Vision impairment (VI) is defined as a functional limitation of the eye/s or visual system because of a disorder, which can result in visual disability or visual handicap (Heath, Kishiki & Courtright 2007; World Health Organization [WHO] 2019a). Vision impairment includes low vision (visual acuity [VA] less than 6/18 to 3/60) and blindness (VA worse than 3/60 to light perception) based on presenting VA (WHO 2022). Vision impairment can manifest as reduced VA or contrast sensitivity, visual field loss, photophobia, colour vision loss, diplopia, visual distortion, visual perceptual difficulties or any combination of the abovementioned symptoms (Heath et al. 2007). An individual with functional low vision has impairment of visual functioning even after treatment and/or standard refractive correction, with VA less than 6/18 to light perception or visual field less than 10 degree from the point of fixation, but uses or is potentially able to use vision for the planning and/or execution of a task (WHO 2008).

Globally, approximately 295 million individuals have moderate to severe VI, 43 million are blind and 510 have near VI (Bourne et al. 2021a). Furthermore, about 90% of the visually impaired individuals live in low- and middle-income countries (LMICs) (Ackland, Resnikoff & Bourne 2017; Bourne et al. 2021a). In South Africa, VI accounted for 9.9% among all disabilities, making it the largest disability group in the country (Statistics South Africa 2024). The main global causes of VI include uncorrected refractive errors (UREs), cataracts, diabetic retinopathy and age-related macular degeneration (WHO 2021). In South Africa, a recent study identified UREs, cataracts and glaucoma as the most common causes of VI (Xulu-Kasaba & Kalinda 2022).

Vision impairment restricts affected individuals from attaining optimum function and independence in their daily lives, leading to decreased quality of life and contributing to poor psycho-social well-being, physical health, economic participation and educational achievements (Bassey, Ellison & Walker 2019; Bourne et al. 2021a; Watermeyer, et al. 2024; WHO 2021). To improve their daily functioning, individuals with VI require comprehensive VI services encompassing promotional, preventative, treatment and/or rehabilitation services. People with irreversible VI (congenital or acquired) require low vision care and rehabilitation services (WHO 2019a). Several studies have shown that comprehensive VI services are effective in improving functioning for activities of daily living (ADL) and psychological well-being in affected individuals (Da Silva et al. 2014; McKnight, Crudden & McDonnall 2021; Ovenseri-Ogbomo et al. 2016).

Low vision care and rehabilitation services include vision assessment and goal identification, refraction, provision of assistive devices and training on their use, psychological counselling on the underlying condition, adaptation and use of residual vision, mobility and orientation training, occupational rehabilitation and environmental modification, referral to special education and job placement services (Monye, Kyari & Momoh 2020; Owsley et al. 2009; WHO 2019a). The services require a professional multidisciplinary approach which involves personnel including optometrists, ophthalmologists, ophthalmic nurses, occupational therapists, orientation and mobility trainers, psychologists, community–based rehabilitation workers, audiologists, social workers, special educators, physiotherapists and low vision therapists to ensure comprehensive rehabilitation services (Heath et al. 2007; Oduntan 2008; WHO 2017).

Optometry is defined as a profession concerned with the eyes and related structures, as well as vision, visual systems and vision information processing in humans (Bergin 2017). Optometrists are licensed or registered primary healthcare practitioners of the eye and visual system who provide comprehensive eye and vision care, which includes refraction and dispensing, detecting and/or diagnosis and management of eye disease and the rehabilitation of the condition of the visual system (Health Professional Council of South Africa [HPCSA] 2025; World Council of Optometrists 2025). Given the scope of practice of optometrists, they possess the requisite skills and expertise to deliver services related to VI (Naidoo et al. 2023).

Globally, the demand for VI services is projected to rise because of the ageing population, prevailing lifestyle comorbidities and complications arising from non-communicable systemic and/or ocular diseases (Bourne et al. 2021a; WHO 2017). The WHO action plan prioritises reducing avoidable VI as a global public health issue and ensuring access to rehabilitation services for individuals with irreversible VI. This empowerment aims to enable full participation in social, economic, political and cultural aspects of life (WHO 2013). Despite these efforts, significant inequalities and gaps persist in the awareness, access and uptake of VI services worldwide. Approximately 5% of the population with chronic VI has access to low vision care and rehabilitation services worldwide (Chiang et al. 2011). In most instances, LMICs are underserved or the services are inadequate and generally poor (Bourne et al. 2021b; WHO 2017, 2021).

In South Africa, provision of low vision and rehabilitation services is variable, inadequate and gravely constrained in most rural parts of the country (Oduntan 2007; Sacharowitz 2005; Watermeyer et al. 2024). The low vision care and rehabilitation services are mainly offered by the four optometric teaching institutions, one college, few public special schools, several non-profit organisations (NPOs) and few private practice optometrists (Oduntan 2007; Sacharowitz 2005). Barriers to the provision, access and uptake of VI services are multifaceted, involving healthcare system constraints, individual factors, societal issues; and they vary across and within countries (Bourne et al. 2021a, 2021b; Chiang et al. 2011; Wallace et al. 2020).

The Limpopo province is the fifth most populous province in South Africa, with a predominantly rural landscape (Limpopo Provincial Government 2020; Statistics South Africa 2019). While numerous studies have examined the epidemiology of VI in various parts of Limpopo province (Maake & Oduntan 2015; Mabaso & Oduntan 2014; Oduntan et al. 2003), there is a notable paucity of literature addressing the awareness, availability and barriers to accessing VI services in the public hospitals of Limpopo province. This study aimed to elucidate the perceptions of optometrists regarding VI services in the public hospitals of Limpopo province. The findings are anticipated to be instrumental for policymakers, eye care personnel and the Department of Health in facilitating informed planning, resource allocation and management of VI, ultimately enhancing the quality of life of affected individuals and their families.

Vision impairment interferes with developmental growth in children and significantly impacts the quality of life among the adult population (Bassey et al. 2019; Bourne et al. 2021a; WHO 2021). The demand for VI services is anticipated to increase globally because of ageing population and prevailing lifestyle comorbidities (Bourne et al. 2021a; WHO 2021). This study aimed to describe optometrists’ perceptions of VI services in public hospitals in the Limpopo province, South Africa.

The findings from this study on awareness of VI showed that 90% of the participants were aware of the WHO definition of VI. However, only 50% of the participants applied the WHO criteria to identify and classify individuals with VI. This discrepancy in VI classifications may stem from the lack of standardised guidelines for VI classifications or the absence of necessary enablers for implementation, such as diagnostic equipment in public hospitals. Interestingly, the majority of those who adhered and used the WHO criteria in classifying an individual as having VI were those with 10 years or less of working experience (68%). This trend may be attributed to their greater involvement in patient care and a higher likelihood of engaging in continuous education and skill development than their more experienced counterparts. Inconsistencies in the classification of VI contribute to inaccurate estimations of the number of individuals who could benefit from VI services, including refractive error correction, cataract surgery, low vision care and taking into account the person’s vision-related problems and needs, and vision rehabilitation (Dijk, Kishiki & Courtright 2014). This misclassification may therefore lead to affected individuals being denied access to essential services as accurate estimates of VI are crucial for planning effective eye care services and monitoring progress (WHO 2019a). The use of the International Classification of Diseases (ICD) for classifying VI, as recommended by the WHO, is commonly employed in clinical settings and research studies (Ali et al. 2022; Bourne et al. 2021b; Seid et al. 2022; WHO 2019b).

Vision impairment services aim to optimise the use of residual vision through the use of assistive devices, medical and surgical interventions, psychological counselling and environmental adaptations (WHO 2019a). Early reports indicated that the main causes of VI in parts of Limpopo Province were correctable and/or preventable (Maake & Oduntan 2015; Mabaso & Oduntan 2014; Magakwe, Xulu-Kasaba & Hansraj 2020; Oduntan et al. 2003). However, findings from this study revealed that only 9% of the participants offered low vision care services, less than 50% of participants provided optimal spectacle correction and approximately 54% referred patients with VI to ophthalmologists, psychologists or occupational therapists. Only eight participants (12%) frequently referred patients for vision rehabilitation services, while the majority (88%) either never or rarely made such referrals.

Despite that refractive error correction services are cost-effective and feasible to implement (WHO 2021), poor provision of spectacles and other visual assistive devices might be because of anecdotal reports suggesting insufficient budget for optical devices and poor procurement processes at public hospitals in Limpopo province. While similar findings of inadequate refractive error coverage services were reported in Saudi Arabia (Ovenseri-Ogbomo & Alghamdi 2021) and Zambia (Kapatamoyo et al. 2023), the budget and procurement constraints could further worsen the provision and access to low vision care at public hospitals because of the expensive costs of these services, thus leaving the majority of the people who rely on public eye health care services underserved.

Almost all hospitals in Limpopo province had a significant cataract backlog and only three public hospitals were offering cataract surgery services at the time of study. An early study in parts of Limpopo province found that patients were placed on the cataract surgery waiting lists for longer periods (Khoza et al. 2020a). It was found that insufficient ophthalmology personnel, shortage of equipment and consumables for cataract surgery services contributed to limited provision of cataract surgery services in the province (Khoza et al. 2020a, 2020b).

The increase in referrals of patients with VI to the ophthalmologists could be reduced by strengthening the co-management of eye diseases between the optometrists with ocular therapeutics privileges and ophthalmologists. Naidoo et al. (2023) showed that optometrists are best placed to contribute to the disease control strategy to reduce the global burden of VI. The lack of a vision rehabilitation plan and inadequate referrals of those who might benefit from the low vision care and rehabilitation services could be because of the lack of referral guidelines and insufficient vision rehabilitation centres in the province. Consistent with other studies, low vision care and rehabilitation services were reported to be more constrained in LMICs (Oduntan 2007; WHO 2017, 2021).

Participants identified the lack of assistive devices, equipment and access as major barriers inherent within the health care system in the provision of VI services. Assistive devices, both optical and non-optical, can restore vision and/or enhance functionality of individuals with VI, thus their provision significantly impacts the vision-related quality of life (Da Silva et al. 2014; Ovenseri-Ogbomo et al. 2016). However, similar findings were reported in other studies (Javed, Afghani & Zafar 2015; Kapatamoyo et al. 2023; Kyeremeh & Mashige 2021; Lim et al. 2014; Monye et al. 2020; Wallace et al. 2020), where the lack of equipment, access and assistive devices were cited as primary barriers to provision of VI services. The absence of adequate equipment adversely affects the quality of services offered, leading to inadequate diagnosis, inappropriate referrals and redundant skills with overburdening of the receiving institutions.

While 55% of participants expressed interest in providing VI services and 29% provided low vision care and rehabilitation services, barriers such as inadequate human resource and training, limited awareness and increased workload were identified as significant obstacles for practitioners in delivering these services. The inadequate human resource which might be the reason for increased workload could be because of shortage of optometrists in some hospitals as majority of optometrists are predominantly located in the private sector (Naidoo et al. 2023). This could be the contributing factor for poor integration of low vision care and rehabilitation services in the public sector as optometrists may mainly focus on providing refractive services and screening for diseases (Naidoo et al. 2023). The lack of awareness among practitioners may be attributed to insufficient involvement in continuous professional education and low interest in professional skill development. This deficiency in awareness has been reported as a major barrier to effective VI services (Dilkash et al. 2021; Jose et al. 2016). Furthermore, inadequate training leads to incompetent practitioners and ineffective service delivery. Continuous educational training is important to ensure that practitioners maintain up-to-date skills and developments in their fields and adherence to such training is mandatory (HPCSA 2021). These limitations and inadequacies deprive persons with VI to attain and maintain maximum independence, full physical, mental, social and vocational ability, and full inclusion and participation in all aspects of life and could infringe on their rights and well-being (Department of Social Development 2016; United Nations 2025).

Participants identified the primary barriers to the uptake of VI services as a lack of awareness and the cost of services. The lack of awareness may be attributed to the literacy levels of the population being served and poor eye-care-seeking behaviours (WHO 2021). A deficiency in awareness and knowledge about available services negatively impacts the utilisation of these services (Akuffo et al. 2020; Ntsoane et al. 2012). Although public health services in South Africa are subsidised, individuals who are not fully subsidised may still be unable to afford their portion of the hospital bill because of their socio-economic status (Bourne et al. 2021a; Limpopo Provincial Government 2020). Furthermore, inadequate coverage for refractive error correction and cataract surgery in the province may contribute to the ineffectiveness of services, resulting in a lack of patient satisfaction because of unmet expectations.

The limitations of this study include its hospital-based design, which is subject to the inherent constraints of facility-based studies, such as limited generalisability of the findings. In addition, the study is susceptible to information bias because of the selection of participants being limited to optometrists. Despite these limitations, the study offers valuable insights for policymakers, and eye care practitioners, aiding in the effective planning of visual impairment services and serving as a foundation for further research.

The availability and provision of VI services in Limpopo province are currently limited. Advocacy for the use of recommended guidelines is essential to ensure the delivery of quality eye care services. It is necessary to enhance the availability of equipment, improve awareness of VI services, develop and ensure implementation of guidelines for referral to improve access and provision of effective VI services. The factors contributing to the limited VI services are avoidable. Therefore, appropriate planning on provision of comprehensive VI services and resource allocation are necessary to reduce the burden of VI and ultimately improve the quality of life of affected individuals utilising the public hospitals in Limpopo province.