C L I N I C A L
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E X P E R I M E N T A L
OPTOMETRY RESEARCH PAPER
Do recycled spectacles meet the refractive needs of a developing country? Clin Exp Optom 2015; 98: 177–182 Sue Ling Wan* MBBS (Hons) MMed (Ophth Sci) Seyhan Yazar* BMedSci MOrth Lisa Booth* BA Valerie Hiew* Johnson Hong* Danny Tu* Joanna Ward* Sonia Gengatharen* Leonel Ximenes Barbosa† B Environ Health David A Mackey* FRANZCO MD * Centre for Ophthalmology and Visual Sciences, University of Western Australia/ Lions Eye Institute, Perth, Western Australia, Australia † Fo Naroman Timor-Leste E-mail: [email protected]
DOI:10.1111/cxo.12217 Purpose: The aim was to compare the power of spectacles donated to a recycled spectacle program to the custom-made spectacle refractive prescriptions dispensed in a developing country. Methods: Two hundred consecutive prescriptions were audited in an optical dispensary in Timor-Leste, a developing nation. These refractions were compared against measurements of 2,075 wearable donated spectacles. We determined how many of the 200 prescriptions could be matched to a donated spectacle measurement, how many donated spectacles could be tried for each prescription and how long it would take to find the matched spectacles. Results: There were 1,854 donated spectacles identified as being suitable for comparison with the 200 refractive prescriptions. Twenty-nine out of 200 prescriptions (14.5 per cent) were matched to at least one pair of donated spectacles. Conclusion: Recycling all spectacles is not cost-effective in a developing country that has the ability to make custom-made spectacles and dispense ready-made spectacles.
Submitted: 4 July 2014 Revised: 8 August 2014 Accepted for publication: 15 August 2014
Key words: custom-made, donated spectacles, ready-made, recycled spectacles, uncorrected refractive error
Uncorrected refractive error is a major reversible cause of visual impairment worldwide. The World Health Organization (WHO) and the International Agency for the Prevention of Blindness (IAPB) have made refractive error correction a priority in their global campaign: Vision 2020- Right to Sight.1,2 This campaign was launched in 1999 to eliminate avoidable blindness by the year 2020. In providing this eye health-care, there must also be plans to ensure that it continues into the future and is financially viable for the country in which it is established. The revised global target is to reduce the prevalence of avoidable visual impairment by 25 per cent by 2019 from the baseline of 2010.3 An updated global estimate of visual impairment in 2010 of people of all ages is 285 million, of which 39 million are blind.4 According to data in 2010, 80 per cent of visual impairment is avoidable with the leading causes being uncorrected refractive
errors (43 per cent) followed by cataracts (33 per cent).4,5 Uncorrected refractive errors account for three per cent of blindness. Presbyopia, the age-related decrease in near vision, is not included in the WHOreported prevalence of uncorrected refractive errors. An estimate of the number of individuals experiencing disability from uncorrected presbyopia in 2005 was 410 million, 94 per cent of whom live in a less- or least-developed country.6 This is predicted to grow to 563 million people by 2020, if access to spectacles continues to be limited for those in need.6 Refractive errors can be corrected through spectacles, contact lenses and laser refractive surgery. The majority of people with uncorrected refractive errors live in developing countries where spectacles are the most accessible solution. Many spectacles dispensed in affluent societies to correct refractive errors are custom-made with a
© 2014 The Authors Clinical and Experimental Optometry © 2014 Optometry Australia
small proportion of ready-made spectacles (RMS) used to correct presbyopia. Programs that recycle spectacles are established in developed countries to provide an opportunity for people to donate their old spectacles,7–14 which can include multifocal and progressive lenses. Progressive spectacles are more difficult to recycle, as they need to be properly fitted to the individual. Recycled spectacle programs continue to exist worldwide despite evidence in the literature that concludes these schemes cannot successfully address uncorrected refractive error in developing countries with limited resources.15,16 Since 2007, a custom-made spectacle (CMS) service has been available in Dili, the capital city of the Democratic Republic of Timor-Leste. This service is provided through Fo Naroman Timor-Leste (FNTL), the local national non-government organisation (NGO) providing health promotion, Clinical and Experimental Optometry 98.2 March 2015
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Recycled spectacles Wan, Yazar, Booth, Hiew, Hong, Tu, Ward, Gengatharen, Barbosa and Mackey
vision screening, refractive error correction, cataract referral and spectacle dispensing services throughout Timor-Leste. Spherical, astigmatic and bifocal corrective lenses are dispensed as custom-made spectacles in addition to a selection of ready-made spectacles. The range of ready-made spectacles available at Fo Naroman Timor-Leste is ± 0.5 to ± 4.00 DS, while custom-made lenses are available in a range of -14.00 to +14.00 DS with -4.00 DC. Other powers are not stocked at the workshop but can be ordered. With the support of the Timorese Ministry of Health and international NGOs, Fo Naroman Timor-Leste is able to provide screening for refractive errors and dispense spectacles to all 13 districts of Timor-Leste. The mobile outreach program services remote villages with difficult access. The East Timorese people are also willing to pay for the new spectacles.17,18 Fo Naroman TimorLeste has provided vision screening services to more than 44,000 people throughout the country and dispensed more than 36,000 spectacles since 2006.19 Through proper internal management, the trained screening and dispensing staff of Fo Naroman Timor-Leste may provide a financially sustainable and self-sufficient operation. The East Timor Eye Program (ETEP) and Fo Naroman Timor-Leste do not accept recycled spectacles for dispensing in Timor-Leste. The Lions Save Sight Foundation (LSSF) in Perth, Western Australia, collects spectacles for recycling programs. It is estimated that approximately 50 per cent of the donated spectacles are discarded as they are broken or badly scratched. After the first culling, we obtained 2,075 spectacles that were stored in cardboard boxes at the Lions Eye Institute (LEI), from a consecutive series of collections in 2012. A comparison of these donated spectacles was made with custommade spectacle prescriptions dispensed in the optical workshop at Fo Naroman TimorLeste to assess the viability of recycling spectacles in a developing country that has the capacity to dispense custom-made as well as ready-made spectacles. METHODS Between the months of June and August 2013, the refractive prescriptions and interpupillary distances (IPD) of 200 consecutive custom-made spectacles dispensed at the optical workshop at Fo Naroman TimorLeste were audited to assess the need for an Clinical and Experimental Optometry 98.2 March 2015
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optical dispensary in a developing country. There were 107 females and 93 males in the de-identified data. Each patient attending the Fo Naroman Timor-Leste clinic had visual acuity assessed and was subjectively refracted by trained eye-care technicians. These assessments are documented in clinical records. If custom-made spectacles were dispensed, the details of the frames, lenses and IPD were recorded chronologically according to date. Custom-made spectacles were dispensed by one of the trained optical technicians in Fo Naroman Timor-Leste. If ready-made spectacles were dispensed, these were separately recorded. For the year 2013, a total of 2,090 ready-made spectacles as well as 703 custom-made single-focus and 165 custom-made bifocals were dispensed at Fo Naroman Timor-Leste. The 2,075 donated spectacles that passed Lions Save Sight Foundation’s first cull were cleaned and prepared for lensmeter measurement. All spectacles were measured twice with the same lensmeter (Auto Lensmeter LM-600PD, Nidek, Gamagori, Japan) by two teams of three medical students. The two readings were recorded in a database with each pair of spectacles assigned an identification number and stored in a box of 200 spectacles with the range of identification numbers labelled on the box. We estimated how long it would take to try on every pair of spectacles to find a suitable and tolerable pair. One of the authors (LB) was given a random box of 200 spectacles and tried on each pair. This was performed with all spectacles and the time taken was recorded. The most tolerable pair of spectacles out of the cohort had to be worn for 24 hours to assess tolerance. We also assessed how long it would take to find 20 specific pairs of spectacles, once the patient’s refraction was matched against the database. The time from when the identification number was matched until the pair of spectacles was tried on was recorded. Moreover, we assessed how long it would take one subject to find the first pair of acceptable spectacles and whether the spectacles would be tolerated for 24 hours. This was performed to simulate a situation where the boxes were given to a developing country and there was no trained eye-care technician to dispense them. RESULTS The 2,075 wearable donated spectacles were reassessed and spectacles with prisms,
slightly scratched lenses, broken sides and lenses that were difficult to check using the lensmeter were excluded, reducing the number to 2,014 spectacles for analysis. Furthermore, if 0.25 DS or more difference was found between the two measurements for the right spherical lens (1,960), the spectacles were excluded. This criterion was applied to ensure the two groups accurately performed the lensmeter readings on the donated spectacles before the comparison was made with the dispensed prescriptions. If more than 0.25 DS difference was found between the two measurements, this implied a measurement discrepancy during lensometry. This exclusion criterion was subsequently applied to the sphere of the left lens (1,909), the right (1,891) and left (1,860) lens cylinders. Finally, six multifocal and progressive spectacles were excluded (only one lens had a near addition measurement, representing a measurement discrepancy) to arrive at the final inclusion of 1,854 spectacles (Figure 1). The average measurement for the two readings was taken for each pair of spectacles. The power of each pair of recycled spectacles was compared to the subject’s prescription in the Fo Naroman Timor-Leste optical dispensary. The total number of usable recycled spectacles that could be offered for each prescription was determined. This study did not consider fit or aesthetics, including the gender appropriateness of each spectacle frame. The 1,854 spectacles were compared against the 200 refractions from the optical dispensary in Fo Naroman Timor-Leste: 664 multifocal and progressive spectacles (163 minus to plano lens, 501 plus lenses) and 1,190 single focus spectacles (339 minus to plano lenses, 851 plus lenses). Of the 1,854 spectacles, there were 539 with a cylinder of 1.00 D or more (29 per cent) and 594 with 0.50 D or more of anisometropia (32 per cent). Each right spherical refractive TimorLeste prescription was matched to the recycled spectacles, then right cylindrical, left spherical and left cylindrical errors then finally the IPD. Custom-made spectacles are available in Timor-Leste, so it was considered unacceptable if there was not a match in refraction within 0.125 D for both spherical and cylindrical errors (corresponding to American National Standards for Ophthalmics—Prescription Spectacle Lenses20 and Australian/New Zealand Standard—Ophthalmic Optics—Mounted © 2014 The Authors
Clinical and Experimental Optometry © 2014 Optometry Australia
Recycled spectacles Wan, Yazar, Booth, Hiew, Hong, Tu, Ward, Gengatharen, Barbosa and Mackey
All spectacles arriving at LSSF
Remaining donated spectacles, n=2,075
Physically usable n=2,014 (97%)
Optically accurate n=1,854 (89%)
1,190 unifocal spectacles
Spectacles discarded by LSSF volunteers on initial inspection (approximately 50%)
Physically unusable n=61 (3%)
Optically inaccurate n=160 (8%)
664 multifocal and progressive spectacles
tacles that the subject could try (five myopic and 24 hypermetropic) (Table 2). There was a greater number of spectacles available to try, if the larger IPD range of ±3.0 mm was considered tolerable (Table 2). There were between one and 20 extra pairs of recycled spectacles that could have been tried. Once a refractive prescription was matched to a recycled spectacle identification number in our collection, it took an average of seven minutes and nine seconds (range 1.5 to 13.5 minutes) for a subject to search, find them and try one pair in a box of 200 spectacles (143 minutes to find 20 pairs of spectacles). It took 310 minutes for one subject to try on every pair of the 1,854 spectacles to find those that were suitable; however, the subject was unable to tolerate the spectacles for more than an hour. It took another subject 45 minutes to find the first pair of spectacles that were acceptable; however, she was unable to tolerate wearing them for more than five minutes due to asthenopia. DISCUSSION
339 minus to plano spectacles
163 minus to plano spectacles
851 plus spectacles
501 plus spectacles
Figure 1. Flow chart for determining the use of donated spectacles. Spectacles were collected by The Lions Save Sight Foundation and underwent a first cull of approximately 50 per cent. All of the remaining donated spectacles underwent further inspection and physically unusable spectacles (scratched lenses, bent or broken spectacle sides, lenses that were difficult to measure with a lensometer) were discarded. Then optically inaccurate spectacles (greater than ±0.25 DS between the two measurements for right lens sphere, left lens sphere, right lens cylinder and left lens cylinder) were removed. Multifocal and progressive spectacles without unilateral addition were included.
Spectacle Lenses21). An axis range for the cylinder of within five degrees was considered tolerable. An IPD up to ± 3.0 mm was accepted so that the subject could try them on. A further limitation criterion of IPD ±1.0 mm was also analysed. The process of matching also assumes that each person will have the full quota of spectacles to choose from, so each subject does not choose and take a pair leaving a smaller number for
the next subject. The prismatic effects of spectacle centre to centre were ignored for this analysis. The range of the recycled spectacles (single, multifocal and progressive) and the subjects’ refractions are shown in Table 1. Out of the 200 refractions from the optical workshop at Fo Naroman Timor-Leste, 29 (14.5 per cent) were able to be matched with at least one pair of the 1,854 donated spec-
© 2014 The Authors Clinical and Experimental Optometry © 2014 Optometry Australia
There is a continuing global challenge to prevent and treat causes of visual impairment. The ultimate objective is to foster selfsufficient and sustainable local programs that provide relevant eye health-care. Many longstanding recycling spectacle programs exist worldwide. Each has its own system for recycling the donated spectacles, including collection, logistics, assessment, sorting, cleaning, dispensing, storing and when appropriate, destroying unwanted spectacles. It has been questioned whether this practice should continue and if so, in what capacity can it add value to eye health-care in the developing world. Some people support discontinuing the use of recycled spectacles in developing countries.15,16,22–25 To the authors’ knowledge, this is the first paper that compares a collection of almost 2,000 recycled spectacles for the refractive needs of a developing country. The availability of good-quality low-cost ready-made spectacles has been shown to be acceptable in multiple studies, including those performed in developed countries.26 One double-masked randomised clinical trial of junior high school students in urban Guangzhou, China, supports the use of ready-made spectacles for a refractive services program in which custom-made spectacles are not readily accessible.27 This study compared the acceptability of custom-made Clinical and Experimental Optometry 98.2 March 2015
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Recycled spectacles Wan, Yazar, Booth, Hiew, Hong, Tu, Ward, Gengatharen, Barbosa and Mackey
Range
Donated single vision spectacles
Donated multifocal and progressive spectacles
Subjects’ refractions
-10.75 to +8.00
-8.875 to +7.75
-8.00 to +15.00
0 to -6.50
0 to -6.50
-10.875 to +8.00
-9.125 to +8.00
Right sphere (D) Right cylinder (D) Left sphere (D) Left cylinder (D)
0 to -6.875
Near addition (D)
0 to -6.875
NA
Interpupillary distance (mm)
39.50 to 74.50
0 to -4.00 -8.00 to +14.00 0 to -4.00
+0.5 to +4.25
+1.00 to +3.00
42.75 to 81.75
51.00 to 70.00
Table 1. Ranges for donated spectacles strengths and prescriptions
Number of subjects
Right sphere (D)
Left sphere (D)
Addition (D)
IPD (mm)
Number of spectacles with IPD +/-1 mm
Number of spectacles with IPD +/-3 mm
1
-1.50
-1.50
—
65
1
1
1
-0.75
-0.75
—
63
1
1
1
-0.50
-0.50
—
62
2
3
1
-0.50
-0.50
—
60
1
3
1
-0.25
-0.25
—
64
1
1
2
+0.75
+0.75
—
64
1
4
1
+0.75
+0.75
+1.25
64
1
1
1
+1.00
+1.00
—
64
8
15
1
+1.00
+1.00
—
60
6
13
2
+1.25
+1.25
—
65
2
7
1
+1.50
+1.50
—
64
10
21
2
+1.50
+1.50
—
65
6
16
1
+1.50
+1.50
—
67
2
9
1
+1.75
+1.75
—
65
2
3
2
+1.75
+1.75
—
60
3
4
1
+1.75
+1.75
—
64
2
2
1
+1.75
+1.25
—
64
1
2
1
+2.00
+2.00
—
63
13
27
4
+2.00
+2.00
—
60
9
29
1
+2.75
+2.75
—
60
2
3
1
+4.00
+4.00
—
64
1
2
1
Plano
Plano
—
Any
4
4
Total 29 IPD: interpupillary distance
Table 2. Number of recycled spectacles matched for each prescription
versus ready-made spectacles for correcting refractive error. Although visual acuity was better with custom-made spectacles, the acceptability between the two groups was no different at one month. Another similar double-masked randomised clinical trial was Clinical and Experimental Optometry 98.2 March 2015
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conducted on an urban adult population in India.28 Similar satisfaction at one month was achieved with ready-made compared with custom-made spectacles, despite the readymade group not having their refractive error fully corrected. This supports programs dis-
pensing ready-made spectacles in areas where access to custom-made spectacles is difficult; however, some patients with high levels of astigmatism would benefit from custom-made spectacles and they should be offered to individuals if possible. © 2014 The Authors
Clinical and Experimental Optometry © 2014 Optometry Australia
Recycled spectacles Wan, Yazar, Booth, Hiew, Hong, Tu, Ward, Gengatharen, Barbosa and Mackey
Wilson and colleagues15 analysed the costs and benefits of recycled spectacles compared to ready-made spectacles, where only seven per cent of the 275 donated spectacles were considered usable. All donated spectacles were given an initial inspection and eliminated, if they were progressive lenses, had noticeable scratches or flakes, had lenses with noticeable cylindrical power or had damaged frames. The spectacles were also excluded if they met any of the following optical criteria: more than 0.75 D cylindrical power, more than 0.5 D anisometropia or more than 0.5 D vertical prism. In our study, we did not exclude spectacles according to these optical criteria nor did we exclude progressive lenses. In a response to the study by Wilson and colleagues,15 a program argued they used a ‘best match’ system with a computerised database of the inventory and matched the total optical blur calculated using power vectors.29 In our study, we did not consider matching total optical blur or spherical equivalence as acceptable for patients because there is an optical workshop that is able to dispense custom-made spectacles and thus our study had stricter exclusion criteria. Ramke, de Toit and Brian16 compared a donated box of 102 spectacles with the refractive errors of subjects from Tuvalu, a small South Pacific nation of 11,600 people. The donated spectacles were excluded if they had more than 1.00 DC, anisometropia of more than 0.50 D, scratched lenses or broken frames. Only 13 per cent of donated spectacles were considered likely to be suitable for dispensing based on satisfactory optics, physical intactness and cosmetic appropriateness. The paper calculated at least 5,538 spectacles would be required to match a pair of spectacles for each of the 266 subjects, if they were prepared to spend the time to search to find one. The intentions behind recycling spectacle programs are altruistic and aimed at helping lower-resourced countries; however, the true cost of recycling these donated spectacles is more than importing and dispensing ready-made spectacles in a developing country.15 If the developing country also has the capacity to make custom-made spectacles, the use of recycled spectacles is further limited. Programs that are designed to fund high-quality, sustainable eye-care services should be encouraged rather than dispensing recycled spectacles. An alternative to recycling spectacles for dispensing is a program such as Ohio State
Student Volunteer Optometric Services to Humanity where the recycled spectacles are sold for scrap.30 Students studying optometry select high-quality usable spectacles and the unusable spectacles are sent to a company in California that recycles the materials and pays the students approximately US$1.50 per pound for the scrap. They use this income to fund travel to countries to provide eye-care services; however, it is argued that value should be placed on the volunteers’ time and skills that could be better used elsewhere. It would be more economical to send all of the spectacles for scrap and use the income to provide eye health services as this would remove the need to use valuable skilled time sorting the donated spectacles.30 Scrap metal companies in Western Australia were approached for a quote to recycle our spectacles. Most companies would not accept them. One company that was prepared to recycle them quoted AUS$80.00 per tonne (AUS$0.08 per kilogram or AUS$0.04 per pound). Lions International claims that it costs less than US$0.08 to recycle one pair of spectacles; however, this does not include the cost of the volunteers’ donated time nor the cost of storage facilities.31 Also, it is the responsibility of the dispensing program in the developing country to pay for shipment costs and custom clearance when they request the spectacles.8 Vision Aid Overseas does not send recycled spectacles overseas because the organisation believes it is not a cost-effective way to develop long-term eye-care programs.32 The donated spectacles are divided into three categories: gold-coloured frames for metal recycling, vintage frames for sale to eye wear merchants interested in restoring them for retail and the remainder for recycling in the most environmentally friendly way to prevent landfill. All of the custom-made refractive prescriptions that were matched to recycled spectacles could have been purchased as ready-made spectacles from Fo Naroman Timor-Leste apart from the bifocals and one pair with a difference of 0.5 DS between the lenses. However, these patients decided to have custom-made spectacles, so one could assume they were not happy with the readymade spectacles. This may reflect the patient’s desire to have a better-quality frame or one that fits better physically and aesthetically. This suggests that patients in developing countries consider these qualities to be important. Philosophically, one
© 2014 The Authors Clinical and Experimental Optometry © 2014 Optometry Australia
could argue old, worn, out-fashioned spectacles that would not be acceptable in developed countries should not be given to patients in developing countries. For Fo Naroman Timor-Leste, the cost of the 2,090 ready-made spectacles for the year 2013 was US$3,534.00, which equates to US$1.69 per pair of ready-made spectacles. The cost of the 703 single-focus custommade spectacles was US$7,030 or US$10.00 per pair of custom-made spectacles and the cost of the 165 bifocal custom-made spectacles dispensed by Fo Naroman Timor-Leste was US$2,145.00. This means that it would have cost Fo Naroman Timor-Leste US$49.04 to provide ready-made spectacles for the 29 refractive prescriptions that were matched in our study. In a cost comparison between Fo Naroman Timor-Leste with the Lions Save Sight Foundation, the room in which The Lions Save Sight Foundation performs the sorting and storage of the donated spectacles is provided by the Lions Eye Institute and would cost approximately AUS$2,500.00 per annum to rent. Calculating the true cost of the Lions Save Sight Foundation program is beyond the scope of this study and could be analysed in a future project. In developed countries, post-operative cataract patients could consider borrowing these spectacles whilst awaiting their new spectacles. Given the availability of readymade readers in developed countries and the presumptive uncleanliness of the recycled spectacles, it is unlikely that a patient would prefer them. With the strong desire of Lions Clubs to continue recycling spectacles, we could consider refining the collection of spectacles to only include plus readers from +1.00 to +3.00 DS that are of good quality for distribution; however, the usefulness of such a refined program would need to be investigated as to whether it is a cost-effective exercise. A recent paper systematically reviewed the literature on clinical outcomes following the dispensing of ready-made spectacles and recycled spectacles.33 This paper included only articles that reported on three outcomes: visual function, patient satisfaction and continued use. The author was unable to find an article following the dispensing of recycled spectacles that described all three clinical outcomes. It is beyond the scope of this paper to assess the visual function of subjects matched with recycled spectacles. Further research is required to analyse how well recycled spectacles improve visual function and whether patients continue to use Clinical and Experimental Optometry 98.2 March 2015
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Recycled spectacles Wan, Yazar, Booth, Hiew, Hong, Tu, Ward, Gengatharen, Barbosa and Mackey
their spectacles. Logistically, this would be a difficult task to undertake and would consume resources that are best used toward providing sustainable services for the correction of refractive errors. If the Lions Save Sight Foundation continues to use recycled spectacles, then immediate and long-term clinical outcomes should be measured to justify the program.
CONCLUSION The matching of recycled spectacles to the prescriptions of a sample of the Timor-Leste population suggests that sending donated spectacles to a developing country may not be an effective way of correcting refractive errors. Instead of recycling spectacles, aid organisations should focus their resources on increasing the capacity of the local eyecare workforce to establish self-sustaining screening and spectacle-dispensing programs to correct refractive errors worldwide. ACKNOWLEDGEMENTS
Authors thank the RANZCO Eye Foundation/Hobart Eye Surgeons East Timor Scholarship for funding the collection of data in Dili, Timor-Leste. We are grateful to Adilson (Joni) Juvinal Da Silva, Fo Naroman Timor-Leste, for information regarding the spectacles and lenses at the optical dispensary, Julianne Sanders for helping Fo Naroman Timor-Leste audit their spectacle dispensing records for the year 2013, Lions Save Sight Foundation volunteers for collecting the spectacles and allowing us to analyse more than 2,000 pairs for the study and Kate Hanman for teaching and supervising the medical students. REFERENCES 1. Chandra SR. Global blindness: VISION 2020: the right to sight. Arch Ophthalmol 2008; 126: 1457. 2. Pizzarello L, Abiose A, Ffytche T, Duerksen R, Thulasiraj R, Taylor H, Faal H et al. VISION 2020: The Right to Sight: a global initiative to eliminate avoidable blindness. Arch Ophthalmol 2004; 122: 615–620. 3. World Health Organization. Prevention of blindness and visual impairment. Available at: http://www.who.int/blindness/actionplan/en/ index.html. [Accessed 10 January, 2014]. 4. Pascolini D, Mariotti SP. Global estimates of visual impairment: 2010. Br J Ophthalmol 2012; 96: 614– 618. 5. World Health Organization. Action plan for the prevention of avoidable blindness and visual impairment for 2014–2019. Available at: http:// www.who.int/blindness/actionplan/en/. [Accessed 10 January, 2014].
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32.
33.
-%20Recycling%20of%20used%20spectacles.pdf. [Accessed 23 January, 2014]. World Council of Optometry. Draft Position Paper Recycling of Used Spectacles. Available at: http:// www.worldoptometry.org/en/about-wco/what -we-do/position-papers.cfm. [Accessed 23 January, 2014]. Maini R, Keeffe J, Weih LA, McCarty CA, Taylor HR. Correction of refractive error in the Victorian population: the feasibility of ‘off the shelf’ spectacles. Br J Ophthalmol 2001; 85: 1283–1286. Zeng Y, Keay L, He M, Mai J, Munoz B, Brady C, Friedman DS. A randomized, clinical trial evaluating ready-made and custom spectacles delivered via a school-based screening program in China. Ophthalmology 2009; 116: 1839–1845. Brady CJ, Villanti AC, Gandhi M, Friedman DS, Keay L. Visual function after correction of distance refractive error with ready-made and custom spectacles: a randomized clinical trial. Ophthalmology 2012; 119: 2014–2020. Horner DG, Thibos L, Jennifer Page J, Perotti J, Kollbaum P, Peabody T. Real cost of recycled spectacles. Optom Vis Sci 2012; 89: e95–e96; author reply e6-e7. Manning JL. Real cost of recycled spectacles. Optom Vis Sci 2012; 89: e95; author reply e6-e7. Lions Club International. The need for eye-glasses. Available at: http://www.lionsclubs.org/EN/ our-work/sight-programs/eyeglass-recycling/the -need-for-eyeglasses.php. [Accessed 4 February, 2014]. Vision Aid Overseas. How we recycled spectacles. Available at: http://www.visionaidoverseas.org/ how-we-recycle-spectacles. [Accessed 24 January, 2014]. Pearce MG. Clinical outcomes following the dispensing of ready-made and recycled spectacles: A systematic literature review. Clin Exp Optom 2014; 97: 225–33.
© 2014 The Authors Clinical and Experimental Optometry © 2014 Optometry Australia
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A N D
E X P E R I M E N T A L
OPTOMETRY RESEARCH PAPER
Do recycled spectacles meet the refractive needs of a developing country? Clin Exp Optom 2015; 98: 177–182 Sue Ling Wan* MBBS (Hons) MMed (Ophth Sci) Seyhan Yazar* BMedSci MOrth Lisa Booth* BA Valerie Hiew* Johnson Hong* Danny Tu* Joanna Ward* Sonia Gengatharen* Leonel Ximenes Barbosa† B Environ Health David A Mackey* FRANZCO MD * Centre for Ophthalmology and Visual Sciences, University of Western Australia/ Lions Eye Institute, Perth, Western Australia, Australia † Fo Naroman Timor-Leste E-mail: [email protected]
DOI:10.1111/cxo.12217 Purpose: The aim was to compare the power of spectacles donated to a recycled spectacle program to the custom-made spectacle refractive prescriptions dispensed in a developing country. Methods: Two hundred consecutive prescriptions were audited in an optical dispensary in Timor-Leste, a developing nation. These refractions were compared against measurements of 2,075 wearable donated spectacles. We determined how many of the 200 prescriptions could be matched to a donated spectacle measurement, how many donated spectacles could be tried for each prescription and how long it would take to find the matched spectacles. Results: There were 1,854 donated spectacles identified as being suitable for comparison with the 200 refractive prescriptions. Twenty-nine out of 200 prescriptions (14.5 per cent) were matched to at least one pair of donated spectacles. Conclusion: Recycling all spectacles is not cost-effective in a developing country that has the ability to make custom-made spectacles and dispense ready-made spectacles.
Submitted: 4 July 2014 Revised: 8 August 2014 Accepted for publication: 15 August 2014
Key words: custom-made, donated spectacles, ready-made, recycled spectacles, uncorrected refractive error
Uncorrected refractive error is a major reversible cause of visual impairment worldwide. The World Health Organization (WHO) and the International Agency for the Prevention of Blindness (IAPB) have made refractive error correction a priority in their global campaign: Vision 2020- Right to Sight.1,2 This campaign was launched in 1999 to eliminate avoidable blindness by the year 2020. In providing this eye health-care, there must also be plans to ensure that it continues into the future and is financially viable for the country in which it is established. The revised global target is to reduce the prevalence of avoidable visual impairment by 25 per cent by 2019 from the baseline of 2010.3 An updated global estimate of visual impairment in 2010 of people of all ages is 285 million, of which 39 million are blind.4 According to data in 2010, 80 per cent of visual impairment is avoidable with the leading causes being uncorrected refractive
errors (43 per cent) followed by cataracts (33 per cent).4,5 Uncorrected refractive errors account for three per cent of blindness. Presbyopia, the age-related decrease in near vision, is not included in the WHOreported prevalence of uncorrected refractive errors. An estimate of the number of individuals experiencing disability from uncorrected presbyopia in 2005 was 410 million, 94 per cent of whom live in a less- or least-developed country.6 This is predicted to grow to 563 million people by 2020, if access to spectacles continues to be limited for those in need.6 Refractive errors can be corrected through spectacles, contact lenses and laser refractive surgery. The majority of people with uncorrected refractive errors live in developing countries where spectacles are the most accessible solution. Many spectacles dispensed in affluent societies to correct refractive errors are custom-made with a
© 2014 The Authors Clinical and Experimental Optometry © 2014 Optometry Australia
small proportion of ready-made spectacles (RMS) used to correct presbyopia. Programs that recycle spectacles are established in developed countries to provide an opportunity for people to donate their old spectacles,7–14 which can include multifocal and progressive lenses. Progressive spectacles are more difficult to recycle, as they need to be properly fitted to the individual. Recycled spectacle programs continue to exist worldwide despite evidence in the literature that concludes these schemes cannot successfully address uncorrected refractive error in developing countries with limited resources.15,16 Since 2007, a custom-made spectacle (CMS) service has been available in Dili, the capital city of the Democratic Republic of Timor-Leste. This service is provided through Fo Naroman Timor-Leste (FNTL), the local national non-government organisation (NGO) providing health promotion, Clinical and Experimental Optometry 98.2 March 2015
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Recycled spectacles Wan, Yazar, Booth, Hiew, Hong, Tu, Ward, Gengatharen, Barbosa and Mackey
vision screening, refractive error correction, cataract referral and spectacle dispensing services throughout Timor-Leste. Spherical, astigmatic and bifocal corrective lenses are dispensed as custom-made spectacles in addition to a selection of ready-made spectacles. The range of ready-made spectacles available at Fo Naroman Timor-Leste is ± 0.5 to ± 4.00 DS, while custom-made lenses are available in a range of -14.00 to +14.00 DS with -4.00 DC. Other powers are not stocked at the workshop but can be ordered. With the support of the Timorese Ministry of Health and international NGOs, Fo Naroman Timor-Leste is able to provide screening for refractive errors and dispense spectacles to all 13 districts of Timor-Leste. The mobile outreach program services remote villages with difficult access. The East Timorese people are also willing to pay for the new spectacles.17,18 Fo Naroman TimorLeste has provided vision screening services to more than 44,000 people throughout the country and dispensed more than 36,000 spectacles since 2006.19 Through proper internal management, the trained screening and dispensing staff of Fo Naroman Timor-Leste may provide a financially sustainable and self-sufficient operation. The East Timor Eye Program (ETEP) and Fo Naroman Timor-Leste do not accept recycled spectacles for dispensing in Timor-Leste. The Lions Save Sight Foundation (LSSF) in Perth, Western Australia, collects spectacles for recycling programs. It is estimated that approximately 50 per cent of the donated spectacles are discarded as they are broken or badly scratched. After the first culling, we obtained 2,075 spectacles that were stored in cardboard boxes at the Lions Eye Institute (LEI), from a consecutive series of collections in 2012. A comparison of these donated spectacles was made with custommade spectacle prescriptions dispensed in the optical workshop at Fo Naroman TimorLeste to assess the viability of recycling spectacles in a developing country that has the capacity to dispense custom-made as well as ready-made spectacles. METHODS Between the months of June and August 2013, the refractive prescriptions and interpupillary distances (IPD) of 200 consecutive custom-made spectacles dispensed at the optical workshop at Fo Naroman TimorLeste were audited to assess the need for an Clinical and Experimental Optometry 98.2 March 2015
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optical dispensary in a developing country. There were 107 females and 93 males in the de-identified data. Each patient attending the Fo Naroman Timor-Leste clinic had visual acuity assessed and was subjectively refracted by trained eye-care technicians. These assessments are documented in clinical records. If custom-made spectacles were dispensed, the details of the frames, lenses and IPD were recorded chronologically according to date. Custom-made spectacles were dispensed by one of the trained optical technicians in Fo Naroman Timor-Leste. If ready-made spectacles were dispensed, these were separately recorded. For the year 2013, a total of 2,090 ready-made spectacles as well as 703 custom-made single-focus and 165 custom-made bifocals were dispensed at Fo Naroman Timor-Leste. The 2,075 donated spectacles that passed Lions Save Sight Foundation’s first cull were cleaned and prepared for lensmeter measurement. All spectacles were measured twice with the same lensmeter (Auto Lensmeter LM-600PD, Nidek, Gamagori, Japan) by two teams of three medical students. The two readings were recorded in a database with each pair of spectacles assigned an identification number and stored in a box of 200 spectacles with the range of identification numbers labelled on the box. We estimated how long it would take to try on every pair of spectacles to find a suitable and tolerable pair. One of the authors (LB) was given a random box of 200 spectacles and tried on each pair. This was performed with all spectacles and the time taken was recorded. The most tolerable pair of spectacles out of the cohort had to be worn for 24 hours to assess tolerance. We also assessed how long it would take to find 20 specific pairs of spectacles, once the patient’s refraction was matched against the database. The time from when the identification number was matched until the pair of spectacles was tried on was recorded. Moreover, we assessed how long it would take one subject to find the first pair of acceptable spectacles and whether the spectacles would be tolerated for 24 hours. This was performed to simulate a situation where the boxes were given to a developing country and there was no trained eye-care technician to dispense them. RESULTS The 2,075 wearable donated spectacles were reassessed and spectacles with prisms,
slightly scratched lenses, broken sides and lenses that were difficult to check using the lensmeter were excluded, reducing the number to 2,014 spectacles for analysis. Furthermore, if 0.25 DS or more difference was found between the two measurements for the right spherical lens (1,960), the spectacles were excluded. This criterion was applied to ensure the two groups accurately performed the lensmeter readings on the donated spectacles before the comparison was made with the dispensed prescriptions. If more than 0.25 DS difference was found between the two measurements, this implied a measurement discrepancy during lensometry. This exclusion criterion was subsequently applied to the sphere of the left lens (1,909), the right (1,891) and left (1,860) lens cylinders. Finally, six multifocal and progressive spectacles were excluded (only one lens had a near addition measurement, representing a measurement discrepancy) to arrive at the final inclusion of 1,854 spectacles (Figure 1). The average measurement for the two readings was taken for each pair of spectacles. The power of each pair of recycled spectacles was compared to the subject’s prescription in the Fo Naroman Timor-Leste optical dispensary. The total number of usable recycled spectacles that could be offered for each prescription was determined. This study did not consider fit or aesthetics, including the gender appropriateness of each spectacle frame. The 1,854 spectacles were compared against the 200 refractions from the optical dispensary in Fo Naroman Timor-Leste: 664 multifocal and progressive spectacles (163 minus to plano lens, 501 plus lenses) and 1,190 single focus spectacles (339 minus to plano lenses, 851 plus lenses). Of the 1,854 spectacles, there were 539 with a cylinder of 1.00 D or more (29 per cent) and 594 with 0.50 D or more of anisometropia (32 per cent). Each right spherical refractive TimorLeste prescription was matched to the recycled spectacles, then right cylindrical, left spherical and left cylindrical errors then finally the IPD. Custom-made spectacles are available in Timor-Leste, so it was considered unacceptable if there was not a match in refraction within 0.125 D for both spherical and cylindrical errors (corresponding to American National Standards for Ophthalmics—Prescription Spectacle Lenses20 and Australian/New Zealand Standard—Ophthalmic Optics—Mounted © 2014 The Authors
Clinical and Experimental Optometry © 2014 Optometry Australia
Recycled spectacles Wan, Yazar, Booth, Hiew, Hong, Tu, Ward, Gengatharen, Barbosa and Mackey
All spectacles arriving at LSSF
Remaining donated spectacles, n=2,075
Physically usable n=2,014 (97%)
Optically accurate n=1,854 (89%)
1,190 unifocal spectacles
Spectacles discarded by LSSF volunteers on initial inspection (approximately 50%)
Physically unusable n=61 (3%)
Optically inaccurate n=160 (8%)
664 multifocal and progressive spectacles
tacles that the subject could try (five myopic and 24 hypermetropic) (Table 2). There was a greater number of spectacles available to try, if the larger IPD range of ±3.0 mm was considered tolerable (Table 2). There were between one and 20 extra pairs of recycled spectacles that could have been tried. Once a refractive prescription was matched to a recycled spectacle identification number in our collection, it took an average of seven minutes and nine seconds (range 1.5 to 13.5 minutes) for a subject to search, find them and try one pair in a box of 200 spectacles (143 minutes to find 20 pairs of spectacles). It took 310 minutes for one subject to try on every pair of the 1,854 spectacles to find those that were suitable; however, the subject was unable to tolerate the spectacles for more than an hour. It took another subject 45 minutes to find the first pair of spectacles that were acceptable; however, she was unable to tolerate wearing them for more than five minutes due to asthenopia. DISCUSSION
339 minus to plano spectacles
163 minus to plano spectacles
851 plus spectacles
501 plus spectacles
Figure 1. Flow chart for determining the use of donated spectacles. Spectacles were collected by The Lions Save Sight Foundation and underwent a first cull of approximately 50 per cent. All of the remaining donated spectacles underwent further inspection and physically unusable spectacles (scratched lenses, bent or broken spectacle sides, lenses that were difficult to measure with a lensometer) were discarded. Then optically inaccurate spectacles (greater than ±0.25 DS between the two measurements for right lens sphere, left lens sphere, right lens cylinder and left lens cylinder) were removed. Multifocal and progressive spectacles without unilateral addition were included.
Spectacle Lenses21). An axis range for the cylinder of within five degrees was considered tolerable. An IPD up to ± 3.0 mm was accepted so that the subject could try them on. A further limitation criterion of IPD ±1.0 mm was also analysed. The process of matching also assumes that each person will have the full quota of spectacles to choose from, so each subject does not choose and take a pair leaving a smaller number for
the next subject. The prismatic effects of spectacle centre to centre were ignored for this analysis. The range of the recycled spectacles (single, multifocal and progressive) and the subjects’ refractions are shown in Table 1. Out of the 200 refractions from the optical workshop at Fo Naroman Timor-Leste, 29 (14.5 per cent) were able to be matched with at least one pair of the 1,854 donated spec-
© 2014 The Authors Clinical and Experimental Optometry © 2014 Optometry Australia
There is a continuing global challenge to prevent and treat causes of visual impairment. The ultimate objective is to foster selfsufficient and sustainable local programs that provide relevant eye health-care. Many longstanding recycling spectacle programs exist worldwide. Each has its own system for recycling the donated spectacles, including collection, logistics, assessment, sorting, cleaning, dispensing, storing and when appropriate, destroying unwanted spectacles. It has been questioned whether this practice should continue and if so, in what capacity can it add value to eye health-care in the developing world. Some people support discontinuing the use of recycled spectacles in developing countries.15,16,22–25 To the authors’ knowledge, this is the first paper that compares a collection of almost 2,000 recycled spectacles for the refractive needs of a developing country. The availability of good-quality low-cost ready-made spectacles has been shown to be acceptable in multiple studies, including those performed in developed countries.26 One double-masked randomised clinical trial of junior high school students in urban Guangzhou, China, supports the use of ready-made spectacles for a refractive services program in which custom-made spectacles are not readily accessible.27 This study compared the acceptability of custom-made Clinical and Experimental Optometry 98.2 March 2015
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Recycled spectacles Wan, Yazar, Booth, Hiew, Hong, Tu, Ward, Gengatharen, Barbosa and Mackey
Range
Donated single vision spectacles
Donated multifocal and progressive spectacles
Subjects’ refractions
-10.75 to +8.00
-8.875 to +7.75
-8.00 to +15.00
0 to -6.50
0 to -6.50
-10.875 to +8.00
-9.125 to +8.00
Right sphere (D) Right cylinder (D) Left sphere (D) Left cylinder (D)
0 to -6.875
Near addition (D)
0 to -6.875
NA
Interpupillary distance (mm)
39.50 to 74.50
0 to -4.00 -8.00 to +14.00 0 to -4.00
+0.5 to +4.25
+1.00 to +3.00
42.75 to 81.75
51.00 to 70.00
Table 1. Ranges for donated spectacles strengths and prescriptions
Number of subjects
Right sphere (D)
Left sphere (D)
Addition (D)
IPD (mm)
Number of spectacles with IPD +/-1 mm
Number of spectacles with IPD +/-3 mm
1
-1.50
-1.50
—
65
1
1
1
-0.75
-0.75
—
63
1
1
1
-0.50
-0.50
—
62
2
3
1
-0.50
-0.50
—
60
1
3
1
-0.25
-0.25
—
64
1
1
2
+0.75
+0.75
—
64
1
4
1
+0.75
+0.75
+1.25
64
1
1
1
+1.00
+1.00
—
64
8
15
1
+1.00
+1.00
—
60
6
13
2
+1.25
+1.25
—
65
2
7
1
+1.50
+1.50
—
64
10
21
2
+1.50
+1.50
—
65
6
16
1
+1.50
+1.50
—
67
2
9
1
+1.75
+1.75
—
65
2
3
2
+1.75
+1.75
—
60
3
4
1
+1.75
+1.75
—
64
2
2
1
+1.75
+1.25
—
64
1
2
1
+2.00
+2.00
—
63
13
27
4
+2.00
+2.00
—
60
9
29
1
+2.75
+2.75
—
60
2
3
1
+4.00
+4.00
—
64
1
2
1
Plano
Plano
—
Any
4
4
Total 29 IPD: interpupillary distance
Table 2. Number of recycled spectacles matched for each prescription
versus ready-made spectacles for correcting refractive error. Although visual acuity was better with custom-made spectacles, the acceptability between the two groups was no different at one month. Another similar double-masked randomised clinical trial was Clinical and Experimental Optometry 98.2 March 2015
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conducted on an urban adult population in India.28 Similar satisfaction at one month was achieved with ready-made compared with custom-made spectacles, despite the readymade group not having their refractive error fully corrected. This supports programs dis-
pensing ready-made spectacles in areas where access to custom-made spectacles is difficult; however, some patients with high levels of astigmatism would benefit from custom-made spectacles and they should be offered to individuals if possible. © 2014 The Authors
Clinical and Experimental Optometry © 2014 Optometry Australia
Recycled spectacles Wan, Yazar, Booth, Hiew, Hong, Tu, Ward, Gengatharen, Barbosa and Mackey
Wilson and colleagues15 analysed the costs and benefits of recycled spectacles compared to ready-made spectacles, where only seven per cent of the 275 donated spectacles were considered usable. All donated spectacles were given an initial inspection and eliminated, if they were progressive lenses, had noticeable scratches or flakes, had lenses with noticeable cylindrical power or had damaged frames. The spectacles were also excluded if they met any of the following optical criteria: more than 0.75 D cylindrical power, more than 0.5 D anisometropia or more than 0.5 D vertical prism. In our study, we did not exclude spectacles according to these optical criteria nor did we exclude progressive lenses. In a response to the study by Wilson and colleagues,15 a program argued they used a ‘best match’ system with a computerised database of the inventory and matched the total optical blur calculated using power vectors.29 In our study, we did not consider matching total optical blur or spherical equivalence as acceptable for patients because there is an optical workshop that is able to dispense custom-made spectacles and thus our study had stricter exclusion criteria. Ramke, de Toit and Brian16 compared a donated box of 102 spectacles with the refractive errors of subjects from Tuvalu, a small South Pacific nation of 11,600 people. The donated spectacles were excluded if they had more than 1.00 DC, anisometropia of more than 0.50 D, scratched lenses or broken frames. Only 13 per cent of donated spectacles were considered likely to be suitable for dispensing based on satisfactory optics, physical intactness and cosmetic appropriateness. The paper calculated at least 5,538 spectacles would be required to match a pair of spectacles for each of the 266 subjects, if they were prepared to spend the time to search to find one. The intentions behind recycling spectacle programs are altruistic and aimed at helping lower-resourced countries; however, the true cost of recycling these donated spectacles is more than importing and dispensing ready-made spectacles in a developing country.15 If the developing country also has the capacity to make custom-made spectacles, the use of recycled spectacles is further limited. Programs that are designed to fund high-quality, sustainable eye-care services should be encouraged rather than dispensing recycled spectacles. An alternative to recycling spectacles for dispensing is a program such as Ohio State
Student Volunteer Optometric Services to Humanity where the recycled spectacles are sold for scrap.30 Students studying optometry select high-quality usable spectacles and the unusable spectacles are sent to a company in California that recycles the materials and pays the students approximately US$1.50 per pound for the scrap. They use this income to fund travel to countries to provide eye-care services; however, it is argued that value should be placed on the volunteers’ time and skills that could be better used elsewhere. It would be more economical to send all of the spectacles for scrap and use the income to provide eye health services as this would remove the need to use valuable skilled time sorting the donated spectacles.30 Scrap metal companies in Western Australia were approached for a quote to recycle our spectacles. Most companies would not accept them. One company that was prepared to recycle them quoted AUS$80.00 per tonne (AUS$0.08 per kilogram or AUS$0.04 per pound). Lions International claims that it costs less than US$0.08 to recycle one pair of spectacles; however, this does not include the cost of the volunteers’ donated time nor the cost of storage facilities.31 Also, it is the responsibility of the dispensing program in the developing country to pay for shipment costs and custom clearance when they request the spectacles.8 Vision Aid Overseas does not send recycled spectacles overseas because the organisation believes it is not a cost-effective way to develop long-term eye-care programs.32 The donated spectacles are divided into three categories: gold-coloured frames for metal recycling, vintage frames for sale to eye wear merchants interested in restoring them for retail and the remainder for recycling in the most environmentally friendly way to prevent landfill. All of the custom-made refractive prescriptions that were matched to recycled spectacles could have been purchased as ready-made spectacles from Fo Naroman Timor-Leste apart from the bifocals and one pair with a difference of 0.5 DS between the lenses. However, these patients decided to have custom-made spectacles, so one could assume they were not happy with the readymade spectacles. This may reflect the patient’s desire to have a better-quality frame or one that fits better physically and aesthetically. This suggests that patients in developing countries consider these qualities to be important. Philosophically, one
© 2014 The Authors Clinical and Experimental Optometry © 2014 Optometry Australia
could argue old, worn, out-fashioned spectacles that would not be acceptable in developed countries should not be given to patients in developing countries. For Fo Naroman Timor-Leste, the cost of the 2,090 ready-made spectacles for the year 2013 was US$3,534.00, which equates to US$1.69 per pair of ready-made spectacles. The cost of the 703 single-focus custommade spectacles was US$7,030 or US$10.00 per pair of custom-made spectacles and the cost of the 165 bifocal custom-made spectacles dispensed by Fo Naroman Timor-Leste was US$2,145.00. This means that it would have cost Fo Naroman Timor-Leste US$49.04 to provide ready-made spectacles for the 29 refractive prescriptions that were matched in our study. In a cost comparison between Fo Naroman Timor-Leste with the Lions Save Sight Foundation, the room in which The Lions Save Sight Foundation performs the sorting and storage of the donated spectacles is provided by the Lions Eye Institute and would cost approximately AUS$2,500.00 per annum to rent. Calculating the true cost of the Lions Save Sight Foundation program is beyond the scope of this study and could be analysed in a future project. In developed countries, post-operative cataract patients could consider borrowing these spectacles whilst awaiting their new spectacles. Given the availability of readymade readers in developed countries and the presumptive uncleanliness of the recycled spectacles, it is unlikely that a patient would prefer them. With the strong desire of Lions Clubs to continue recycling spectacles, we could consider refining the collection of spectacles to only include plus readers from +1.00 to +3.00 DS that are of good quality for distribution; however, the usefulness of such a refined program would need to be investigated as to whether it is a cost-effective exercise. A recent paper systematically reviewed the literature on clinical outcomes following the dispensing of ready-made spectacles and recycled spectacles.33 This paper included only articles that reported on three outcomes: visual function, patient satisfaction and continued use. The author was unable to find an article following the dispensing of recycled spectacles that described all three clinical outcomes. It is beyond the scope of this paper to assess the visual function of subjects matched with recycled spectacles. Further research is required to analyse how well recycled spectacles improve visual function and whether patients continue to use Clinical and Experimental Optometry 98.2 March 2015
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Recycled spectacles Wan, Yazar, Booth, Hiew, Hong, Tu, Ward, Gengatharen, Barbosa and Mackey
their spectacles. Logistically, this would be a difficult task to undertake and would consume resources that are best used toward providing sustainable services for the correction of refractive errors. If the Lions Save Sight Foundation continues to use recycled spectacles, then immediate and long-term clinical outcomes should be measured to justify the program.
CONCLUSION The matching of recycled spectacles to the prescriptions of a sample of the Timor-Leste population suggests that sending donated spectacles to a developing country may not be an effective way of correcting refractive errors. Instead of recycling spectacles, aid organisations should focus their resources on increasing the capacity of the local eyecare workforce to establish self-sustaining screening and spectacle-dispensing programs to correct refractive errors worldwide. ACKNOWLEDGEMENTS
Authors thank the RANZCO Eye Foundation/Hobart Eye Surgeons East Timor Scholarship for funding the collection of data in Dili, Timor-Leste. We are grateful to Adilson (Joni) Juvinal Da Silva, Fo Naroman Timor-Leste, for information regarding the spectacles and lenses at the optical dispensary, Julianne Sanders for helping Fo Naroman Timor-Leste audit their spectacle dispensing records for the year 2013, Lions Save Sight Foundation volunteers for collecting the spectacles and allowing us to analyse more than 2,000 pairs for the study and Kate Hanman for teaching and supervising the medical students. REFERENCES 1. Chandra SR. Global blindness: VISION 2020: the right to sight. Arch Ophthalmol 2008; 126: 1457. 2. Pizzarello L, Abiose A, Ffytche T, Duerksen R, Thulasiraj R, Taylor H, Faal H et al. VISION 2020: The Right to Sight: a global initiative to eliminate avoidable blindness. Arch Ophthalmol 2004; 122: 615–620. 3. World Health Organization. Prevention of blindness and visual impairment. Available at: http://www.who.int/blindness/actionplan/en/ index.html. [Accessed 10 January, 2014]. 4. Pascolini D, Mariotti SP. Global estimates of visual impairment: 2010. Br J Ophthalmol 2012; 96: 614– 618. 5. World Health Organization. Action plan for the prevention of avoidable blindness and visual impairment for 2014–2019. Available at: http:// www.who.int/blindness/actionplan/en/. [Accessed 10 January, 2014].
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