Objective To explore the association between blindness and deprivation in a nationally representative sample of adults in Pakistan. Design Cross sectional population based survey. Setting 221 rural and urban clusters selected randomly throughout Pakistan. Participants Nationally representative sample of 16 507 adults aged 30 or above (95.3% response rate). Main outcome measures Associations between visual impairment and poverty assessed by a cluster level deprivation index and a household level poverty indicator; prevalence and causes of blindness; measures of the rate of uptake and quality of eye care services. Results 561 blind participants (<3/60 in the better eye) were identified during the survey. Clusters in urban Sindh province were the most affluent, whereas rural areas in Balochistan were the poorest. The prevalence of blindness in adults living in affluent clusters was 2.2%, compared with 3.7% in medium clusters and 3.9% in poor clusters (P<0.001 for affluent v poor). The highest prevalence of blindness was found in rural Balochistan (5.2%). The prevalence of total blindness (bilateral no light perception) was more than three times higher in poor clusters than in affluent clusters (0.24% v 0.07%, P<0.001). The prevalences of blindness caused by cataract, glaucoma, and corneal opacity were lower in affluent clusters and households. Reflecting access to eye care services, cataract surgical coverage was higher in affluent clusters (80.6%) than in medium (76.8%) and poor areas (75.1%). Intraocular lens implantation rates were significantly lower in participants from poorer households. 10.2% of adults living in affluent clusters presented to the examination station wearing spectacles, compared with 6.7% in medium clusters and 4.4% in poor cluster areas. Spectacle coverage in affluent areas was more than double that in poor clusters (23.5% v 11.1%, P<0.001). Conclusion Blindness is associated with poverty in Pakistan; lower access to eye care services was one contributory factor. To reduce blindness, strategies targeting poor people will be needed. These interventions may have an impact on deprivation in Pakistan. INTRODUCTIONPoverty has multiple dimensions at the individual, household, and community level, in relation to material aspects (such as employment, income, costs, debt, land, consumption, and housing), services (such as education, health care, and poverty alleviation or development assistance), and social or psychological elements (such as social contact, marriage, self esteem and stigma, violence, and voice and authority). Poverty can, therefore, be thought of as the deprivation of opportunities that enhance human capabilities, so denying people a life of dignity, respect, and value.Disability is often reported as a characteristic of poor people 2 ; studies suggest that up to 15-20% of poor people in developing countries are affected.3 The detrimental impact of visual disability on life expectancy and quality of life is well documented, 4 5 and blindness (classified in terms of the person ...

Approximately 570 000 adults are estimated to be blind (<3/60) as a result of cataract in Pakistan, and 3,560000 eyes have a visual acuity of <6/60 because of cataract. Overall, the national surgical coverage is good but underserved populations have been identified.

The results provide a simple and clinically useful model to employ when counselling patients on macular hole surgery.

Aim: To determine preoperative demographic, clinical, and optical coherence tomography (OCT) factors which might predict the visual and anatomical outcome at 1 year in patients undergoing vitrectomy and inner limiting membrane peel for diabetic macular oedema (DMO). Methods: A prospective, interventional case series of 33 patients who completed 1 year follow up. Measurements were taken preoperatively and at 1 year. Outcome measures were logMAR visual acuity (VA) and OCT macular thickness. A priori explanatory variables included baseline presence of clinical and/or OCT signs suggesting macular traction, grade of diabetic maculopathy, posterior vitreous detachment, fluorescein leakage and ischaemia on angiography, presence of subretinal fluid, and peroperative indocyanine green (ICG) use. T he majority of published reports 1-35 regarding vitrectomy for diabetic macular oedema (DMO) are retrospective with varying inclusion criteria, methodology, and follow up. Most studies have suggested that the procedure is effective, particularly in those with clinically evident signs of a taut thickened posterior hyaloid (TTPH 1 ). In the first published randomised controlled trial (RCT) on this subject we found that vitrectomy with internal limiting membrane (ILM) peeling did not improve the visual acuity (VA) of patients with a clinically attached but otherwise normal posterior hyaloid. 24 To investigate whether there are subgroups within which vitrectomy is an effective intervention we have prospectively studied a cohort of patients, all with 1 year follow up, who underwent vitrectomy for chronic DMO. PATIENTS AND METHODSEthics approval was obtained (EC 00/004). Patients included were over 21 years of age with diffuse or diffuse and focal DMO in an eye that had already received one or more grid laser treatments no less than 3 months previously. VA of Snellen 6/12 or worse and the ability to give informed consent was required. Exclusion criteria were acuity impairing ocular co-morbidity, active proliferative retinopathy, uncontrolled hypertension (blood pressure .140/95) or severe renal impairment. VA was measured in logMAR using a standardised methodology. 24The vitreous, macula, and vitreomacular interface were examined clinically (DAHL) for the features of a PVD, TTPH, and epiretinal membrane (ERM). PVD was defined as a Weiss ring or continuous folded layer of optically dense vitreous behind which no normal vitreous structure could be clinically defined. Preoperative colour imaging and fluorescein angiography (FFA) was performed using the standard 30 degree seven field Diabetic Retinopathy Study protocol. Images were graded by the Retinopathy Grading Centre, London. The presence of haemorrhages, microaneurysms, and exudates in field 2 photographs (macula) were each graded 0-5 against standardised photographs, 37 with the results averaged to produce a maculopathy score (0-5). FFAs were graded for ischaemia and leakage. Ischaemia was graded from 0-4: four quadrants were marked out within a 0.5 disc diameter (DD) marker centr...

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