The content of optometric eye examinations for a presbyopic patient presenting with symptoms of flashing lights

Background: Standardised patients (SPs) are the gold standard methodology for evaluating clinical care. This approach was used to investigate the content of optometric eyecare for a presbyopic patient who presented with recent photopsia. Methods: A total of 102 community optometrists consented to be visited by an actor for a recorded eye examination. This actor received extensive training to enable accurate reporting of the content of the eye examinations, via an audio recording and a checklist completed for each clinical encounter. The actor presented unannounced (incognito) as a 59‐year‐old patient seeking a private eye examination and complaining of recent onset flashing lights. The results of each clinical encounter were recorded on a pre‐designed checklist based on evidence‐based reviews on photopsia, clinical guidelines and the views of an expert panel. Results: The presence of the symptom of photopsia was proactively detected in 87% of cases. Although none of the optometrists visited asked all seven gold standard questions relating to the presenting symptoms of flashing lights, 35% asked four of the seven questions. A total of 85% of optometrists asked the patient if he noticed any floaters in his vision and 36% of optometrists asked if he had noticed any shadows in his vision. The proportion of the tests recommended by the expert panel that were carried out varied from 33 to 100% with a mean of 67%. Specifically, 66% recommended dilated fundoscopy to be carried out either by themselves or by another eyecare practitioner, and 29% of optometrists asked the patient to seek a second opinion regarding the photopsia. Of those who referred, 70% asked for the referral to be on the same day or within a week. Conclusion: SP encounters are an effective way of measuring clinical care within optometry and should be considered for further comparative measurements of quality of care. As in research using SPs in other healthcare disciplines, our study has highlighted substantial differences between different practitioners in the duration and depth of their clinical investigations. This highlights the fact that not all eye examinations are the same but inherently different and that there is no such thing as a ‘standard sight test’. Future optometric continuing education could focus on history taking, examination techniques and referral guidelines for patients presenting with symptoms of posterior vitreous detachment, retinal breaks and secondary retinal detachment.     

How well does record abstraction quantify the content of optometric eye examinations in the UK?

Background: A recent review found standardised patient (SP) methodology to be the gold standard method for evaluating clinical care. We compared the clinical records describing the content of optometric eye examinations with the actual content, as revealed by SPs. Methods: We recruited 111 community optometrists in the South East of the UK who consented to be visited by unannounced actors for an eye examination. The actors received extensive training to enable accurate reporting of the content of the eye examinations, via an audio recording and a checklist completed for each clinical encounter. Each participating optometrist was visited by three standardised patients. Upon completion of the standardised patient visits, copies of the clinical records were requested. Using the SP findings as the gold standard, the information gathered from the clinical record was classified for each quality criterion as true positive (reported by SP and documented on the record card), false negative (reported by SP but not documented on the record card), false positive (not reported by SP but recorded on the record card) and true negative (not reported by SP and not recorded on the record card). Results: Compared to the gold standard, false positives were identified during record abstraction in 4% of cases and false negatives in 18% of cases. For symptoms and history, the proportion of false negatives ranged from 15% to 25% and 3 to 4% for false positives. The proportion of false negatives for tests performed during the eye examinations ranged from 12% to 22% and false positives ranged from 2% to 6%. Optometrists give patients more verbal advice than is indicated in their records (false negatives, 11–19%). Five to 15% of practitioners recorded patient management and advice that was not reported by the SPs. Conclusions: Our findings regarding optometric consultation mirror the findings in other healthcare disciplines: clinical records are an imperfect representation of the content of a clinical consultation. Clinical records are subject to a recording bias leading to both under‐ and over‐estimation of the care provided due to the presence of false negatives and false positives. This study has important implications for clinico‐legal cases, where clinical records are a key item of evidence; and our findings indicate that accurate record‐keeping should be a priority for optometric continuing education.     

A comparison of standardised patients,record abstraction and clinical vignettes for the purpose of measuring clinical practice

Background: A recent review found standardised patient (SP) methodology to be the gold standard method for evaluating clinical care. Alternative methods include record abstraction and computerised clinical vignettes. SPs were compared to clinical records and to computerised vignettes in order to assess whether record abstraction and vignettes are accurate measures of clinical care provided within optometry. Methods: A total of 111 community optometrists in the south east of the UK consented to be visited by unannounced actors for an eye examination. The SPs received extensive training to enable accurate reporting of the content of the eye examinations using checklists. Clinical records were requested from optometrists who chose to receive feedback following the SP visits. The SP checklists were used as a guide to extract relevant information from the clinical records. An opportunity was made available to all UK qualified optometrists, through publicity in the College of Optometrists’ monthly newsletter, the Association of Optometrists’ monthly newsletter (Blink) and the UK optometry e‐mail discussion list to complete three computerised clinical vignettes by performing a virtual eye examination using an on‐line optometric record card. The average differences were calculated between the record abstraction and vignette results compared to the standardised patient encounter findings for different domains of an eye examination. Chi‐square analyses were performed on the tests which were of the greatest clinical significance for each scenario. Results: The average overall difference for information gathered from record abstraction compared to the standardised patient encounter ranged from +2 to ?26% (positive values indicate items that were recorded on the clinical records but not reported by the SP). For history and symptoms, the average difference ranged from ?9 to ?26%; for the proportion of tests performed during the examination this value ranged from +2 to ?24% and for management issues the difference ranged from ?1 to ?4%. The average overall difference for the vignette data compared to the standardised patient encounter ranged from 0 to +26% (positive values indicate items that were not carried out in a clinical setting, as recorded by the SP, but were described by optometrists who completed the vignette as tests they would have carried out). For history and symptoms, the average difference for the vignette data ranged from +2 to +26%; from 0 to +20% for tests performed during the eye examination and from 0 to +11% for management. Conclusion: Different methods of measuring clinical care capture different elements of clinical practice and are prone to different biases. This three‐way comparison indicates that clinical records tend to under‐estimate actual care provided, while vignette scores tend to over‐estimate clinical performance. Low participation rates mean that the participating optometrists could be described as a ‘self‐selected sample’. This is a limitation of the research and the conclusions should be considered with this in mind. The significance of these findings for future research and for litigation and disciplinary cases is discussed.     

The effectiveness of interventions for optometric referrals into the hospital eye service: A review

Purpose

Ophthalmic services are currently under considerable stress; in the UK, ophthalmology departments have the highest number of outpatient appointments of any department within the National Health Service. Recognising the need for intervention, several approaches have been trialled to tackle the high numbers of false-positive referrals initiated in primary care and seen face to face within the hospital eye service (HES). In this mixed-methods narrative synthesis, we explored interventions based on their clinical impact, cost and acceptability to determine whether they are clinically effective, safe and sustainable. A systematic literature search of PubMed, MEDLINE and CINAHL, guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), was used to identify appropriate studies published between December 2001 and December 2022.

Recent Findings

A total of 55 studies were reviewed. Four main interventions were assessed, where two studies covered more than one type: training and guidelines (n = 8), referral filtering schemes (n = 32), asynchronous teleophthalmology (n = 13) and synchronous teleophthalmology (n = 5). All four approaches demonstrated effectiveness for reducing false-positive referrals to the HES. There was sufficient evidence for stakeholder acceptance and cost-effectiveness of referral filtering schemes; however, cost comparisons involved assumptions. Referral filtering and asynchronous teleophthalmology reported moderate levels of false-negative cases (2%–20%), defined as discharged patients requiring HES monitoring.

Summary

The effectiveness of interventions varied depending on which outcome and stakeholder was considered. More studies are required to explore stakeholder opinions around all interventions. In order to maximise clinical safety, it may be appropriate to combine more than one approach, such as referral filtering schemes with virtual review of discharged patients to assess the rate of false-negative cases. The implementation of a successful intervention is more complex than a ‘one-size-fits-all’ approach and there is potential space for newer types of interventions, such as artificial intelligence clinical support systems within the referral pathway.     

A survey of the availability of state-funded primary eye care in the UK for the very young and very old

BACKGROUND: The National Health Service (NHS) provides General Ophthalmic Services (GOS) to eligible patients in the UK. Nearly all community optical practices have a contract with the NHS via local primary care organisations (primary care trusts in England) allowing the practices to provide NHS sight tests to eligible patients. OBJECTIVE: To determine the accessibility of GOS sight tests for certain groups of patient in the UK. METHOD: A telephone survey was carried out to investigate the availability of GOS sight tests for two categories of eligible patient. A total of 200 primary eye care practices were randomly selected, of which 100 were telephoned to establish the availability of a sight test for a child aged 1 year whose mother is concerned due to the presence of a family history (parental) of strabismus. The other 100 practices were telephoned to investigate the availability of a sight test for a person aged 90 years who was described as having dementia. RESULTS: A total of 199 of the 200 practices provided GOS sight tests. The mean age at which practices declared that they start examining children was 3.1 years. Most (76%) practices recommended an eye examination for the 1-year-old child, but only 46% said that they would carry this out themselves. Of the other 100 practices telephoned across the country, 93% said that they could arrange an eye examination for the patient with dementia. DISCUSSION: Of the UK optical practices that participated in this study, 99.5% provide GOS sight tests. About half of these would not offer a GOS sight test to a 1-year-old child. It has been suggested that the GOS Terms of Service do not permit practitioners to exclude categories of patients from GOS services, although we argue that this interpretation is equivocal. Indeed, it is suggested that clinical and ethical reasons may sometimes require practitioners to decline to examine certain categories of patient. It is worrying that one quarter of practices did not recommend an eye examination for a young child with a family history of strabismus. It is hoped that a continuing education and training project will increase interest in paediatric optometry.     

VEP验光技术研究及法医学应用

目的:通过VEP验光结果与电脑验光结果的比较,评价VEP验光技术在眼外伤法医学鉴定中的应用价值。方法:通过对50例86眼不同程度的屈光不正依次行电脑验光和VEP验光,将两种方法所得的结果进行比较分析。结果:VEP验光与电脑验光结果比较无显著性差异。两者差值约有66.1%在0～0.25D之间;约有51.2%的电脑验光结果高于VEP验光结果。结论:在眼损伤的法医学鉴定中,VEP验光技术可以作为一种客观评价受检者屈光不正程度的验光手段。     

Measuring clinical practice

The goals of this paper are to review techniques for measuring clinical practice within healthcare professions and to discuss possible applications of these techniques to primary care optometry. A review of the literature suggests a lack of systematic research investigating standards of clinical practice within optometry. It is argued that evidence‐based research to determine the content of typical optometric eye examinations would be valuable for several reasons: to evaluate the service provided to the public by the profession; setting priorities and assessing the outcomes of continuous education and training; to influence governmental and professional policy decisions; National Health Service General Ophthalmic Services issues; the equitable management of clinicolegal matters and consumer complaints; setting appropriate professional guidelines and developing undergraduate training. Evidence‐based studies within other healthcare professions have evaluated the content of clinical consultations. The literature reviewed reveals three main approaches: (1) abstraction of medical records, (2) use of clinical vignettes and (3) use of standardized patients (SPs) who present unannounced to clinics. In this review, we compare and contrast the use of these different methods in assessing the content of clinical consultations. It is clear from the literature reviewed that the use of SPs is the ‘gold standard’ methodology. Clinical vignettes can also provide useful data, especially if computerized.     

The role of optometrists in India: An integral part of an eye health team

India has a proud tradition of blindness prevention, being the first country in the world to implement a blindness control programme which focused on a model to address blinding eye disease. However, with 133 million people blind or vision impaired due to the lack of an eye examination and provision of an appropriate pair of spectacles, it is imperative to establish a cadre of eye care professionals to work in conjunction with ophthalmologists to deliver comprehensive eye care. The integration of highly educated four year trained optometrists into primary health services is a practical means of correcting refractive error and detecting ocular disease, enabling co-managed care between ophthalmologists and optometrists. At present, the training of optometrists varies from two year trained ophthalmic assistants/optometrists or refractionists to four year degree trained optometrists. The profession of optometry in India is not regulated, integrated into the health care system or recognised by the majority of people in India as provider of comprehensive eye care services. In the last two years, the profession of optometry in India is beginning to take the necessary steps to gain recognition and regulation to become an independent primary health care profession. The formation of the Indian Optometry Federation as the single peak body of optometry in India and the soon to be established Optometry Council of India are key organisations working towards the development and regulation of optometry.     

The future of optometric practice? The results of a survey of optometrists and optometry students

BACKGROUND: There is an apparent increase in the number of private optometry practices that are closing due to a lack of interested buyers. We examined some of the factors that influence the market for optometry practices in a survey of practicing optometrists and third- and fourth-year optometry students. METHODS: Optometrists in six states, and students at four schools and colleges of optometry, completed a mailed or faxed survey regarding attitudes toward optometric practice, including fair/reasonable compensation for a new optometrist, the value of optometric practices, and preferred mode of practice on graduation. RESULTS: Doctors and students differed significantly in the amount of money they reported as fair/reasonable compensation for a recently graduated optometrist joining a practice. Comparing students to doctors in specific categories of compensation, students chose a higher fair/reasonable compensation compared to doctors. Students were more likely than doctors to choose >$70,000 as fair/reasonable compensation, while doctors were more likely than students to choose $40,000 to $69,000. Doctors tended to overvalue their practices for the purpose of selling the practice when using percentage of gross income as a valuation method. Students' choices for mode of practice changed dramatically from their ideal when taking their current financial situation into consideration. Students were more likely to choose corporate practice as their preferred practice mode when considering their current financial situation than when not restricted. CONCLUSIONS: There are many factors that affect the value and marketability of an optometric practice. In order to sell a practice, the owner must consider the effects of the needs and desires of recently graduated optometrists.     

An investigation of barriers and enablers to community eye care for children in England: A qualitative descriptive study

Purpose

Research suggests that there are challenges in the accessibility of eye care for children in England. This study explores the barriers and enablers to eye examinations for children under 5 years of age from the perspective of community optometrists in England.

Methods

Optometrists working in community settings were invited to participate in virtual focus group discussions using an online platform based on a topic guide. The discussions were audio-recorded, transcribed and thematically analysed. Themes were derived from the focus group data based on the study aim and research question.

Results

Thirty optometrists participated in the focus group discussions. The overarching themes identified as barriers to eye examinations for young children in a community setting were as follows: ‘Time and Money’, ‘Knowledge, Skills and Confidence’, ‘Awareness and Communication’, ‘Range of Attitudes’ and ‘Clinical Setting’. The key themes for enabling eye examinations for young children were as follows: ‘Improving behaviour’, ‘Enhancing training and education’, ‘Enhancing eye care services’, ‘Raising awareness’, ‘Changes in professional bodies’ and ‘Balancing commercial pressures and health care’.

Conclusion

Time, money, training and equipment are perceived by optometrists as key factors in providing an eye examination for a young child. This study identified a need for improved training and robust governance related to eye examinations for young children. There is a need for change within eye care service delivery such that all children, regardless of age and ability, are examined regularly, and by conducting these examinations, optometrists remain confident.     

Clinical effectiveness of diquafosol ophthalmic solution 3% in Korean patients with dry eye disease: a multicenter prospective observational study

AIM: To investigate the effectiveness of diquafosol ophthalmic solution 3% administered in Korean patients with dry eye disease in real-world clinical settings. METHODS: Diquafosol was administered for 8wk to 3 patient groups who received diquafosol as add-on therapy to existing medication (Add group, n=150); received diquafosol only (Monotherapy group, n=196); or discontinued part of their existing medication in favor of diquafosol (Switch group, n=11). Tear break-up time (TBUT), cornea and conjunctival staining based on National Eye Institute/Industry scoring scheme, subjective symptoms using the Ocular Surface Disease Index (OSDI) questionnaire, and meibum quality and expressibility were evaluated at baseline, week 4, and week 8. RESULTS: The mean TBUT increased (from 3.46, 3.92, and 5.84s, respectively, to 5.15, 5.53, and 8.59s, respectively) and corneal staining score decreased (from 2.23, 2.24, and 3.09, respectively, to 0.85, 0.97, and 1.64, respectively) in a time-dependent manner from baseline to week 8 in all three groups. Conjunctival staining score, OSDI questionnaire, and meibum quality and expressibility improved over time from baseline to week 8 in the Add and Monotherapy groups, but differences were not statistically significant in the Switch group. CONCLUSION: Diquafosol improves subjective symptoms and objective signs in patients treated with existing medicines combined with diquafosol and treated solely with diquafosol. Diquafosol can be used as an effective therapeutic agent for dry eye disease or additionally applied in patients who have insufficient response to existing medicines.     

盐酸环喷托酯滴眼液在远视儿童散瞳验光中的应用

目的：研究盐酸环喷托酯滴眼液在远视儿童散瞳验光中的综合应用效果。方法：选取2014－02／2015－03于本院进行散瞳验光的84例远视儿童为研究对象,将其分别采用托吡卡胺和盐酸环喷托酯滴眼液进行散瞳验光,然后将两种方法的屈光度结果、给药前及给药后不同时间的瞳孔直径及残余调节量进行比较,并比较两种方法中不同严重程度者的检查结果。结果：两种检查方法的屈光度检查结果、给药前的瞳孔直径及残余调节量无统计学差异（P＞0．05）,而给药后20、40、60 min及24 h盐酸环喷托酯滴眼液的残余调节量均小于托吡卡胺（P＜0．05）,给药后60min两种方法的瞳孔直径无统计学差异（P＞0．05）,给药后48h两种方法的瞳孔直径均与给药前无统计学差异（P＞0．05）。结论：盐酸环喷托酯滴眼液在远视儿童散瞳验光中的综合应用效果较好,对于睫状肌麻痹的效果尤为明显。     

Integrated model of primary and secondary eye care for underserved rural areas: The L V Prasad Eye Institute experience

Blindness is a major global public health problem and recent estimates from World Health Organization (WHO) showed that in India there were 62 million visually impaired, of whom 8 million are blind. The Andhra Pradesh Eye Disease Study (APEDS) provided a comprehensive estimate for prevalence and causes of blindness for the state of Andhra Pradesh (AP). It also highlighted that uptake of services was also an issue, predominantly among lower socio-economic groups, women, and rural populations. On the basis of this analysis, L V Prasad Eye Institute (LVPEI) developed a pyramidal model of eye care delivery. This article describes the LVPEI eye care delivery model. The article discusses infrastructure development, human resource development, and service delivery (including prevention and promotion) in the context of primary and secondary care service delivery in rural areas. The article also alludes to opportunities for research at these levels of service delivery and the amenability of the evidence generated at these levels of the LVPEI eye health pyramid for advocacy and policy planning. In addition, management issues related to the sustainability of service delivery in rural areas are discussed. The article highlights the key factors required for the success of the LVPEI rural service delivery model and discusses challenges that need to be overcome to replicate the model. The article concludes by noting the potential to convert these challenges into opportunities by integrating certain aspects of the existing healthcare system into the model. Examples include screening of diabetes and diabetic retinopathy in order to promote higher community participation. The results of such integration can serve as evidence for advocacy and policy.