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Figure 1.
Estimated Numbers of Persons With Visual Impairment in the United States by Race/Ethnicity (All Persons) and Year
Estimated Numbers of Persons With Visual Impairment in the United States by Race/Ethnicity (All Persons) and Year

AA indicates African American; NHW, non-Hispanic white.

Figure 2.
Estimated Number of Persons With Blindness in the United States by Race/Ethnicity (All Persons) and Year
Estimated Number of Persons With Blindness in the United States by Race/Ethnicity (All Persons) and Year

AA indicates African American; NHW, non-Hispanic white.

Figure 3.
Per Capita Prevalence of Visual Impairment in the United States in 2015
Per Capita Prevalence of Visual Impairment in the United States in 2015
Figure 4.
Per Capita Prevalence of Visual Impairment in the United States in 2050
Per Capita Prevalence of Visual Impairment in the United States in 2050
Table.  
Projected Number of Persons With Visual Impairment and Blindness in the United States, Stratified by Age Group, From 2015 to 2050 (in Millions)a
Projected Number of Persons With Visual Impairment and Blindness in the United States, Stratified by Age Group, From 2015 to 2050 (in Millions)a
Supplement.

eTable 1. Characteristics of Population-Based Studies Utilized for Calculating Estimated Numbers of Persons With Visual Impairment and Blindness in the United States in the Main Model and for Sensitivity Analysis

eTable 2. Pooled Prevalence of Visual Impairment and Blindness by Age and Race/Ethnicity (in Percentage) Estimated From US Population-Based Studies

eTable 3. Sensitivity Analysis: Percent Difference Between the Estimated Numbers of Individuals With Visual Impairment and Blindness in the United States in 2015 and 2050 Using Different Models Compared to the Main Model

eTable 4. Estimated Numbers of Persons With Visual Impairment and Blindness in the United States, Stratified By Race/Ethnicity And Sex, From 2015 to 2050 (in Millions)

eFigure 1. Estimated Numbers of Persons With Visual Impairment in the United States by Age Group (All Persons) and Year

eFigure 2. Estimated Numbers of Persons With Visual Impairment in the United States by Age Group (Men) and Year

eFigure 3. Estimated Numbers of Persons With Visual Impairment in the United States by Age Group (Women) and Year

eFigure 4. Estimated Numbers of Persons With Visual Impairment in the United States by Sex and Year

eFigure 5. Estimated Numbers of Persons With Visual Impairment in the United States by Race/Ethnicity (Men) and Year

eFigure 6. Estimated Numbers of Persons With Visual Impairment in the United States by Race/Ethnicity (Women) and Year

eFigure 7. Estimated Numbers of Persons With Blindness in the United States by Age Group (All Persons) and Year

eFigure 8. Estimated Numbers of Persons With Blindness in the United States by Age Group (Men) and Year

eFigure 9. Estimated Numbers of Persons With Blindness in the United States by Age Group (Women) and Year

eFigure 10. Estimated Numbers of Persons With Blindness in the United States by Sex and Year

eFigure 11. Estimated number of persons with blindness in the United States by race/ethnicity (men) and year

eFigure 12. Estimated Number of Persons With Blindness in the United States by Race/Ethnicity (Women) and Year

eFigure 13. Per Capita Prevalence of Blindness in the United States in 2015

eFigure 14. Per Capita Prevalence of Blindness in the United States in 2050

eFigure 15. Per Capita Prevalence of Visual Impairment Due to Uncorrected Refractive Error in the United States in 2015

eFigure 16. Per Capita Prevalence of Visual Impairment Due to Uncorrected Refractive Error in the United States in 2050

eFigure 17. Per Capita Prevalence of Blindness Due to Uncorrected Refractive Error in the United States in 2015

eFigure 18. Per Capita Prevalence of Blindness Due to Uncorrected Refractive Error in the United States in 2050

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Original Investigation
Journal Club
July 2016

Visual Impairment and Blindness in Adults in the United States: Demographic and Geographic Variations From 2015 to 2050

Journal Club PowerPoint Slide Download
Author Affiliations
  • 1USC Roski Eye Institute, Department of Ophthalmology, Keck School of Medicine of the University of Southern California, Los Angeles
  • 2Department of Preventive Medicine, Keck School of Medicine of the University of Southern California, Los Angeles
  • 3Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago Eye and Ear Infirmary, Chicago
JAMA Ophthalmol. 2016;134(7):802-809. doi:10.1001/jamaophthalmol.2016.1284
Abstract

Importance  The number of individuals with visual impairment (VI) and blindness is increasing in the United States and around the globe as a result of shifting demographics and aging populations. Tracking the number and characteristics of individuals with VI and blindness is especially important given the negative effect of these conditions on physical and mental health.

Objectives  To determine the demographic and geographic variations in VI and blindness in adults in the US population in 2015 and to estimate the projected prevalence through 2050.

Design, Setting, and Participants  In this population-based, cross-sectional study, data were pooled from adults 40 years and older from 6 major population-based studies on VI and blindness in the United States. Prevalence of VI and blindness were reported by age, sex, race/ethnicity, and per capita prevalence by state using the US Census projections (January 1, 2015, through December 31, 2050).

Main Outcomes and Measures  Prevalence of VI and blindness.

Results  In 2015, a total of 1.02 million people were blind, and approximately 3.22 million people in the United States had VI (best-corrected visual acuity in the better-seeing eye), whereas up to 8.2 million people had VI due to uncorrected refractive error. By 2050, the numbers of these conditions are projected to double to approximately 2.01 million people with blindness, 6.95 million people with VI, and 16.4 million with VI due to uncorrected refractive error. The highest numbers of these conditions in 2015 were among non-Hispanic white individuals (2.28 million), women (1.84 million), and older adults (1.61 million), and these groups will remain the most affected through 2050. However, African American individuals experience the highest prevalence of visual impairment and blindness. By 2050, the highest prevalence of VI among minorities will shift from African American individuals (15.2% in 2015 to 16.3% in 2050) to Hispanic individuals (9.9% in 2015 to 20.3% in 2050). From 2015 to 2050, the states projected to have the highest per capita prevalence of VI are Florida (2.56% in 2015 to 3.98% in 2050) and Hawaii (2.35% in 2015 and 3.93% in 2050), and the states projected to have the highest projected per capita prevalence of blindness are Mississippi (0.83% in 2015 to 1.25% in 2050) and Louisiana (0.79% in 2015 to 1.20% in 2050).

Conclusions and Relevance  These data suggest that vision screening for refractive error and early eye disease may reduce or prevent a high proportion of individuals from experiencing unnecessary vision loss and blindness, decrease associated costs to the US economy for medical services and lost productivity, and contribute to better quality of life. Targeted education and screening programs for non-Hispanic white women and minorities should become increasingly important because of the projected growth of these populations and their relative contribution to the overall numbers of these conditions.

Introduction

The number of individuals with visual impairment (VI) and blindness is increasing in the United States and around the globe as a result of shifting demographics and aging populations.1-4 Tracking the number and characteristics of individuals with VI and blindness is especially important given the negative effect of these conditions on physical and mental health.5,6 In particular, individuals who are visually impaired or blind have a higher risk of chronic health conditions,7 unintentional injuries,8 social withdrawal,9 depression,9,10 and mortality.11

Accordingly, an important aim of Health People 202012 is to improve visual health and well-being through interventions to reduce VI and blindness in the United States. Such interventions, including public health services and policy planning, rely on projections of the estimated magnitude of VI and blindness in the United States. These projections should be based on the most recently available US Census data and prevalence estimates, defined as the proportion of people with VI or blindness of the total number of people at risk. A 2004 analysis13 of the magnitude of legal blindness in the United States determined its prevalence as 0.78% in adults 40 years and older in 2000 and projected a 70% increase from 937 000 in 2000 to 1.6 million in 2020.

Quiz Ref IDIn the current report, we present an updated projection of the numbers and prevalence of uncorrected refractive error (URE) that could potentially be improved through refraction (eg, glasses, contact lenses, and refractive surgery). In addition, we describe the numbers and prevalence of VI and legal blindness in the United States from 2015 to 2050 using pooled prevalence data from population-based studies1,14-19 representing 5 major racial/ethnic groups in the United States. Furthermore, we identify subgroups of the population (age, sex, and race/ethnicity) expected to experience a higher prevalence of VI and blindness during the next 4 decades in the United States.

Box Section Ref ID

Key Points

  • Question What is the projected prevalence of visual impairment and blindness in the United States from 2015 to 2050?

  • Findings Despite the high prevalence of VI and blindness in minorities, the largest current and future burden in the United States is predicted to be among older non-Hispanic white women. The state with the highest projected per capita prevalence of VI is Florida, and the state with the highest projected per capita prevalence of blindness is Mississippi.

  • Meaning Our results suggest that screening vision programs should include a focus on populations with high numbers of older non-Hispanic white individuals, women, and minorities.

Methods

We calculated the prevalence and numbers of individuals with VI and blindness in the United States among 5 racial/ethnic groups: African American, Asian, Latino/Hispanic, non-Hispanic white, and other minorities (racial groups). The term other minorities is based on the US Census and refers to populations classified as American Indian, Alaskan Native, Native Hawaiian, and other Pacific Islander. All US population estimates and projections were obtained from data available at the US Census Bureau website (http://www.census.gov).

Study Selection and Data Extraction

The studies with data representing each racial/ethnic group in the United States were selected according to the following inclusion criteria: (1) population-based studies conducted in the United States to avoid inherent differences with other countries’ health care systems; (2) studies that included data after 1980 to minimize differences in screening methods, medical treatments, and ophthalmic surgery; (3) studies that used US definitions for VI and blindness; and (4) studies with available age-, sex-, and race/ethnicity-specific estimates of participants 40 years or older.

Six major population-based studies1,14-19 were included to provide race-specific data: Beaver Dam Eye Study (non-Hispanic white populations), Baltimore Eye Survey and Salisbury Eye Evaluation Study (white and African American populations), Proyecto VER and Los Angeles Latino Eye Study (LALES) (Latino/Hispanic populations), and Chinese American Eye Study (CHES) (Asian American populations). Summary descriptions of these studies are given in eTable 1 in the Supplement. Age-specific and age-adjusted summary pooled prevalence estimates of VI and blindness were calculated by combining age, race/ethnicity, and sex-specific numbers from the 6 studies (eTable 2 in the Supplement).

Statistical Analysis

Pooled prevalence estimates for VI and blindness by age, sex, and race/ethnicity were multiplied by corresponding stratum-specific population estimates to obtain the number of persons with VI and blindness in the United States from 2015 to 2050. This number was then divided by the total population size, and 95% CIs were then calculated as the prevalence ± 1.96 × SE. Prevalence per capita was defined as the number of people with VI or blindness of the number of people in each state based on the US Census. The criterion for VI (presenting) was presenting visual acuity (VA) less than 20/40 in the better-seeing eye (excluding blindness). The criterion for blindness (presenting) was presenting VA of 20/200 or less in the better-seeing eye. The criterion for VI (best corrected) was best-corrected VA (BCVA) of less than 20/40 in the better-seeing eye. The criterion for blindness (best corrected) was BCVA of 20/200 or less in the better-seeing eye. Estimates of VI owing to URE were calculated as the difference between the prevalence of presenting VI and best-corrected VI relative to the prevalence of presenting VI. Studies with data available for both presenting and BCVA calculations included the Baltimore Eye Survey, the Salisbury Eye Evaluation, LALES, and CHES. A regression of VI or blindness prevalence by age, sex, and race/ethnicity was used to impute stratum-specific prevalence for the strata in which prevalence was reported as zero or missing. Calculations were based on the 2014 US Census data.

Sensitivity Analysis

Sensitivity analyses were performed on prevalence estimates by using several models and different pooled prevalence (eTable 3 in the Supplement). For scenario 1, the pooled prevalence from the Eye Diseases Prevalence Research Group (EDPRG)1,13 and the combined data for European-derived non-Hispanic white individuals were used to represent non-Hispanic white individuals.1 For scenario 2, the pooled prevalence was calculated based on data from the Baltimore Eye Survey, the Beaver Dam Study, the Salisbury Eye Evaluation, the Proyecto VER, and LALES for Asian individuals.14-17,19-21 For scenario 3, the pooled prevalence from the EDPRG for minorities was used for Asian individuals.1 For scenario 4, the pooled prevalence from the EDPRG was used for other minorities. We then compared the estimates from each scenario to those obtained from the main model.

Results
Current and Projected Estimates of VI and Blindness in the United States in 2015 and 2050

In 2015 for persons 40 years and older in the United States, the overall estimated prevalence of VI was 2.14% (95% CI, 2.12–2.15%), and the overall estimated prevalence of blindness was 0.68% (95% CI, 0.66–0.69%). We based these summary estimates on pooled prevalence estimates by age and race/ethnicity (eTable 2 in the Supplement), which reveal the highest prevalence of VI and blindness among African American men and women followed by non-Hispanic white men and women.

In 2015, approximately 3.22 million persons in the United States were visually impaired based on the best-corrected, better-seeing eye. By age, the largest proportion of VI was among those 80 years and older (1.61 million of 3.22 million [50.0%]), followed by those aged 70 to 79 years (24.2%), 60 to 69 years (16.1%), 50 to 59 years (5.3%), and 40 to 49 years (4.0%) (Table). In 2050, an estimated 6.95 million persons are projected to be visually impaired—an increase of 115.8%. The proportion of VI cases is projected to range from 63.3% (4.4 million of 6.95 million) for individuals 80 years and older to 2.3% for individuals aged 40 to 49 years (Table). The projected pattern of VI prevalence by age from 2015 to 2050 is shown in eFigure 1, eFigure 2, and eFigure 3 in the Supplement for the total US population and by sex. The number of women with VI outnumbered men by approximately 33.0% in 2015 (Table), and this pattern is projected to continue through 2050 (eFigure 4 in the Supplement). In 2015 with respect to race/ethnicity, non-Hispanic white individuals (2.28 million of 3.22 million [70.8%]) represented the largest proportion of VI cases, followed by African American individuals (15.2%), Hispanic individuals (9.9%), Asian individuals (3.1%), and other minorities (0.9%) (eTable 4 in the Supplement). Through 2050, the number of people with VI are projected to continue to increase and remain higher among non-Hispanic white individuals compared with other racial/ethnic groups for both men and women (Figure 1 and eFigure 5 and eFigure 6 in the Supplement). In 2050, most VI cases are projected to remain among non-Hispanic white individuals but to a lesser degree (projected 56.5% vs current 70.8%) (eTable 4 in the Supplement). In 2050, the second highest number of VI cases is projected to shift from African American to Hispanic adults (20.3% for Hispanic vs 16.3% for African American adults) (Figure 1 and eFigure 5 and eFigure 6 in the Supplement).

In 2015, a total of 1.02 million persons in the United States were legally blind (Table). By age, the prevalence of people with blindness ranged from 42.2% (0.43 million of 1.02 million) for those 80 years and older to 10.8% for those aged 40 to 49 years (Table). In 2050, an estimated 2.01 million persons are projected to be blind—an increase of 97.1%. From 2015 to 2050, the number of people with blindness is projected to increase most markedly in adults 80 years and older for both men and women (eFigure 7, eFigure 8, and eFigure 9 in the Supplement). Through 2050, the number of women with blindness compared with men is projected to remain higher (Table and eFigure 10 in the Supplement). In 2015 with respect to race/ethnicity, non-Hispanic white individuals (0.69 million of 1.02 million [67.6%]) comprised the largest number of cases of legal blindness, followed by African American (20.6%), Hispanic (9.8%), Asian (0.9%), and other minorities (0.7%) (eTable 4 in the Supplement). The pattern of blindness by race/ethnicity through 2050 is shown in Figure 2 and eFigure 11 and eFigure 12 in the Supplement. Similar to the projections for VI, non-Hispanic white adults are projected to continue to represent most cases of blindness (projected 53.2% vs current 67.6%) (eTable 4 in the Supplement), followed by African American adults (projected 23.4% vs current 20.6%).

Geographic Distribution of the Estimated Number of Cases of VI and Legal Blindness in the United States in 2015 and 2050

In 2015, the 3 states with the highest per capita prevalence of VI were Florida, Hawaii, and Mississippi (2.56%, 2.35%, and 2.35%, respectively) (Figure 3). In 2050, states projected to have the highest per capita VI prevalence are Florida, Hawaii, and South Dakota (3.98%, 3.93%, and 3.70, respectively) (Figure 4).

In 2015, the states with the highest per capita prevalence of blindness were Mississippi, Louisiana, and Florida (0.83%, 0.79%, and 0.78%, respectively) (eFigure 13 in the Supplement). In 2050, the prevalence of blindness is projected to be highest in Mississippi and Louisiana (1.25% and 1.20%, respectively) (eFigure 13 in the Supplement). By 2050, the per capita prevalence of blindness by state is projected to increase and reach 1% to 1.25% in 18 states (eFigure 14 in the Supplement).

Projected Number of People With URE in 2015 and 2050

Quiz Ref IDIn 2015 in the United States, the estimated numbers of people with VI and blindness due to URE were 8.24 million (95% CI, 4.52 million–17.77 million) and 290 000 (95% CI, 20 000-4 200 000), respectively. In 2050, the numbers with VI and blindness due to URE are projected to increase to 16.4 million (95% CI, 8.76 million-25.84 million) and 529 000 (95% CI, 40 000-4 380 000), respectively. An epidemiologic map showing the change in the per capita prevalence of VI due to URE from 2015 to 2050 is shown in eFigure 15 and eFigure 16 in the Supplement. The expected prevalence will increase across the country, with the projected prevalence reaching 10% or more in 15 states by 2050. The patterns of the per capita prevalence of blindness are shown in eFigure 17 and eFigure 18 in the Supplement.

Sensitivity Analysis

For the projections for 2015 and 2050, the sensitivity analyses for VI revealed minimal differences among models from different scenarios (eTable 3 in the Supplement), ranging from 0% to 4.89%. For the 2050 projections, the sensitivity analyses for blindness revealed minimal differences among models from different scenarios (eTable 3 in the Supplement).

Discussion

Quiz Ref IDWe estimate that, in 2015 in the United States among people 40 years and older, 3.22 million people were visually impaired and 1.02 million were legally blind. Our 35-year projections indicate a 24.6% increase per decade in VI and a 20.6% increase per decade in blindness, predicting 6.95 million people with VI and 2.01 million people with blindness in 2050. This increase in VI and blindness results from an aging population. All members of the Baby Boomer generation (born in 1946–1964) will reach the ages of 65 years and older by 2029. Furthermore, the proportion of the US population 75 years and older will increase to 12% by 2050.

Between 2015 and 2050, non-Hispanic white individuals and women are projected to remain the largest demographics with respect to absolute numbers of VI and blindness. Women are projected to outnumber men by 30% to 32% with respect to VI and by 6% to 11% with respect to blindness. After non-Hispanic white individuals, Hispanic individuals are projected to have the most cases of VI, and African American individuals are projected to have the most cases of blindness.

The EDPRG previously projected that the number of cases of legal blindness in the United States would increase by 35% per decade—from 0.94 million in 2000 to 1.6 million in 2020.1 Our analysis predicted a per-decade increase of 25%, and our model projected 44% fewer cases of legal blindness in 2020 (1.12 million). This discrepancy most likely occurred because of differences in methods and data sources. The EDPRG used population estimates and projections based on the 2000 US Census, whereas our model generated population estimates and projections based on the 2014 US Census. Furthermore, the numbers of cases were estimated using prevalence from different selected population-based studies (eTable 2 in the Supplement).

Changes in the Estimated Numbers of VI and Blindness in the US From 2015 to 2050 by Sex

Similar to previous reports, we found that women outnumber men with respect to both VI and blindness4,22 and attributed this difference to the higher prevalence and longer life expectancy of women compared with men (81 years in women vs 76 years in men).23 In addition, previous studies24-26 suggest that women are less likely to be treated for various medical conditions, including blinding ophthalmologic diseases, such as glaucoma.

Changes in the Estimated Numbers of VI and Blindness in the US From 2015 to 2050 by Race/Ethnicity

African American individuals and Hispanic individuals experience a relatively high prevalence of VI and blindness. However, as the largest proportion of the overall population, non-Hispanic white individuals represent the largest number of people affected by these conditions. Our analysis predicts that, between 2015 and 2050, non-Hispanic white individuals will continue to represent the largest numbers of people with VI and blindness, whereas African American, Hispanic, and Asian individuals will experience an increasing prevalence over time.

African Americans are the minority population most frequently afflicted by VI and blindness and will remain the most affected minority population with regard to blindness in 2050. However, Hispanic individuals are projected to become the most affected minority population with regard to VI by 2050. This shift reflects the fact that, despite the lower overall prevalence of VI in Hispanic individuals, their population size is larger than that of African American individuals. Hispanic individuals are the fastest-growing US minority group, with a longer life expectancy than all other non-Hispanic groups.

Changes in VI and Blindness From 2015 to 2050 in the United States by Geographic Area

Although the highest estimates and projections for total cases of VI and legal blindness in the United States are within populous states, such as California, Florida, Texas, and New York, the highest per capita prevalence is in Florida for VI and Mississippi for blindness. From 2015 to 2050, the states with the highest per capita prevalence for VI and blindness are projected to remain unchanged.

Effect of URE on the US Population

Quiz Ref IDWe estimate that up to 71.9% of US individuals with VI (8.24 million estimated with URE/3.22 million with best corrected RE + 8.24 million with URE) and 22.1% of individuals with blindness could experience clinical improvement with vision screening followed by proper refractive correction. Refractive error is the leading cause of VI in the United States and worldwide,27,28 and URE can diminish a person’s quality of life and ability to complete vision-related daily tasks.29,30 It also contributes to the annual cost of VI and blindness to the US economy, estimated at $5.48 billion in medical and informal care.31,32

These data suggest that vision screening for refractive error and early eye disease may prevent a high proportion of unnecessary vision loss and blindness and promote better quality of life with age. Furthermore, the relatively low cost of vision screening and refractive correction may result in lower costs to the US economy for medical services and lost productivity related to VI and blindness.

Study Limitations

Our study has several limitations to consider. Inherent errors in the data from selected studies and the US Census might lead to differences between our predictions and actual future occurrences.33 For instance, our projections assume that the age-, sex-, and race/ethnicity-specific prevalence of VI and blindness will not change markedly over time. We also assume that the selected population-based studies1,14-19 provide a reasonable estimate of VI, blindness, and URE experienced by individuals of similar age, sex, and racial/ethnic groups in the United States. Furthermore, our model does not account for changes in the future treatment or prevention of the leading causes of VI and blindness. In addition, the race/ethnicity and age data in the US Census are self-reported. Finally, the criterion for blindness is based solely on VA, and visual field is not included in this report or in other previous studies. This limitation might lead to an underestimation of the prevalence of VI and blindness consequent to diseases, such as glaucoma and certain retinal degenerations that cause peripheral visual field loss. Regardless of these limitations and uncertainties, the present study uses the best currently available resources to provide estimated numbers and trends with regard to VI and blindness in the US population from 2015 to 2050.

Conclusions

Currently, the highest prevalence of VI and blindness is found in non-Hispanic white women. In 2050, non-Hispanic white individuals are projected to continue to represent the largest prevalence of VI cases, followed by African American individuals. However, the minority group with the largest prevalence of visually impaired and blind individuals is projected to shift from African American individuals in 2015 to Hispanic individuals in 2050.

These data suggest that the yield from screening programs for VI, blindness, and other eye disease would be greatest when focused on high-risk populations (older non-Hispanic white women). Finally, these data suggest that different regions of the country will experience the effect of VI and potentially benefit from screening programs differentially in the next several decades.

Given a projected doubling of the prevalence of VI and blindness in the next 35 years, vision screening and intervention for refractive error and early eye disease may prevent and/or reduce a high proportion of individuals from developing these conditions, enhance their quality of life, and potentially decrease direct and indirect costs to the US economy.

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Article Information

Submitted for Publication: February 29, 2016; final revision received April 3, 2016; accepted April 4, 2016.

Corresponding Author: Rohit Varma, MD, MPH, USC Roski Eye Institute, Department of Ophthalmology, Keck School of Medicine of the University of Southern California, 1450 San Pablo St, Room 4900, Los Angeles, CA 90033 (rvarma@usc.edu).

Published Online: May 19, 2016. doi:10.1001/jamaophthalmol.2016.1284.

Author Contributions: Drs Varma and McKean-Cowdin had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Varma, Vajaranant, Torres.

Acquisition, analysis, or interpretation of data: Varma, Burkemper, Wu, Torres, Hsu, Choudhury, McKean-Cowdin.

Drafting of the manuscript: Vajaranant, Burkemper, Wu, Torres, Choudhury, McKean-Cowdin.

Critical revision of the manuscript for important intellectual content: Varma, Vajaranant, Torres, Hsu, Choudhury, McKean-Cowdin.

Statistical analysis: Burkemper, Wu, Choudhury.

Obtained funding: Varma.

Administrative, technical, or material support: Varma, Torres, Hsu, McKean-Cowdin, Choudhury.

Study supervision: Varma, Choudhury, McKean-Cowdin.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Funding/Support: This study was supported by grants K23EY022949-01 (Dr Vajaranant, principal investigator) and U10EY017337-05 (Dr Varma, principal investigator) from the National Eye Institute, National Institutes of Health, Bethesda, Maryland, and Research to Prevent Blindness, New York, New York.

Role of the Funder/Sponsor: The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and the decision to submit the manuscript for publication.

Additional Contributions: Joanne Katz, ScD, MS, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, James Tielsch, PhD, Division of Global Disease Epidemiology and Control, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, and Tien Wong, MD, PhD, Department of Ophthalmology, National University of Singapore, Singapore National Eye Centre, Singapore, provided unpublished data from their studies.

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