Patient pathways for macular disease: what will the new optometrist with special interest achieve?
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Choroidal Neovascularization↗
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Use of eye care services by older Australians: the Blue Mountains Eye Study.
PURPOSE: To assess utilization of eye care services in an older Australian population. METHODS: The Blue Mountains Eye Study examined 3654 permanent residents aged 49 years or older from two New South Wales postcode areas. At interview, we collected information about past attendance to eye care practitioners, demographic and socio-economic status variables and past medical and eye history. Full-time optometric and part-time ophthalmic services were available in this community. RESULTS: Almost all participants (99%) had seen either an ophthalmologist or optometrist in the past, with 62, 27, 7 and 3% having last attended in the last 2, 2-5, 5-10 and > 10 years, respectively. Among those participants (2251) who had been seen in the last 2 years, 50.2% (1131) last saw an ophthalmologist, 48.6% (1094) last saw an optometrist and 26 (1.2%) could not state whom they saw. After adjusting for age and sex, factors statistically significantly associated with attending an ophthalmologist included older age, female gender, higher socio-economic status, moderate to high myopia and presence of systemic disease (diabetes, hypertension) or any significant eye pathology. Factors statistically significantly associated with attending an optometrist were younger age, living alone, not currently married, being able to go out alone, having better presenting visual acuity, hyperopia and absence of diabetes or significant eye pathology, including moderate to high myopia. CONCLUSIONS: Findings from this study indicate that whether people use eye care services and whom they visit is mainly driven by need factors. Although there was considerable overlap, this study found relatively appropriate utilization of eye care services by this population.
Age Distribution↗
Changes in attitudes and practices of optometrists in their management of diabetic retinopathy after the release of NHMRC guidelines. National Health and Medical Research Council.
The purpose of this study was to document attitudes and practices of Australian optometrists in their management of diabetic retinopathy prior to the release of the National Health and Medical Research Council (NHMRC) Clinical Practice Guidelines for the Management of Diabetic Retinopathy and at two time points following their release. A self-administered questionnaire was mailed to a stratified random sample of 500 Australian optometrists at the three time points. The same sample was used for the first two surveys and a new random sample was drawn for the second follow-up survey. The response to the three questionnaires was 86%, 80% and 84%, respectively. More than 90% of optometrists reported receiving a copy of the guidelines and 82% reported receiving the supplementary Retinopathy Chart. Fifty-seven per cent reported having read the guidelines at least once in entirety and 65% reported that they refer to the Retinopathy Chart at least monthly in their clinical practice. There was a significant decrease in the number of optometrists who reported that patient unwillingness to be dilated and their fear of precipitating angle closure glaucoma were moderate or major barriers to performing dilated ophthalmoscopy. Concomitantly, the percentage of optometrists who reported that they often or always perform dilated ophthalmoscopy on new patients with diabetes increased significantly from 74.5% (95% confidence limit = 70.2, 78.8) to 81.5% (95% confidence limit = 77.5, 85.5). There have been some significant changes in the self-reported management practices of optometrists in relation to diabetic retinopathy since the release of the NHMRC guidelines and Retinopathy Chart.
Attitude to Health↗
Undergraduate ophthalmology education survey of New Zealand ophthalmologists, general practitioners and optometrists.
AIM: To determine what New Zealand ophthalmologists, general practitioners and optometrists consider important ophthalmic topic areas requiring emphasis in the medical undergraduate curriculum. METHOD: A total of 793 questionnaires related to the content and teaching of undergraduate ophthalmology were sent to ophthalmologists, general practitioners and optometrists. Results were analysed separately for the three respondent groups and as a whole. RESULTS: Four hundred and fourteen questionnaires were returned (52% return rate). Overall responses of the three participant groups were similar and agreed favourably with the current curriculum. The ability to measure visual acuity (97%) and pupillary reflexes (93%), perform ophthalmoscopy (92%), and assess visual fields (68%) were regarded as 'important or essential' by the majority of respondents. Only 53% of respondents consider the ability to diagnose chronic open angle glaucoma as important. The respondents stressed the importance of the diagnosis of predominantly anterior segment disease contrasting with the traditional bias towards the teaching of ophthalmoscopy and posterior segment disease. The majority of respondents stressed the importance of graduating medical students being able to treat bacterial and allergic conjunctivitis, styes, blepharitis, corneal abrasion, and corneal and conjunctival foreign bodies, areas present but not normally emphasized in current curricula. CONCLUSION: The findings of this study provided additional data to facilitate curriculum design and illustrated the value of an integrated problem-based learning approach in ophthalmology undergraduate teaching.
Clinical Competence↗
Diabetic retinopathy: effects of national guidelines on the referral, examination and treatment practices of ophthalmologists and optometrists.
OBJECTIVE: To investigate the changes in referral, examination and treatment practices for diabetic retinopathy by ophthalmologists and optometrists following the release of national guidelines. METHODS: A two-page self-administered questionnaire was mailed to all Australian ophthalmologists and a random sample of 500 Australian optometrists prior to and 1 year after release of the National Health and Medical Research Council of Australia (NHMRC) clinical practice guidelines for the management of diabetic retinopathy. The questionnaires elicited information about current practice related to the management of patients with diabetic retinopathy. RESULTS: Of the 464 contactable ophthalmologists who responded to the baseline survey, 374 (80.6% response) completed the follow-up survey The response rate for the contactable optometrists was 80.1% (310 of 384). There were almost no significant changes in management practices from baseline to follow up. For example, the percentage of ophthalmologists who reported that they were often or almost always confident in detecting moderate retinal thickening near the macula remained nearly identical from baseline to follow up (80.2% vs 79.1 %). The rate was also similar from baseline to follow up for optometrists (31.1% vs 28.8%). The one area in which ophthalmologists reported significant changes in management towards agreement with the NHMRC guidelines was use of angiography; they were less likely to manage their patients this way (20.4% vs 14.2% with laser and 48.9% vs 38.4% without laser for increasing level of severity in clinical signs; both P < 0.05). CONCLUSIONS: The NHMRC guidelines for diabetic retinopathy have been successfully distributed to ophthalmologists and optometrists in Australia. However, the mere provision of the guidelines has had little impact on management practices. It will be important to determine if ongoing dissemination and implementation strategies not only increase awareness of health-care practitioners to the guidelines, but also change behaviours.
Adolescent↗
Closing the gaps between urban and rural eye health and eye care services.
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Australia↗
Eye health in rural Australia.
A review of the current literature relating to eye health in rural Australia was conducted. Few studies have been undertaken, with most information provided by the Australian Institute of Health and Welfare databases, The National Trachoma and Eye Health Program of 1980 and the Visual Impairment Project in Victoria in the mid 1990s. Key findings were that the rural population has an increased prevalence of pterygium, cataract, ocular trauma and glaucoma, but no difference in refractive error or diabetic retinopathy (although data are limited). Rural residents are more likely to have seen an optometrist but less likely to have seen an ophthalmologist. Interventions have been undertaken in ophthalmologist training to increase the rural workforce and tele-ophthalmology to provide city-based metropolitan ophthalmological support for rural practitioners. Further epidemiological data and evaluated interventions are urgently required to help identify and address the needs of rural Australian communities.
Australia↗
Evaluation of a district-wide screening programme for diabetic retinopathy utilizing trained optometrists using slit-lamp and Volk lenses.
BACKGROUND: Debate exists about the optimum way to screen for diabetic retinopathy. Cameras produce a permanent record, but offer patients less choice about when and where to be screened. Optometrists offer flexibility but sensitivity and specificity of schemes have varied considerably, perhaps because of variability in screening methodology and that there is frequently no quality assurance programme. AIMS: To audit our district-wide (population 340000) screening programme for diabetic retinopathy against national targets: sensitivity > 80%, specificity > 95% and referral to review < 3 months. METHODS: Trained optometrists performed slit-lamp examination with Volk lenses (78 dioptre) with standardized reporting. Audit was by ophthalmologist with slit-lamp and Volk lenses through dilated pupils. RESULTS: We examined 872 eyes of 439 patients; 64% were normal, 29% background diabetic retinopathy, 7% sight-threatening eye disease (STED). Sixty-three percent of patients were seen within 6 months of the original screen. Of these, sensitivity for any retinopathy was 72%, specificity 77%, positive predictive value (PPV) 53%, negative predictive value (NPV) 88%. For STED, in this group, sensitivity was 87% and specificity 91%, PPV 30%, NPV 99%. Median interval referral to ophthalmological review was 11.5 weeks with 73% reviewed in under the 13-week target. Of those referred 25% received laser therapy. Eleven patients found to have referable eye disease at their initial screen were not referred to an ophthalmologist by their GP. CONCLUSIONS: We conclude that effective district-wide screening for diabetic retinopathy by optometrists using slit-lamp and Volk lenses is possible; however, only 36% of identified people with diabetes in the district were screened over a 4-year period.
Diabetic Retinopathy↗
A comparative evaluation of digital imaging, retinal photography and optometrist examination in screening for diabetic retinopathy.
AIMS: To compare the respective performances of digital retinal imaging, fundus photography and slit-lamp biomicroscopy performed by trained optometrists, in screening for diabetic retinopathy. To assess the potential contribution of automated digital image analysis to a screening programme. METHODS: A group of 586 patients recruited from a diabetic clinic underwent three or four mydriatic screening methods for retinal examination. The respective performances of digital imaging (n=586; graded manually), colour slides (n=586; graded manually), and slit-lamp examination by specially trained optometrists (n=485), were evaluated against a reference standard of slit-lamp biomicroscopy by ophthalmologists with a special interest in medical retina. The performance of automated grading of the digital images by computer was also assessed. RESULTS: Slit-lamp examination by optometrists for referable diabetic retinopathy achieved a sensitivity of 73% (52-88) and a specificity of 90% (87-93). Using two-field imaging, manual grading of red-free digital images achieved a sensitivity of 93% (82-98) and a specificity of 87% (84-90), and for colour slides, a sensitivity of 96% (87-100) and a specificity of 89% (86-91). Almost identical results were achieved for both methods with single macular field imaging. Digital imaging had a lower technical failure rate (4.4% of patients) than colour slide photography (11.9%). Applying an automated grading protocol to the digital images detected any retinopathy, with a sensitivity of 83% (77-89) and a specificity of 71% (66-75) and diabetic macular oedema with a sensitivity of 76% (53-92) and a specificity of 85% (82-88). CONCLUSIONS: Both manual grading methods produced similar results whether using a one- or two-field protocol. Technical failures rates, and hence need for recall, were lower with digital imaging. One-field grading of fundus photographs appeared to be as effective as two-field. The optometrists achieved the lowest sensitivities but reported no technical failures. Automated grading of retinal images can improve efficiency of resource utilization in diabetic retinopathy screening.
Adolescent↗
Keratometric variation: the influence of a fluid layer.
Variation of keratometric measurements on an approximately spherical surface on a polymethyl methacrylate (PMMA) button is compared to keratometric variation on the PMMA button after the application of an artificial solution. The variation is shown by means of scatter plots in a three-dimensional space, as well as quantitatively in the form of variance-covariance matrices. The wet button showed variances a factor of more than 1000 times that of the dry button. This suggests that the precorneal tear film could be an important, often-overlooked contributing factor to keratometric variation in the case of the eye.
Humans↗
Repeatability of measurements of interpupillary distance.
The purpose of this study was to determine inter- and intra-examiner repeatability of measurements of interpupillary distance (IPD). Three methods were used: Viktorin's, corneal reflection, and pupillometer. In Experiment 1, an experienced optometrist measured IPD on forty-nine subjects, on two occasions, using each method. In Experiment 2, thirty-five optometrists measured the IPD of one subject, on one occasion only, using the same three methods. The results of Experiment 1 showed that measurements of IPD differed depending on the method used, although the differences were small. The 95% limits of agreement were largest with Viktorin's method and least with the pupillometer. The results of Experiment 2 also revealed a small difference in IPD between the three methods of measurement. As in Experiment 1, the 95% limits of agreement were greatest with Viktorin's method and least with the pupillometer. Small differences in IPD were found between Viktorin's, corneal reflection and pupillometer methods of measurement. Not surprisingly, inter-examiner repeatability was slightly poorer than intra-examiner repeatability. However, the differences were small enough not to be clinically significant for the majority of patients.
Analysis of Variance↗
Positive predictive value of optometrist-initiated referrals for glaucoma.
A study was conducted at the Moorfields Community Eye Clinic at Ealing Hospital to determine the positive predictive value (ppv) of optometric referrals for suspected glaucoma. The information reported in the referrals and the reasons given for referral were also assessed and evaluated in relation to the ppv. Information was gathered through prospective analysis of patient clinic notes. Ninety patients were referred over a six-month period of which 87 fulfilled the inclusion criteria. The optometrist referral letters for 79 of these patients were supplied by the GP. Results indicate a ppv of 0.43. The reason for referral in the majority of cases (48%) was raised IOP alone. However the most frequently reported mode of practice was a combination of disc and IOP assessment (57%). In line with other research our study demonstrates that referral accuracy improves as the number of suspicious findings increases. In addition those referrals reporting all three tests (IOP measurement, optic disc assessment and perimetry) are shown to have the highest ppv.
Adult↗
An extended role for the hospital optometrist.
The management of patients within shared care programmes would seem to have significant benefits in terms of individuals' convenience, addressing resource needs and expanding professional horizons. To date, these schemes have typically concentrated on the monitoring of patients with diabetes and glaucoma. At Moorfields Eye Hospital, we attempted to develop the role of the hospital optometrist by establishing a study to evaluate the clinical appraisal of new referrals in a busy out-patient clinic. The results showed a high level of diagnostic accuracy which suggests that the role of hospital optometrists may be successfully extended to include some aspects of patient evaluation not typically undertaken.
Adolescent↗
Response AC/A ratios are elevated in myopic children.
In children little is known about the relationship between the AC/A ratio and the development of myopia, although they have been linked in adults. The purpose of this study was to investigate the interaction between accommodation and convergence and its relationship to refractive errors in children. Accommodation was measured for the right eye using the Canon R-1 autorefractor, and concomitant changes in vergence were assessed using a Maddox rod and a Risley prism before the left eye. Thirty-three myopic and 68 emmetropic children were tested wearing best subjective correction while looking at a distant (4.0 m) letter array and a near (0.33 m) one through additional plus and minus lenses. Lens-induced and distance-induced response AC/A ratios were calculated from the data. Both types of AC/A ratios are elevated in myopic children, who show reduced accommodation and enhanced accommodative convergence. Myopic children with esophoria underaccommodate at near. This suggests that a child who is esophoric must relax accommodation to reduce accommodative convergence and maintain single binocular vision. The reduction in accommodation could produce blur during near work, which could induce myopia as in animal models.
Accommodation, Ocular↗
Accommodation to static chromatic simulations of blurred retinal images.
The eye's longitudinal chromatic aberration (LCA) is known to drive 'reflex' accommodation to moving objects, but the evidence is not as clear for stationary objects. The present study examined whether accommodation can be driven by static simulations of the effects of defocus and LCA. Accommodation was recorded continuously while each of 12 subjects viewed images (through a 0.75 mm pinhole) that simulated the appearances of blurred sine wave gratings (3.9 c.p.d.). In two experimental conditions, an eye with normal LCA was assumed and defocus of +1 D or -1 D was simulated. In a control condition, an eye with neutralised LCA was assumed and target defocus of 1 D was simulated. Subjects' accommodation responses were consistent with the hypothesis that LCA provides a stimulus to accommodation. Chromatic aberration drives accommodation to both moving and stationary objects, and thus is an important stimulus for accommodation in everyday situations. The study findings are discussed in relation to colour vision, visual display terminals and emmetropization.
Accommodation, Ocular↗
A review of the management of 323 consecutive patients seen in a specific learning difficulties clinic.
Visual correlates of specific learning difficulties (SpLD) include: binocular instability, low amplitude of accommodation, and Meares-Irlen Syndrome. Meares-Irlen Syndrome describes asthenopia and perceptual distortions which are alleviated by using individually prescribed coloured filters. Data from 323 consecutive patients seen over a 15 month period in an optometric clinic specialising in SpLD are reviewed. Visual symptoms and headaches were common. 48% of patients were given a conventional optometric intervention (spectacles, orthoptic exercises) and 50% were issued with coloured filters, usually for a trial period. 40% of those who were given orthoptic exercises were later issued with coloured overlays. 32% of those who were issued with coloured overlays were ultimately prescribed Precision Tinted lenses. Approximately half the sample were telephoned more than a year after the last clinical appointment. More than 70% of those who were prescribed Precision Tints were still wearing them daily, and results for this intervention compared favourably with data for non-tinted spectacles. The data suggest that many people with SpLD need optometric care and that the optometrist needs to be skilled in orthoptic techniques and cognisant of recent research on coloured filters.
Accommodation, Ocular↗
Referrals to the Glaucoma Clinic of the Royal Infirmary of Edinburgh.
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Glaucoma, Open-Angle↗
The effect of monochromatic aberrations on Autoref R-1 readings.
The Canon Autoref R-1 is used extensively to investigate aspects of the accommodation response of the human eye. The measurement zone of the Autoref R-1 is known to lie outside the central pupil and the instrument's readings are therefore potentially influenced by the monochromatic aberrations of the eye. Since these aberrations are known to change as a function of accommodation, the error associated with the aberrations might influence the stimulus-response slope. We used masks and contact lenses with known amounts of spherical aberration to establish the region of the pupil used by the Autoref R-1 in deriving a reading of the refractive power of the eye. This region was estimated to be narrowly centred on a 3.5-mm diameter. The spherical aberration of the eye was measured for five subjects across a range of accommodation levels and used to predict the likely effect upon Autoref R-1 readings. Positive spherical aberration will result in an apparent lead of accommodation, while negative spherical aberration causes an apparent lag of accommodation. For eyes with normal levels of spherical aberration, the slope of the stimulus-response will appear to be marginally flatter when measured with the Autoref R-1. An example of an eye with coma-like aberrations is also shown to produce Autoref R-1 results that will differ significantly from more central refractive measurements.
Accommodation, Ocular↗