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Eye health can be affected by a number of factors, including genetics, ageing, premature birth, diseases (such as diabetes), injuries, ultra-violet (UV) exposure, nutrition and tobacco use . Poor vision can limit opportunities in education, employment and social engagement; it can also increase the risk of injury and be a reason for dependence on services and other people . Even mild vision loss can reduce an individual’s ability to live independently and increase the risk of mortality .
Nationally, eye and vision health issues: are responsible for 11% of years of life lost to disability (YLD) for Indigenous people; constitute the fourth leading cause of the gap in health between Indigenous and non-Indigenous people; and increase mortality at least two-fold . Around 94% of vision loss among Indigenous people nationally is preventable or treatable, with the leading eye conditions being cataract, refractive error, optic atrophy, diabetic retinopathy, and trachoma .
The most recent comprehensive source of information about the eye health of Indigenous Australians is the National Indigenous eye health survey (NIEHS), conducted in 2007-2009 by the Indigenous Eye Health Unit at the University of Melbourne in collaboration with the Centre for Eye Research Australia and the Vision Cooperative Research Centre . The survey examined all children aged from 5 to 15 years and adults 40 years and older living in 30 communities across Australia; with a total of 2,883 Indigenous participants.
Eye and sight problems were reported by one-third (33%) of Indigenous people who participated in the 2012-2013 AATSIHS, making it the most commonly reported long-term health condition . Eye and sight problems were reported by 38% of Indigenous females and by 29% of Indigenous males . The age-adjusted levels of eye and sight problems were slightly lower for both Indigenous males and females than those for their non-Indigenous counterparts (ratio 0.9) . The proportion of Indigenous people reporting eye or sight problems was lower among those living in remote areas (28%) than among those living in non-remote areas (35%) .
The 2008 NIEHS found that the eyesight of Indigenous children was generally better than that of non-Indigenous children, particularly for children living in remote communities . After adjusting for age and sampling, blindness was five times less common among Indigenous children aged 5-15 years than among non-Indigenous children.
The 2008 NATSISS reported that 9% of Indigenous children aged 4-14 years had some form of eye or sight problems . The most common forms of these problems were refractive errors: long-sightedness (37%) and short-sightedness (28%) . The 2008 NIEHS reported that more than one-half of low vision (56%) among Indigenous children aged 5-15 years was due to refractive error . Of the three children who were blind, one child was blind due to refractive error.
According to the 2008 NIEHS, low vision was 2.8 times more common among Indigenous adults aged over 40 years than among their non-Indigenous counterparts . The most common causes of low vision were uncorrected refractive error (54%), cataract (27%), and diabetic retinopathy (12%).
The 2008 NIEHS found that 1.9% of Indigenous adults were blind, a level 6.2 times higher than that for non-Indigenous adults . The leading cause of blindness among Indigenous adults was cataract (32%) (Figure 1), which was 12 times more common among Indigenous adults than among non-Indigenous adults . The next leading causes of blindness among Indigenous people were refractive error and optic atrophy (both 14%), followed by diabetic retinopathy (a complication of diabetes) and trachoma (an infectious eye disease) (both 9%) .
Figure 1. Prevalence (%) of vision loss and blindness, by cause, Indigenous adults, Australia, 2008
Source: NIEHS 2009 
Refractive error is a common eye condition that is easily corrected with glasses. Refractive error was the cause of more than one-half of low vision (54%) and 14% of blindness among Indigenous adults in the 2008 NIEHS . Uncorrected refractive error leading to blindness was five times more common among Indigenous adults than among non-Indigenous adults. Impaired distance vision (hyperopia) affected 5% of Indigenous adults. Only 20% of Indigenous adults wore glasses for distance vision, compared with 56% of non-Indigenous adults . Around 39% of Indigenous adults were not able to read normal size print (difficulty with near vision or myopia) .
As noted above, cataract was the leading cause of blindness among Indigenous adults and the second most common cause of low vision . Reflecting the high levels of cataract-associated blindness, the hospital separation rate ratio for cataract extraction surgery in public hospitals was more than twice as high for Indigenous people in 2011-12 than it was for their non-Indigenous counterparts .The median wait for cataract surgery in 2012-13 was 140 days for Indigenous people and around 90 days for non-Indigenous people .
Diabetic retinopathy, a complication of diabetes that causes damage to the small blood vessels in the retina, can impair vision and cause blindness . The 2008 NIEHS reported that blinding diabetic retinopathy was 30 times more common among Indigenous adults than among non-Indigenous adults . Overall, the NIEHS reported that diabetes was the cause of 12% of low vision and 9.1% of blindness among Indigenous adults. Of Indigenous adults with diabetes, only 20% had had an eye exam within the previous year.
Vision loss and blindness from diabetic eye diseases are up to 98% preventable  with regular screening and timely treatment . Annual screening is recommended for Indigenous people with diabetes . Prevention measures include the management of diabetes (blood glucose control, blood pressure and lipids) and following a healthy lifestyle (maintaining a normal BMI, nutritious diet, and regular exercise) .
Trachoma has been virtually eliminated in the developed world, but still occurs among Indigenous people . According to the 2008 NIEHS, 60% of Indigenous communities in very remote areas had endemic trachoma .1 The overall prevalence of active trachoma among Indigenous children aged 5-15 years was 3.8%, ranging from 0.6% in major cities to 7.3% in very remote coastal inland areas. The highest prevalence was 23% in very remote inland NT.
At around the same time as the NIEHS, the overall prevalence of active trachoma was found among 14% of children aged 5-9 years living in 289 specifically-screened communities in the NT, SA and WA . In 2012, the overall prevalence of active trachoma among these children had decreased to 4% (4% in the NT and WA, 2% in SA and nil in Qld) . The level of trachoma was endemic in 25% and hyper-endemic2 in 8% of the screened communities .
In 2012, trichiasis was detected in 2% of Indigenous adults aged 40 years and older living in 108 at-risk communities in WA, SA and the NT . A total of 94 cases were reported (22 in WA, 11 in SA and 61 in the NT). In the 2008 NIEHS, the overall prevalence of trichiasis was 1.4%, the highest level of 15% being found in very remote inland areas of Australia .
A number of factors (including geographical location, socio-economic status, lack of access to transport, and lack of access to health services) limit the timely identification, management and treatment of eye health problems for Indigenous people . The limited availability of eye care providers in more remote areas is such that a four-fold increase in services is needed to address the shortage . There may be enough eye care providers in urban areas but they are not fully utilised by Indigenous people.
Overall, Indigenous people are less likely than non-Indigenous people to access eye health practitioners, optometry, or specialist ophthalmology services . The 2008 NIEHS found that 35% of Indigenous adults have never had an eye examination . The rate of eye examinations provided in areas with a high Indigenous population was two-thirds the rate for areas with a low Indigenous population .