## 4 Discussion  
Screening for vision impairment is a highly effective way to prevent long-term disability, as recently reiterated by the WHO [2]. A few studies have addressed eye health among migrant populations, especially in Italy, and the PROTECT project is the first Italian project tailored to the head and neck health of a wide sample of fragile populations that live in reception centers and have several different demographic origins [14]. Indeed, very few screening tools have been validated for diagnosis accuracy among migrants overall, and several heterogeneous data have been reported on the ocular health of migrants in the word, highlighting the lack of proper medical care for this fragile population. In fact, while a reduction in visual impairment in high-income countries has been described, migrants and vulnerable populations that live in these European countries experience obstacles to health care access. As shown in our study, about 50% of migrants carried out their first ophthalmological visit during this screening project and about 9% of subjects could not report if they had a previous eye exam. These data, in line with the previous evidence, suggest a potential increased risk of amblyopia [21]. This defect of vision becomes irreversible in adulthood, affecting the quality of life, and interfering with the ability to socialize and work. Recent studies showed that screening for amblyopia is cost-effective, but highly related to long-term impacts of unilateral loss that are common in migrant populations. In fact, analyzing the answers to the questionnaire, the presence of vision impairment or ocular pain (the main reasons for a request for an eye examination in the Italian population) was reported by 17% and 7% of subjects, respectively. The PROTECT project result showed that an easy and fast eye screening with portable technologies is able to highlight the main causes of visual problems and to plan specific management of the patient with different levels of urgency [22]. In addition, the strategy of our screening, based on a non-invasive assessment and in many cases carried out directly at the center of reception, has allowed the obtaining of good compliance by these vulnerable subjects often reticent to visits and treatment [23]. Figure 4: Principal retinal findings of the screened migrants within the PROTECT project. Of note, in certain cases, multiple findings coexisted in the same patient. According to evidence, the eye screening results indicate that uncorrected refractive error was the more frequent finding associated with visual impairment, and patients were referred within 30 days (yellow card) at the optometrist clinic to evaluate the prescription of eyeglasses and associated ocular motility alterations. A special agreement with a large private company for the provision of spectacles for refugees is fundamentally advisable to complete the management of vision impairment of this disadvantaged population. Despite the sample's young average age, cataracts were the second most frequent cause of vision loss, likely related to traumatic or dysmetabolic diseases, and a second appointment in the specialist eye hospital was booked to follow up and manage the patients [24]. Interestingly, by using simple and rapid eye screening programs in the reception centers, the diagnosis of acute pathologies such as ocular hypertension and conjunctivitis, was performed, and urgent treatment or further investigations in specialist vision care were started (red card). The few ocular fundus changes requiring further investigation were managed by the retinal specialist (yellow card) to diagnose dysmetabolic pathologies early, such as diabetes or hypertension, or to follow up on choroidal nevus.