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1.  Use of Cooking Fuels and Cataract in a Population-Based Study: The India Eye Disease Study 
Environmental Health Perspectives  2016;124(12):1857-1862.
Background:
Biomass cooking fuels are commonly used in Indian households, especially by the poorest socioeconomic groups. Cataract is highly prevalent in India and the major cause of vision loss. The evidence on biomass fuels and cataract is limited.
Objectives:
To examine the association of biomass cooking fuels with cataract and type of cataract.
Methods:
We conducted a population-based study in north and south India using randomly sampled clusters to identify people ≥ 60 years old. Participants were interviewed and asked about cooking fuel use, socioeconomic and lifestyle factors and attended hospital for digital lens imaging (graded using the Lens Opacity Classification System III), anthropometry, and blood collection. Years of use of biomass fuels were estimated and transformed to a standardized normal distribution.
Results:
Of the 7,518 people sampled, 94% were interviewed and 83% of these attended the hospital. Sex modified the association between years of biomass fuel use and cataract; the adjusted odds ratio (OR) for a 1-SD increase in years of biomass fuel use and nuclear cataract was 1.04 (95% CI: 0.88, 1.23) for men and 1.28 (95% CI: 1.10, 1.48) for women, p interaction = 0.07. Kerosene use was low (10%). Among women, kerosene use was associated with nuclear (OR = 1.76, 95% CI: 1.04, 2.97) and posterior subcapsular cataract (OR = 1.71, 95% CI: 1.10, 2.64). There was no association among men.
Conclusions:
Our results provide robust evidence for the association of biomass fuels with cataract for women but not for men. Our finding for kerosene and cataract among women is novel and requires confirmation in other studies.
Citation:
Ravilla TD, Gupta S, Ravindran RD, Vashist P, Krishnan T, Maraini G, Chakravarthy U, Fletcher AE. 2016. Use of cooking fuels and cataract in a population-based study: the India Eye Disease Study. Environ Health Perspect 124:1857–1862; http://dx.doi.org/10.1289/EHP193
doi:10.1289/EHP193
PMCID: PMC5132636  PMID: 27227523
2.  Prevalence of Trachoma in Car-Nicobar Island, India after Three Annual Rounds of Mass Drug Administration with Azithromycin 
PLoS ONE  2016;11(7):e0158625.
Background
A high proportion of active trachoma infection in children of Car-Nicobar Island was reported through the Trachoma Rapid Assessment survey conducted in year 2010 by the same researchers. Annual mass drug treatment with azithromycin was administered from years 2010–12 to all individuals residing in this island for reducing the burden of active trachoma infection. A cross-sectional prevalence survey was conducted in the year 2013 to assess the post-treatment burden of trachoma in this population.
Methods
In the 15 randomly selected compact segments from each village of the island, children aged 1–9 years were examined for evidence of active trachoma infection and participants aged ten years and above were examined for trachomatous trichiasis and corneal opacity.
Results
A total of 809 children (1–9 years) and 2735 adults were examined. Coverage with azithromycin for all the three rounds was more than 80%. The prevalence of active trachoma infection in children aged 1–9 years old was 6.8% (95% CI 5.1, 8.5) and Trachomatous Trichiasis (TT) was 3.9% (95% CI 3.2, 4.6). The risk factors associated with active trachoma infection were older age and unclean faces. The risk factors associated with TT were older age and lower literacy level.
Conclusion
Trachoma has not been eliminated from Car-Nicobar Island in accordance to ‘Global Elimination of Trachoma, 2020’ guidelines. Sustained efforts and continuous surveillance admixed with adequate programmatic response is imperative for elimination of trachoma in the island.
doi:10.1371/journal.pone.0158625
PMCID: PMC4938255  PMID: 27391274
3.  Prevalence of visual impairment due to uncorrected refractive error: Results from Delhi-Rapid Assessment of Visual Impairment Study 
Indian Journal of Ophthalmology  2016;64(5):387-390.
Aim:
To estimate the prevalence of visual impairment (VI) due to uncorrected refractive error (URE) and to assess the barriers to utilization of services in the adult urban population of Delhi.
Materials and Methods:
A population-based rapid assessment of VI was conducted among people aged 40 years and above in 24 randomly selected clusters of East Delhi district. Presenting visual acuity (PVA) was assessed in each eye using Snellen's E chart. Pinhole examination was done if PVA was <20/60 in either eye and ocular examination to ascertain the cause of VI. Barriers to utilization of services for refractive error were recorded with questionnaires.
Results:
Of 2421 individuals enumerated, 2331 (96%) individuals were examined. Females were 50.7% among them. The mean age of all examined subjects was 51.32 ± 10.5 years (standard deviation). VI in either eye due to URE was present in 275 individuals (11.8%, 95% confidence interval [CI]: 10.5–13.1). URE was identified as the most common cause (53.4%) of VI. The overall prevalence of VI due to URE in the study population was 6.1% (95% CI: 5.1 CI: 5.1–7.0). The elder population as well as females were more likely to have VI due to URE (odds ratio [OR] = 12.3; P < 0.001 and OR = 1.5; P < 0.02). Lack of felt need was the most common reported barrier (31.5%).
Conclusions:
The prevalence of VI due to URE among the urban adult population of Delhi is still high despite the availability of abundant eye care facilities. The majority of reported barriers are related to human behavior and attitude toward the refractive error. Understanding these aspects will help in planning appropriate strategies to eliminate VI due to URE.
doi:10.4103/0301-4738.185614
PMCID: PMC4966377  PMID: 27380979
Barriers; population-based; uncorrected refractive error; urban; visual impairment
4.  Situational analysis of services for diabetes and diabetic retinopathy and evaluation of programs for the detection and treatment of diabetic retinopathy in India: Methods for the India 11-city 9-state study 
Background:
Diabetic retinopathy (DR) is a leading cause of visual impairment in India. Available evidence shows that there are more than 60 million persons with diabetes in India and that the number will increase to more than a 100 million by 2030. There is a paucity of data on the perceptions and practices of persons with diabetes and the available infrastructure and uptake of services for DR in India.
Objectives:
Assess perception of care and challenges faced in availing eye care services among persons with diabetics and generate evidence on available human resources, infrastructure, and service utilization for DR in India.
Methods:
The cross-sectional, hospital-based survey was conducted in eleven cities across 9 States in India. In each city, public and private providers of eye-care were identified. Both multispecialty and standalone facilities were included. Specially designed semi-open ended questionnaires were administered to the clients. Semi-structured interviews were administered to the service providers (both diabetic care physicians and eye care teams) and observational checklists were used to record findings of the assessment of facilities conducted by a dedicated team of research staff.
Results:
A total of 859 units were included in this study. This included 86 eye care and 73 diabetic care facilities, 376 persons with diabetes interviewed in the eye clinics and 288 persons with diabetes interviewed in the diabetic care facilities.
Conclusions:
The findings will have significant implications for the organization of services for persons with diabetes in India.
doi:10.4103/2230-8210.179770
PMCID: PMC4847445  PMID: 27144132
Access to health care; diabetes; diabetic retinopathy; India; patient care
5.  Eye care infrastructure and human resources for managing diabetic retinopathy in India: The India 11-city 9-state study 
Background:
There is a paucity of information on the availability of services for diagnosis and management of diabetic retinopathy (DR) in India.
Objectives:
The study was undertaken to document existing healthcare infrastructure and practice patterns for managing DR.
Methods:
This cross-sectional study was conducted in 11 cities and included public and private eye care providers. Both multispecialty and stand-alone eye care facilities were included. Information was collected on the processes used in all steps of the program, from how diabetics were identified for screening through to policies about follow-up after treatment by administering a semistructured questionnaire and by using observational checklists.
Results:
A total of 86 eye units were included (31.4% multispecialty hospitals; 68.6% stand-alone clinics). The availability of a dedicated retina unit was reported by 68.6% (59) facilities. The mean number of outpatient consultations per year was 45,909 per responding facility, with nearly half being new registrations. A mean of 631 persons with sight-threatening-DR (ST-DR) were registered per year per facility. The commonest treatment for ST-DR was laser photocoagulation. Only 58% of the facilities reported having a full-time retina specialist on their rolls. More than half the eye care facilities (47; 54.6%) reported that their ophthalmologists would like further training in retina. Half (51.6%) of the facilities stated that they needed laser or surgical equipment. About 46.5% of the hospitals had a system to track patients needing treatment or for follow-up.
Conclusions:
The study highlighted existing gaps in service provision at eye care facilities in India.
doi:10.4103/2230-8210.179768
PMCID: PMC4847447  PMID: 27144134
Diabetes complications; diagnostic equipment; diabetic retinopathy; health facilities; human resources; India
6.  Perception of care and barriers to treatment in individuals with diabetic retinopathy in India: 11-city 9-state study 
Background:
Diabetic retinopathy is a leading cause of visual impairment. Low awareness about the disease and inequitable distribution of care are major challenges in India.
Objectives:
Assess perception of care and challenges faced in availing care among diabetics.
Materials and Methods:
The cross-sectional, hospital based survey was conducted in eleven cities. In each city, public and private providers of eye-care were identified. Both multispecialty and standalone facilities were included. Specially designed semi-open ended questionnaires were administered to the clients.
Results:
376 diabetics were interviewed in the eye clinics, of whom 62.8% (236) were selected from facilities in cities with a population of 7 million or more. The mean duration of known diabetes was 11.1 (±7.7) years. Half the respondents understood the meaning of adequate glycemic control and 45% reported that they had visual loss when they first presented to an eye facility. Facilities in smaller cities and those with higher educational status were found to be statistically significant predictors of self-reported good/adequate control of diabetes. The correct awareness of glycemic control was significantly high among attending privately-funded facilities and higher educational status. Self-monitoring of glycemic status at home was significantly associated with respondents from larger cities, privately-funded facilities, those who were better educated and reported longer duration of diabetes. Duration of diabetes (41%), poor glycemic control (39.4%) and age (20.7%) were identified as the leading causes of DR. The commonest challenges faced were lifestyle/behavior related.
Conclusions:
The findings have significant implications for the organization of diabetes services in India.
doi:10.4103/2230-8210.179772
PMCID: PMC4847448  PMID: 27144135
Clients; diabetic retinopathy; health care utilization; India; perceptions; risk factors
8.  Rapid Assessment of Visual Impairment in Urban Population of Delhi, India 
PLoS ONE  2015;10(4):e0124206.
Purpose
To determine the prevalence, causes and associated demographic factors related to visual impairment amongst the urban population of New Delhi, India.
Methods
A population-based, cross-sectional study was conducted in East Delhi district using cluster random sampling methodology. This Rapid Assessment of Visual Impairment (RAVI) survey involved examination of all individuals aged 40 years and above in 24 randomly selected clusters of the district. Visual acuity (VA) assessment and comprehensive ocular examination were done during the door-to-door survey. A questionnaire was used to collect personal and demographic information of the study population. Blindness and Visual Impairment was defined as presenting VA <3/60and <6/18 in the better eye, respectively. Descriptive statistics were computed along with multivariable logistic regression analysis to determine associated factors for visual impairment.
Results
Of 2421 subjects enumerated, 2331 (96.3%) were available for ophthalmic examination. Among those examined, 49.3% were males. The prevalence of visual impairment (VI) in the study population, was 11.4% (95% C.I. 10.1, 12.7) and that of blindness was 1.2% (95% C.I. 0.8, 1.6). Uncorrected refractive error was the leading cause of VI accounting for 53.4% of all VI followed by cataract (33.8%). With multivariable logistic regression, the odds of having VI increased with age (OR= 24.6[95% C.I.: 14.9, 40.7]; p<0.001). Illiterate participants were more likely to have VI [OR= 1.5 (95% C.I.: 1.1,2.1)] when compared to educated participants.
Conclusions
The first implementation of the RAVI methodology in a North Indian population revealed that the burden of visual impairment is considerable in this region despite availability of adequate eye care facilities. Awareness generation and simple interventions like cataract surgery and provision of spectacles will help to eliminate the major causes of blindness and visual impairment in this region.
doi:10.1371/journal.pone.0124206
PMCID: PMC4411096  PMID: 25915659
9.  Models for Primary Eye Care Services in India 
Blindness and visual impairment continues to be a major public health problem in India. Availability and easy access to primary eye care services is essential for elimination of avoidable blindness. ‘Vision 2020: The Right to Sight - India’ envisaged the need for establishing primary eye care units named vision centers for every 50,000 population in the country by the year 2020. The government of India has given priority to develop vision centers at the level of community health centers and primary health centers under the ‘National Program for Control of Blindness’. NGOs and the private sector have also initiated some models for primary eye care services.
In the current situation, an integrated health care system with primary eye care promoted by government of India is apparently the best answer. This model is both cost effective and practical for the prevention and control of blindness among the underprivileged population. Other models functioning with the newer technology of tele-ophthalmology or mobile clinics also add to the positive outcome in providing primary eye care services. This review highlights the strengths and weaknesses of various models presently functioning in the country with the idea of providing useful inputs for eye care providers and enabling them to identify and adopt an appropriate model for primary eye care services.
doi:10.4103/0970-0218.153868
PMCID: PMC4389507  PMID: 25861167
Primary eye care; tele-ophthalmology; vision center
10.  Prevalence of Myopia and Its Risk Factors in Urban School Children in Delhi: The North India Myopia Study (NIM Study) 
PLoS ONE  2015;10(2):e0117349.
Purpose
Assess prevalence of myopia and identify associated risk factors in urban school children.
Methods
This was a cross-sectional study screening children for sub-normal vision and refractive errors in Delhi. Vision was tested by trained health workers using ETDRS charts. Risk factor questionnaire was filled for children with vision <6/9.5, wearing spectacles and for a subset (10%) of randomly selected children with normal vision. All children with vision <6/9.5 underwent cycloplegic refraction. The prevalence of myopia <-0.5 diopters was assessed. Association of risk factors and prevalence of myopia was analyzed for children with myopia and randomly selected non myopic children and adjusted odds ratio values for all risk factors were estimated.
Results
A total number of 9884 children were screened with mean age of 11.6 + 2.2 years and 66.8% boys. Prevalence of myopia was 13.1% with only 320 children (24.7%) wearing appropriate spectacles. Mean myopic spherical error was -1.86 + 1.4 diopters. Prevalence of myopia was higher in private schools compared to government schools (p<0.001), in girls vs. boys (p = 0.004) and among older (> 11 years) children (p<0.001). There was a positive association of myopia with studying in private schools vs. government schools (p<0.001), positive family history (p< 0.001) and higher socio-economic status (p = 0.037). Positive association of presence of myopia was observed with children studying/reading > 5 hours per day (p < 0.001), watching television > 2 hours / day (p < 0.001) and with playing computer/video/mobile games (p < 0.001). An inverse association with outdoor activities/playing was observed with children playing > 2 hours in a day.
Conclusion
Myopia is a major health problem in Indian school children. It is important to identify modifiable risk factors associated with its development and try to develop cost effective intervention strategies.
doi:10.1371/journal.pone.0117349
PMCID: PMC4342249  PMID: 25719391
11.  Accuracy of Visual Assessment by School Teachers in School Eye Screening Program in Delhi 
Background:
Although school eye screening is a major activity of the National Program for Control of Blindness, inadequate evidence exists about accuracy of school teachers in screening.
Objectives:
Compare quality of referral for subnormal vision by school teachers and primary eye care workers (PECW) in school children and to establish appropriate cutoff for identification of subnormal vision in school going children.
Materials and Methods:
This was a cross-sectional study involving school children studying in classes 1 to 9 in different schools of Delhi evaluated for sub-normal vision. Vision was recorded by the teacher and a primary eye care worker especially trained for the study using the optotypes of Early treatment Diabetic Retinopathy Survey (ETDRS) vision chart with standard lighting.
Results:
The total number of children enlisted in the 20 selected schools was 10,114. Of these, 9838 (97.3%) children were examined in the study. The mean age of children enrolled in the study was 11.6 ± 2.19 years with 6752 (66.9%) males. The sensitivity and specificity of teachers in comparison to PECW using 6/9.5 vision level as cutoff for referral was 79.2% and 93.3%, respectively compared to 77.0% and 97.1%, respectively on using the 6/12 optotype. The results showed significantly higher sensitivity and lower specificity for private schools against government schools and for older against younger children.
Conclusions:
Our results show that the use of teachers and shift to use of the 6/12 sized “E” for the school eye screening (SES) program is appropriate and would substantially reduce the work of eye care providers while improving its overall efficiency.
doi:10.4103/0970-0218.149269
PMCID: PMC4317979  PMID: 25657511
Accuracy; national program for control of blindness; refractive errors; school eye screening; sensitivity and specificity
14.  Rapid Assessment of Trachoma in Underserved Population of Car-Nicobar Island, India 
PLoS ONE  2013;8(6):e65918.
Purpose
To determine the burden of trachoma and its related risk factors amongst the native population of Car-Nicobar Island in India.
Methods
Rapid assessment for trachoma was conducted in ten villages of Car- Nicobar Island according to standard WHO guidelines. An average of 50 children aged 1–9 years were assessed clinically for signs of active trachoma and facial cleanliness in each village. Additionally, all adults above 15 years of age in these households were examined for evidence of trachomatous trichiasis and corneal opacity. Environmental risk factors contributing to trachoma like limited access to potable water & functional latrine, presence of animal pen and garbage within the Nicobari hut were also noted in all villages.
Results
Out of a total of fifteen villages in Car-Nicobar Island, ten villages were selected for trachoma survey depending on evidence of socio-developmental indicators like poverty and decreased access to water, sanitation and healthcare facilities. The total population of the selected clusters was 7277 in the ten villages. Overall, 251 of 516 children (48.6%;CI: 46.5–55.1) had evidence of follicular stage of trachoma and 11 children (2.1%;CI:1.0–3.4) had evidence of inflammatory stage of trachoma. Nearly 15%(CI:12.1–18.3) children were noted to have unclean faces in the ten villages. Trachomatous trichiasis was noted in 73 adults (1.0%;CI:0.8–1.2). The environmental sanitation was not found to be satisfactory in the surveyed villages mainly due to the co-habitance of Nicobari people with domestic animals like pigs, hens, goats, dogs, cats etc in most (96.4%) of the households.
Conclusion
Active trachoma and trachomatous trichiasis was observed in all the ten villages surveyed, wherein trachoma control measures are needed.
doi:10.1371/journal.pone.0065918
PMCID: PMC3683059  PMID: 23799063
15.  Polymorphisms in ARMS2/HTRA1 and Complement Genes and Age-Related Macular Degeneration in India: Findings from the INDEYE Study 
Purpose.
Association between genetic variants in complement factor H (CFH), factor B (CFB), component 2 (C2), and in the ARMS2/HTRA1 region with age-related macular degeneration (AMD) comes mainly from studies of European ancestry and case-control studies of late-stage disease. We investigated associations of both early and late AMD with these variants in a population-based study of people aged 60 years and older in India.
Methods.
Fundus images were graded using the Wisconsin Age-Related Maculopathy Grading System and participants assigned to one of four mutually exclusive stages based on the worse affected eye (0 = no AMD, 1–3 = early AMD, 4 = late AMD). Multinomial logistic regression was used to derive risk ratios (RR) accounting for sampling method and adjusting for age, sex, and study center.
Results.
Of 3569 participants, 53.2% had no signs of AMD, 45.6% had features of early AMD, and 1.2% had late AMD. CFH (rs1061170), C2 (rs547154), or CFB (rs438999) was not associated with early or late AMD. In the ARMS2 locus, rs10490924 was associated with both early (adjusted RR 1.22, 95% confidence interval [CI]: 1.13–1.33, P < 0.0001) and late AMD (adjusted RR 1.81, 95% CI: 1.15–2.86; P = 0.01); rs2672598 was associated only with early AMD (adjusted RR 1.12, 95% CI: 1.02–1.23; P = 0.02); rs10490923 was not associated with early or late AMD.
Conclusions.
Two variants in ARMS2/HTRA1 were associated with increased risk of early AMD, and for one of these, the increased risk was also evident for late AMD. The study provides new insights into the role of these variants in early stages of AMD in India.
We report results from a genetic association study of early AMD in an Indian population. Two variants in the ARMS/HTRA1 region were associated with early AMD but variants in C2, CFH, and CFB were not.
doi:10.1167/iovs.12-10073
PMCID: PMC3490538  PMID: 23060141
16.  Is Myopia a Public Health Problem in India? 
Myopia, a form of refractive error is a leading cause of visual disability throughout the world. In India uncorrected refractive errors are the most common cause of visual impairment and second major cause of avoidable blindness. Due to this the public health and economic impact of myopia is enormous. Although school vision screening programme is very successful in many states, still a significant number of school going children remain unidentified and the unmet need for correcting refractive errors in children appears to be significant.
doi:10.4103/0970-0218.112436
PMCID: PMC3714946  PMID: 23878419
Avoidable blindness; myopia; refractive error; school screening
18.  EPHA2 Polymorphisms and Age-Related Cataract in India 
PLoS ONE  2012;7(3):e33001.
Objective
We investigated whether previously reported single nucleotide polymorphisms (SNPs) of EPHA2 in European studies are associated with cataract in India.
Methods
We carried out a population-based genetic association study. We enumerated randomly sampled villages in two areas of north and south India to identify people aged 40 and over. Participants attended a clinical examination including lens photography and provided a blood sample for genotyping. Lens images were graded by the Lens Opacification Classification System (LOCS III). Cataract was defined as a LOCS III grade of nuclear ≥4, cortical ≥3, posterior sub-capsular (PSC) ≥2, or dense opacities or aphakia/pseudophakia in either eye. We genotyped SNPs rs3754334, rs7543472 and rs11260867 on genomic DNA extracted from peripheral blood leukocytes using TaqMan assays in an ABI 7900 real-time PCR. We used logistic regression with robust standard errors to examine the association between cataract and the EPHA2 SNPs, adjusting for age, sex and location.
Results
7418 participants had data on at least one of the SNPs investigated. Genotype frequencies of controls were in Hardy-Weinberg Equilibrium (p>0.05). There was no association of rs3754334 with cataract or type of cataract. Minor allele homozygous genotypes of rs7543472 and rs11260867 compared to the major homozygote genotype were associated with cortical cataract, Odds ratio (OR) = 1.8, 95% Confidence Interval (CI) (1.1, 3.1) p = 0.03 and 2.9 (1.2, 7.1) p = 0.01 respectively, and with PSC cataract, OR = 1.5 (1.1, 2.2) p = 0.02 and 1.8 (0.9, 3.6) p = 0.07 respectively. There was no consistent association of SNPs with nuclear cataract or a combined variable of any type of cataract including operated cataract.
Conclusions
Our results in the Indian population agree with previous studies of the association of EPHA2 variants with cortical cataracts. We report new findings for the association with PSC which is particularly prevalent in Indians.
doi:10.1371/journal.pone.0033001
PMCID: PMC3297613  PMID: 22412971
19.  Prevalence and Risk Factors for Vitamin C Deficiency in North and South India: A Two Centre Population Based Study in People Aged 60 Years and Over 
PLoS ONE  2011;6(12):e28588.
Background
Studies from the UK and North America have reported vitamin C deficiency in around 1 in 5 men and 1 in 9 women in low income groups. There are few data on vitamin C deficiency in resource poor countries.
Objectives
To investigate the prevalence of vitamin C deficiency in India.
Design
We carried out a population-based cross-sectional survey in two areas of north and south India. Randomly sampled clusters were enumerated to identify people aged 60 and over. Participants (75% response rate) were interviewed for tobacco, alcohol, cooking fuel use, 24 hour diet recall and underwent anthropometry and blood collection. Vitamin C was measured using an enzyme-based assay in plasma stabilized with metaphosphoric acid. We categorised vitamin C status as deficient (<11 µmol/L), sub-optimal (11–28 µmol/L) and adequate (>28 µmol/L). We investigated factors associated with vitamin C deficiency using multivariable Poisson regression.
Results
The age, sex and season standardized prevalence of vitamin C deficiency was 73.9% (95% confidence Interval, CI 70.4,77.5) in 2668 people in north India and 45.7% (95% CI 42.5,48.9) in 2970 from south India. Only 10.8% in the north and 25.9% in the south met the criteria for adequate levels. Vitamin C deficiency varied by season, and was more prevalent in men, with increasing age, users of tobacco and biomass fuels, in those with anthropometric indicators of poor nutrition and with lower intakes of dietary vitamin C.
Conclusions
In poor communities, such as in our study, consideration needs to be given to measures to improve the consumption of vitamin C rich foods and to discourage the use of tobacco.
doi:10.1371/journal.pone.0028588
PMCID: PMC3232233  PMID: 22163038
20.  Inverse Association of Vitamin C with Cataract in Older People in India 
Ophthalmology  2011;118(10):1958-1965.e2.
Objective
To examine the association between vitamin C and cataract in the Indian setting.
Design
Population-based cross-sectional analytic study.
Participants
A total of 5638 people aged ≥60 years.
Methods
Enumeration of randomly sampled villages in 2 areas of north and south India to identify people aged ≥60 years. Participants were interviewed for socioeconomic and lifestyle factors (tobacco, alcohol, household cooking fuel, work, and diet); attended a clinical examination, including lens photography; and provided a blood sample for antioxidant analysis. Plasma vitamin C was measured using an enzyme-based assay in plasma stabilized with metaphosphoric acid, and other antioxidants were measured by reverse-phase high-pressure liquid chromatography.
Main Outcome Measures
Cataract and type of cataract were graded from digital lens images using the Lens Opacity Classification System III (LOCS III), and cataract was classified from the grade in the worse eye of ≥4 for nuclear cataract, ≥3 for cortical cataract, and ≥2 for posterior subcapsular cataract (PSC). Any cataract was defined as any unoperated or operated cataract.
Results
Of 7518 enumerated people, 5638 (75%) provided data on vitamin C, antioxidants, and potential confounders. Vitamin C was inversely associated with cataract (adjusted odds ratio [OR] for highest to lowest quartile = 0.61; 95% confidence interval (CI), 0.51–0.74; P=1.1×10−6). Inclusion of other antioxidants in the model (lutein, zeaxanthin, retinol, β-carotene, and α-tocopherol) made only a small attenuation to the result (OR 0.68; 95% CI, 0.57–0.82; P < 0.0001). Similar results were seen with vitamin C by type of cataract: nuclear cataract (adjusted OR 0.66; CI, 0.54–0.80; P < 0.0001), cortical cataract (adjusted OR 0.70; CI, 0.54–0.90; P < 0.002), and PSC (adjusted OR 0.58; CI, 0.45–0.74; P < 0.00003). Lutein, zeaxanthin, and retinol were significantly inversely associated with cataract, but the associations were weaker and not consistently observed by type of cataract. Inverse associations were also observed for dietary vitamin C and cataract.
Conclusions
We found a strong association with vitamin C and cataract in a vitamin C–depleted population.
Financial Disclosure(s)
The author(s) have no proprietary or commercial interest in any materials discussed in this article.
doi:10.1016/j.ophtha.2011.03.016
PMCID: PMC3185206  PMID: 21705085
21.  Role of Early Screening for Diabetic Retinopathy in Patients with Diabetes Mellitus: An Overview 
Diabetes has emerged as a major public health problem in India. It is estimated that there were 40 million persons with diabetes in India in 2007 and this number is predicted to rise to almost 70 million by 2025. The impact of rapid urbanization, industrialization and lifestyle changes has led to an increasing trend in prevalence of diabetes and its associated complications such as neuropathy, nephropathy, vascular diseases (cardiac, cerebral and peripheral) and retinopathy. Diabetic retinopathy is a important cause of avoidable blindness in India. Treatment interventions at early stages of diabetic retinopathy can reduce burden of blindness due to diabetic retinopathy. With the available cost-effective methods of early screening, appropriate strategies/models need to be developed. Such models need to have a well-developed mode for screening, diagnosis and referral at each hierarchal level beginning from primary health centers to specialized institutes for eye care. The National Program for Control of Blindness of India recommends opportunistic screening for identification of diabetic retinopathy. Every opportunity of contact with high-risk cases for diabetes and/or diabetic retinopathy should be utilized for screening, diagnosis and referral. All the stakeholders including the private sector will need to play a role. Along with this, awareness generation and behavior change amongst the diabetics and care support systems should also be part of the overall model. A major role can be played by community participation and improving the health seeking behavior among diabetics in order to reach a larger population and increasing the compliance for continued care.
doi:10.4103/0970-0218.91324
PMCID: PMC3263142  PMID: 22279252
Community participation; diabetic retinopathy; public health problem; screening
22.  Prevalence of Cataract in an Older Population in India 
Ophthalmology  2011;118(2-19):272-278.e2.
Purpose
To describe the prevalence of cataract in older people in 2 areas of north and south India.
Design
Population-based, cross-sectional study.
Participants
Randomly sampled villages were enumerated to identify people aged ≥60 years. Of 7518 enumerated people, 78% participated in a hospital-based ophthalmic examination.
Methods
The examination included visual acuity measurement, dilatation, and anterior and posterior segment examination. Digital images of the lens were taken and graded by type and severity of opacity using the Lens Opacity Classification System III (LOCS III).
Main Outcome Measures
Age- and gender-standardized prevalence of cataract and 95% confidence intervals (CIs). We defined type of cataract based on the LOCS III grade in the worse eye of: ≥4 for nuclear cataract, ≥3 for cortical cataract, and ≥2 for posterior subcapsular cataract (PSC). Any unoperated cataract was based on these criteria or ungradable dense opacities. Any cataract was defined as any unoperated or operated cataract.
Results
The prevalence of unoperated cataract in people aged ≥60 was 58% in north India (95% CI, 56–60) and 53% (95% CI, 51–55) in south India (P = 0.01). Nuclear cataract was the most common type: 48% (95% CI, 46–50) in north India and 38% (95% CI, 37–40) in south India (P<0.0001); corresponding figures for PSC were 21% (95% CI, 20–23) and 17% (95% CI, 16–19; P = 0.003), respectively, and for cortical cataract 7.6% (95% CI, 7–9) and 10.2% (95% CI, 9–11; P<0.004). Bilateral aphakia/pseudophakia was slightly higher in the south (15.5%) than in the north (13.2%; P<0.03). The prevalence of any cataracts was similar in north (73.8%) and south India (71.8%). The prevalence of unoperated cataract increased with age and was higher in women than men (odds ratio [OR], 1.8). Aphakia/pseudophakia was also more common in women, either unilateral (OR, 1.2; P<0.02) or bilateral (OR, 1.3; P<0.002).
Conclusions
We found high rates of unoperated cataract in older people in north and south India. Posterior subcapsular cataract was more common than in western studies. Women had higher rates of cataract, which was not explained by differential access to surgery.
Financial Disclosure(s)
The authors have no proprietary or commercial interest in any of the materials discussed in this article.
doi:10.1016/j.ophtha.2010.05.020
PMCID: PMC3146699  PMID: 20801514
23.  Prevalence of Early and Late Age-Related Macular Degeneration in India: The INDEYE Study 
This large, two-center, population-based study provides estimates of the prevalence of age-related macular degeneration in India.
Purpose.
To estimate the prevalence of early and late age-related macular degeneration (AMD) in India.
Methods.
Of 7518 people aged 60 years and older identified from randomly sampled villages in North and South India, 5853 (78%) attended an eye examination including fundus photography. Fundus images were graded according to the Wisconsin Age-Related Maculopathy Grading System.
Results.
Fundus images were ungradable in 1587 people, mainly because of cataract. People 80 years of age and older were less likely to attend the eye examination and more likely to have ungradable images. For ages 60 to 79 years, the percent prevalence (95% confidence interval [CI]) were late AMD 1.2 (0.8–1.5); and early AMD: grade 1 (soft distinct drusen or pigmentary irregularities), 39.3 (37.2–41.5); grade 2 (soft distinct drusen with pigmentary irregularities or soft indistinct or reticular drusen), 6.7 (5.8–7.6); and grade 3 (soft indistinct or reticular drusen with pigmentary irregularities), 0.2 (0.1–0.4). For ages 80 and older, the respective percent prevalence was: late AMD, 2.5 (0.4–4.7); and early AMD: grade 1, 43.1(35.7–50.6); grade 2, 8.1 (4.3–12.0); and grade 3, 0.5 (0–1.5).
Conclusions.
The prevalence of early AMD (grades 1 and 2) is similar to that observed in Western populations, but grade 3 appears to be lower. The prevalence of late AMD is comparable to that in Western populations in the age group 60 to 79 years. It is likely that the prevalence in the 80 and older age group is underestimated.
doi:10.1167/iovs.09-4114
PMCID: PMC2868454  PMID: 19696177
24.  Current status of cataract blindness and Vision 2020: The right to sight initiative in India 
Indian Journal of Ophthalmology  2008;56(6):489-494.
Background:
India is a signatory to the World Health Organization resolution on Vision 2020: The right to sight. Efforts of all stakeholders have resulted in increased number of cataract surgeries performed in India, but the impact of these efforts on the elimination of avoidable blindness is unknown.
Aims:
Projection of performance of cataract surgery over the next 15 years to determine whether India is likely to eliminate cataract blindness by 2020.
Materials and Methods:
Data from three national level blindness surveys in India over three decades, and projected age-specific population till 2020 from US Census Bureau were used to develop a model to predict the magnitude of cataract blindness and impact of Vision 2020: the right to sight initiatives.
Results:
Using age-specific data for those aged 50+ years it was observed that prevalence of blindness at different age cohorts (above 50 years) reduced over three decades with a peak in 1989. Projections show that among those aged 50+ years, the quantum of cataract surgery would double (3.38 million in 2001 to 7.63 million in 2020) and cataract surgical rate would increase from 24025/million 50+ in 2001 to 27817/million 50+ in 2020. Though the prevalence of cataract blindness would decrease, the absolute number of cataract blind would increase from 7.75 million in 2001 to 8.25 million in 2020 due to a substantial increase in the population above 50 years in India over this period.
Conclusions:
Considering existing prevalence and projected incidence of cataract blindness over the period 2001-2020, visual outcomes after cataract surgery and sight restoration rate, elimination of cataract blindness may not be achieved by 2020 in India.
PMCID: PMC2612994  PMID: 18974520
Blindness; cataract; the right to sight; vision 2020

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