Transforming Ophthalmology Training via Mobile Learning during the COVID-19 Pandemic

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Dear Editor,
This is an appendix of previously published paper: Rapid Assessment of Avoidable Blindness in Kurdistan, Iran. [1] Despite a widely distributed access to cataract surgery in Iran, we face populations in remote and marginal areas who have been left behind and/or are unaware of the need for surgery. [2][3][4][5] This report assesses surgical coverage and visual outcome of cataract surgery and the selfreported barriers of surgery among subjects aged 50 years or more in Kurdistan Province of Iran. Of the 3465 eligible persons who were invited to Kurdistan Rapid Assessment of Available Blindness-Diabetic Retinopathy (RAAB-DR) study, 3203 participated (response rate: 92.4%). Among the participants, 1,546 (44.6%) were males and 1,657 (55.4%) were females. The mean age of the participants was 62.7 ± 10.1 (range, 50-99) years. Of these, 12% (384 participants) had cataract surgery. Cataract surgery coverage was 90% in males and 89% in females (P = 0.91). The corresponding coverage for rural versus urban Information about barriers of surgery was obtained in 40 participants with bilateral visual acuity (VA) < 6/60 (18 males and 23 females) and 111 participants with unilateral VA < 6/60 due to cataract. "Need not felt" was reported remarkably as the commonest barrier in 75% of bilateral and 83.5% unilateral blindness or severe visual impairment (PVA < 6/60) due to cataract. It was followed by cost; 7.5% in bilateral and 8.7% in unilateral PVA < 6/60 due to cataract.
None of the patients complained about "treatment denied by the provider" and "cannot access treatment". "Need not felt" was comparable in both genders (P = 0.8) and rural versus urban residence (P = 0.79). Women were more likely to report "fear" as a barrier rather than men (P = 0.05). Fear and cost were more significantly reported in rural areas than in urban population (P = 0.05 and P = 0.04, respectively).
Of those who underwent cataract surgery with an intraocular lens (IOL) implantation, 71.5%, 17.3%, and 11.1% had good, borderline, and poor outcomes, respectively. Poor outcomes in females and rural residents were 13.1% and 12.4%, respectively. There was no significant difference between the two genders and the place of residence in terms of rural versus urban areas in this regard. Patient's selection (75%) was the primary reason for the poor outcome and it resulted from the concurrent eye problems (e.g., glaucoma, optic atrophy). Meanwhile, spectacles unmet need (49.2%) comprised most of the patients who had a borderline outcome. Posterior capsule opacification in 1.4% and aphakia in 1.2% were other reasons of poor outcome.
In conclusion, the current RAAB survey in Kurdistan demonstrated that CSC at PVA < 6/60 was 90% and was higher than similar studies. Of note, we did not observe a significant gender gap with respect to cataract surgery service.
Different patterns of CSC barriers were observed which were not similar to low-income countries where cost and unavailable resources are the main barriers.

Financial Support and Sponsorship
The protocol of the current study was approved by the Iran Eye Research Network and Tehran University of Medical Sciences (#27816).