Detection of vision impairment in people admitted to aged care assessment centres

Vision is not routinely tested when the health of older people is assessed, and the aim of this study was to detect older people with vision impairment for referral to appropriate eye care services. People admitted for assessment and or rehabilitation in three aged care assessment centres had distance and near visual acuity assessed with a simplified vision test. A pinhole test was used when necessary. Referral criteria were distance visual acuity of less than 6/12; near vision of less than N8, and people with diabetes who had not attended a dilated fundus examination in the last 2 years. Visual acuity results were obtained in 93% of patients (685/735). Those unable to perform the vision test were very ill or had severe cognitive impairment. Forty-three per cent of patients (266/646) had impaired vision and, of these, 70.6% (188/266) were referred to eye care specialists. Forty-five per cent were referred to ophthalmologists, 36% to optometrists and 20% to low vision services. This significant proportion of patients with poor vision suggests that vision screening is warranted.     

Referral to low vision services by ophthalmologists

Purpose: People in need of low vision rehabilitation services often experience delays in referral to services. This study investigated referral criteria of Australian ophthalmologists, the frequency of referral of their patients with low vision and their perceptions of low vision services.
Methods: A survey was sent to a representative, random sample of 200 ophthalmologists. They were asked about criteria used for the referral of their patients with low vision. The survey included questions on the frequency with which they prescribed low vision devices (LVD) and referral of their patients to low vision and rehabilitation services and peer support groups. Perceptions of the quality and availability of low vision services were also investigated.
Results: The response rate was 82%. Approximately 11% of ophthalmologists' patients have low vision. It is uncommon for ophthalmologists to prescribe LVD but 67% refer most of their patients with low vision. It is less common for them to refer to rehabilitation services (29%) or peer support services (18%). The perceived local availability of services influences the rate of referral. Ophthalmologists who used the criteria of moderate low vision (<6/21 to <6/60) are more likely to refer more of their patients than those who use the criteria of severe low vision.
Conclusions: Australian ophthalmologists refer most of their visually impaired patients to low vision services, but infrequently to rehabilitation services or peer support groups. Differences in perceived need for low vision services indicated by the criteria used for referral, and the perceived availability, influence the rate at which ophthalmologists refer their patients for services. Ophthalmologists are encouraged to refer patients with permanent visual loss to low vision services earlier.     

An audit of disease diagnoses made by optometrists

Background : Several Australian ophthalmologists have sworn affidavits that, in their opinion, optometrists have deficient training in the detection of eye disease and systemic disease having ocular manifestations, and are unable to detect a number of medical conditions having ocular manifestations. The deponents swore that optometrists could not make a medical diagnosis because they lack medical Hampton, Victoria training. To test these opinions this report details a prospective comparison of diagnoses made by three optometrists with the diagnosis subsequently made by the ophthalmologist or physician to whom the patients were referred. Methods : All referrals made to ophthalmologists or physicians were recorded, together with the optometrists' diagnoses, which were recorded prior to referral. On receipt of the medical practitioner's report, his or her diagnosis was recorded and compared with the optometrist's diagnosis. Results : Four patients referred to ophthalmologists were lost to follow-up. Agreement between the optometrist's and ophthalmologist's diagnoses was unequivocally correct in 114 (93.4 per cent) of the 122 referrals for which follow-up was available. The optometric diagnoses of ophthalmic disease were correct, but incomplete, in six cases and, in two cases (Saltzman's dystrophy and Chandler's syndrome), the optometrist's diagnosis was inappropriate. Referrals to family physicians totalled 18, of which three were lost to follow-up. Of the remaining 15 patients referred, 12 diagnoses (70 per cent) were correct and three were incorrect. The three incorrect diagnoses were one case of suspected cranial arteritis and two cases of suspected diabetes, or impaired glucose tolerance. There were 38 separate diagnostic conditions referred to ophthalmologists and 11 separate conditions referred to general physicians. Conclusions : The optometrists who conducted this study were able to make diagnoses over a wide range of ocular and systemic diseases. These diagnoses were substantially in agreement with the diagnoses made by ophthalmologists and general physicians. This suggests that die training and clinical experience of optometrists can be adequate to provide a high standard of primary eye care and that optometrists are able to detect disease conditions that require referral to medical practitioners.     

Optometrist referrals to an emergency ophthalmology department: a retrospective review to identify current practise and development of shared care working strategies,in England

BackgroundDirect referrals from optometrists account for up to 10% eye casualty attendances. Despite this, there remains a paucity of literature on optometrist referrals to eye casualty. A better understanding of these referrals could be helpful in the development of shared care emergency pathways. Diagnostic agreement between optometrists and ophthalmologists for emergency referrals can be used to identify areas for development of shared care working strategies in emergency ophthalmology.MethodsA retrospective evaluation of 1059 consecutive optometric emergency referrals to Moorfields Eye Hospital was conducted. Referrals were only included when a letter or documentation for the reason for referral was provided. Diagnostic information from the referring optometrist and casualty doctor was summarised for each patient by an investigator (VMT) and recorded on a single spreadsheet. These clinical summaries were compared by a second independent investigator (IJ) and marked as agreeing, disagreeing or uncertain. Each clinical summary was then mapped to a diagnostic category using key word searches which were manually re-checked against the original summaries. Information on the timing of the referral and the outcome at the emergency department visit was also collated. Inter-observer agreement for diagnostic categories was measured using kappa coefficients.ResultsDiagnostic agreement ranged between kappa 0.59 and 0.87. It was best for diagnoses within the red eye category (kappa 0.87). Compliance with College of Optometrists referral guidance ranged between 11 and 100%. More than half of referrals for elevated intra-ocular pressure were discharged at the eye casualty visit. Overall, 54% of patients were managed with advice alone, 39% required treatment following referral and 7% required onward referral from eye casualty.ConclusionThe majority of patients referred by optometrists were managed with advice alone. A collaborative approach at the point referral could be helpful to improve referral efficiency.Subject terms: Eye manifestations, Health care economics     

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.     

Access to low‐vision rehabilitation services: barriers and enablers

Background: The current mismatch between the need for and uptake of low‐vision services has been attributed to various barriers including different service delivery models and referral pathways. This study evaluates the referral pathway and low‐vision service provision of the Royal Society for the Blind (RSB) in South Australia. Methods: All new referrals from the 2008–2009 financial year to the RSB were reviewed. Initially, patients were contacted by a triage officer within one week of referral. Initial appointments were made in the Low Vision Clinic with a multidisciplinary team. Reasons for declining the appointment or non‐attendance were tracked via telephone. Results: There were 1116 patients referred over a 12‐month period and 1082 (97 per cent) were reviewed in the Low Vision Clinic. Most attendees (92 per cent) lived within 50 kilometres of the clinic. There were 34 referred patients, who declined or did not attend the assessment. All non‐attendees also lived within 50 kilometres of the Low Vision Centre. Concurrent major health problems (27 per cent) and patients not feeling the need for low‐vision rehabilitation (27 per cent) were the most common reasons for not accessing the service. Only 125 patients (11.6 per cent) accessed volunteer transport services and only 24 patients (2.2 per cent) needed an interpreter service. Conclusion: The attendance rate is significantly higher than in other published studies. The distance to travel or transport difficulties were not significant barriers. Patient perception that either the service was not required or would not help them was the main barrier. The referral and triage process appeared to be a major enabler of low‐vision service uptake.     

Perspectives on low vision service in Canada: a pilot study

BACKGROUND: A review of the literature and current practice patterns for vision rehabilitation care in Canada provide a basis for this pilot study, which was undertaken to explore related issues from the perspectives of older adults and low vision service providers. The pilot study was overseen by a number of collaborators whose names are listed at the end of this paper. METHODS: Thirty people aged 60 years or older who had vision impairments and were clients of the Canadian National Institute for the Blind were surveyed by telephone. Ophthalmologists, optometrists, and opticians completed a mail questionnaire. Vision rehabilitation practitioners and nurses, ophthalmic technicians, and service providers for low vision technical aids were surveyed by e-mail. RESULTS: Ophthalmologists are a primary source of referrals to low vision services, but low functional vision does not always trigger such referrals, nor are referrals always timely. Optometrists are primary providers of low vision services, including dispensing of low vision aids, but such aids are expensive, and inadequate training in their use may contribute to noncompliance. Costs associated with providing low vision assessments and services are higher than compensation to vision service providers, whose capacity to meet increasing demand is limited. In addition, there are disparities between rural and urban areas and among provinces in the availability of, and funding for, services and aids. INTERPRETATION: On the basis of the findings, an emergent theory is proposed on the consequences resulting from lack of planning and standards for vision rehabilitation care. The implications of this study form the basis for further research.     

Agreement between ophthalmologists and optometrists in the certification of vision impairment

Background/objectivesThe certification process to register patients as sight impaired or severely sight impaired is undertaken by consultant ophthalmologists, in the UK. We sought to assess the agreement between optometrists and a consensus panel, in identifying patient eligibility for certification, relative to the agreement between ophthalmologists and the consensus panel.MethodsThe consensus panel (4 consultant ophthalmologists and 3 optometrists with a formal accreditation in low vision), 30 consultant ophthalmologists and 99 low vision optometrists reviewed 40 randomly selected abridged cases. The eligibility outcomes from the ophthalmologists and the optometrists were compared with the consensus panel outcomes.ResultsFor ophthalmologists and optometrists, the median (IQR) number of cases in which there was agreement with the consensus panel was 33.0 (31.0, 33.0) and 36.0 (34.0, 36.5), respectively. In severely sight impaired cases, the probabilities of agreeing on eligibility for certification were 76.0% (95% CIs 71.4%, 80.1%) for ophthalmologists and 61.8% (59.0%, 64.6%) for optometrists. In sight impaired cases, the corresponding values were 51.6% (46.7%, 56.4%) for ophthalmologists and 72.2% (69.8%, 74.5%) for optometrists. In cases of bilateral atrophic age-related macular degeneration (AMD), both groups were more likely to agree with the consensus panel and the differences between optometrists and ophthalmologists were less marked.ConclusionsOptometrists demonstrated a comparable agreement relative to ophthalmologists, with the consensus panel on the eligibility of randomly selected, abridged cases for certification. The findings support the clinical decision-making ability of low vision optometrists in the certification of patients with vision impairment and provide evidence in support of policy change to allow low vision optometrists to certify individuals with atrophic AMD.Subject terms: Health occupations, Health services, Public health     

Optimal clinical management of eye problems: the role of optometrists in managed care plans.

BACKGROUND: Recent developments in the education and licensure of optometrists have created new opportunities for more-efficient provision of eye care. This study was conducted to determine the extent to which optometrists provided various kinds of eye care independently in managed care organizations. We compared optometric practices in health plans located in states in which the legal authority of optometrists was limited, to optometric practices in plans situated in states in which optometric licensure permitted broader prescribing authority. The volume and nature of referrals to ophthalmologists were assessed in relation to state law and organizational protocols. METHODS: A 15-item patient encounter form was developed and completed for all patients examined by the optometrists at each site during a 4-week period in 1998. Specific conditions were selected and criteria developed to help determine whether referrals to ophthalmologists were appropriate, or if they could have been managed by the optometrist These referrals were assessed by an independent panel of four optometrists. RESULTS: This study documented that optometrists provide a substantial range of eye care, and their individual scope of practice is influenced not only by legal boundaries, but also by financial and organizational factors found within managed care organizations. The pattern of referrals to ophthalmologists helped indicate the extent to which optometrists were underutilized or used appropriately in various settings. CONCLUSIONS: There is no single reliable predictor of whether optometrists will be used at the highest level of their abilities and scope of license. Although state licensure sets the overall parameters for care, optometric practice in managed care plans may be modified by internal protocols and organizational factors.     

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.     

Accuracy of referral to a glaucoma clinic

The accuracy of referral to the glaucoma clinic in Edinburgh was evaluated retrospectively by case note analysis. Two hundred and ninety-five patients suspected of having glaucoma were referred during a 6 month period. Optometrists accounted for 96% of referrals with the remainder being referred directly by the GP. The highest overall detection rates (glaucoma + glaucoma suspects) were amongst those optometrists who combined tonometry with either a field assessment, ophthalmoscopy or both (66–78%). Despite this there was a high false positive rate with 36% of referrals being discharged or having conditions unrelated to glaucoma. To improve referral efficiency it is recommended that optometrists should routinely combine tonometry with ophthalmoscopy and perimetry, and tests should preferably be repeated priar to referral if an abnormality is suspected. The accuracy of referrals could be improved by the use of Goldmann applanation tonometry and by better interpretation of perimetric findings.     

Referrals to ophthalmology: optometric and general practice comparison

Purpose:  To assess referrals from primary care practitioners to an ophthalmological practice in order to determine whether any differences exist between the two primary care groups in the types of conditions referred, and in concurrence between reasons for referral and ophthalmological diagnosis.
Methods:  This study investigated patient referrals from general practitioners and optometrists to an ophthalmologist's practice in Belfast, over a period of 3 months from January 2007 to the end of March 2007. Anonymised data were divided into two groups depending on the referring practitioner. Within the two groups, patient numbers were sub-divided into 15 categories covering the range of diagnoses made. Preliminary diagnoses or reasons for referral were compared with the definitive diagnoses made by the ophthalmologist.
Results:  Optometrists contributed the greatest number of referrals (323) with 243 patients referred by general practitioners. Cataract was the most common condition referred by optometrists, and the second most common condition referred by general practitioners: agreement with ophthalmological diagnosis was high for both groups of primary care practitioners. Concurrence of referral reason with ophthalmological diagnosis for glaucoma was lower for general practitioners (56%) than for optometrists (76%), but optometrists referred more false positive patients for glaucoma than did general practitioners. The opposite was true for lid/tear duct/conjunctival conditions, the most common basis for referral by general practitioners.
Conclusions:  The differences between the two primary care practitioner groups may reflect variations in training, skills and practice. Further investigation of the particular strengths of both groups, and how they can be optimised to promote effective shared care, is required.     

Access and utilization of a new low-vision rehabilitation service

Background: A new low‐vision service linking a public hospital and a non‐governmental organization was trialled in Melbourne, Australia. The factors associated with service use were investigated. Methods: A survey was conducted with patients who used the service, those who accepted referrals but failed to attend and those who refused a referral. Hospital and non‐governmental organization representatives were also interviewed. Results: Ninety‐eight eligible vision impaired people who were referred to the new service were recruited. Less than half (49%) followed through with their referral and attended the service. Proximity and convenience were listed as the main facilitators to service use while issues relating to transport, needing an accompanying person, lack of information about the service and poor health were the main barriers. More than a third of the non‐compliant and referral refusers spoke a language other than English. Sixty‐three per cent of all participants had not previously used low‐vision services. Of the two main eye conditions, 81% of referred age‐related macular degeneration participants (n = 26) attended the service, but only 32% of those with diabetic retinopathy (n = 31) did so. Conclusion: As more than 60% of participants in each of the three groups had no prior use of low‐vision services, clearly current models of care are not reaching many who could benefit from such services. This suggests that higher rates of referral are warranted. However, given that substantially more were referred than attended, referral alone is obviously not the answer. Access and attitudinal barriers also need to be addressed.     

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.     

A practical guide to low vision management of patients with diabetes

Diabetic retinopathy is the leading cause of low vision and blindness in developed countries.^1,2 Optometrists have an important role in the detection of diabetic‐related eye disease. They are also well‐placed to manage patients with reduced vision due to diabetes. In 1998, visual rehabilitation information was analysed from 590 visually impaired patients attending the multidisciplinary Low Vision Clinic at Kooyong in Melbourne, Australia. Diabetes was the primary cause of vision loss in 43 (7.3 per cent) of the patients. This paper investigates the characteristics of these 43 patients and the strategies employed to assist them. In doing so we hope to assist practitioners in managing patients with low vision due to diabetes.     

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.     

Barriers to accessing low vision services

AIM: To investigate barriers to accessing low vision services in Australia. METHODS: Adults with a vision impairment (<6/12 in the better eye and/or significant visual field defect), who were current patients at the Royal Victorian Eye and Ear Hospital (RVEEH), were interviewed. The questions investigated self-perceived vision difficulties, duration of vision loss and satisfaction with vision and also examined issues of awareness of low vision services and referral to services. Focus groups were also conducted with vision impaired (<6/12 in the better eye) patients from the RVEEH, listeners of the Radio for the Print Handicapped and peer workers at Vision Australia Foundation. The discussions were recorded and transcribed. RESULTS: The questionnaire revealed that referral to low vision services was associated with a greater degree of vision loss (p = 0.002) and a greater self-perception of low vision (p = 0.005) but that referral was not associated with satisfaction (p = 0.144) or difficulties related to vision (p = 0.169). Participants with mild and moderate vision impairment each reported similar levels of difficulties with daily activities and satisfaction with their vision (p > 0.05). However, there was a significant difference in the level of difficulties experienced with daily activities between those with mild-moderate and severe vision impairment (p < 0.05). The participants of the focus groups identified barriers to accessing low vision services related to awareness of services among the general public and eye care professionals, understanding of low vision and the services available, acceptance of low vision, the referral process, and transport. CONCLUSION: In addition to the expected difficulties with lack of awareness of services by people with low vision, many people do not understand what the services provide and do not identify themselves as having low vision. Knowledge of these barriers, from the perspective of people with low vision, can now be used to guide the development and content of future health-promotion campaigns.     

Detection of diabetic retinopathy by optometrists

Optometrists examined 25 eyes with varying severity of diabetic retinopathy. No history or clinical information was provided to the optometrists who performed fundus examinations on dilated eyes using direct or indirect ophthalmoscopes. Color stereoscopic fundus photographs were independently graded and used as the standard. Optometrists made a correct diagnosis of whether retinopathy was present in 77% of the eyes (95% confidence interval (CI): 73%, 82%). They made a correct diagnosis of the type and degree of diabetic retinopathy in 57% of the eyes (95% CI: 39%, 75%). This diagnosis rate exceeded the rate reported for physician examiners (39%) and equaled that of general ophthalmologists (52%) in the only other similar study. Sensitivity for diagnosis of diabetic retinopathy in eyes of diabetic patients using only ophthalmoscopy was 74% (95% CI: 67%, 81%), while specificity for diagnosis of the absence of retinopathy was 84% (95% CI: 73%, 96%). 100% of these optometrists would have referred the eye with preproliferative retinopathy. 53% would have referred the eye classified as proliferative retinopathy without high risk characteristics, and 79% would have referred the eye with macular edema.     

Enhancing vision care integration: 2. Implementation of practice algorithms

BACKGROUND: Appropriate access to the best quality of vision care is enhanced when patients receive eye care services from the right professional, at the right time, and in the right place. In the preceding article the authors describe the development of two patient-centred vision care algorithms for the multidisciplinary management of diabetic retinopathy and red eye. Subsequently, a questionnaire survey was done to determine ophthalmologist, optometrist and general practitioner (GP) familiarity with and acceptance of the vision care algorithms. METHODS: The survey was conducted in the summer of 2001 among all ophthalmologists, optometrists and GPs registered with their respective professional body in Nova Scotia to assess their knowledge and acceptance of the diabetes mellitus and red eye algorithms. They were also asked to indicate their preferred method(s) of education and dissemination regarding these and future algorithms. RESULTS: Of the 740 practising GPs in Nova Scotia, 188 completed the questionnaire, for a response rate of 25.4%. The corresponding figures for optometrists and ophthalmologists were 73.6% (53/72) and 43.5% (20/46) respectively. Most of all three types of clinicians practise in Halifax County. More than 80% of the optometrists and ophthalmologists were aware of the algorithms, but less than 50% of the GPs were aware of them. A large majority of respondents in all three groups (77% to 98%) indicated that they were comfortable using the diabetes and red eye algorithms as presented. INTERPRETATION: Ophthalmologists, optometrists and GPs indicated an understanding of and willingness to use the diabetes and red eye algorithms. However, they were not unanimous regarding the choice of implementation method. Therefore, six different strategies for implementing the vision care algorithms are currently being used and are described in the paper.