Suggestions for a Research Agenda to Reduce the Burden of Uncorrected Refractive Error in Children

1. Suggestions for a Research Agenda to Reduce the Burden of Uncorrected Refractive Error in Children Zhongshan Ophthalmic Center Sun Yat Sen University Guangzhou, China ORBIS International Nathan Congdon, MD, MPH

2. Financial interest • No financial interest

3. Why is research needed? • Refractive error is the simplest and safest to treat of the major vision problems • Yet uncorrected and under-corrected refractive error remain the most common cause of poor vision among children in the world • More effective solutions are needed, guided by research

4. Research directions discussed in this talk • Problem: Children and their families often do not use glasses even when they are available • Research solution: Find means to improve uptake • Problem: Governments, medical bodies, etc., often do not prioritize refractive error as a children’s health issue • Research solution: Demonstrate impact of correcting RE on children’s lives

5. Research directions discussed in this talk • Problem: Refractive error prevalence is growing in many large populations • Research solution: Find means to prevent refractive error • Problem: High-quality refractive services are unavailable in many areas • Research solutions: Train new practitioners, develop technologies to increase their efficiency

6. IMPROVING UPTAKE OF REFRACTIVE SERVICES

7. In a Mexican program, only one in eight kids were wearing their free glasses six months after dispensing 13% Castanon, Congdon, et al, IOVS 2006

8. What needs to be done to get kids and families to buy and wear glasses? • Demonstration: Children don’t know how poor their vision really is and how it can be improved • Examination: Parents don’t know their children have a problem • Education: All stakeholders are likely to believe incorrectly that glasses harm the eyes • Li et al, IOVS 2008 Li et al, Arch Ophthalmol 2010

9. The “See Well to Learn Well” Trial Congdon et al, Ophthalmology, 2011

10. Bottom Line • Our educational intervention designed based on extensive studies in the area DID NOT INCREASE spectacle uptake • Now carrying out an RCT in western China on 20,000 elementary school children

11. The challenge of improving uptake • Lessons learned: • Parents as key decision-makers must be a focus of intervention (more challenging with school-based programs) • Professionally-designed materials are needed: • Movie by Carol Liu (“Restoring the Light”) • Cartoon booklets for kids and parents • Posters including faces of kids in local schools who win contests • Consults with health education specialists and marketers

12. DEMONSTRATING IMPACT OF REFRACTIVE CORRECTION

13. “Holy Grail” of Children’s RE for Advocacy • Does vision correction improve school performance? • Very little evidence to date • Challenging to establish: A multitude of other factors impacting school performance must be measured • How important is distance vision in the classroom after all?

14. “Better Vision for Higher Grades”: Studying the Impact of RE Correction • Setting: 200 poor schools in Shaanxi and Gansu, western China • Design: • RCT randomized by school, free glasses versus control • Adjust for actual observed use

15. “Better Vision for Higher Grades”: Studying the Impact of RE Correction • Outcome: • Baseline and final scores on a battery of tests designed by education specialist • Control for numerous other SES indicators • Timeline: • Began September 2012 • Completion June 2013

16. PREVENTING OR DELAYING MYOPIA

17. The appeal of prevention strategies • Promoting optimal spectacle use is daunting: • Many years required • Need for regular replacement due to myopia progression • Recent epidemiologic evidence suggests possibility of a “two for one” strategy for Chinese kids: • Increasing time outdoors associated with reduced myopia risk, even with high levels of near work • Impact appears associated with increased light levels • More time outdoors may help with China’s obesity epidemic

18. Concrete research strategies for prevention • Add time outdoors to school day • Limited practically to 1 hr/day • RCT in Guangzhou suggests effect is measurable but limited • Create an “open classroom” with light levels near those of outdoors • On-going practicality trials in GZ in collaboration with School of Architecture

19. IMPROVING QUALITY AND EFFICIENCY OF REFRACTIVE SERVICE DELIVERY

20. Improved Training • Evidence from China and elsewhere shows existing services in rural areas are often poor • Glasses worn by some 50% of rural Chinese kids are inaccurate by >= 1D, 10% off by >= 3D • Training programs aimed at rural practitioners are needed • BHVI/ICEE has been a leader in this area • Further research to demonstrate refraction outcomes among trainees and efficacy of different training methods Zhang et al, IOVS 2009

21. Improved Efficiency • Self-refraction with adjustable glasses has recently been studied as a potential modality to multiply the output of scarce refraction professionals • Self-refraction could eventually be used for screening • Children with self-refracted vision below cutoff receive conventional refraction and exam

22. Self-refraction: Methods • Adspecs (Adlens, Ltd) contain two fluid-filled lenses • Power determined by curvature of surfaces, controlled by volume of liquid in lens through two user-controlled pumps • Power range -6.0 to +6.0 D, no cylindrical correction

23. Self-refraction: Results • Initial results from 3 studies: • Visual acuity of >= 6/7.5 in > 90% • Accuracy comparable to non-cycloplegic automated refraction • Pending issues: • Cosmetic acceptability and practicality of actual wear • On-going trials in Guangdong

24. Summary • Many opportunities for research to help reduce the burden of uncorrected RE among the world’s children • RE is a vision problem that we have possessed for centuries the technical capacity to solve • Research can still help to: • Harness the will to act • Demonstrate better ways of using the simple and highly effective means we already have at our disposal