Scoping question: For older people with visual impairment, does case finding, provision of care or referral produce any benefit and/or harm compared with controls? The full ICOPE guidelines and complete set of evidence profiles are available at: who.int/publications/i/item/9789241550109# Background
Worldwide, approximately 185 million people aged 50 years and over are visually impaired (1). More than half of all people with visual impairment live in low-and middle-income countries, with India having the highest number of blind people: 8.3 million (2,3). In older people, visual impairment influences their ability to live an independent life (4), and increases the need for social care (5). Moreover, there is a strong association between vision impairment and undesirable outcomes, including depressive symptoms (6), lower life satisfaction (7), poor quality of life (8,9) and reduced social interaction and function (10)(11)(12). Poor vision in older people increases the risk of falls (13)(14)(15)(16)(17)(18)(19)(20)(21)(22) and mortality (23)(24)(25)(26)(27)(28)(29).
Among the causes of visual impairment, cataract and refractive errors are most common in older people. Cost-effective interventions, such as cataract surgery and provision of corrective glasses, have shown consistent benefit in reducing disability, limitation in activities, anxiety, depression, risk of falls and fractures (30)(31)(32)(33)(34). Despite the availability of cost-effective treatments, eye care utilization by older adults has been found to be infrequent: only 10%, 24%, 22% and 37% of older people living in low-, lower-middle-, upper-middle-and high-income countries, respectively, reported having had an eye exam during the preceding year, while approximately 61% of older people living in low-income countries had never had an eye exam. Research evidence suggests that community case-finding and immediate provision of eye care or referral for cataract surgery might reduce the substantial treatment gap for vision impairment in older people. However, the majority of intervention trials were conducted in highincome countries, and the feasibility of implementing this approach in a resource-poor setting is unclear. Further, mass communitybased screening of asymptomatic older people has been reported to produce no benefits in reducing visual impairment (35,36). The lack of effectiveness found by studies may be due to the absence of immediate provision of a subsequent intervention to treat the detected problem or to the fact that the majority of studies have been carried out in high-income countries, where vision testing is available and accessible, and the unmet need is relatively small. Therefore, this review has been conducted to synthesize the evidence for community case-finding and provision of care or referral for visual impairment in older people.

# Search strategy
The search strategy is provided in Annex 1 (page 20).

# List of systematic reviews (and individual studies) identified by the search process
Included in GRADE 1

# Narrative description of the studies that went into the analysis

# Screening and referral
The Cochrane systematic review by Smeeth and Iliffe was carried out to assess the effectiveness of community screening for visual impairment in older people for improving vision (35). The authors searched the Cochrane Eyes and Vision Group Trials Register, The Cochrane Library, the National Research Register, MEDLINE, Embase, PubMed, SciSearch and additional sources for published data. There were no language or date restrictions on the search for trials. Also, they contacted investigators to identify additional unpublished studies or further information not included in the published reports of the trials. Both authors worked independently to extract data and assess trial quality. The authors included randomized trials (RCTs) comparing visual or multicomponent assessment for visual impairment with usual care in older adults who were not identified as belonging to a particular risk group.
Moore et al. conducted a cluster RCT at a community-based practice in the United States America to evaluate the effectiveness of a 10-minute office-staff administered screening to assess several conditions including visual impairment (33). They enrolled 261 patients aged 70 years and older and compared screening with usual care. The intervention consisted of a question to assess difficulty performing everyday activities followed by use of a Snellen eye chart if impairment was indicated by the answer to the question. Six months after enrolment, authors contacted the participants through a mailed questionnaire that addressed, among others, changes in self-reported vision. No differences were noted between the intervention (screening) and control (usual care) groups regarding changes in self-reported problems with vision.
The study by Coleman et al. was carried out in the United States to evaluate the benefits of eyeglasses and magnifiers in elderly patients with uncorrected refractive errors (32). In this RCT, the authors assessed the effects of immediate versus delayed corrective lenses. They enrolled 131 community-dwelling people aged 65 years and older whose distant visual acuity, near visual acuity or both could be improved with eyeglasses, a magnifier or both. The primary outcome of the study was vision-specific functioning, measured using the 25-item National Eye Institute Visual Functioning Questionnaire (NEI-VFQ-25). Results showed improvements in vision-related quality of life in the participants who received a prescription and voucher for eyeglasses immediately. Moreover, they had significant improvement in perception of their general vision, distance visual acuity, near visual acuity and mental health.
IMPORTANT CI: confidence interval; MD: mean difference; SMD: standardized mean difference a. Risk of bias: Downgraded once as randomization method was inadequate in one of the included trials and allocation concealment method was unclear in the other trial. b. Inconsistency: Downgraded once as moderate heterogeneity was observed in the meta-analysis (Tau2 = 0.16; Chi2 = 5.82, df = 1 ; I2 = 83%). Reason for heterogeneity could be the characteristics of the participants: one study recruited older people living in the community and the other recruited from nursing home settings (41,42). c. Indirectness: Downgraded once as all included studies were from high-income countries and generalizing the evidence to other settings is questionable. d. Imprecision: Downgraded once as sample size was small (smaller than 200).

# ICOPE guidelines -World Health Organization
Additional evidence GRADE

# Evidence-to-recommendation table Problem Explanation
Is the problem a priority?
Yes No Uncertain 
Visual impairment is associated with a risk of significant decline in functional ability in older people, and with several adverse outcomes, including reduced quality of life and functional ability, and increased falls and mortality. Many conditions that contribute to vision impairment can be treated effectively, and loss of vision can be prevented in many older people. Currently, there is huge gap in timely access to comprehensive eye care, which can be improved through community case-finding, and appropriate provision of referral and care at primary or community care settings.

# Benefits and harms Explanation
Do the desirable effects outweigh the undesirable effects?

# Yes No Uncertain
There is no direct evidence on the effectiveness of community case-finding through screening and referral for visual impairment in older people. Six population-based randomized controlled trials (RCTs) were evaluated and found no difference in vision and other clinical or functional outcomes when comparing case-identification through vision screening with visual acuity testing or questions with usual care, no vision screening or delayed screening. Five of the RCTs recruited people aged 70 years and over and were conducted in primary or community care settings (8)(9)(10)(11)(12). Vision screening was performed as part of a multicomponent risk assessment of health functioning. Vision screening in four of those trials was conducted in the older person's own home (8)(9)(10)(11). Data on self-reported improvements in vision were pooled together in the meta-analysis. The pooled risk ratio of self-reported visual problems for older people in the intervention versus control groups was 1.03 (3494 participants, 95% confidence interval : 0.92 to 1.15). There was no significant heterogeneity observed in the pooled estimated ( 2 = 0.88, df = 4, P = 0.93, I 2 = 0%). The reasons for the lack of benefit across the six trials might have included: the high loss to follow-up in all trials; contamination of the intervention; a similar frequency of vision disorder detection and treatment in the screening and control groups in one trial; the use of a screening question to identify people for further testing; and low uptake of recommended interventions.
In the Cochrane review, three included randomized trials (n = 3346) of vision screening performed as part of a multicomponent screening intervention in older people (mean age, 76-81 years) were analysed (35). The trials found no difference between vision screening compared with no vision screening, usual care or delayed screening on vision and other clinical outcomes at follow-up assessment, six months to five years later.  impairment (using the Glasgow Acuity Card followed by pinhole testing for people with visual acuity worse than 20/60) with targeted screening based on a brief screening questionnaire. Only 34% of vision assessments were carried out in peoples' own homes; the rest were undertaken at the general practice surgery. At follow-up, 3-5 years after screening, the risk ratio for visual acuity less than 6/18 in either eye for universal versus targeted screening was 1.07 (95% CI: 0.84 to 1.36, P = 0.58). The mean composite score of the 25-item National Eye Institute Visual Functioning Questionnaire (NEI-VFQ-25) was 85.6 in the targeted screening group and 86.0 in the universal group; the difference of 0.4 was not significant (95% CI: -1.7 to 2.5, P = 0.69). In this trial, only half of the patients who were advised to see an eye care provider after vision screening actually received new glasses, which could have attenuated the potential benefits.
There is limited low-quality evidence on the effectiveness of community case-finding and immediate provision of care services for refractive error and cataracts for improving visual acuity in older people. Two RCTs reported that immediate correction of refractive error with eyeglasses for older people was associated with moderate improvements in short-term (2-to 3-month follow-up), vision-related quality of life or function compared with delayed treatment (32,34). In one trial, older people in the intervention arm received prescriptions and vouchers for free eyeglasses, while in the other trial, older people were immediately provided with corrective glasses. Participants in one trial were community-dwelling older people aged 65 years and over, whereas the other trial recruited nursing home residents aged 55 years and over. In both trials, general vision subscale scores of the NEI-VFQ were improved by a mean of about 10 (out of 100) points in the immediate-treatment groups. The pooled mean difference between intervention and control groups was 11.87 (95% CI: 6.87 to 16.87).
We found no RCTs that evaluated cataract surgery versus no surgery. However, we identified three trials that examined the effectiveness of expedited cataract surgery compared with routine cataract surgery. Results showed that the expedited surgery was associated with gains in visual function and reduced visual disability.
The benefits of this approach outweighs harms: the adverse consequences associated with community case-finding and immediate provision of care were small or none.

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ICOPE guidelines -World Health Organization

# Values and preferences/acceptability Explanation
Is there important uncertainty or variability about how much people value the options?

# Major variability
Visual impairment is a common and significant public health problem in older people. Many conditions that contribute to vision impairment can be treated efficiently, and loss of vision can often be prevented in older people. Currently, there is a huge gap in timely access to comprehensive eye care, which can be improved through community case-finding and timely provision of referral and care at primary health care or community-based settings.
The guideline development group believed that the recommendation would be valued by older people and acceptable to key stakeholders.
No Uncertain  Implementation of community case-finding and immediate provision of care might lead to substantial costs to health care systems. These costs would include "opportunity costs" for time spent in administering the visual acuity test and providing eyeglasses at primary health care settings or facilitating referral and follow-up. However, in most countries, prevention of blindness comes under the umbrella of the national programme for chronic and noncommunicable diseases.
The recommendation can be incorporated into existing national programme budgets with minimal additional cost.
The guideline development group firmly believed that the recommendation was feasible to implement in high-, middle-and low-resource health care settings.
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# ICOPE guidelines -World Health Organization Equity Explanation
Would the option improve equity in health?
The guideline development group firmly believed that the recommendation would increase equity in health.

# ICOPE guidelines -World Health Organization

# Guideline development group recommendation and remarks Recommendation
Older people should receive routine screening for visual impairment in the primary care setting, and timely provision of comprehensive eye care.

# Strength of the recommendation: Strong
Quality of evidence: Low
- All of the primary studies available were carried out in high-income countries.
- The recommendation is applicable to people over 60 years of age (who may or may not visit primary care facilities to present with complaints of low visual acuity). - Risk factors, such as diabetes, smoking, alcohol use, corticosteroid use and exposure to ultraviolet light should be considered and addressed. - Comprehensive vision rehabilitation should be considered when services are available.
- Over half of older adults with impaired visual acuity achieve vision better than 20/40 with a refractive correction which can be obtained through non-invasive methods, in most cases with corrective lenses. - The accuracy of responses to subjective questions during screening is unclear.
Therefore, an objective visual acuity test should be the preferred choice in community case-finding.