1. RAPID ASSESSMENT OF REFRACTIVE ERROR (RARE)
This course describes data collection issues at various levels for different decision making purposes. Speakers will address tools from the perspectives of point of service to implementers, to donors, to industry, and also at the national and to regional levels. The strengths and limitations of current approaches will be discussed by each speaker and the potential for integration in health systems.
At the conclusion of this course, participants will:
Define data collection needs at various levels of eye care
Apply monitoring tools for different programme needs
Use existing data for making decisions about planning services
Prepare results-based reports for stakeholders at various levels
Explore the use of social networking technology in data collection
Professor Kovin Naidoo
Global Programs Director
IAPB AFRICA CHAIRPERSON

2. Uncorrected Refractive Error (URE) “The Crisis”
URE is most common cause of Visual impairment (VI) worldwide and 2nd most common cause of blindness1,2
URE drives children and adults further into poverty:3
Limits opportunities to education
Employment
Seriously impacts quality of life and productivity
Link between poverty and VI due to URE places heavy economic burden on individuals  families  affected nations
Resnikoff S, Pascolini D, Mariotti S, Pokharel P. Global magnitude of visual impairment caused by uncorrected refractive errors in Bull World Health Organ 2008;86:63-70.
2. Holden BA, Fricke T, Ho S, Wong R, Schlenther G, Cronje S, et al. Global vision impairment due to uncorrected presbyopia. Arch Ophthalmol 2008;126:
3. Durban Declaration on Refractive error and service development

3. What is the status of URE?4
Prevalence of Visual Impairment
158 million cases of Distance VI
544 million cases of Near VI
Human Resources Required
47000 full-time refractionists
18000 ophthalmic dispensers
Cost of Human Resource Development
US $20-28 billion
Estimated loss in global GDP due to DVI
US $ 202 billion
Implications
4. Fricke, Holden, Wilson, Schlenther, Naidoo, Resnikoff, Frick. Global cost of correcting vision impairment from uncorrected refractive error. Bulletin of WHO
There were an estimated 158 million cases of distance vision impairment and 544 million cases of near vision impairment caused by URE worldwide in Approximately additional full-time functional clinical refractionists and ophthalmic dispensers would be required to provide refractive care services for these individuals. The global cost of educating the additional personnel and of establishing, maintaining and operating the refractive care facilities needed was estimated to be around 20 billion United States dollars (US$) and the upper-limit cost was US$ 28 billion. The estimated loss in global gross domestic product due to distance vision impairment caused by URE was US$ 202 billion annually
Conclusion The cost of establishing and operating the educational and refractive care facilities required to deal with vision impairment resulting from URE was a small proportion of the global loss in productivity associated with that vision impairment.
Implications

4. Historical Situation Paucity of Data Refractive data elicited through:
RESC studies
From community to school
Children only
Conventional Population based studies
Prohibitively expensive
High level of expertise
Few and far between
Lag between completion and Program implementation timelines

5. CONTEXT SETTING Why and where do we need data National level
Planning
Evaluation
Awareness
Advocacy
Regional level
Establish priorities for investment in regions
Information needed at national level provides:
Information on the needs
Awareness
Advocacy
Information needed at Regional level enables:
Needs

6. RARE Evolved out of RACSS and RAABS
Rapid
Quick
Cost effective
Assessment
Simple
Results
Refractive Error
Prevalence
Barriers

7. EXPAND to the national or even global context
How does RARE data help?
RARE data can be used in a top-down or bottom-up approach.
TOP-DOWN
Globally
mil VI
mil Blind
RARE STUDIES
LOCATE
Blind
and VI
Regional
RARE
RARE STUDIES
EXPAND to the national or even global context
In looking at it as a TOP-Down approach, we know that there are according to recent stats by Pascolini et al, globally 285 mil people with VI and 246 blind. RARE studies allow us to LOCATE these individuals and then allows to take the appropriate action. At the national level, there are several approaches that can be employed to address this dire situation.
Alternatively, we can look at it as a bottom-up approach. We conduct RARE studies at region levels and then if the sample is representative, we can expand broadly to national and in some cases, even global …. Kovin we should do this with SA RARE data….i hav asked Farai/research team to provide this.
BOTTOM-UP

8. METHODOLOGY

9. Target Group
RARE studies used to assess prevalence of URE, presbyopia, spectacle coverage, and barriers to uptake of services for refractive errors and presbyopia5
Studies are focused on:
Younger age groups more affected by RE
Presbyopia
15-49 years

10. Uncorrected Refractive Error (URE)
Definitions
Condition
Definition
Visual Impairment
Binocular Presenting VA<6/12 in the better eye
Uncorrected Refractive Error (URE)
Presenting VA<6/12 but improving ≥6/12 with pinhole
Presbyopia
Binocular near vision < N8 at
33-35cms

11. Uncorrected Presbyopia Corrected Presbyopia (Met need)
Definitions
Definition
Description
URE
(Unmet need)
Unaided VA <6/12 but improving to 6/12 or better with pinhole and no spectacles
Uncorrected Presbyopia
Binocular Unaided near vision <N8 in subjects aged >35 years with no distance VI and no spectacles
Corrected RE
(Met need)
Unaided VA<6/18 but improved to 6/18 or better with spectacles
Corrected Presbyopia (Met need)
Unaided near vision < N8, but improved to N8 or better with their spectacles

12. RARE Toolkit Equipment Purpose Snellen chart (E, Alphabet optotypes)
Distance Visual Acuity
Measuring tape or String
Measure testing distance: subject and chart
Multiple pinhole occluder
Presenting VA, if VA<6/12
N notation chart
Near vision
Torch light
External examination
Ready made spectacles (+1.0 to +3.0 Ds)
Best corrected near vision assessment in individuals with presbyopia

13. OUTPUTS OF RARE STUDIES
Magnitude of RE (uncorrected)
Prevalence of presbyopia
Spectacle coverage and utilisation patterns
Understanding barriers to access of services
Provide baseline information
Trends in prevalence determined on follow up studies
What is the impact of gathering this information? ....

14. Spectacle Coverage
[met need’ ]
[(‘met need’ + ‘unmet need’) X 100]

15. Barriers – URE6

16. Current and future RARE studies
Studies conducted
Eritrea
Ghana
Uganda
South Africa
Tanzania
Studies in preparation
Mozambique
Gambia
Zambia
Cameroon
Ethiopia
Malawi

17. MAJOR BARRIERS IDENTIFIED IN RARE STUDIES CONDUCTED
Affordability of the spectacle exam
Aware of problem but felt no need for consultation
Unaware of problem
Cannot afford the cost of glasses

18. Comparison of visual impairment and refractive error prevalence across various RARE studies
Presbyopia was present in 690 (63.7%, 95% CI, %) subjects aged over 35 years. Spectacle coverage for refractive error was 29% and for presbyopia it was 19%.
CONCLUSIONS:
There is a large unmet need for refractive correction in this area in India. Rapid assessment methods are an effective means of assessing the need for services and the impact of models of care.
FYI: Reasons for looking at age and sex adjusted data: The age and sex adjusted rate can be considered an average of each of the individual age or gender specific rates, but rather than being a simple average, it is a weighted average with each age or gender specific rate weighted by the proportion of people in the same age or gender group in the standard population.

20. References
Resnikoff S, Pascolini D, Mariotti S, Pokharel P. Global magnitude of visual impairment caused by uncorrected refractive errors in Bull World Health Organ 2008;86:63-70.
Holden BA, Fricke T, Ho S, Wong R, Schlenther G, Cronje S, et al. Global vision impairment due to uncorrected presbyopia. Arch Ophthalmol 2008;126:
Fricke TR, Holden BA, Wilson DA, Schlenther G, Naidoo KS, Resnikoff S and Frick KD. Global cost of correcting vision impairment from uncorrected refractive error.
Naidoo KS, Wallace DB, Holden, BA, Minto H, Faal HB, Dube P. The challenge of uncorrected refractive error: driving the agenda of the Durban Declaration on refractive error and service development. Clin Exp Opt 2010: 93(3):
Marmamula S, Keeffe JE, Rao GN. Uncorrected refractive errors, presbyopia and spectacle coverage: Results from a Rapid Assessment of Refractive Error survey. Ophthalmic Epidemiology 2009;16:
Marmamula et al. Population-based cross-sectional study of barriers to utilisation of refraction services in South India: Rapid Assessment of Refractive Errors (RARE) Study. British Medical Journal.

21. Acknowledgements Pirindha Govender
Brien Holden Vision Institute (Public Health Division) – Research Department