Multi-stakeholder perspectives of locally commissioned enhanced optometric services.

OBJECTIVES: To explore views of all stakeholders (patients, optometrists, general practitioners (GPs), commissioners and ophthalmologists) regarding the operation of community-based enhanced optometric services. DESIGN: Qualitative study using mixed methods (patient satisfaction surveys, semi-structured telephone interviews and optometrist focus groups). SETTING: A minor eye conditions scheme (MECS) and glaucoma referral refinement scheme (GRRS) provided by accredited community optometrists. PARTICIPANTS: 189 patients, 25 community optometrists, 4 glaucoma specialist hospital optometrists (GRRS), 5 ophthalmologists, 6 GPs (MECS), 4 commissioners. RESULTS: Overall, 99% (GRRS) and 100% (MECS) patients were satisfied with their optometrists' examination. The vast majority rated the following as 'very good'; examination duration, optometrists' listening skills, explanations of tests and management, patient involvement in decision-making, treating the patient with care and concern. 99% of MECS patients would recommend the service. Manchester optometrists were enthusiastic about GRRS, feeling fortunate to practise in a 'pro-optometry' area. No major negatives were reported, although both schemes were limited to patients resident within certain postcode areas, and some inappropriate GP referrals occurred (MECS). Communication with hospitals was praised in GRRS but was variable, depending on hospital (MECS). Training for both schemes was valuable and appropriate but should be ongoing. MECS GPs were very supportive, reporting the scheme would reduce secondary care referral numbers, although some MECS patients were referred back to GPs for medication. Ophthalmologists (MECS and GRRS) expressed very positive views and widely acknowledged that these new care pathways would reduce unnecessary referrals and shorten patient waiting times. Commissioners felt both schemes met or exceeded expectations in terms of quality of care, allowing patients to be seen quicker and more efficiently. CONCLUSIONS: Locally commissioned schemes can be a positive experience for all involved. With appropriate training, clear referral pathways and good communication, community optometrists can offer high-quality services that are highly acceptable to patients, health professionals and commissioners.

Evaluation of a minor eye conditions scheme delivered by community optometrists.

BACKGROUND: The establishment of minor eye conditions schemes (MECS) within community optometric practices provides a mechanism for the timely assessment of patients presenting with a range of acute eye conditions. This has the potential to reduce waiting times and avoid unnecessary referrals to hospital eye services (HES). OBJECTIVE: To evaluate the clinical effectiveness, impact on hospital attendances and patient satisfaction with a minor eye service provided by community optometrists. METHODS: Activity and outcome data were collected for 12 months in the Lambeth and Lewisham MECS. A patient satisfaction questionnaire was given to patients at the end of their MECS appointment. A retrospective difference-in-differences analysis of hospital activity compared changes in the volume of referrals by general practitioners (GPs) from a period before (April 2011-March 2013) to after (April 2013-March 2015) the introduction of the scheme in Lambeth and Lewisham relative to a neighbouring area (Southwark) where the scheme had not been commissioned. Appropriateness of case management was assessed by consensus using clinical members of the research team. RESULTS: A total of 2123 patients accessed the scheme. Approximately two-thirds of patients (67.5%) were referred by their GP. The commonest reasons for patients attending for a MECS assessment were 'red eye' (36.7% of patients), 'painful white eye' (11.1%) and 'flashes and floaters' (10.2%). A total of 64.1% of patients were managed in optometric practice and 18.9% were referred to the HES; of these, 89.2% had been appropriately referred. First attendances to HES referred by GPs reduced by 26.8% (95% CI -40.5% to -13.1%) in Lambeth and Lewisham compared to Southwark. CONCLUSIONS: The Lambeth and Lewisham MECS demonstrates clinical effectiveness, reduction in hospital attendances and high patient satisfaction and represents a successful collaboration between commissioners, local HES units and primary healthcare providers.

A qualitative study of stakeholder views regarding participation in locally commissioned enhanced optometric services.

OBJECTIVES: To explore the views of optometrists, general practitioners (GPs) and ophthalmologists regarding the development and organisation of community-based enhanced optometric services. DESIGN: Qualitative study using free-text questionnaires and telephone interviews. SETTING: A minor eye conditions scheme (MECS) and a glaucoma referral refinement scheme (GRRS) are based on accredited community optometry practices. PARTICIPANTS: 41 optometrists, 6 ophthalmologists and 25 GPs. RESULTS: The most common reason given by optometrists for participation in enhanced schemes was to further their professional development; however, as providers of 'for-profit' healthcare, it was clear that participants had also considered the impact of the schemes on their business. Lack of fit with the 'retail' business model of optometry was a frequently given reason for non-participation. The methods used for training and accreditation were generally thought to be appropriate, and participating optometrists welcomed the opportunities for ongoing training. The ophthalmologists involved in the MECS and GRRS expressed very positive views regarding the schemes and widely acknowledged that the new care pathways would reduce unnecessary referrals and shorten patient waiting times. GPs involved in the MECS were also very supportive. They felt that the scheme provided an 'expert' local opinion that could potentially reduce the number of secondary care referrals. CONCLUSIONS: The results of this study demonstrated strong stakeholder support for the development of community-based enhanced optometric services. Although optometrists welcomed the opportunity to develop their professional skills and knowledge, enhanced schemes must also provide a sufficient financial incentive so as not to compromise the profitability of their business.

Agreement between specially trained and accredited optometrists and glaucoma specialist consultant ophthalmologists in their management of glaucoma patients.

AIMS: Optometrists are becoming increasingly involved in the co-management of glaucoma patients as the burden on the Hospital Eye Service continues to escalate. The aim of this study was to assess the agreement between specially trained optometrists and glaucoma-specialist consultant ophthalmologists in their management of glaucoma patients. METHODS: Four optometrists examined 23-25 patients each and the clinical findings, up to the point of dilation, were documented in the hospital records. The optometrist, and one of two consultant ophthalmologists, then independently examined and documented the optic-disc appearance before recording their decisions regarding the stability and management of the patient on a specially designed proforma. Percentage agreement was calculated together with kappa or weighted kappa statistics, where appropriate. RESULTS: Agreement between consultants and optometrists in evaluating glaucoma stability was 68.5% (kappa (κ)=0.42-0.50) for visual fields, 64.5% (weighted κ=0.17-0.31) for optic discs, and 84.5% (weighted κ=0.55-0.60) for intraocular pressures. Agreement regarding medical management was 96.5% (κ=0.73-0.81) and for other glaucoma management decisions, including timing of follow-up, referral to a consultant ophthalmologist, and discharge, was 72% (weighted κ=0.65). This agreement increased to 90% following a retrospective independent then consensus review between the two consultants and when qualified agreements were included. Of the 47 glaucoma and non-glaucoma queries generated during the study, 42 resulted in a change of management. CONCLUSION: Confirming the ability of optometrists to make appropriate decisions regarding the stability and management of glaucoma patients is essential if their involvement is to continue to develop to meet the demand of an aging population.

Glaucoma detection: the content of optometric eye examinations for a presbyopic patient of African racial descent.

AIMS: Standardised patient (SP) methodology is the gold standard for evaluating clinical practice. We investigated the content of optometric eyecare for an early presbyopic SP of African racial descent, an "at-risk" patient group for primary open-angle glaucoma (POAG). METHODS: A trained actor presented unannounced as a 44-year-old patient of African racial descent, complaining of recent near vision difficulties, to 100 community optometrists for an audio-recorded eye examination. The eye examinations were subsequently assessed via a checklist based on evidence-based POAG reviews, clinical guidelines and expert panel opinion. RESULTS: Ninety-five per cent of optometrists carried out optic disc assessment and tonometry, which conforms to the UK College of Optometrists' advice that those patients aged >40 years should receive at least two of the following tests: tonometry, optic disc assessment, visual field testing. Thirty-five per cent of optometrists carried out all of these tests and 6% advised the SP of increased POAG risk in those of African racial descent. CONCLUSION: SP encounters are an effective measure of optometric clinical practice. As in other healthcare disciplines, there are substantial differences between optometrists in the depth of their clinical investigations, challenging the concept of a "standard sight test". There is a need for continuing professional development (CPD) in glaucoma screening, in which the increased risk of POAG in those of African racial descent should be emphasised.

Effects of repeated oral examinations on ophthalmology residents.

BACKGROUND/AIM: Oral examinations are required for board certification in Ophthalmology in the USA. The current literature offers no recommendation on the number of administrations during residency. The purpose of this study was to determine how often oral examinations (OEs) should be administered and what effects repeated OEs might have on residents' comfort level with OEs and confidence level in their knowledge base. METHODS: From 2004 to 2006, a structured oral examination was administered every 4 months to ophthalmology residents at the University of Arkansas for Medical Sciences. A survey was administered just prior to each oral examination. RESULTS: After two oral examinations, self-confidence and ability to self-assess one's knowledge increased and anxiety decreased in the residents. Residents' belief that they could pass an oral examination for board certification statistically improved after the third oral examination. CONCLUSIONS: To achieve the full benefits of oral examination training, the exam should be taken at least three times during residency. Formal, structured oral examinations, repeated over time, seem to reduce resident anxiety and improve the residents' ability to realistically assess their level of preparation for an OE.

The effectiveness of the Heidelberg Retina Tomograph and laser diagnostic glaucoma scanning system (GDx) in detecting and monitoring glaucoma.

OBJECTIVES: To determine the potential of optic nerve head tomography [Heidelberg Retina Tomograph (HRT)] and scanning laser polarimetry (GDx) for identifying patients with glaucomatous visual field loss. DESIGN: Examinations were performed with the HRT, GDx and Humphrey Field Analyzer (HFA). Glaucoma was defined by the presence of a field defect. Patients within the cross-sectional groups underwent a single examination, whereas patients in the longitudinal groups were examined 6 monthly, for an average of 3.5 years. SETTING: Manchester Royal Eye Hospital, UK. PARTICIPANTS: Patients with primary open angle glaucoma (POAG) or who were at risk of developing glaucoma. INTERVENTIONS: The diagnostic accuracies of the HRT and GDx were compared; specificity was set at 95%. The rate of change was determined by linear regression. To estimate the clinical application of the instruments, the proportion of an unselected group of patients on whom the examinations could be performed was calculated. Additionally, the time taken to perform and process each examination was measured. MAIN OUTCOME MEASURES: The ability of the techniques to identify cases showing deterioration. The level of agreement and applicability of the techniques. Time taken to perform and process each examination. RESULTS: From the cross-sectional group, the maximum sensitivities of the HRT and GDx were 59% and 45%, respectively (at 95% specificity). From the two longitudinal cohorts, the level of agreement between the three instruments for identification of the development and deterioration of POAG was low. The applicability of the techniques was 80% (HRT), 88% (GDx) and 98% (HFA). The length of time to perform a full examination with each instrument was 12.3, 11.8 and 28.3 minutes, respectively. Agreement of HRT and GDx parameters between and within observers was largely good. CONCLUSIONS: There is poor agreement for detection of glaucoma between the HFA, HRT and GDx. The techniques are amenable to use in the clinical environment, but no single examination has sufficient diagnostic precision to be used in isolation; also, the imaging techniques were not universally applicable. Neither the HRT nor GDx should be viewed as a replacement for visual field examination. Further research is needed into why most patients within the longitudinal arms of the study showed very little deterioration and into determining aspects of the structure versus function relationship in glaucoma that may explain why any one technique fails to detect a proportion of cases.

Enhanced low vision rehabilitation for people with age related macular degeneration: a randomised controlled trial.

AIM: To compare the effectiveness of three models of low vision rehabilitation for people with age related macular degeneration (AMD) referred for low vision rehabilitation (LVR): (a) an enhanced low vision rehabilitation model (ELVR) including supplementary home based low vision rehabilitation; (b) conventional low vision rehabilitation (CLVR) based in a hospital clinic; (c) CLVR with home visits that did not include rehabilitation (CELVR), intended to act as a control for the additional contact time with ELVR. METHOD: A single centre parallel group randomised controlled trial in participants' homes and the low vision clinic, Manchester Royal Eye Hospital. People referred for LVR with a primary diagnosis of AMD and visual acuity worse than 6/18 in both eyes and equal to or better than 1/60 in the better eye. The main outcome measures were vision specific quality of life (QoL) (primary outcome, VCM1) and generic health related QoL (SF-36); psychological adjustment to vision loss; measured task performance; restriction in everyday activities; use of low vision aids (LVAs). RESULTS: 226 participants were recruited (median age 82 years); 194 completed the trial (86%). Except for SF-36 physical and mental component summary scores, arms did not differ significantly for any of the outcomes. Differences for the VCM1 were ELVR v CLVR, 0.06 (95% CI to 0.17 to 0.30, p = 0.60); ELVR v CELVR, 0.12 (95% CI to 0.11 to 0.34, p = 0.31); CELVR v CLVR, -0.05 (95% CI -0.29 to 0.18, p = 0.64). Differences for the SF-36 favoured CLVR compared to ELVR (ELVR v CLVR: physical = -6.05, 95% CI -10.2 to -1.91, p = 0.004; mental = -4.04, 95% CI -7.44 to -0.65, p = 0.02). At 12 months, 94% of participants reported using at least one LVA. CONCLUSION: ELVR was no more effective than CLVR. Researchers should be wary of proposing new LVR interventions without preliminary evidence of effectiveness, given the manifest lack of effectiveness of the model of enhanced LVR evaluated in the trial.

Face recognition in age related macular degeneration: perceived disability, measured disability, and performance with a bioptic device.

AIMS: (1) To explore the relation between performance on tasks of familiar face recognition (FFR) and face expression difference discrimination (FED) with both perceived disability in face recognition and clinical measures of visual function in subjects with age related macular degeneration (AMD). (2) To quantify the gain in performance for face recognition tasks when subjects use a bioptic telescopic low vision device. METHODS: 30 subjects with AMD (age range 66-90 years; visual acuity 0.4-1.4 logMAR) were recruited for the study. Perceived (self rated) disability in face recognition was assessed by an eight item questionnaire covering a range of issues relating to face recognition. Visual functions measured were distance visual acuity (ETDRS logMAR charts), continuous text reading acuity (MNRead charts), contrast sensitivity (Pelli-Robson chart), and colour vision (large panel D-15). In the FFR task, images of famous people had to be identified. FED was assessed by a forced choice test where subjects had to decide which one of four images showed a different facial expression. These tasks were repeated with subjects using a bioptic device. RESULTS: Overall perceived disability in face recognition did not correlate with performance on either task, although a specific item on difficulty recognising familiar faces did correlate with FFR (r = 0.49, p<0.05). FFR performance was most closely related to distance acuity (r = -0.69, p<0.001), while FED performance was most closely related to continuous text reading acuity (r = -0.79, p<0.001). In multiple regression, neither contrast sensitivity nor colour vision significantly increased the explained variance. When using a bioptic telescope, FFR performance improved in 86% of subjects (median gain = 49%; p<0.001), while FED performance increased in 79% of subjects (median gain = 50%; p<0.01). CONCLUSION: Distance and reading visual acuity are closely associated with measured task performance in FFR and FED. A bioptic low vision device can offer a significant improvement in performance for face recognition tasks, and may be useful in reducing the handicap associated with this disability. There is, however, little evidence for a correlation between self rated difficulty in face recognition and measured performance for either task. Further work is needed to explore the complex relation between the perception of disability and measured performance.

Neurologic and psychiatric manifestations in a family with a mutation in exon 2 of the guanosine triphosphate-cyclohydrolase gene.

OBJECTIVE: To investigate the range of clinical features to correlate genotypic and phenotypic manifestations in hereditary progressive and/or levodopa-responsive dystonia due to a defect in the guanosine triphosphate-cyclohydrolase (GCH1) gene. DESIGN AND SETTING: A large family from Texas was studied in an ambulatory setting by clinicians in genetics, neurology, and psychiatry using structured interviews and examinations. PATIENTS: The family was selected after neurometabolic investigations of a young boy (proband) with foot dystonia and fatigue and his father, who had a long history of anxiety and depression. Results of metabolic studies showed decreased levels of metabolites of biopterin and biogenic amines in cerebrospinal fluid. Subsequently, a novel mutation (37-base pair deletion) in exon 2 of the GCH1 gene was demonstrated in 11 family members. There was no observed female sex bias, but there was a wide variability of motor dysfunctions in family members. Approximately 50% had clinical deafness and a similar number had significant psychiatric dysfunction, including depression and anxiety. CONCLUSION: Study of additional families with hereditary progressive and/or levodopa-responsive dystonia using modern molecular methods will be necessary to confirm the neuropsychiatric spectrum of this disorder, in which important clinical features may be unrecognized and thus inappropriately managed.

The brief psychiatric rating scale for children (BPRS-C): validity and reliability of an anchored version.

OBJECTIVE: Because the accuracy of problems reported by referred children may be compromised by their academic, cognitive, or motivational limitations, clinician rating forms may contribute to the accurate assessment of youth adjustment. One such measure, the 21-item Brief Psychiatric Rating Scale for Children (BPRS-C), received psychometric study to estimate its potential contribution to the measurement of symptom dimensions. BPRS-C reliability and concurrent validity were calculated for youths who were receiving psychiatric services within a medical school department. METHOD: Five hundred forty-seven children aged 3 to 18 years were rated by faculty or trainees; a subsample of 90 was concurrently rated by two observers. BPRS-C psychometric performance was demonstrated through interrater agreement, factor analysis, and multivariate analyses of variance across seven diagnosis-based groups. RESULTS: Although items and scales demonstrated substantial reliability and concurrent validity, item factor analysis revealed a few apparent errors in item-to-scale assignment. These errors were minimized by the use of three new second-order factor-derived scales: Internalization, Developmental Maladjustment, and Externalization. CONCLUSIONS: The BPRS-C can be easily integrated into academic clinical practice and is a reliable and valid method of child description. Additional study of three new BPRS-C factor scales and the application of the BPRS-C to the quantification of clinician observation of child symptomatic status are warranted.

Strontium nitrate decreased histamine-induced itch magnitude and duration in man.

BACKGROUND: Previous studies have demonstrated that strontium salts have a potent and broad ability to suppress sensory irritation. OBJECTIVE: To ascertain the possible antipruritic effects of topical strontium salts, we conducted a double-blind randomized study to evaluate the effect of 20% strontium nitrate on itch magnitude (intensity) and duration. METHODS: In 8 human subjects, strontium nitrate was applied to the volar forearm and vehicle control to the contralateral volar forearm for 30 min; both substances were reapplied for an additional 5 min. Itch was then experimentally induced by intradermal injection of histamine. Itch magnitude was rated each minute for the first 20 min using a visual analogue scale (VAS). Itch duration in minutes was also recorded. RESULTS: Strontium nitrate, in comparison to its vehicle control, significantly shortened itch duration from 28.1+/-5.4 min (mean +/- SEM) to 18.5+/-4.2 min (p<0.01) and reduced itch magnitude at time points 12-20 min and overall (p<0.05). CONCLUSION: Strontium nitrate may act as a topical antipruritic agent in reducing histamine-mediated itch.

Strontium nitrate suppresses chemically-induced sensory irritation in humans.

Skin care products are complex formulations that may cause sensory irritation symptoms, characterized by stinging, burning, and itching. Substances capable of counteracting sensory irritation are of great practical interest. Strontium salts have been demonstrated to inhibit sensory irritation and inflammation when applied topically. In this double-blind study, we evaluated the efficacy of strontium nitrate in reducing chemically-induced skin sensory irritation in 8 subjects. In a random order, 20% strontium nitrate in 70% glycolic acid (pH=0.6) (mixture) was applied to the volar aspect of the forearm and a positive control (70% glycolic acid, pH=0.6) to the contralateral forearm. The irritation sensation was evaluated each min for the first 20 min after topical application using a scale from 0-4. The duration of the irritation sensation in min was also recorded. Strontium nitrate mixed with glycolic acid, in comparison with glycolic acid alone, markedly (p<0.01) shortened the duration of the irritation sensation from 24.4+/-4.1 (mean+/-SEM) min to 8.9+/-3.7 (mean+/-SEM) min, and significantly (p<0.05) reduced the mean magnitude of the irritation sensation at all time points (overall). The study demonstrated that strontium nitrate potently suppresses the sensation of chemically-induced irritation.

Glaucoma screening: the importance of combining test data.

The objective of this study was to evaluate the effectiveness of screening tests for primary open angle glaucoma, both singly and in combination, using a decision analysis approach. A range of screening tests were carried out on 145 nonglaucomatous patients and 67 cases of previously undiagnosed glaucoma. Receiver operator characteristic curves were constructed for single test data to show the trade-off between sensitivity and specificity for varying cut-off criteria. The best discriminators of glaucoma were, in rank order: (1) a multiple stimulus static visual field screening test, (2) optic disc cupping, and (3) intraocular pressure. Decision curves were also constructed for various combinations of screening tests, where the inclusion of the tests were based on discriminant analyses. Sensitivities and specificities of more than 0.90 were obtained when visual field screening, optic disc cupping, and intraocular pressure were combined. Data from other tests when combined with these three variables failed to provide a significant improvement in discrimination.

Lack of microbial proliferation and phototoxic potential of a new matrix patch for estradiol delivery.

OBJECTIVES: To examine the potential of a new matrix system developed for estradiol delivery to cause microbial proliferation under the occluded site or to cause acute phototoxicity reactions. METHODS: Twenty healthy post-menopausal women participated in a microbial proliferation study and 11 in a phototoxicity study. Both studies were single centre, single blind and placebo controlled. Microbial proliferation was assessed by quantitative counts of the total aerobic bacterial population and of eight individual species before patch application and after removal following a 4 day application period on the abdomen. Acute phototoxicity potential was assessed following an 8 h application period on the abdomen by irradiating the application site after patch removal with ultra violet A radiation and visible light and evaluating the sites for up to 48 h post irradiation. Non-irradiated active and placebo patches on the other side of the abdomen served as controls. RESULTS: Total aerobic bacterial populations both before and after the matrix patch application period were low as expected for dry skin. Separate counts of microbial species were also low and did not change in any meaningful or consistent manner after patch application. In the phototoxicity study, mild erythema was observed in some patients at 0, 0.5 and 24 h post patch removal with no differences between irradiated and non-irradiated sites. CONCLUSIONS: These two studies demonstrate that a new matrix patch developed for estradiol delivery does not promote microbial proliferation under the occluded patch site or cause acute phototoxicity following removal.

Information services of the European Bioinformatics Institute.

The scope of the EBI is focused on providing better services to the scientific community. Technological advancements in the hardware area provide EBI with means of producing data much faster than before, and with greater accuracy since there is now a better technical ability to produce more exhaustive searches through larger indices. Hand in hand with the technological developments, research and development work is continuing on better indexing systems and more efficient ways of establishing and maintaining the future databases. The existing links of communication between EBI and the user community are exploited to study the needs of the scientific community, to provide better services, and to enhance the quality of databases by interpreting user feedback and updates. A very important goal is to enhance the awareness of the scientific (and, maybe even more, the nonscientific) public of the importance of the modern field of bioinformatics and to introduce special meetings and courses, in which more specific subjects will be studied in depth. Another aspect of this goal is to help in constructing special bioinformatics programs in university faculties. In such programs, in contrast to the existing layout, students will pursue studies in a combined environment that provides basic training in biology and in computation. Currently, one of the main problems in the field is that scientists are either biologists, who are self-educated in the field of computers and programming, or computer scientists without sufficient knowledge of biology. It is hoped that a combined program will provide a high level of education in both fields of interest at the appropriate ratios. Building an efficient and friendly interface between the EBI and the user community is the basis for any future development. This aim is achieved by using the most modern server systems while continuously researching newer and better systems and interfaces. This task can never be complete without involvement of the user community by providing feedback to any of EBI's services. A better bioinformatics community is a necessity for any future development of the biological research aiming at a better society.

Effectiveness of unsupervised oculokinetic perimetry for detecting glaucomatous visual field defects.

Oculokinetic perimetry (OKP) is a simple, inexpensive technique which was introduced primarily to promote more widespread use of visual field screening for glaucoma. The effectiveness of unsupervised OKP screening was evaluated using 145 non-glaucomatous patients and 64 patients with previously undiagnosed primary open angle glaucoma. Glaucoma cases were validated by the extended 132 point program on the Henson CFS2000 instrument. Both sample populations were representative of patients presenting for primary vision care. The effectiveness of the 26 point OKP test was compared with the 26 point Henson screening program. The results suggest that, in contrast to the Henson screening test (sensitivity = 85.1%, specificity = 93.8%), unsupervised OKP screening (sensitivity = 25.0%, specificity = 93.6%) has limited effectiveness for detecting glaucomatous visual field defects.