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To assess the accuracy of refraction measurements by ClickCheckTM compared with the standard practice of subjective refraction at a tertiary level eye hospital. Diagnostic accuracy trial. All participants, recruited consecutively, underwent auto-refraction (AR) and subjective refraction (SR) followed by refraction measurement using ClickCheckTM (CR) by a trained research assistant. Eyeglass prescriptions generated using ClickCheckTM and the resulting visual acuity (VA) was compared to SR for accuracy. Inter-rater reliability and agreement were determined using Intra-class correlation and Bland Altman analysis respectively. The 1,079 participants enrolled had a mean (SD) age of 39.02 (17.94) years and 56% were women. Overall, 45.3% of the participants had refractive error greater than ±0.5D. The mean (SD) spherical corrections were -0.66D (1.85) and -0.89D (2.20) in SR and CR respectively. There was high level of agreement between the spherical power measured using SR and CR (ICC: 0.940 (95% CI: 0.933 to 0.947). For the assessment of cylindrical correction, there was moderate level of agreement between SR and CR (ICC: 0.493 (0.100 to 0.715). There was moderate level of agreement between the VA measurements performed by using corrections from SR and CR (ICC: 0.577 (95% CI: 0.521-0.628). The subgroup analysis based on the age categories also showed high level of agreement for spherical corrections between the two approaches (ICC: 0.900). Bland Altman analysis showed good agreement for spherical corrections between SR and CR (Mean difference: 0.224D; 95% LoA: -1.647 D to 2.096 D) without evidence of measurement bias. There was a high level of agreement for spherical power measurement between CR and SR. However, improvements are needed in order to accurately assess the cylindrical power. Being a portable, low-cost and easy-to-use refraction device, ClickCheckTM can be used for first level assessment of refractive errors, thereby enhancing the efficiency of refractive services, especially in low- and-middle-income countries.

ObjectivesThere has been increasing epidemiological research examining the association between vision impairment (VI) and cognitive impairment and how poor vision may be a modifiable risk factor for cognitive decline. The objective of this systematic review is to synthesise the published literature on the association of VI with cognitive decline, cognitive impairment or dementia, to aid the development of interventions and guide public policies pertaining to the relationship between vision and cognition.MethodsA literature search was performed with Embase, Medline and Cochrane library databases from inception to March 2020, and included abstracts and articles published in peer-reviewed journals in English. Our inclusion criteria included publications that contained subjective/objective measures of vision and cognition, or a diagnosis of VI, cognitive impairment or dementia. Longitudinal or cross-sectional studies with ≥100 participants aged >50 years were included. The search identified 11 805 articles whose abstracts underwent screening by three teams of study authors. Data abstraction and quality assessment using the Effective Public Health Practice Project Quality Assessment Tool were performed by one author (NN). 10% of the articles underwent abstraction and appraisal by a second author (LA/VV), results were compared between both and were in agreement.Results110 full-text articles were selected for data extraction, of which 53 were cross-sectional, 43 longitudinal and 14 were case–control studies. The mean age of participants was 73.0 years (range 50–93.1). Ninety-one (83%) of these studies reported that VI was associated with cognitive impairment.ConclusionOur systematic review indicates that a majority of studies examining the vision–cognition relationship report that VI is associated with more cognitive decline, cognitive impairment or dementia among older adults. This synthesis supports the need for additional research to understand the mechanisms underlying the association between VI and cognitive impairment and to test interventions that mitigate the cognitive consequences of VI.

Vision impairment (VI) is an important contributor to the global burden of disability and is associated with decreased well-being. Recent research has attempted to devise a conceptual framework to explain the health consequences of VI. One proposed mechanism by which VI leads to declines in well-being and other adverse health and disability outcomes is through limitations in social participation (SP). SP is an integral component of overall functioning, optimal aging, and well-being, and reductions in SP are associated with lower health-related quality of life. The purpose of this systematic review was to appraise the existing literature on the relationship between VI and SP. The protocol for this review was registered on PROSPERO (CRD42018102767) and adhered to PRISMA guidelines. A comprehensive search of five databases (MEDLINE, EMBASE, PsycINFO, Scopus, Sociology Database) yielded 881 unique studies, of which 19 met inclusion criteria. Among the 19 included studies, 18 concluded that VI was associated with reduced SP and one reported mixed results. Bias was assessed using the Effective Public Health Practice Project Quality Assessment. In the quality assessment, four studies were rated “moderate” and fifteen were rated “weak.” There was wide variation in study populations and measurement of VI and SP. In conclusion, there is consensus that VI is associated with reduced SP. However, more rigorous study design and better standardization in the assessment of VI and SP could facilitate valid comparisons across populations, diseases, and levels of VI. Attempts to provide vision rehabilitation and mitigate the effects of VI on overall health and well-being might consider strategies to improve SP.

Background Few studies using rigorous clinical diagnosis have considered whether associations with cognitive decline are potentiated by interactions between genetic and modifiable risk factors. Given the increasing burden of cognitive impairment (CI) and dementia, we assessed whether Apolipoprotein E ε4 (APOE4) genotype status modifies the association between incident CI and key modifiable risk factors . Methods Older adults (70+) in the US were included. APOE4 status was genotyped. Risk factors for CI were self-reported. Cognitive status (normal, CI, or dementia) was assigned by clinical consensus panel. In eight separate Cox proportional hazard models, we assessed for interactions between APOE4 status and other CI risk factors. Result The analytical sample included 181 participants (mean age 77.7 years; 45.9% male). APOE4 was independently associated with a greater hazard of CI in each model (Hazard Ratios [HR] between 1.81–2.66, p  < 0.05) except the model evaluating educational attainment (HR 1.65, p  = 0.40). The joint effects of APOE4 and high school education or less (HR 2.25, 95% CI: 1.40–3.60, p  < 0.001), hypertension (HR 2.46, 95% CI: 1.28–4.73, p  = 0.007), elevated depressive symptoms (HR 5.09, 95% CI: 2.59–10.02, p  < 0.001), hearing loss (HR 3.44, 95% CI: 1.87–6.33, p  < 0.0001), vision impairment (HR 5.14, 95% CI: 2.31–11.43, p  < 0.001), smoking (HR 2.35, 95% CI: 1.24–4.47, p = 0.009), or obesity (HR 3.80, 95% CI: 2.11–6.85, p  < 0.001) were associated with the hazard of incident CIND (compared to no genetic or modifiable risk factor) in separate models. The joint effect of Apolipoprotein ε4 and type 2 diabetes was not associated with CIND (HR 1.58, 95% CI: 0.67–2.48, p  = 0.44). Discussion The combination of APOE4 and selected modifiable risk factors conveys a stronger association with incident CI than either type of risk factor alone.

Background and objectives Adapting cognitive tests to culturally diverse and low-resource settings is essential for expanding knowledge of cognitive health in older adults beyond high-income countries. However, contextual differences in novel settings can affect reliability and validity. There is limited evidence on the feasibility of implementing culturally adapted cognitive assessments in Sub-Saharan Africa, a region projected to have over 158 million adults aged 60 and older by 2050. The Longitudinal Study of Health and Ageing in Kenya (LOSHAK) is designed to address this measurement gap by evaluating cognitive tests in this context. Research design and methods We analyzed data from 205 adults aged 45 years and older from the Kaloleni/Rabai Health and Demographic Surveillance System in Coastal Kenya. Using McDonald’s omega and confirmatory factor analysis, we evaluated the internal consistency reliability and the factor structure of four cognitive domains (orientation, memory, executive functioning, language/fluency) and four psychosocial constructs (depressive symptoms, loneliness, subjective well-being, and life satisfaction). Results McDonald’s omegas ranged from ω = 0.78 to 0.95 for cognitive domains and were above 0.83 for each psychosocial domain, suggesting high reliability. Factor analyses revealed adequate to perfect fit for most domains, and patterns of factor loadings were mostly acceptable. Conclusion The successful adaptation of these assessment tools in Kenya demonstrates the feasibility of implementing rigorous cognitive and psychosocial measurements in low-resource settings. These findings provide a methodological framework for future aging studies in similar contexts across Sub-Saharan Africa.

PurposeTo determine the relationship between retinal ischaemia and the presence of macular oedema (DMO) in patients with diabetic retinopathy (DR) using ultra-widefield fluorescein angiography (UWFA) imaging.MethodsA retrospective review of 122 eyes of 70 treatment-naïve diabetic patients who underwent diagnostic UWFA using the Optos 200Tx imaging system. Two independent, masked graders quantified the area of retinal ischaemia. Based on clinical examination and optical coherence tomography (OCT), each patient was given a binary classification as either having DMO or no DMO. McNemar's test (with Yates' correction as indicated) and a two-sample test of proportions were used to determine the relationship between DMO and ischaemia for binary and proportional data, respectively. Linear and logistic models were constructed using generalised estimating equations to test relationships between independent variables, covariates and outcomes while controlling for inter-eye correlation, age, gender, haemoglobin A1c, mean arterial pressure and dependence on insulin.ResultsSeventy-six eyes (62%) exhibited areas of retinal ischaemia. There was a significant direct correlation between DMO and peripheral retinal ischaemia as seen on UWFA (p<0.001). In addition, patients with retinal ischaemia had 3.75 times increased odds of having DMO compared with those without retinal ischaemia (CI 1.26 to 11.13, p<0.02).ConclusionRetinal ischaemia is significantly correlated with DMO in treatment-naïve patients with DR. UWFA is a useful tool for detecting peripheral retinal ischaemia, which may have direct implications in the diagnosis, follow-up and treatment such as targeted peripheral photocoagulation.

ObjectiveTo report the relationship between visual impairment (VI) and cognitive impairment (CI) among the older population living in residential care homes in Hyderabad, India.Study designCross-sectional study.Setting41 homes for the aged centres in the Hyderabad region.Participants965 participants aged ≥60 years from homes for the aged centres.Primary outcome measuresVisual impairment and cognitive impairment.MethodsThe Hindi mini-Mental Status Examination (HMSE) questionnaire was used to assess the cognitive function. The final HMSE score was calculated after excluding vision-dependent tasks (HMSE-VI). A detailed eye examination was conducted, including visual acuity (VA) measurement for distance and near vision, using a standard logarithm of the minimum angle of resolution chart under good illumination. CI was defined as having a HMSE-VI score of ≤17. VI was defined as presenting VA worse than 6/12 in the better-seeing eye. Near VI (NVI) was defined as binocular presenting near vision worse than N8 and distance VA of 6/18 or better in the better-seeing eye. Multiple logistic regression was done to assess the association between VI and CI.ResultsThe mean age (±SD) was 74.3 (±8.3) years (range: 60–97 years). There were 612 (63.4%) women, and 593 (61.5%) had a school education. In total, 260 (26.9%; 95% confidence intervals: 24.2 to 29.9) participants had CI. The prevalence of CI among those with VI was 40.5% compared with 14.6% among those without VI (p<0.01). The logistic regression analysis showed that the participants with VI for distance vision had three times higher odds of having CI (OR 3.09; 95% confidence intervals: 2.13 to 4.47; p<0.01). Similarly, participants with NVI had two times higher odds of having CI (OR 2.11; 95% confidence intervals: 1.36 to 3.29; p<0.01) after adjusting for other covariates.ConclusionsCI was highly prevalent among those with distance and near VI. VI was independently and positively associated with CI after adjusting for potential confounders. Interventions can be planned to address VI in this vulnerable population which could have a ripple effect in preventing cognitive decline.

IntroductionVision impairment and eye disease are major global health concerns and have been associated with increased morbidity and mortality, and lower quality of life. Quality of life, whether generic, vision-specific or disease-specific, is an important measure of the impact of eye health on people’s daily activities, well-being and visual function, and is increasingly used to evaluate the impact of ophthalmic interventions and new devices. While many studies and reviews have examined the relationship between vision or eye health and quality of life across different contexts, there has yet to be a synthesis of the impact of vision impairment, eye disease and ophthalmic interventions on quality of life globally and across the lifespan.Methods and analysisAn umbrella review of systematic reviews will be conducted to address these two questions: (1) What is the association of vision impairment and eye disease with quality of life? (2) What is the impact of ophthalmic interventions on quality of life? A search of related literature will be performed on the 11 February 2020 in Medline Ovid, Embase.com, Cochrane Database of Systematic Reviews, Proquest Dissertations and Theses Global, and the grey literature, and repeated at the synthesis stage. Title/abstract and full-text screening, methodological quality assessment and data extraction will be conducted by reviewers working independently and in duplicate. Assessment of methodological quality and data extraction will be performed using Joanna Briggs Institute standard forms. Findings from the systematic reviews and their methodological quality will be summarised qualitatively in the text and using tables.Ethics and disseminationNo ethical approval is required. Results of this umbrella review will be published in a peer-reviewed journal and summarised in the Lancet Global Health Commission on Global Eye Health.Trial registration numberThis protocol was registered in the Open Science Framework Registries (https://osf.io/qhv9g/).

Background Impairments in sensory and motor function are common in older adults and have been linked with higher prevalence of dementia. However, their independent associations with dementia have not been examined in a nationally representative population. Methods Cross-sectional analysis of the National Health and Aging Trends Study (NHATS; Round 11/2021) of U.S. Medicare beneficiaries. Dementia was classified per NHATS protocol as none, possible, or probable dementia. Vision measures included presenting binocular distance visual acuity, near visual acuity, and contrast sensitivity. Hearing measures included the pure tone average of the better ear. Motor function measures included gait speed, chair stands time, balance score, and grip strength. Dichotomized or categorized presence of impairment in each sensory and motor function was defined and used as the main exposures. Multivariable survey-weighted logistic regression was used to assess the independent associations of sensory and motor function impairments with dementia status. Results Our final analytic sample included 2,379 participants with 36.6% aged ≥ 80 years, 56.2% female, 82.9% non-Hispanic White, and 9.8% having possible or probable dementia. In adjusted models including visual, hearing, and motor function variables, participants with impairment in gait (odds ratio (OR), 2.18; 95% CI, 1.32–3.6; p  = 0.004), chair stand performance (OR, 1.69; 95% CI, 1.17–2.44; p  < 0.01), or visual contrast sensitivity (OR, 1.52; 95% CI, 1.04–2.22; p  = 0.03) had higher odds of dementia. Impaired standing balance, grip strength, hearing, and near visual acuity were not associated with higher odds of dementia ( p  > 0.05). Conclusions Findings suggest current impairment in vision or motor function may be strong indicators of prevalent dementia in older adults.