataract, causes other tha cataract, or operated for cataract) were obtaied from a relative or eighbor. The participat was cosidered abset for cliical examiatio if ot available o 2 repeat visits. Ethical Cosideratios The protocol was reviewed ad approved by the Health Research Committee, Miistry of Health, Maldives. A writte coset form i the local laguage (Dhivehi) was read out with explaatio ad each study participat s sigature was obtaied for coset. Participats were also iformed that they could withdraw from the study at ay time. The participats were iformed of the fidigs of eye examiatio ad advised of ay appropriate actios. Treatmet for mior ocular coditios was give durig the examiatio at o cost to the subjects. Those who required cataract surgery or advaced ivestigatio/examiatio were referred to the Idira Gadhi Table 2. Prevalece of Blidess, SVI, ad MVI by Bilateral Presetig Visual Acuity VA Category Prevalece Male (9 CI) Female (9 CI) All (9 CI) Blidess ( < 3/60) SVI ( < 6/60 3/60) MVI ( < 6/18 6/60) 2.4 (1. 3.2) 1.8 ( ) 3.0 ( ) 2.2 ( ) 1.4 ( ) 12.7 ( ) 2.4 ( ) 2.3 ( ) 1.6 ( ) 1.9 ( ) 10. ( ) 10.0 ( ) 2.4 ( ) 2.0 (1. 2.6) 2.2 ( ) 1.9 ( ) 12. ( ) 11.4 ( ) idicates presetig visual acuity.

3 Asia-Pacific Joural of Ophthalmology Volume 0, Number 0, Moth 2017 Maldives RAAB Survey Table 3. Prevalece of Blidess Accordig to Age Group Age Group Male (9 CI) Female (9 CI) All (9 CI) 0 9 y y y 80+ y All 0+ y 0.6 ( ) 1.0 ( ) 3.0 ( ) 10.7 ( ) 2.4 (1. 3.2) 0.6 ( ) 1.1 ( ).4 ( ) 16.3 ( ) 2.4 ( ) 0.6 ( ) 1.0 ( ) OR, 1.8 ( ; P = 0.2) 4.2 (2..9) OR, 7.6 ( ; P < 0.0) 13.1 ( ) OR, 23.2 ( ; P < 0.0) 2.4 ( ) Memorial Hospital (govermet facility) i Malé. All services were provided free of cost to study participats covered by the atioal health isurace scheme. Statistical Aalysis We used the followig statistical methods for aalysis of the collected data: 1) the crude ad estimated age- ad sex-adjusted prevalece of visual impairmet ad blidess; 2) 9 cofidece iterval (CI); 3) odds ratio (OR) to assess the ratio of blidess accordig to age ad sex; ad 4) cataract surgery visual outcome aalysis compariso betwee public ad private hospitals ad those treated i the coutry ad abroad. A P value of less tha or equal to 0.0 was cosidered statistically sigificat. Results Iterobserver Variatio The fidigs of iterobserver agreemet Kappa aalysis were 0.78 (right eye) ad 0.79 (left eye) for presetig visio; 0.76 (right eye) ad 0.74 (left eye) for best-corrected visio; 0.94 (right eye) ad 0.82 (left eye) for les status; ad 0.67 for assigig the pricipal cause of visual impairmet. A total of 3020 (97.4) people of the 3100 erolled survey participats were examied. Reasos for the 80 people ot examied icluded refused ( = 43), ot available ( = 26), ad could ot commuicate ( = 11). The age- ad sex-specific distributio of the study participats showed that females were more likely to be examied i this study [ = 1787, 98.; OR, 2.8 (9 CI ); P < 0.00] (Table 1). The distributio of blidess is show i Table 2. The crude prevalece ad age- ad sex-adjusted prevalece of blidess was 2.4 ad 2.0, respectively; severe visual impairmet (SVI) was 2.2 ad 1.9, respectively; ad moderate visual impairmet (MVI) was 12. ad 11.4, respectively. The prevalece of blidess (visio less tha 3/60) was 1.8 for males ad 2.3 for females. visual impairmet ad blidess (visio less tha 6/18) was 16.7 i males ad 14.7 i females. There was o sex differece i blidess ad visual impairmet i the study populatio. Age-specific prevalece of blidess is show i Table 3. There was a icrease i blidess i the older age cohort. The distributio of blidess ad visual impairmet is show i Table 4. Cataract was the pricipal cause of avoidable blidess ad severe visual impairmet, whereas refractive error ad cataract were the mai causes of moderate visual impairmet. Complicatios of cataract surgery accouted for 1.4 ad 4.6 of blidess ad severe visual impairmet, respectively. Notrachomatous coreal opacity accouted for.6 of all blidess; age-related macular degeeratio (AMD) accouted for 6.3 of severe visual impairmet (visio less tha 6/60 to 3/60) ad 3.2 of moderate visual impairmet (visio less tha 6/18 to 6/60) (Table 4). Cataract surgical coverage amog the bilateral cataract blid was 93. (male, 94.4 ad female, 92.7). Amog the cataract blid eyes (icludes uilateral cataract blid) the coverage was 86.0 (male, 8. ad female, 86.). The cataract surgical coverage at other presetig visual acuities is show i Table. Eight hudred fifty people (80 eyes) had udergoe surgery for cataract; 817 (96.1) eyes had IOL implatatio ad 33 eyes did ot. Overall good visual outcome (at least 6/18) accordig to Table 4. Pricipal Causes of Blidess, SVI, ad MVI () Causes Blidess () SVI () MVI () Refractive error Cataract Cataract surgical complicatios Notrachomatous coreal opacity Glaucoma Diabetic retiopathy AMD Other posterior segmet disease All other globe/cetral ervous system abormalities 1.4 (37) 1.4 (1).6 (4) 2.8 (2) 2.8 (2) 27.8 (20) 8.3 (6) (72) 1. (1) 64.6 (42) 4.6 (3) 3.1 (2) 3.1 (2) 6.2 (4) 12.3 (8) 4.6 (3) (6) 0.9 (192) 36.3 (137) 1.9 (7) 1.3 () 0.3 (1) 0.8 (3) 3.2 (12) 4.0 (1) 1.3 () (377)

4 Thoufeeq et al Asia-Pacific Joural of Ophthalmology Volume 0, Number 0, Moth 2017 Table. Adjusted Results for Cataract Surgical Coverage Cataract Surgical Coverage VA < 3/60 Persos VA < 6/60 Persos VA < 6/18 Persos Male Female the WHO defiitio was see i 67.9 ad 76.6 presetig ad best-corrected visual acuity (), respectively. Overall, a poor outcome was see i 14.8 ad 13.4 presetig ad best-corrected visual acuity, respectively. I geeral, aphakic eyes had a poorer outcome (Table 6). Cataract surgery i 409 (48.1) of 80 eyes was performed outside the coutry ad i 92 (10.8) eyes surgery was performed i the govermet hospital i Malé. The visual outcomes of surgery are show i Table 7. A higher percetage of people who were treated outside the coutry had good visual outcome compared with those patiets operated o i the Maldives [OR, 2.0 (9 CI ); P < 0.0] (Table 7). The 2 major barriers to the uptake of cataract surgery i the study cohort were did ot feel the eed (29.7) ad treatmet deferred by the provider (). Other causes icluded fear, cost, access, ad lack of accompayig perso (Table 8). Discussio The Maldives health care delivery system cosists of 20 atoll-based hospitals, 7 regioal hospitals (icludig 2 operated at the tertiary level), ad 16 health ceters located o populated islads. Several private cliics also operate ad are maily located i the capital Malé. The capital city of Malé houses over a third of the total populatio. The city has 2 tertiary level hospitals: 1 govermet ad 1 private. The eye health persoel distributio is as follows: 1 ophthalmologist per 34,000 people, 1 optometrist per 34,100 people, ad 1 eye care urse per 23,184 people. All Maldivias are isured by the Aasadha uiversal health isurace scheme fully fiaced by the govermet ad eye health services are itegrated withi the health care system. There has ever bee a blidess ad visual impairmet survey i the Maldives to date. The respose rate of 97.4 to the first atiowide survey was very good. This success owes much to the atiowide media coverage ahead of the study, good housespecific local area maps, ad excellet local support for survey work. The RAAB survey method, by desig, focuses o cataract, the most commo cause of avoidable blidess. Examiatio techiques do ot measure the posterior segmet i detail ad do ot measure the visual field. Hece, it is likely to overlook the retia, glaucoma, or optic erve disorders if visual acuity is ot reduced cocurretly. The blidess ad visual impairmet prevalece ad causes i the Maldives were ot much differet tha the global profile, with cataract accoutig for 1.4 of blidess ad 64.6 of severe visual impairmet ad ucorrected refractive error accoutig for 60 of visual impairmet. 1,2 Trachoma, still prevalet i other South Asia coutries, was ot detected i this study cohort. There was a high prevalece of posterior segmet disorders. Cataract surgical coverage at 93. is very good, although close to half (409 of 80) of the patiets had opted to have surgery outside the coutry, ad these eyes had better visual outcome. Although the cost of surgery was ot a importat barrier ad fear of surgery was withi a reasoable limit, the 2 importat barriers were did ot feel the eed ad deferred by the service provider. The former barrier could be addressed by better advocacy ad patiet educatio. Deferred by the service provider, which traslates to icreased waitig time ad additioal expese, is related to the curret ophthalmic surgical ifrastructure ad uavailability of cataract surgical services i atoll hospitals. Maldivia eye health persoel, at 1 ophthalmologist per 34,000 people ad 1 optometrist per 34,100 people, are withi the WHO recommedatios 9,10 ; however, more tha half of the ophthalmologists ad all of the optometrists are expatriates ad are based i the capital city of Malé. To improve the service stadards, the Maldives should icrease ad expad the skill base by establishig regioal cataract surgical ceters amog the atolls beyod the capital city of Malé. Deliverig uiversal eye health care that is based o the pyramid model of eye care 3,11 from primary care at the village level, secodary level eye care at the tow level, ad tertiary eye care at the city level could be a good model of equitable eye care i the Maldives. Huma resources are key to success i this model. Midlevel ophthalmic persoel play a importat role. 12 Availability of comprehesive eye care, icludig correctio of refractive error ad quality cataract surgery i the regioal hospitals ad elevatig the cetral hospital at Malé to deliver tertiary eye care, will accelerate the ecessary eye care reforms. The limitatio of this study is the RAAB itself i the sese that it assesses blidess ad visual impairmet of people 0 Table 6. Visual Outcomes of Cataract Surgery Outcomes Visual Acuity Aphakia () Pseudophakia () All () Good ( 6/18) Borderlie (<6/18 6/60) Poor (<6/60) All cataract operated eyes 42.4 (14) 42.4 (14) 12.1 (4) 12.1 (4) 4. (1) 4. (1) (33) 68.9 (63) 78 (637) 17. (143) 9.9 (81) 13.6 (111) 12.1 (99) (817) 67.9 (77) 76.6 (61) 17.3 (147) 10.0 (8) 14.8 (116) 13.4 (114) (80)

5 Asia-Pacific Joural of Ophthalmology Volume 0, Number 0, Moth 2017 Maldives RAAB Survey Table 7. Visual Outcomes of Cataract Surgery Accordig to Locatio of Surgery Govermet Abroad Private Eye Camp Outcomes Good Borderlie Poor Table 8. Barriers to Uptake of Cataract Surgery ( < 6/18 Due to Cataract) Males Females Did ot feel the eed Fear Cost Treatmet deferred by provider Caot access treatmet Lack of accompayig perso years ad older. A all-age eye disease study could have more ideal results. However, RAAB has bee prove to cost-effectively detect the most commo cause of blidess ad visual impairmet. The stregth of this study is that it is the first study to measure the prevalece of blidess ad visual impairmet i the coutry, though this particular study was cofied to the elderly populatio. Additioally, the populatio cohort was pooled from the etire coutry despite difficult travel logistics. It is believed that the results could help the Maldives desig a soud eye health policy plaig ad eye care delivery system. Ackowledgmet We thak Dr. Sujata Das of LV Prasad Eye Istitute Bhubaeswar for providig the study ophthalmologist for this survey work ad Dr. Fathimath Shaamaly Jaufar, cosultat ophthalmologist at Idira Gadhi Memorial Hospital i Malé, for takig care of all referrals idetified i the survey for further care. The Health Protectio Agecy, Miistry of Health, Maldives provided office space for the survey, desigated study coordiator, eumerators, ad other survey persoel. The Health Protectio Agecy took care of all admiistratio of the survey work ad its implemetatio i the Maldives. The Maldivia Nurse Associatio helped i fiacial admiistratio of the survey work ad esured a smooth flow of fiaces. 1. Refereces Pascolii D, Mariotti SP. Global estimates of visual impairmet: Br J Ophthalmol. 2012;96: Steves GA, White RA, Flaxma SR, et al; Visio Loss Expert Group. Global prevalece of visio impairmet ad blidess: magitude ad temporal treds, Ophthalmology. 2013:120: World Health Orgaizatio. Uiversal eye health: a global actio pla A rapid survey methodology to provide data o prevalece ad causes of visual loss. Iteratioal Cetre for Eye Health Web site. ac.uk/rapid-assessmet-of-avoidable-blidess/. Accessed December 12, Isipradit S, Sirimaharaj M, Charukamoostkaok P, et al. The first rapid assessmet of avoidable blidess (RAAB) i Thailad. PLoS Oe. 2014;9: e Edussuriya K, Seaayake S, Searate T, et al. The prevalece ad causes of visual impairmet i cetral Sri Laka. The Kady Eye Study. Ophthalmology. 2009;116: Sapkota YD, ed. Epidemiology of blidess i Nepal. wp-cotet/uploads/epidemiology-of-blidess-nepal.pdf Limburg H, Ig WM, Kuper H, et al. RAAB Versio.0 for Widows Istructio Maual. Lodo: Iteratioal Cetre of Eye Health; October World Health Orgaizatio. Global iitiative for the elimiatio of avoidable blidess: actio pla Visio2020_report.pdf World Health Orgaizatio. Actio pla for the prevetio of avoidable blidess ad visio impairmet ACTION_PLAN_WHA62-1-Eglish.pdf Rao GN. The Barrie Joes Lecture-Eye Care for the eglected populatio: challeges ad solutios. Eye (Lod). 201;29: World Health Orgaizatio Regioal Office for South-East Asia. Mid-level ophthalmic persoel i South-East Asia