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

Financial interest  No financial interest

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

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

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

IMPROVING UPTAKE OF REFRACTIVE SERVICES

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

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

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

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

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”)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 contestsPosters including faces of kids in local schools who win contests Consults with health education specialists and marketersConsults with health education specialists and marketers

DEMONSTRATING IMPACT OF REFRACTIVE CORRECTION

“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?

“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

“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

PREVENTING OR DELAYING MYOPIA

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

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

IMPROVING QUALITY AND EFFICIENCY OF REFRACTIVE SERVICE DELIVERY

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

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

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

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

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