The Asia-Pacific Journal of Ophthalmology

  • Current Issue

    November/December 2018 - Volume 7 - Issue 6
    Special Issue on Prevention of Blindness, Ocular Epidemiology, Telemedicine, and Big Data
    pp: 367-445
    Guest Editors-in-Chief: Nathan Congdon, Mingguang He
    Guest Editors: Augusto Azuara-Blanco, Tony Realini, Amanda Davis, Jialiang Zhao


Promoting Eye Health in Low-Resource Areas by “Doing More With Less” Congdon, Nathan; He, Mingguang
We are very pleased to share with our readers unique articles highlighting different topics under the theme of “Prevention of Blindness, Ocular Epidemiology, Telemedicine, and Big Data” in this issue. Reducing the burden of vision impairment in low-resource areas depends essentially on the principle of “doing more with less”. Although there are many approaches to accomplish this, the key lies in the use of novel technologies, either for the detection or treatment of eye diseases.

Review Article

Impact of Presbyopia and Its Correction in Low- and Middle-Income Countries Chan, Ving Fai; MacKenzie, Graeme E.; Kassalow, Jordan; Gudwin, Ella; Congdon, Nathan
Presbyopia affects more than 1 billion people worldwide, and the number is growing rapidly due to the aging global population. Uncorrected presbyopia is the world’s leading cause of vision impairment, and as with other causes. The burden falls unfairly on low- and middle-income countries (LMICs), in which rates of presbyopic correction are as low as 10%. The importance of presbyopia as a cause of vision impairment is further underscored by the fact that it strikes at the heart of the productive working years, although it can be safely and effectively treated with a pair of inexpensive glasses. To galvanize action for programs to address uncorrected presbyopia in the workplace and beyond LMICs, it is crucial to build a solid evidence base detailing the impact of presbyopia and its correction in important areas such as work productivity, activities of daily living, visual function, and quality of life. The aim of this review was to provide an up-to-date reference for program planners and policymakers seeking to build support for programs of presbyopia correction, particularly in low-resource settings.
The Current Status of Glaucoma and Glaucoma Care in Sub-Saharan Africa Kyari, Fatima; Adekoya, Bola; Abdull, Mohammed Mahdi; Mohammed, Abdullahi Sadiq; Garba, Farouk
Glaucoma is a serious and irreversibly blinding eye condition of public health importance in Africa. The absence of distinct early symptoms makes the condition hard to recognize by patients. The gradual vision deterioration that occurs is worse in one eye, thereby making it difficult for those affected to be aware of the vision loss until the advanced stages of the disease. We discuss the epidemiology of glaucoma in sub-Saharan Africa, highlighting the risk factors for the disease as well as risk factors for blindness in glaucoma patients. Available evidence suggests that treatment options of medical, surgical, and laser therapies for glaucoma are limited by availability of medicines and equipment, lack of adequate surgical and diagnostic skills, and high costs of treatment. We propose 3 complementary strategies in developing models of glaucoma care: strengthening clinical services for glaucoma; earlier detection of glaucoma in the clinics and communities; and strengthening health systems governance. Further research to define a suitable cost-beneficial treatment modality and mechanisms for financing eye care is required.
The Rationale for Selective Laser Trabeculoplasty in Africa Realini, Tony; Olawoye, Olusola; Kizor-Akaraiwe, Nkiru; Manji, Selina; Sit, Arthur
Glaucoma is the leading cause of irreversible blindness in Africa. The condition is treatable but not curable. There are numerous obstacles to glaucoma care in Africa, including availability, accessibility and affordability of treatments, as well as medication nonadherence among patients. Medical therapy is costly relative to the average income in Africa and it requires daily self-dosing by patients. Surgery is of limited availability in many regions in Africa, and a high proportion of patients refuse surgery because it is expensive. Selective laser trabeculoplasty (SLT) proves to be a favorable alternative to medical or surgical care, as it is highly effective and safe in people of African descent, more
cost-effective than medical therapy, quick and easy to perform, and portable. The procedure also requires no postoperative care, thus obviates the issue of nonadherence. In uncontrolled studies, SLT has a high response rate and it lowers intraocular pressure by 30% to 40%, which exceeds the goal in international guidelines for initial therapies. The African Glaucoma Consortium (AGC), a member-driven stakeholder collective, has been formed in part to develop the infrastructure for continent-wide improvements in glaucoma care. It embraces SLT as a potential key tool in their development plans. The mission of AGC includes improving clinical care by educating existing and new health care professionals to expand the provider network, by conducting trials to identify optimal care strategies for glaucoma in Africa, and by facilitating the development of an integrated network of Centers of Excellence to bring SLT and other crucial glaucoma therapies to communities throughout Africa.
New Technologies for Glaucoma Detection Rodriguez-Una, Ignacio; Azuara-Blanco, Augusto
This review describes some of the most recent advances in the development and application of new technologies for detecting and managing glaucoma, including imaging, visual function testing, and tonometry. The widespread availability of mobile technology in the developing world is improving health care delivery, for example, with smartphones and mobile applications that allow patient data to be assessed remotely by health care providers.
Controlling Progression of Myopia: Optical and Pharmaceutical Strategies Sankaridurg, Padmaja; Conrad, Fabian; Tran, Huy; Zhu, Jianfeng
The burden associated with the rising prevalence of myopia and high myopia, and the associated vision impairment and
sight-threatening complications, has triggered the need to evaluate strategies to control the progression of myopia. We provide an overview of the literature on the use of optical (spectacles, contact lenses, and orthokeratology) and pharmaceutical approaches to slow progress of myopia. The evidence indicates that myopia progression can be slowed by varying degrees using these strategies. All approaches play a role in the management of myopia as needs and requirements of an individual vary based on age, suitability, affordability, safety of the approach, subjective needs of the individual, and rate of progression. This review also identifies and discusses the lack of long-term efficacy data and rebound on discontinuation of myopia control products.
Diagnosis and Treatment of Myopic Maculopathy Yokoi, Tae; Ohno-Matsui, Kyoko
Visual impairment resulting from pathologic myopia is a serious issue worldwide. This is mainly due to the development of different types of myopic maculopathy. Despite being a major cause of visual impairment worldwide, myopic maculopathy was not consistently defined. To overcome this problem, in 2015 the Meta-Analysis for Pathologic Myopia Study Group proposed a simplified, uniform classification system for myopic maculopathy. Among several lesions of myopic maculopathy, myopic choroidal neovascularization (CNV) is one of the most common and severe vision-threatening complications. Recent large clinical trials have reported a good initial efficacy for visual acuity improvement by application of anti–vascular endothelial growth factor therapy for myopic CNVs. However, long-term clinical studies demonstrate a gradual decrease in the visual acuity gain and return to the baseline level due to the development of myopic CNV-related macular atrophy. Regarding visual impairment caused by advanced myopic chorioretinal atrophy, the only way to prevent blindness is to prevent myopia from developing or progressing at a young age before the axial length elongates extremely. As peripapillary diffuse atrophy in childhood may be an indicator of more advanced myopic chorioretinal atrophy in later life, some preventive measures should be considered in such children.
Fenofibrate for Diabetic Retinopathy Stewart, Stephen; Lois, Noemi
Fenofibrate is a safe and inexpensive orally administered fibric acid derivative conventionally used to treat dyslipidemia. Two large randomized clinical trials, the Fenofibrate Intervention and Event Lowering in Diabetes (FIELD) and the Action to Control Cardiovascular Risk in Diabetes (ACCORD) studies, demonstrated the benefit of oral fenofibrate in the treatment of patients with type 2 diabetes and diabetic retinopathy (DR), including reduced disease progression and need for laser treatment for diabetic macular edema and proliferative diabetic retinopathy. These findings are supported by results of experimental studies, which have demonstrated beneficial effects of fenofibrate ameliorating retinal vascular leakage and leukostasis, downregulating vascular endothelial growth factor, and reducing endothelial cell and pericyte loss, among others; all of these are characteristic features of DR. In spite of this evidence, fenofibrate is not prescribed routinely for treating patients with diabetes and DR. In FIELD and ACCORD studies, retinopathy was not the primary outcome and this may explain, at least partly, its lack of use for this indication. New trials are now underway to specifically address the effects of fenofibrate in DR; these trials will provide additional and robust data that may support current evidence favoring the use of fenofibrate in this common microvascular complication of diabetes.
Simulation in Ophthalmic Training Flanagan, Judith L.; De Souza, Neilsen
Vision impairment and blindness arise both as a cause and a consequence of poverty. Achievement of the United Nations Sustainable Development Goals in providing universal access and equity in eye care, both within and between countries, remains challenging. A severe shortage of eye care providers is creating unnecessary blindness and vision impairment in developing communities worldwide. Education and training develops and strengthens the capacity of emerging nations to contribute to global eye health and the World Health Organization Development Goals in an effective and sustainable way. Compared with other medical professions, adoption of simulation in ophthalmic training has been relatively slow. Simulation potentially reduces training costs, increases accessibility, offers objective measurement of training outcomes, and improves patient safety during and after clinician training, all of which can help address the global burden of vision impairment and blindness. Simulation training offers advantages over apprenticeship models, the traditional mode of transferring knowledge and skills in medicine and health, which suffers from imperfect transference due to inherent biases, heuristic and idiosyncratic expectations of experts, and subjective measures of outcomes. Simulation does not completely remove these confounders because it is made to fit into established curricula, making it difficult to measure effectiveness of the simulation in isolation. The power of simulation training for resource-limited regions and countries is immense in offering cost-effective training in-country; however, it is important that any such tools are developed within the context of the limitations in situ.
Can Artificial Intelligence Make Screening Faster, More Accurate, and More Accessible? Li, Zhixi; Keel, Stuart; Liu, Chi; He, Mingguang
Diabetic retinopathy, glaucoma, and age-related macular degeneration are leading causes of vision loss and blindness worldwide. They tend to be asymptomatic in the early phase of disease and therefore require active screening programs to identify the patients requiring referral and treatment. Deep learning–based artificial intelligence technology has recently become a major topic in the field of ophthalmology. This paper aimed to provide a general view of the major findings on the application of deep learning for the classification of eye diseases from common imaging modalities. In the future, it is expected that these technologies will be applied in real-world screening programs to improve their efficiency and affordability.

Original Study - Clinical

Concept and Uptake of Just-A-Minute Clinical Pearl: A Novel Tele-Ophthalmology Teaching Tool Dave, Vivek Pravin; Pathengay, Avinash; Keeffe, Jill; Green, Catherine
Purpose: To describe the concept and report the uptake of a novel tele-ophthalmology educational tool, Just-A-Minute (JAM) clinical pearl, which was sent to all ophthalmologists in the email database of L V Prasad Eye Institute on a daily basis from September 2016 to August 2017.

Design: A survey was conducted among the recipients of JAM clinical pearls.

Methods: An online questionnaire was sent to the recipients and their responses were recorded and analyzed to evaluate the JAM pearls regarding qualifications of the recipients, their type of practice and regularity of accessing the pearls, type of pearl most sought, clarity of content, applicability to the clinic, relevance to practice, satisfaction with the format, and likelihood of recommendation.

Results: Of 14,311 recipients of JAM clinical pearls, 719 (5%) responded to the survey. The majority of respondents were in India (66.5%) followed by the United States (26.4%). Among the respondents, 52.9% were postgraduate ophthalmologists in general practice, 38.3% post-fellowship subspecialty practitioners, 5.8% fellows, and 2.9% residents. Private practitioners constituted 57.3% of all respondents. The pearls were accessed “always” by 53.7%, “very regularly” by 34.6%, and “intermittently” by 11.8% of respondents. The subspecialty of the pearls most desired was cornea and anterior segment (48.7%). The JAM pearls scored high in clarity of content (9/10), applicability to the clinic (9/10), satisfaction with the format (9/10), and recommendation to a colleague (10/10).
Conclusions: In this survey, it was found that the JAM clinical pearls are a unique, beneficial mode of tele-education with easily understandable and clinically applicable concepts.
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