Invited Editorial: Uniting the vision and aging sectors to advance healthy aging and eye health—The Manila Statement

A large percentage of the older population is affected by avoidable vision loss. It is estimated that people 50 years and older account for 73% of all cases of avoidable vision loss globally. This totals 800 million older people today and is projected to hit 1.28 billion by 2050, primarily in low- and middle-income countries.1 The prevalence of vision loss is highest in older populations compared with other age groups, and it rises sharply from the age of 50 years.2 Age-related eye conditions such as cataracts, glaucoma, age-related macular degeneration, and diabetic retinopathy are currently among the primary global causes of vision impairment and blindness.3,4 Notably, cataracts are the cause of 94 million cases of blindness and mild to severe vision impairment in people 50 years and older.3 This is a condition that can be effectively treated with a straightforward and cost-effective intervention. On average, it has been estimated that cataract surgery returns U.S. $20.50 for every dollar spent.5 Similarly, uncorrected refractive error is the cause of 88 million cases of mild to severe vision impairment and blindness in this age group and can often be effectively addressed through refraction and spectacle provision.3 Vision loss in older age does not only impact this sensory function but can also have wide-ranging impacts on an individual's health and well-being.1 Older people with vision impairment or blindness face higher mortality rates,6 often exacerbated by comorbid chronic conditions such as cardiovascular disease.4 Vision loss is further associated with accelerated cognitive decline, dementia, and depression.4 The loss of vision complicates self-care routines, making activities such as physical exercise and attending medical appointments more challenging, which in itself can also result in worse health outcomes.7 Vision impairment is also an independent risk factor for falls among older people.4 Older people who are blind or have a vision impairment and live in a nonenabling environment with no access to vision rehabilitation, assistive technologies and aids, or accessible infrastructure face further limitations.1 For example, they may not be able to live independently or continue to participate and contribute to society through employment, volunteer work, and caregiving. This can impact older people's personal fulfillment as well as their financial situation. In Bangladesh, Kenya, and the Philippines, a study found that people living with vision impairment before cataract surgery were poorer than those without a vision impairment. After surgery, no difference was found in household per-capita expenditure between these groups.8 A recent systematic review concluded that vision loss has a measurable impact on health-related quality of life, mostly in domains associated with physical health and functioning, including mobility and the ability to carry out usual activities.9 Other research has shown that older people with vision loss report poorer levels of functioning with respect to activities of daily living than the general population or older patients with various chronic conditions.10 Older people with vision impairment or blindness living in nonenabling environments tend to face the greatest limitations in functioning. For example, in settings where technologies such as screen readers or magnifying glasses are unavailable, older people will face barriers in their ability to access information, learn, grow, and make decisions. Socially, impaired vision complicates the development and maintenance of relationships, isolating older people and affecting their overall well-being.11 Economically, vision loss results in substantial productivity losses when individuals are unable to work, contributing to broader economic impacts.12,13 The burden of caregiving of people who are blind and require such support often falls on family members, predominantly women and girls, who may experience heightened levels of stress, anxiety, and depression and be forced to forgo employment and educational opportunities.1 Altogether, addressing vision loss in older populations is crucial not only for individual health and well-being but also for mitigating broader societal and economic repercussions.1,14 Older people are disproportionally and avoidably affected by vision loss and its consequences, mostly because they do not have access to proven and cost-effective interventions and assistive products.1 An analysis of data from 62 countries revealed that only 17% of people 50 years and older in need of cataract surgery could access an operation, with coverage being more than four times lower in low-income countries compared with high-income countries.15 Disparities also exist within the older population, with older women and those with lower income or education being most disadvantaged. POLITICAL AND ADVOCACY CONTEXT In 2021, the Lancet Global Health Commission on Global Eye Health highlighted that, despite the progress made in addressing the eye health care needs of people globally in the past decades, “business as usual” was not going to address the inequities that persist within and between countries and across age groups.16 To spur collective action within the global eye health sector to improve access to two of the most highly cost-effective health interventions, the 74th World Health Assembly in May 2021 endorsed ambitious global targets for 2030: achieving a 30-percentage point increase in effective cataract surgery coverage and a 40-percentage point increase in effective refractive error coverage.15 The United Nations (UN) General Assembly also adopted resolution 75/310 “Vision for Everyone: Accelerating Action Towards Achieving the Sustainable Development Goals” in 2021, elevating eye health as a sustainable development issue. Building on these and other initiatives and with the intention to drive action to improve the eye health of populations, the International Agency for the Prevention of Blindness (IAPB) launched “2030 In Sight,” a global strategy that centers around three elements: elevating vision as a fundamental economic, social, and development issue; integrating eye health in wider health care systems; and activating patient, consumer, and market change.16 Given the significant prevalence of vision loss in older populations, it will be impossible to achieve the 2030 global targets and the objectives of 2030 In Sight if older populations are not prioritized. At the same time, the UN General Assembly officially endorsed the UN Decade of Healthy Aging (Decade) (2021–2030) in December 2020.17 This represents a concerted global effort to address the challenges and opportunities associated with an aging population. By mobilizing governments, civil society, academia, and the private sector, the Decade seeks to catalyze global, regional, and national efforts to promote healthy aging, advancing initiatives to deliver integrated care and long-term care, address ageism, and design age-friendly environments. Given that eye health and optimal vision are critical to healthy aging, the Decade cannot afford to overlook the eye health care of older populations. THE MANILA STATEMENT: A CALL TO ACTION Recognising the disparities faced by older populations in accessing essential eye health care and the need to respond to their unmet needs, The Fred Hollows Foundation and the IAPB organized a multistakeholder meeting in Manila on April 17–18, 2024, emphasizing the importance of cross-sector collaboration and intensified collective efforts. The meeting convened 49 stakeholders from the ministries of health, nongovernmental organizations, industry, and development agencies across the vision and aging sectors, representing a total of 13 countries from Asia and the Pacific, and was supported with funding from the Australia—Association of Southeast Asian Nations Council and the Australian NGO Cooperation Program. At the culmination of the meeting, participants agreed on the Manila Statement (see Appendix, available at https://links.lww.com/OPX/A768), which confirms a mutual recognition that eye health is fundamental to the advancement of healthy aging and captures the commitment of leading organizations in both fields to preserve and protect vision in older age, as well as compensate for any permanent losses. The Manila Statement resolved to prioritize older people's vision by empowering older people to be at the center of decisions regarding their eye health, raising awareness about the importance of eye care in older age and combatting ageism, and improving access to integrated models of care that include comprehensive eye health services. Further actions include the need to guarantee financial protection to ensure equitable access to care, supported by increased investments in eye health care services tailored to older populations, especially in resource-limited settings. Creating age-friendly environments and providing affordable assistive technologies and rehabilitation services to those at risk of or living with vision loss are equally important. Additional commitments include the need to protect and preserve vision in older age, promoting research and innovation, fostering collaboration across sectors and stakeholders, and building capacity and robust accountability mechanisms. The intention behind this statement is to take a practical approach to leveraging the current political momentum in eye health and aging and catalyze collaboration between the aging and eye health sectors, urging organizations working in these two sectors at global, national, and local levels to come together to address this common challenge. It also aims to support advocacy efforts that call for increased attention to the eye health needs of older populations. MOVING FORWARD The Manila Statement calls for enhanced collaboration and joint action to improve the eye health of older populations, a goal that is of mutual interest to the aging and vision sectors. Opportunities and reasons for collaboration abound. Both the eye sector and the aging sector are seeking integrated care solutions. Within the aging sector, the Integrated Care for Older People (ICOPE) has been proposed by the World Health Organization as the model of care that can best respond to the diverse and complex health care needs of the older population.18 It focuses on six domains of intrinsic capacity, of which one is visual capacity. At the same time, the eye health sector is working toward Integrated People-Centered Eye Care (IPEC), to increase connectiveness and coordination with the broader health system and ensure that eye health services are comprehensive and consider the individual's overall health and well-being.19 Both ICOPE and IPEC are heavily oriented toward primary care and prioritize the needs, preferences, and values of the patient, encouraging people to be active participants in their own care. The principles and objectives of these two frameworks are tightly aligned, meaning that the delivery of IPEC for the older population can happen through the implementation of ICOPE. Opportunities for further policy, advocacy, and programming Several opportunities exist to advance the commitments of the Manila Statement and improve eye health in older age. Public awareness campaigns can be used to highlight the importance of regular eye checkups in older age and improve health literacy among older people. Existing networks can be mobilized, and new ones can be created to effectively engage older populations and their communities to drive the demand for high-quality and affordable eye health services where they live. Legislative and regulatory frameworks can be introduced or strengthened to safeguard older persons' right to health and eliminate ageism as a barrier to accessing health care. Older people's access to and utilization of assistive technology for low vision can be enhanced through coordinated approaches between the disability and aging sectors, better procurement pathways, and integration within existing services. Advocacy and policy efforts can be enhanced through collaboration and concerted action. Building on IAPB's collaborative approach and its network of more than 200 members, an Eye Health and Aging Strategy Group could be established to bring together key representatives from eye health and aging organizations. This group could develop a common advocacy roadmap to influence governments, institutional donors, industry partners, new philanthropic donors, and other stakeholders to prioritize and unlock funding to deliver integrated models of care for older people that include eye care. Generating evidence on the cost-benefit of integrated models of care for older people and translating it into a policy brief would be a crucial step. Influencing policy by harnessing opportunities provided by upcoming global summits and conferences, as well as engaging policymakers at key events, will also drive change. The upcoming 17th Global Conference on Aging in 2025 and the 2026 Global Summit on Eye Health are two milestone events to influence the policy landscape to prioritize the eye health of older populations, in alignment with the commitments outlined in the Manila Statement. CONCLUSIONS The staggering statistic that individuals 50 years and older comprise 73% of all cases of avoidable vision loss worldwide underscores the critical need to address the eye health care needs of older populations. In response to this pressing issue, key organizations dedicated to aging and vision health convened in the Philippines in April 2024, resulting in the issuance of the Manila Statement. This landmark declaration is a pivotal move toward enhancing the eye health of older people and critical to achieving World Health Organization's 2030 eye health targets and the goals of IAPB's 2030 In Sight strategy, as well as the UN Decade of Healthy Aging (2021–2030). The Manila Statement calls for concerted actions between these two sectors to safeguard and improve vision in older age and to support those with permanent vision loss, recognizing the critical role of eye health in ensuring healthy aging. This article has highlighted the global challenge of vision loss in older age, discussed recent advocacy and policy efforts, and urges more organizations and stakeholders to join the collaborative endeavor initiated in Manila.