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PubMed2001

Do locally agreed guidelines for optometrists concerning the referral of glaucoma suspects influence referral practice?

PURPOSE: To assess whether the issuing of local guidelines for glaucoma detection including a protocol for the referral of suspects can improve the quality and accuracy of referrals from optometrists. METHODS: Universally agreed guidelines, which included a protocol for referring glaucoma suspects, were circulated to all optometrists in the catchment area of a major teaching hospital ophthalmic unit. Data on 207 new patients referred to one glaucoma clinic were collected from GOS18 forms and hospital records covering two 12 month periods spanning the guideline dissemination. Referral accuracy was calculated and the reasons for protocol violations and referral of normal individuals were determined. Where possible, data were compared with a similar study relating to referrals made to the same clinic in 1988 and 1993. RESULTS: The mean (SD) intraocular pressure (IOP) at which optometrists referred patients was 22.5 (6.6) in 1997 and 21.9 mmHg (6.6) in 1998/9, both significantly less than in 1988. A statistically significant upward trend with time was found in the number of patients referred with an assessment of cup/disc ratio and in those with details of a visual field assessment. The overall 'true positive diagnosis' was 40% (42/105) in 1997 and 32.3% (33/102) in 1998/9 after the guidelines (p = 0.32), both of which were significantly lower than the 1988 rate of 56% (34/75) (p = 0.03 and 0.003). Fifty per cent of false positive referrals in both 1997 and 1998/9 were associated with an assessment by the optometrist of the optic disc(s) that was at variance with the ophthalmologist's. False positive visual fields were associated with 22% and 35% of non-true positive referrals in 1997 and 1998/9. Protocol violations were observed in 48% of referrals after the guidelines had been disseminated. When the referral was both a false positive and the guideline protocol was not followed, 88% of violations were associated with IOP measurement in 1997 and 73% in 1998/9. The equivalent figures for visual field violations were 70% in 1997 and 76% in 1998/9. Normal individuals referred as suspects were significantly (p = 0.001) less likely to be referred on IOP grounds if their optometrist followed the referral protocol. CONCLUSION: Local dissemination of glaucoma screening guidelines with a protocol for referral did not appear to improve the diagnostic accuracy of optometrists in our area. Optometrists who follow the guidelines refer fewer normal individuals on IOP grounds, but false positive visual fields and optic disc interpretation difficulties remain a factor in such referrals. Additional strategies will be necessary to improve the quality and accuracy of referrals for suspect glaucoma by optometrists.

Aged↗
PubMed2001

Effectiveness of optometrist screening for diabetic retinopathy using slit-lamp biomicroscopy.

PURPOSE: To assess the effectiveness of optometrists as screeners for diabetic retinopathy using slit-lamp binocular indirect ophthalmoscopy through dilated pupils. METHODS: Prospective study of a screening scheme. Screening was performed by 27 locally accredited optometrists in their practice. The referral protocol used a new simple grading system of retinopathy, especially designed for use in an optometrist screening programme. All positive referrals and 10% of negative referrals were reexamined by an ophthalmologist. Sensitivity, specificity, likelihood ratios and technical failure rates were calculated. RESULTS: The optometrists screened 4904 people with diabetes in 18 months. 'Subthreshold' (screen negative) reports accounted for 4438 (90.5% of 4904); 429 (9.67%) of these were re-examined at secondary screening. There was disagreement regarding grading in 13 patients, of whom 5 (1.16% of 429) had sight-threatening retinopathy (STDR); this extrapolates to 52 patients if all the 4438 test-negatives had been examined. Of the 371 'threshold' patients, 112 (30.18%) were false positives; the commonest cause for false positive referral was drusen in patients with background diabetic retinopathy. The sensitivity for identification of STDR was 76% (95% CI 70% to 81%) and specificity 95% (95% CI 95% to 96%). The likelihood ratio of a positive test indicating STDR was 16.54 (95% CI 14.17 to 19.23) and that of a negative test 0.25 (95% CI 0.20 to 0.32). The technical failure rate was 0.2%. CONCLUSIONS: Suitably trained and accredited community optometrists performed well when screening for diabetic retinopathy using slit-lamp biomicroscopy through a dilated pupil. This was facilitated by the use of simple grading and referral criteria. The sensitivity, positive likelihood ratio and specificity were high.

Accreditation↗
PubMed2001

Time to treatment of uveal melanoma in the United Kingdom.

PURPOSE: To measure delay before treatment of uveal melanoma. METHODS: A retrospective study was carried out of patients referred for diagnosis and treatment of uveal melanoma at the Liverpool Ocular Oncology Centre (LOOC), a tertiary adult ocular oncology service. Participants were patients with uveal melanoma presenting to an optometrist or general practitioner in the United Kingdom between 1997 and 2000. Main outcome measures were delay at each stage of the referral process according to route of referral and tumour size. RESULTS: Delays greater than 2 weeks occurred (1) between presentation to the optometrist or general practitioner and the ophthalmologist's examination in 50% of patients; (2) between the ophthalmologist's examination and receipt of the referral at the ocular oncology centre in 34%; (3) between receipt of referral at the oncology centre and first assessment at that centre in 16%; and (4) between first assessment at the oncology centre and treatment in 8%. The waiting time for the ophthalmologist's examination was greater if the optometrist referred the patient via the general practitioner instead of directly. The median overall delays between presentation and treatment were 129 days for small tumours, 50 days for medium-sized tumours and 34 days for large tumours. CONCLUSIONS: Many patients with uveal melanoma experience long delays before treatment. Patients wait longer to see an ophthalmologist if their tumour is small or if they are referred by the optometrist to the general practitioner instead of directly to the ophthalmologist. Several patients also experience long delays after seeing the ophthalmologist, some having a large tumour by the time of teatment.

Adult↗
PubMed2001

What optic disc parameters are most accurately assessed using the direct ophthalmoscope?

PURPOSE: It has been suggested that over-reliance on the cup-to-disc ratio is a major factor in the misinterpretation of the optic disc. In spite of this optometrist assessment of the optic disc tends to be restricted to measurement of the cup-to-disc ratio and cup depth only. Would interpretation of the disc improve if optometrists were to evaluate other parameters? The aim of this study was to evaluate the accuracy of optometrist assessment of nine parameters of the optic nerve head using direct ophthalmoscopy. METHODS: Eight optometrists evaluated nine parameters of the optic nerve head (vertical disc diameter, vertical cup-to-disc ratio, neuroretinal rim configuration, cup shape, neuroretinal rim colour, vessel path, presence/ absence of haemorrhage, extent and location of peripapillary atrophy and classification of health status of the disc) in 50 eyes of 50 patients using direct ophthalmoscopy. Intensive training in optic nerve head assessment was given prior to assessing the patients. Criteria for evaluation were discussed. The 'gold standard' reference was the classification of the parameters by a consultant ophthalmologist with a special interest in glaucoma. RESULTS: Interobserver agreement for vertical cup-to-disc ratio was almost perfect (mean weighted kappa 0.84). Agreement for neuroretinal rim configuration, cup shape, haemorrhage and final classification of the disc was good (mean kappa 0.62-0.67). There was moderate agreement for vessel configuration (mean kappa 0.53). For assessment of peripapillary atrophy, disc size and neuroretinal rim colour, agreement was fair (mean kappa 0.22-0.34). CONCLUSIONS: Accuracy of assessment was greatest for vertical cup-to-disc ratio, neuroretinal rim configuration and cup shape. Improved agreement has been demonstrated for the final classification of the disc compared with previous reports. The combination of training and assessment of additional disc parameters appears to improve interpretation of the optic nerve head by optometrists.

Clinical Competence↗
PubMed2002

The assessment and management of strabismus and amblyopia: a national audit.

AIMS: To determine what systems are in place within ophthalmic services for the assessment and management of children suspected of having amblyopia and strabismus. To find out what methods are used for the assessment of these children. METHODS: A questionnaire-based study auditing 288 orthoptic departments in the UK. RESULTS: Responses were received from 75% orthoptic departments. Most hospitals employ more than one system for the assessment of strabismus and amblyopia, which is generally dependent on route of referral. These include 'orthoptic assessment without refraction' (66%), 'combined orthoptist and ophthalmologist assessment' (66%), while 22% have an entirely orthoptist/optometric system. Ophthalmologists are involved in the initial assessment in 145 units (67%), whereas some units involve an ophthalmologist only if response to treatment is poor (15%), or if surgery is required (6%). Fourteen per cent of units reviewed all children, with discharge criteria being based on normal visual acuity (52%), accurate visual acuity (39%) and a normal orthoptic assessment (42%). Seventy-six per cent of units review some children, commonly as a result of family history (55%), parental concern (43%), poor co-operation (30%) and young age (72%). In the absence of squint or amblyopia children are discharged at the first visit, in only 8% of units. There is considerable variation in the tests used to assess visual acuity. LogMAR-based tests (eg EDTRS) are not routinely used in 75% of units. CONCLUSION: Different systems exist for the assessment and management of squint and amblyopia across the country. While much of this variation is to be expected given their possible aetiologies, some could be reduced to produce a more cohesive service. There is also considerable scope for rationalising the tests used to screen infants and children for amblyopia and strabismus.

Amblyopia↗
PubMed2003

Community refinement of glaucoma referrals.

AIM: To describe a Manchester-based glaucoma referral refinement scheme designed to reduce the number of false-positive referrals to the hospital eye service. To report on the first years results of this scheme and its financial costs to the NHS. METHODS: Patients with suspected glaucoma, instead of being referred to their GP and then on to the hospital eye service, were referred to a group of specially trained community optometrists working to an agreed set of referral criteria. Those patients who did not meet the referral criteria were returned to the referring optometrist, while those who met the referral criteria were referred directly to Manchester Royal Eye Hospital. The patient's GP was informed in all cases. RESULTS: The number of suspect glaucoma cases referred to the Manchester Royal Eye Hospital was reduced by 40%. This figure is close to the percentage of false-positive referrals measured at Manchester Royal Eye Hospital prior to the onset of this study. The information accompanying referral has been improved and the scheme produces a small financial cost saving to the NHS of approximately 17 pounds sterling per patient. CONCLUSION: Community refinement of suspect glaucoma offers some important benefits over the current referral pathway.

Community Health Services↗
PubMed2004

Glaucoma case finding: a cluster-randomised intervention trial.

PURPOSE: To assess the effect of an intervention comprising training in optic disc assessment, explicit referral criteria and ophthalmologist feedback on referred patients, on the number of optometrist referrals for suspected glaucoma seen at a referral site and the positive predictive value of those referrals. METHODS: Optometric practices routinely referring to the Ealing Hospital Eye Clinic were randomly divided into two groups taking into consideration those practices, which shared an optometrist (a cluster) and the number of optometrist days worked per week. One group of practices acted as controls, while the other practices were invited to receive the intervention. Data on 397 new patients referred and presenting to Ealing Hospital with suspected glaucoma were collected over a 20-month period. The data on patients who had failed to attend their appointment were collected over 7 months of this period. The number of referrals seen, the positive predictive value of those referrals, and the attendance rate were calculated. Optometrist's opinions of the intervention were assessed qualitatively. Data relating to optometrist compliance with the intervention were also collected. RESULTS: The number of glaucoma referrals presenting to Ealing Hospital from the intervention practices was almost double that from the control practices (210 vs 119). When cluster randomisation, the number of optometrist days per cluster and the number of assessed referrals in the preintervention period are taken into consideration, it is estimated that the intervention is associated with a 52% increase in the number of referrals reaching Ealing Hospital. However, the design effect resulting from the cluster randomisation was unexpectedly high (of the order of 13-14)and so the confidence intervals around the estimate of 52% are very wide (95% c.i. 35% decrease to 253% increase, P = 0.34). There was no evidence of an association between optometrist compliance with the intervention and the number of referrals seen at Ealing Hospital. The positive predictive value (PPV)of referrals was similar for the intervention(0.49 (95% c.i. 0.42, 0.55)) and control groups(0.46 (95% c.i. 0.33, 0.60)). Optometrist opinions of the intervention were largely favourable. All expressed a willingness to participate in future programmes. CONCLUSION: A large difference in the number of referrals between the practice groups was observed. Since the PPV of referral was unchanged, the potential impact of the intervention in terms of numbers of new cases of glaucoma detected in the community is substantial. However, because of its large design effect, this trial does not provide conclusive evidence of an impact of the intervention on referral numbers. A considerably larger trial will be required to produce conclusive evidence of an effect.

Attitude of Health Personnel↗
PubMed2004

Referrals for cataract surgery: variations between different geographic areas within a Welsh Health Authority.

AIM: The aim of the study was to identify variations in cataract presentation within three different eye units in a single health authority and to identify any correlation between cataract presentation and social deprivation indices. We also compared our patient profile and results with the UK National Cataract Audit Statistics. METHODS: It was a prospective multicentre questionnaire-based project involving three hospitals: Cardiff Eye Unit--University Hospital of Wales (UHW), Royal Glamorgan Hospital--Llantristant (RGH), and Prince Charles Hospital--Merthyr Tydfil (PCH). Demographic, clinical, and socioeconomic data were collected in patients undergoing cataract surgery. Patients were also asked to fill in the questionnaire based on Berth-Petersen Visual Function Index (VF-14) indicating difficulty in performing daily living activities. RESULTS: A total of 112 patients were recruited in the study. Demographics were similar to National Cataract Audit. However, the percentage of patients with poor visual acuity (less than 6/60) at the time of surgery was greater at all the three hospitals compared to the national statistics. Among the three hospitals at South Wales, PCH had the lowest visual acuity in both listed and fellow eye and the lowest VF-index. Both the outpatient and surgery waiting times were longest at PCH. The population at PCH also visited their optician least frequently. CONCLUSION: Our results show significant variation in cataract presentation between the three eye units within a single Health Authority. These variations correlate well with social deprivation indices and poor use of Optometric services. Local policies are needed to redress these inequalities and raise public and professional awareness of causes of poor sight in the elderly population.

Age Distribution↗
PubMed2006

Glaucoma detection in the community: does ongoing training of optometrists have a lasting effect?

PURPOSE: To establish whether the effect of improved glaucoma detection in the community suggested by an intervention study is maintained when intervention is extended to include all optometrists in the area. METHODS: Optometrists' in the Ealing, Hammersmith, and Hounslow area were invited to ongoing training sessions following completion of an intervention study. The number of optometrist initiated referrals to Ealing Hospital Eye Clinic (EHEC) for suspect glaucoma was assessed over a 12-month period. The positive predictive value (PPV) of those referrals was calculated and a historical comparison made with the results of the original study. RESULTS: A total of 376 new referrals for suspected glaucoma were assessed at EHEC during the 12-month period of data collection. This represents an increase in the number of referrals of 58% compared with an equivalent 12-month period during the initial intervention trial (376 vs. 238). The PPV was maintained at 0.45 (95% CI 0.41-0.51). CONCLUSION: The rising number of new referrals for glaucoma together with maintenance of the PPV suggests an impact on the number of new cases of glaucoma detected in the community. The increase in referral numbers was limited to glaucoma when compared with new referrals for cataract. This implies a targeted effect of the intervention in terms of glaucoma detection. We believe the next step is to perform the study in an alternative location to see if the effect is repeatable elsewhere. If proven to be the case, there is a coherent argument for widespread adoption of this strategy to improve glaucoma case finding.

Community Health Services↗
PubMed2005

Glaucoma electronic patient record--design, experience and study of high-risk patients.

AIM: To set-up a glaucoma electronic patient record (GEPR) and study referral details to a new glaucoma service, concentrating on high-risk patients. METHOD: A GEPR was designed using the pre-existing hospital information technology (IT) infrastructure. Referral details of all new patients to the glaucoma service were completely electronically entered and analysed. RESULTS: A GEPR was successfully established. A total of 402 referrals were studied. In all, 43% (40) of high-risk clinic patients (IOP>29 mmHg, or C/D ratio >0.8 or moderate to advanced visual field defects) had to wait longer than 8 weeks from GP referral to be seen at the glaucoma service. Of these, nine patients lost more than one line of Snellen's visual acuity attributable to glaucoma. The optometrist failed to document IOP in 17%, fundoscopy in 30%, and visual fields in 45% of all referrals. CONCLUSIONS: A GEPR can be introduced in an NHS setting without disruption of clinical care and ophthalmic training, and facilitates detailed, accurate and rapid audit. Study of high-risk glaucoma referrals showed inadequate optometric referral details and poor prioritisation of urgent cases. This information is being utilised with the cooperation of local optometrists to refine the pattern of glaucoma referrals.

Glaucoma↗
PubMed2006

Intraocular lens power calculation using ray tracing following excimer laser surgery.

PURPOSE: To evaluate intraocular lens (IOL) power calculation using ray tracing in patients presenting with cataract after excimer laser surgery. METHODS: Ten eyes of seven consecutive patients who presented for cataract surgery following excimer laser treatment without any pre-refractive biometry data were enrolled in this prospective clinical study. Preoperatively, IOL power calculation was performed using a ray tracing software called OKULIX. Keratometry data (C-Scan) were imported and axial length (IOLMaster) was entered manually. Accuracy of IOL power calculation was investigated by subtracting attempted and achieved spherical equivalent. RESULTS: Mean spherical equivalent was -3.51+/-2.77 D (range -10.38 to -0.5 D) preoperatively and -1.01+/-1.08 D (range -2.5 to +0.75 D) postoperatively. Mean error was 0.31+/-0.84 D, mean absolute error was 0.74+/-0.46 D, and IOL calculation errors ranged from -1.39 to +1.47 D. A total of 40% of eyes were within +/-0.5 D, 70% within +/-1.0 D, and 100% within +/-1.5 D. Three eyes with corneal radii over 10 mm showed calculation errors exceeding +/-1.0 D. Mean best-corrected visual acuity increased from 20/60 to 20/30 postoperatively. CONCLUSIONS: IOL power calculation after excimer laser surgery can be difficult, especially when pre-refractive keratometry values are not available. In these cases, ray tracing combined with corneal topography measurements provides reliable and satisfactory postoperative results. However, it is advisable to be careful when calculating IOL power for eyes with corneal radii exceeding 10 mm because of slightly higher prediction errors.

Aged↗
PubMed2006

ReGAE 2: glaucoma awareness and the primary eye-care service: some perceptions among African Caribbeans in Birmingham UK.

AIMS: Investigations into glaucoma awareness have drawn on informed, clinic-based populations. The paper reports a section of findings from a larger study that aimed to elicit the perceptions of those potentially less informed in community settings. METHODS: A qualitative investigation used face-to-face interviews and focus group discussions with 48 African Caribbean participants outside the hospital eye-service. Interview data were transcribed and coded using manual and computer-aided methods. Inferences and interpretations were corroborated by discussion with expert advisors and community members not directly involved in the study. RESULTS: Positive attitudes to health promotion existed, but 'eye health' did not appear to be integral to individuals' health schemas. The capacity for primary eye care to enhance glaucoma knowledge appeared under utilised and inconsistent across modes of service delivery and was undermined by perceived conflicts of interest. CONCLUSIONS: Enhancing reciprocal understanding between service users and ophthalmic practitioners in primary care is central to developing flexible, responsive local eye-care services. The study suggested useful foci for cultural self-reflection and self-awareness on the part of health professionals themselves, in relation to glaucoma detection. Areas for further research are identified.

Adult↗