Examining the evidence base used by optometrists in Australia and New Zealand

Background: The optometrist's role in primary eye care is expanding to include not only diagnosis but also management and co‐management of a range of eye diseases and visual disorders. This role calls for evidence‐based practice, including an ability to source and reliably assess the various forms of evidence, on which eye care might be based. It is not known whether optometrists registered to practise in Australasia use high or low quality evidence as a basis for their clinical decisions. Methods: The present study addressed this question by surveying 3,589 optometrists registered to practise in Australia and New Zealand. A 16‐item questionnaire was made available for completion online. Results: Responses from the 279 optometrists who completed the questionnaire (response rate 7.8 per cent) indicate that, after the patient's history, symptoms and signs, optometrists in our sample place most weight on knowledge and information gained via undergraduate and postgraduate education, including continuing education, as a basis for clinical decision‐making. Conclusion: These findings highlight the need for current, critically evaluated content in optometric education and suggest that optometrists currently prefer to receive information and knowledge from an educator rather than sourcing and assessing the material independently.     

Patterns of Practice in Australian Optometry Part III — The influence of education,age, location of practice,and nationality on optometrists' work practices

ABSTRACT: Questionnaires completed by 106 Australian optometrists were used to test predictions concerning four factors (educational qualification, time since graduation, location of practice, nationality) hypothesised to be associated with differing work practices. Comparison of graduates from the Universities of New South Wales and Melbourne indicated that the latter devoted significantly more time to contact lens practice and performed the following procedures more frequently: cover test, measurement of amplitude of convergence and stereopsis, and Bjerrum screen field analysis. Graduates from UNSW had longer consultation times; measured ductions, fixation disparity and visual fields more frequently; and were more likely to perform tonometry and cycloplegic and mydriatic examinations. Comparison of recent graduates with those of more than ten years standing, revealed few significant differences. Older graduates devoted greater time to history taking and were less likely to perform tonometry using a Goldmann probe mounted on a slit lamp. Location of practice influenced some professional activities. Rural optometrists spent a greater proportion of their time carrying out general examinations and less time doing industrial optometry than did urban optometrists. Results of the Australian sample were compared with British data collected by Fox¹. Australians were less likely than British optometrists to measure fixation disparity or to examine versions of older patients.     

The Optometric Management of the Child with Low Vision

ABSTRACT In recent years, optometrists have taken a greater interest in paediatric optometry, yet the optometric management of the child with low vision has received little attention. Optometrists have the fundamental training, clinical expertise and attitudes to manage the paediatric low vision patient effectively. Although visually handicapped children receive specialist medical care from birth or at a very early age, referral to other low vision services frequently does not occur until the child enters the education system. Optometrists in private practice can bridge the gap between medicine and education and improve the quality of paediatric low vision care by understanding the rationale for improvement of efficiency in visual functioning and developing a sincere commitment to extending their involvement with these children beyond the provision of low vision aids.     

The mobility of optometrists practising in Australia in 2005: Do optometry graduates move to states without schools of optometry?

Background: Three schools of optometry in the eastern states of Australia provide optometrists for the entire country. Concerns have been expressed about attracting optometrists to practise in the other states. This paper analyses the source of optometric qualification of optometrists practising in each state, to assess the proportion who have chosen to practise in a state different from that in which they qualified and to determine whether there are gender differences in preparedness to move to a different state. Method: Data on year and school of qualification, primary professional activity and current state or territory of practice were extracted from the Optometrists Association Australia database to determine a profile of place of qualification of optometrists in each state or territory of Australia in 2005. Results: More than 77 per cent of practising optometrists from Australian schools practised in the state where they graduated. The majority of optometrists for the Australian Capital Territory (ACT), South Australia (SA) and Western Australia (WA) were New South Wales graduates; the majority of Tasmanian optometrists were Victorian graduates. Optometrists from overseas accounted for 17.3, 24.6 and 19.9 per cent of optometrists in practice in SA, Tasmania and WA, respectively, but less than 7.5 per cent elsewhere. The highest number of optometrists who had qualified outside Australia practised in NSW. Female graduates from 2000 and later were more likely to move interstate than their male counterparts. Discussion: Approximately 14 per cent of practising optometry graduates practised in states without schools, where 21 per cent of the population resided. This indicates some degree of mobility but the market needs to work further to match supply of optometric services to demand at state level. Further analysis is necessary to determine patterns of graduate movement in the years following graduation, to determine whether movement to different states is short‐ or long‐term.     

The Australian optometric workforce 2005

Background: This paper presents the findings of the Optometrists Association Australia 2005 optometric workforce study. Methods: Data from the association’s database, the Australian Bureau of Statistics, Medicare and the Department of Veterans Affairs were applied to create a profile of the optometric workforce in Australia, including the number of equivalent full‐time optometrists (EFTOs), population to optometrist ratios and workloads. Results: In February 2005, 2,866 (76.7 per cent) of the 3,738 optometrists registered to practise in Australia were in clinical practice. Adjusting for the number of hours worked, there were 2,712 EFTOs in Australia. The ratio of population to EFTO for Australia was 7,016. Ratios were higher in the states without schools of optometry (South Australia 9,413, Western Australia 8,810 and Tasmania 8,172) and in the remote and lightly populated Northern Territory (10,521). The lowest ratio was in New South Wales (6,053). The proportion of women in clinical practice has gradually increased since 1977 and was slightly more than 41 per cent in 2005. The percentage of the profession under the age of 40 years was 48.6. The percentages of female and male optometrists under the age of 50 were 89.3 and 72.5, respectively. On average, female optometrists worked approximately 82 per cent of the hours worked by male optometrists. The average time per week spent on Medicare and Veterans Affairs consultations was 25.8 hours. Conclusions: The profession of optometry in Australia is undergoing considerable change in age and gender make‐up. In 2005, the number of optometrists was adequate for the needs of the Australian population. Further analysis is needed to determine whether the supply of optometrists meets community needs at local levels.     

The Australian optometric workforce 2009

Background: This paper presents the findings of the Optometrists Association Australia 2009 optometric workforce study. Methods: Data from the Association's database, the Australian Bureau of Statistics, Medicare Australia and the Department of Veterans Affairs were applied to create a profile of the optometric workforce in Australia, including the number of optometrists in clinical practice, the number of equivalent full‐time optometrists (EFTOs), population to optometrist ratios and workloads in the states and territories and Australia overall. Results: In July 2009, 3,719 (87.4 per cent) of the 4,255 optometrists registered to practise in Australia were in clinical practice. Adjusting for the number of hours worked, there were 3,664 EFTOs. The ratio of population to EFTO was 5,944:1 overall. Ratios were higher in the states without schools of optometry (South Australia 8,631:1, Western Australia 7,687:1, Tasmania 7,615:1, Australian Capital Territory 7,635:1) and highest in the remote and lightly populated Northern Territory (9,367). The ratios were fewer than 6,200 people per EFTO in states with optometry schools: New South Wales (5,247), Queensland (5,723) and Victoria (6,126). Women comprised 45.3 per cent of the profession, while 45 per cent of the profession was aged under 40 years. The majority of the female (80.7 per cent) and male (60.7 per cent) optometrists were aged under 50 years. On average male and female optometrists worked 40.3 and 32.9 hours per week, respectively. The average time per week spent on Medicare and Veterans Affairs consultations was estimated to be 22.2 hours, varying from 20.1 hours in NSW to 30.6 hours in SA. Conclusions: Population to optometrist ratios indicate that the number of optometrists in 2009 was more than adequate to meet the needs of the community. Further analysis is needed to determine whether the supply of optometrists meets community needs at more local levels.     

The Australian optometric workforce 2005, analysed by local government areas

Background: Previous studies of the Australian optometric workforce have taken a coarse view of the distribution of optometrists, at best comparing concentrations of optometrists in city and country areas and between states and territories. A more discriminating approach recognising the size and variation in population density of the country is necessary for a more realistic insight into the optometric workforce. This study addresses the distribution of optometrists across smaller geographic units, known as local government areas (LGAs). Methods: The number of equivalent full‐time optometrists in each Australian LGA was determined using data from the Optometrists Association Australia database. Data from the Australian Bureau of Statistics and the Australian national health program (Medicare) were applied to determine the demand for services based on age distributions in LGAs and to calculate the adequacy of the number of optometrists. Results: Optometrists are concentrated in areas of high population with capital city regions and their surrounds well‐serviced but with rural and remote LGAs with low populations generally not having optometrists. The highest excesses of optometrists occur in the capital city LGAs of Melbourne, Sydney and Adelaide (64, 60 and 28.4 equivalent full‐time optometrists respectively). The highest deficits occur in Casey (Victoria), Lake Macquarie (New South Wales) and Onkaparinga (South Australia), (‐16.4, ‐15.6 and ‐13.4 equivalent full‐time optometrists, respectively). Conclusions: There are substantial variations in the distribution of optometrists across LGAs in Australia but the variation is often a poor indicator of the ease with which people can access optometric services. In metropolitan areas, people may live close to an optometric practice in a neighbouring LGA. In rural areas, an LGA may appear to have an adequate number of optometrists but some residents may be several hours from the nearest optometrist or the optometric service is provided on a part‐time basis.     

Paediatric Vision and Optometry

ABSTRACT Until recent times remarkably little attention has been paid to the visual problems of children. Few children seek professional eye care, and vision screening services provided by the school health authorities have been shown to be inadequate. National Children's Vision Week (NCVW) in 1979 was the first stage of an AOA programme to inform the public, particularly teachers, of optometrists' unique role in paediatric eye care and the importance of early intervention. The paper presents information resulting from optometry's participation in NCVW, and suggests strongly that all optometrists should be informed as to their responsibilities in paediatric eye care.     

Vision care benefits and optometric services in HMOs

General eye care, although not a required basic health service of federally qualified health maintenance organizations (HMOs), is being offered in virtually all HMOs. Reasons for including vision care benefits and optometric services are presented. Data from the Group Health Association of America and the Department of Health and Human Services demonstrates that HMOs are in fact providing vision care benefits and optometric services. The growth of the independent practice association (IPA) model is significant for optometry as it threatens to limit the scope of optometric practice. New professional problems arise as participating optometrists are constrained from performing the full range of optometric services. In recent years optometry has expanded its scope of licensure and practice to incorporate both diagnostic and therapeutic drugs in its management of visual problems. Managed care and alternate delivery systems, however, may restrict the advances that optometry has made in the legislative arena.     

New Zealand optometrists 2006: demographics,working arrangements and hours worked

Background: Optometry is a regulated health profession in NZ, with limited student places. With 650 registered optometrists in 2005, the optometrist to population ratio was 1 : 6,291 with no apparent national shortage. If optometrists registered in NZ do not actually live there, a workforce shortage is possible. This paper presents findings from the New Zealand Association of Optometrists 2006 workforce survey of members, which aimed to profile the NZ optometric workforce and to explore factors relating to workforce capacity, job stress and future planning. Methods: A questionnaire was developed to collect information on employment status, hours worked and gender distribution of optometrists in New Zealand. It was circulated to 530 active members of the NZ Association of Optometrists representing 86 per cent of the available optometrists. Direct comparisons with the Australian optometric workforce numbers were also undertaken. Results: Of the 243 respondents, 129 (53 per cent) were male. The median age of all respondents was 39 years (46 for males and 34 for females) and 75 per cent of the respondents were aged younger than 50 years. Fifty per cent had practised 15 years or less. Ten per cent of respondents had ‘time‐out’ during their career and this was significantly more likely for females. Nearly half the respondents were self‐employed (46 per cent) and eight per cent worked as locums. Part‐time employees were more likely to be female and males were more likely to be in full‐time self‐employment. Half the group was under 40 (51 per cent), which accounted for 86 per cent of the full‐time salaried arrangements. Those aged 30 to 39 included 52 per cent of the total part‐time salaried workers. The average working week was 34 hours for women and 39 hours for men; the median was 40 hours for both groups. In the typical working week, 80 per cent of an optometrist's time was spent consulting with patients and five per cent was patient‐related paperwork. The distribution of work arrangements was remarkably similar among New Zealand optometrists, New Zealand GPs and Australian optometrists. In 2006, there were 619 optometrists assessed as working in New Zealand. This equated to 544 EFTOs and a ratio of EFTO to population of 1 : 7,517. Conclusions: The New Zealand optometric workforce in 2006 was sufficient to meet the overall population needs. One‐third of optometrists chose to work part‐time and the proportion of female optometrists has increased over the past 15 years. In the face of expected increasing demand for optometric services, a targeted expansion of the workforce appears desirable.     

The measurement of visual acuity in children: an evidence‐based update

Over the past decade, a number of large clinical trials have provided important information relating to the reliability and repeatability of commonly used paediatric tests of vision and their role in the diagnosis and management of paediatric ocular diseases. The aim of this review is to summarise recent findings on the use of paediatric visual acuity tests in clinical practice and to discuss the validity and accuracy of visual acuity measurements in infants and young children. We provide a broad overview of the benefits and challenges of measuring visual acuity in children and then discuss age‐appropriate tests for measuring visual acuity in infants through to school‐age children. We also discuss normative values for visual acuity in each age group and, where possible, provide comparisons of results between tests with a particular focus on the importance of optotype design.     

Visual function in patients with choroidal neovascularization resulting from age-related macular degeneration: the importance of looking beyond visual acuity.

PURPOSE: A detailed understanding of overall quality of vision may help primary care physicians, optometrists, and general ophthalmologists to improve the care of patients with choroidal neovascularization (CNV) resulting from age-related macular degeneration (AMD). METHODS: Published literature was reviewed using Medline searches and the authors' knowledge of the field. RESULTS: Both visual acuity and contrast sensitivity are strongly associated with the ability to perform vision-related activities of daily living. CNV resulting from AMD often leads to scotoma, which is also strongly associated with the ability to perform everyday activities such as reading and driving. Contrast sensitivity and visual field extent may be better predictors of many abilities than visual acuity. Laser photocoagulation, verteporfin therapy, and pegaptanib sodium have been proven to reduce the risk of visual acuity loss in patients with CNV resulting from AMD. Laser photocoagulation frequently causes scotoma, but data on its effects on other aspects of overall quality of vision are scarce. Verteporfin therapy has been shown to also reduce the risk of contrast sensitivity loss and has been associated with stabilization or reduction of scotoma size. Treatment effects beyond visual acuity have not been investigated for pegaptanib. Detailed assessment of overall quality of vision also aids the design of vision rehabilitation programs tailored to the needs of individual patients. CONCLUSIONS: Understanding the impact of vision loss on patients with CNV resulting from AMD and assessing treatment benefits requires assessment of overall quality of vision. Primary care physicians and optometrists have an important role in ensuring that patients receive the best possible care, which can be aided by prompt referral to an ophthalmologist or retina specialist and collaboration with low-vision specialists and optometrists who together can make detailed assessments of overall quality of vision, implement appropriate treatment, and design effective rehabilitation strategies.     

Management of patients with age-related cataracts: a survey of Oklahoma optometrists

Many advances have been made in recent years in the treatment of patients with cataracts, particularly in the area of aphakic vision correction. In this study, 60 optometrists were surveyed about their role in the management of patients who have cataracts significantly affecting vision. It was found that over 90% of the optometrists surveyed attempted to educate their patients about cataracts, cataract surgery, and alternatives for aphakic vision correction. However, these optometrists felt least knowledgeable about intraocular lens implants, the most common form of aphakic vision correction used today. It is recommended that the optometrist keep abreast of advances in the fields of cataract management and aphakic vision correction to provide patients with state of the art optometric care.     

Understanding the Low Vision Patient

ABSTRACT Over the past decade, the role of optometry in low vision care has steadily increased. Unfortunately many optometrists feel they lack the skills to fully service these patients. A functional classification of the visual losses and the aids prescribed for low vision patients has been prepared to encourage and assist the practitioner dealing with such patients.     

Low vision services provided by optometrists in Victoria,Australia

Background: Utilisation of low vision services remains low in Australia. This study investigates low vision service provision by optometrists in Victoria and assesses the optometric human resource potential. Methods: An eight‐item questionnaire was sent to 1,050 optometrists in Victoria in December 2006. It investigated key characteristics of the optometrists and their practices, the extent of their low vision training and service provision and the influence of Medicare item 10942 on low vision service provision. Results: Although only 97 replies were received they represented a significant proportion of optometrists who had undertaken postgraduate training in low vision. Almost 86 per cent of respondents worked in private practice settings. Although 87.6 per cent and 30.9 per cent had undergraduate and postgraduate low vision training, respectively, only 63.9 per cent of all respondents reported that they provided low vision services. The majority who replied to the impact of Medicare item 10942 question indicated that its introduction had not changed their low vision provision. Those who did not provide low vision services reported referrals to other low vision services as their main reason for not doing so. Conclusions: The majority of respondents represent a potential source of low vision service providers. Further work needs to explore their possible involvement in low vision care.     

Optometric practice in Norway: a cross-sectional nationwide study

PURPOSE: To describe optometric practitioners and their encountering patients. METHODS: All members of the Norwegian Association of Optometrists working in the community (n = 761) were invited to participate in a questionnaire survey; questionnaire responders (n = 508) were asked to take part in a practice registration. Data collection was carried out between November 2004 and May 2005 using a questionnaire and a practice registration form. RESULTS: Five hundred and eight optometrists responded to the questionnaire; of these 212 participated in the practice registration, in which 4052 patient encounters were recorded. All optometrists reported taking patient history in the areas of vision and ocular health; 55% asked questions about general health for all patients. More than 80% collaborated with general practitioners and ophthalmologists. The patient encounters were with 1699 men and 2216 women; 60% of patients were aged 45 years or older. Patients reported a history of ocular disease and other conditions of relevance for ocular health in 12% and 17% of encounters, respectively. One per cent had low vision [best corrected visual acuity (BCVA) < 0.33] and 2% were visually impaired (BCVA < 0.5). Ophthalmoscopy was performed for 88% of patients; dilated fundus examinations were carried out for 2%; clinical findings of cataract were reported for 11%; and retinopathy was suspected in 3%. Six per cent of patients were referred to a general practitioner or ophthalmologist. CONCLUSION: Optometrists generally collaborate with general practitioners and ophthalmologists. They take history, investigate and assess patients with ocular problems. A significant number of patients had primary or secondary ocular disease. This illustrates the role of optometrists as healthcare workers.     

Penetrating eye injuries in rural New South Wales

Purpose: To determine the epidemiology and outcomes of penetrating eye injuries in a rural Australian setting. Methods: A retrospective study of an 11 year period to identify 77 cases of penetrating eye injury in Lismore, New South Wales. Results: The commonest cause of penetrating eye injury was fencing wire followed by hammering metal. The average age was 32.6 years, and males were involved in 88% of cases. A final visual acuity of 6/12 or better was achieved in 61% of cases. Enucleation was performed in 14%. Visual outcome was best for wounds involving the cornea only. Conclusions: Penetrating eye injuries are potentially devastating to vision, but with modern surgical techniques patients are likely to achieve reasonable vision. Prevention requires education to ensure adequate protective measures are taken in potentially hazardous settings.     

Reading with low vision: the impact of research on clinical management*

The past 40 years has seen a great expansion in low‐vision research, which has changed low‐vision teaching and our clinical management of people with low vision. Australian optometrists have contributed significantly to this research and the development of multidisciplinary low‐vision services. This paper reviews the research that has shaped our clinical assessment and patient management for reading by adults with low vision. The major improvements in clinical assessment of low vision for reading were brought about by the improvements in distance and near visual acuity measurements during the 1970s and research during the 1980s and 1990s showing the factors affecting the reading rate. These changes, together with a different method for representing the magnification provided by optical and electronic systems, allows a scientific, logical and practical method for prescribing magnification. An illustration of the step‐by‐step approach for prescribing magnification for low‐vision reading that is easy to apply in any clinical practice is included.     

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.