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

ChildrenChildren

Nathan Congdon, MD, MPHNathan Congdon, MD, MPH

Zhongshan Ophthalmic CenterZhongshan Ophthalmic CenterSun Yat Sen UniversitySun Yat Sen University

Guangzhou, ChinaGuangzhou, China

ORBIS InternationalORBIS International

Financial interest

No financial interest

Why is research needed?Why is research needed? Refractive error is the Refractive error is the

simplest and safest to treat simplest and safest to treat of the major vision of the major vision problemsproblems

Yet uncorrected and Yet uncorrected and under-corrected refractive under-corrected refractive error remain the most error remain the most common cause of poor common cause of poor vision among children in vision among children in the worldthe world

More effective solutions More effective solutions are needed, guided by are needed, guided by researchresearch

Research directions discussed in Research directions discussed in this talkthis talk

ProblemProblem: Children and their families often do : Children and their families often do not use glasses even when they are availablenot use glasses even when they are available

Research solutionResearch solution: Find means to improve : Find means to improve uptakeuptake

ProblemProblem: Governments, medical bodies, etc., : Governments, medical bodies, etc., often do not prioritize refractive error as a often do not prioritize refractive error as a children’s health issuechildren’s health issue

Research solutionResearch solution: Demonstrate impact of : Demonstrate impact of correcting RE on children’s livescorrecting RE on children’s lives

Research directions discussed in Research directions discussed in this talkthis talk

ProblemProblem: Refractive error prevalence is : Refractive error prevalence is growing in many large populationsgrowing in many large populations

Research solution:Research solution: Find means to prevent Find means to prevent refractive errorrefractive error

Problem:Problem: High-quality refractive services are High-quality refractive services are unavailable in many areasunavailable in many areas

Research solutions:Research solutions: Train new practitioners, Train new practitioners, develop technologies to increase their efficiencydevelop technologies to increase their efficiency

IMPROVING UPTAKE OF REFRACTIVE SERVICES

In a Mexican program, only one in eight In a Mexican program, only one in eight kids were wearing their free glasses six kids were wearing their free glasses six

months after dispensingmonths after dispensing

Castanon, Congdon, et al, IOVS 2006Castanon, Congdon, et al, IOVS 2006

13%

16%

14%

2%6%9%

17%

9%

14%Wearing glasses

Appearance/ TeasedBroken/Lost

Parents Object

Headache

Don't Need

Left at Home

Special Days (egHolidays) OnlyNo/Other Reason

13%13%

What needs to be done to get kids and What needs to be done to get kids and families to buy and wear glasses?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 2010Li et al, Arch Ophthalmol 2010

The “See Well to Learn Well” TrialThe “See Well to Learn Well” Trial

Congdon et al, Ophthalmology, 2011Congdon et al, Ophthalmology, 2011

Bottom LineBottom Line Our educational Our educational

intervention designed intervention designed based on extensive based on extensive studies in the area DID studies in the area DID NOT INCREASE NOT INCREASE spectacle uptakespectacle uptake

Now carrying out an Now carrying out an RCT in western China RCT in western China on 20,000 elementary on 20,000 elementary school childrenschool children

The challenge of improving The challenge of improving uptakeuptake

Lessons learned:Lessons learned:– Parents as key decision-makers must be a focus of Parents as key decision-makers must be a focus of

intervention (more challenging with school-based intervention (more challenging with school-based programs)programs)

– Professionally-designed materials are needed:Professionally-designed materials are needed:• Movie by Carol Liu (“Restoring the Light”)Movie by Carol Liu (“Restoring the Light”)

• Cartoon booklets for kids and parentsCartoon booklets for kids and parents

• Posters including faces of kids in local schools who win Posters including faces of kids in local schools who win contestscontests

• Consults with health education specialists and marketersConsults with health education specialists and marketers

DEMONSTRATING IMPACT OF REFRACTIVE

CORRECTION

““Holy Grail” of Children’s RE Holy Grail” of Children’s RE for Advocacyfor Advocacy

Does vision correction Does vision correction improve school improve school performance?performance?– Very little evidence to dateVery little evidence to date– Challenging to establish: A Challenging to establish: A

multitude of other factors multitude of other factors impacting school impacting school performance must be performance must be measuredmeasured

– How important is distance How important is distance vision in the classroom after vision in the classroom after all?all?

““Better Vision for Higher Grades”: Better Vision for Higher Grades”: Studying the Impact of RE CorrectionStudying the Impact of RE Correction

Setting: 200 poor Setting: 200 poor schools in Shaanxi schools in Shaanxi and Gansu, western and Gansu, western ChinaChina

Design: Design: – RCT randomized by RCT randomized by

school, free glasses school, free glasses versus controlversus control

– Adjust for actual Adjust for actual observed useobserved use

““Better Vision for Higher Grades”: Better Vision for Higher Grades”: Studying the Impact of RE CorrectionStudying the Impact of RE Correction

Outcome: Outcome: – Baseline and final scores Baseline and final scores

on a battery of tests on a battery of tests designed by education designed by education specialist specialist

– Control for numerous Control for numerous other SES indicatorsother SES indicators

Timeline:Timeline:– Began September 2012Began September 2012

– Completion June 2013Completion June 2013

PREVENTING OR DELAYING MYOPIA

The appeal of prevention The appeal of prevention strategiesstrategies

Promoting optimal spectacle use is daunting:Promoting optimal spectacle use is daunting:– Many years requiredMany years required

– Need for regular replacement due to myopia progressionNeed for regular replacement due to myopia progression

Recent epidemiologic evidence suggests possibility of a Recent epidemiologic evidence suggests possibility of a “two for one” strategy for Chinese kids:“two for one” strategy for Chinese kids:– Increasing time outdoors associated with reduced myopia risk, Increasing time outdoors associated with reduced myopia risk,

even with high levels of near workeven with high levels of near work

– Impact appears associated with increased light levelsImpact appears associated with increased light levels

– More time outdoors may help with China’s obesity epidemicMore time outdoors may help with China’s obesity epidemic

Concrete research strategies Concrete research strategies for preventionfor prevention

Add time outdoors to school Add time outdoors to school dayday– Limited practically to 1 Limited practically to 1

hr/dayhr/day

– RCT in Guangzhou RCT in Guangzhou suggests effect is suggests effect is measurable but limitedmeasurable but limited

Create an “open classroom” Create an “open classroom” with light levels near those with light levels near those of outdoorsof outdoors– On-going practicality trials On-going practicality trials

in GZ in collaboration with in GZ in collaboration with School of ArchitectureSchool of Architecture

IMPROVING QUALITY AND EFFICIENCY OF REFRACTIVE

SERVICE DELIVERY

Improved TrainingImproved Training

Evidence from China and elsewhere shows Evidence from China and elsewhere shows existing services in rural areas are often poorexisting services in rural areas are often poor– Glasses worn by some 50% of rural Chinese kids are Glasses worn by some 50% of rural Chinese kids are

inaccurate by >= 1D, 10% off by >= 3Dinaccurate by >= 1D, 10% off by >= 3D

Training programs aimed at rural practitioners Training programs aimed at rural practitioners are neededare needed– BHVI/ICEE has been a leader in this areaBHVI/ICEE has been a leader in this area– Further research to demonstrate refraction outcomes Further research to demonstrate refraction outcomes

among trainees and efficacy of different training among trainees and efficacy of different training methodsmethods

Zhang et al, IOVS 2009Zhang et al, IOVS 2009

Improved EfficiencyImproved Efficiency

Self-refraction with adjustable glasses has Self-refraction with adjustable glasses has recently been studied as a potential modality to recently been studied as a potential modality to multiply the output of scarce refraction multiply the output of scarce refraction professionalsprofessionals

Self-refraction could eventually be used for Self-refraction could eventually be used for screeningscreening– Children with self-refracted vision below cutoff Children with self-refracted vision below cutoff

receive conventional refraction and examreceive conventional refraction and exam

Self-refraction: MethodsSelf-refraction: Methods Adspecs (Adlens, Ltd) Adspecs (Adlens, Ltd)

contain two fluid-filled contain two fluid-filled lenseslenses

Power determined by Power determined by curvature of surfaces, curvature of surfaces, controlled by volume of controlled by volume of liquid in lens through liquid in lens through two user-controlled two user-controlled pumpspumps

Power range -6.0 to +6.0 Power range -6.0 to +6.0 D, no cylindrical D, no cylindrical correctioncorrection

Self-refraction: ResultsSelf-refraction: Results

Initial results from 3 studies:Initial results from 3 studies:– Visual acuity of >= 6/7.5 in > 90%Visual acuity of >= 6/7.5 in > 90%– Accuracy comparable to non-cycloplegic Accuracy comparable to non-cycloplegic

automated refractionautomated refraction

Pending issues:Pending issues:– Cosmetic acceptability and practicality of Cosmetic acceptability and practicality of

actual wearactual wear

On-going trials in GuangdongOn-going trials in Guangdong

SummarySummary

Many opportunities for research to help reduce Many opportunities for research to help reduce the burden of uncorrected RE among the the burden of uncorrected RE among the world’s childrenworld’s children

RE is a vision problem that we have possessed RE is a vision problem that we have possessed for centuries the technical capacity to solvefor centuries the technical capacity to solve

Research can still help to:Research can still help to:– Harness the will to actHarness the will to act

– Demonstrate better ways of using the simple and Demonstrate better ways of using the simple and highly effective means we already have at our highly effective means we already have at our disposaldisposal