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
13%
9%
13%
Wearing glasses
14%
16%
Appearance/
Teased
Broken/Lost
Parents Object
Headache
Don't Need
17%
Left at Home
14%
9%
6%
Special Days (eg
Holidays) Only
No/Other Reason
2%
Castanon, Congdon, et al, IOVS 2006
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”)
• Cartoon booklets for kids and parents
• Posters including faces of kids in local schools who win
contests
• Consults 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
Zhang et al, IOVS 2009
 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
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