Contact lens education for the practitioners of the future.

The World Health Organization has identified a shortage of trained human resources as one of the greatest challenges to increasing the availability of eye care services and reducing preventable visual impairment around the world. Increased prevalence of myopia and new strategies for myopia management have raised the prospect of various interventions, including contact lenses for therapeutic use as well as for refractive correction. More personnel skilled in contact lens fitting will be needed to address potential worldwide demand for these interventions. This review investigates the current status and future requirements of global contact lens education in light of these developments. The COVD-19 pandemic led educational institutions worldwide to move towards online delivery. An online survey among 546 educators, conducted in May 2020, investigated changes to contact lens education delivery before and after the onset of the pandemic. A total of 214 responses were received from 32 countries. Prior to COVID-19 restrictions, 23% of educators had conducted more than 50% of their total teaching online; however, 69% expected to conduct more than half of their teaching online by the end of 2020 and 12% anticipated 90% or more of their teaching would be online. Some 76% of educators expected to provide more online lectures after the pandemic and 63% anticipated new methods to deliver practical education. Around half were planning to introduce new teaching online platforms (54%) and more online assessment methods (53%). The global need for increasing numbers of skilled personnel points to a crucial role for educators in teaching the contact lens practitioners of the future. Contact lens education delivery was already evolving prior to COVID-19, and changes that are currently occurring may lead to permanent differences in the way contact lenses are taught in future. The International Association of Contact Lens Educators (IACLE) provides educators with a standardised global curriculum, online resources and teaching technology that could also serve as a model for wider ophthalmic education in future.

Private Equity in Ophthalmology and Optometry: Analysis of Acquisitions from 2012 through 2019 in the United States.

PURPOSE: To identify temporal and geographic trends in private equity (PE)-backed acquisitions of ophthalmology and optometry practices in the United States. DESIGN: A cross-sectional study using private equity acquisition and investment data from January 1, 2012, through October 20, 2019. PARTICIPANTS: A total of 228 PE acquisitions of ophthalmology and optometry practices in the United States between 2012 and 2019. METHODS: Acquisition and financial investment data were compiled from 6 financial databases, 4 industry news outlets, and publicly available press releases from PE firms or platform companies. MAIN OUTCOME MEASURES: Yearly trends in ophthalmology and optometry acquisitions, including number of total acquisitions, clinical locations, and providers of acquired practices as well as subsequent sales, median holding period, geographic footprint, and financing status of each platform company. RESULTS: A total of 228 practices associated with 1466 clinical locations and 2146 ophthalmologists or optometrists were acquired by 29 PE-backed platform companies. Of these acquisitions, 127, 9, and 92 were comprehensive or multispecialty, retina, and optometry practices, respectively. Acquisitions increased rapidly between 2012 and 2019: 42 practices were acquired between 2012 and 2016 compared to 186 from 2017 through 2019. Financing rounds of platform companies paralleled temporal acquisition trends. Three platform companies, comprising 60% of platforms formed before 2016, were subsequently sold or recapitalized to new PE investors by the end of this study period with a median holding period of 3.5 years. In terms of geographic distribution, acquisitions occurred in 40 states with most PE firms developing multistate platform companies. New York and California were the 2 states with the greatest number of PE acquisitions with 22 and 19, respectively. CONCLUSIONS: Private equity-backed acquisitions of ophthalmology and optometry practices have increased rapidly since 2012, with some platform companies having already been sold or recapitalized to new investors. Additionally, private equity-backed platform companies have developed both regionally focused and multistate models of add-on acquisitions. Future research should assess the impact of PE investment on patient, provider, and practice metrics, including health outcomes, expenditures, procedural volume, and staff employment.

Changes in Electronic Health Record Use Time and Documentation over the Course of a Decade.

PURPOSE: With the current wide adoption of electronic health records (EHRs) by ophthalmologists, there are widespread concerns about the amount of time spent using the EHR. The goal of this study was to examine how the amount of time spent using EHRs as well as related documentation behaviors changed 1 decade after EHR adoption. DESIGN: Single-center cohort study. PARTICIPANTS: Six hundred eighty-five thousand three hundred sixty-one office visits with 70 ophthalmology providers. METHODS: We calculated time spent using the EHR associated with each individual office visit using EHR audit logs and determined chart closure times and progress note length from secondary EHR data. We tracked and modeled how these metrics changed from 2006 to 2016 with linear mixed models. MAIN OUTCOME MEASURES: Minutes spent using the EHR associated with an office visit, chart closure time in hours from the office visit check-in time, and progress note length in characters. RESULTS: Median EHR time per office visit in 2006 was 4.2 minutes (interquartile range [IQR], 3.5 minutes), and increased to 6.4 minutes (IQR, 4.5 minutes) in 2016. Median chart closure time was 2.8 hours (IQR, 21.3 hours) in 2006 and decreased to 2.3 hours (IQR, 18.5 hours) in 2016. In 2006, median note length was 1530 characters (IQR, 1435 characters) and increased to 3838 characters (IQR, 2668.3 characters) in 2016. Linear mixed models found EHR time per office visit was 31.9±0.2% (P < 0.001) greater from 2014 through 2016 than from 2006 through 2010, chart closure time was 6.7±0.3 hours (P < 0.001) shorter from 2014 through 2016 versus 2006 through 2010, and note length was 1807.4±6.5 characters (P < 0.001) longer from 2014 through 2016 versus 2006 through 2010. CONCLUSIONS: After 1 decade of use, providers spend more time using the EHR for an office visit, generate longer notes, and close the chart faster. These changes are likely to represent increased time and documentation pressure for providers. Electronic health record redesign and new documentation regulations may help to address these issues.

Cornea and ocular surface disease: application of cutting-edge optometric research.

: Clinician-scientists bridge the gap between basic research and patient care. At the 2012 Annual Meeting, a symposium highlighting the application of cutting-edge optometric research within the anterior segment was held to present and discuss some of the recent basic scientific advances that will both shape and guide the development of future clinical care practices. This article summarizes this work, bringing together four experts, all clinician-scientists in the field of cornea and ocular surface. Collectively, this work provides new insights to clinicians and researchers alike, as well as brings forth a greater appreciation of the impact of ongoing optometric bench research in advancing clinical care.

Unintended consequences of delisting routine eye exams on retinopathy screening for people with diabetes in Ontario, Canada.

BACKGROUND: Routine eye examinations for healthy adults aged 20-64 years were delisted from the Ontario Health Insurance Plan in 2004, but they continue to be insured for people with diabetes regardless of age. We sought to assess whether the delisting of routine eye examinations for healthy adults had the unintended consequence of decreasing retinopathy screening for adults with diabetes. METHODS: We used administrative data to calculate eye examinations for people with diabetes ages 40-64 years and 65 years and older in each 2-year period from 1998 to 2010. We examined differences by sex, income, rurality and type of health care provider. We used segmented linear regression to assess the change in trend before and after 2004. RESULTS: For people with diabetes aged 65 years and older, eye examinations rose gradually from 1998 to 2010, with no substantial change between 2004 and 2006. For people with diabetes aged 40-65 years, there was an 8.7% (95% confidence interval [CI] 6.3%-11.1%) decrease in eye examinations between 2004 and 2006. Results were similar for all population subgroups. Ophthalmologic examinations decreased steadily for both age groups during the study period, and there was a decline in optometry examinations for people ages 40-65 years after 2004. INTERPRETATION: The delisting of routine eye examinations for healthy adults in Ontario had the unintended consequence of reducing publicly funded retinopathy screening for people with diabetes. More research is needed to understand whether patients are being charged for an insured service or to what degree misunderstanding has prevented patients from seeking care.

Trends in use of ancillary glaucoma tests for patients with open-angle glaucoma from 2001 to 2009.

PURPOSE: To assess trends in the use of ancillary diagnostic tests in the evaluation of patients with open-angle glaucoma (OAG) and glaucoma suspects over the past decade. DESIGN: Retrospective, longitudinal cohort analysis. PARTICIPANTS: A total of 169 917 individuals with OAG and 395 721 individuals with suspected glaucoma aged ≥40 years enrolled in a national United States managed care network between 2001 and 2009. METHODS: Claims data were analyzed to assess trends in visual field (VF) testing, fundus photography (FP), and other ocular imaging (OOI) testing for patients with OAG or suspected glaucoma between 2001 and 2009. Repeated-measures logistic regression was performed to identify differences in the odds of undergoing these procedures in 2001, 2005, and 2009 and whether differences exist for patients under the exclusive care of optometrists versus ophthalmologists. MAIN OUTCOME MEASURES: Odds and annual probabilities of undergoing VF testing, FP, and OOI for OAG from 2001 to 2009. RESULTS: For patients with OAG, the odds of undergoing VF testing decreased by 36% from 2001 to 2005, by 12% from 2005 to 2009, and by 44% from 2001 to 2009. By comparison, the odds of having OOI increased by 100% from 2001 to 2005, by 24% from 2005 to 2009, and by 147% from 2001 to 2009. Probabilities of undergoing FP were relatively low (13%-25%) for both provider types and remained fairly steady over the decade. For patients cared for exclusively by optometrists, the probability of VF testing decreased from 66% in 2001 to 44% in 2009. Among those seen exclusively by ophthalmologists, the probability of VF testing decreased from 65% in 2001 to 51% in 2009. The probability of undergoing OOI increased from 26% in 2001 to 47% in 2009 for patients of optometrists and from 30% in 2001 to 46% in 2009 for patients of ophthalmologists. By 2008, patients with OAG receiving care exclusively by optometrists had a higher probability of undergoing OOI than VF testing. CONCLUSIONS: From 2001 to 2009, OOI increased dramatically whereas VF testing declined considerably. Because OOI has not been shown to be as effective at detecting OAG or disease progression compared with VF testing, increased reliance on OOI technology, in lieu of VF testing, may be detrimental to patient care.

Statistical methods for conducting agreement (comparison of clinical tests) and precision (repeatability or reproducibility) studies in optometry and ophthalmology.

The ever-expanding choice of ocular metrology and imaging equipment has driven research into the validity of their measurements. Consequently, studies of the agreement between two instruments or clinical tests have proliferated in the ophthalmic literature. It is important that researchers apply the appropriate statistical tests in agreement studies. Correlation coefficients are hazardous and should be avoided. The 'limits of agreement' method originally proposed by Altman and Bland in 1983 is the statistical procedure of choice. Its step-by-step use and practical considerations in relation to optometry and ophthalmology are detailed in addition to sample size considerations and statistical approaches to precision (repeatability or reproducibility) estimates.

A survey of UK practitioner attitudes to the fitting of rigid gas permeable lenses.

PURPOSE: Rigid gas permeable (GP) contact lenses may provide the safest option for lens wear, but prescribing rates are in decline. This study investigated the effect of practitioner attitudes on GP lens prescribing. METHODS: A questionnaire was developed using a focus group and a pilot study. Questions addressed clinical time spent fitting GP lenses, specialist equipment requirements and perceived safety and comfort. With ethical approval, the questionnaire was sent to 1000 randomly selected UK registered eye care practitioners (ECPs). RESULTS: In general, ECPs enjoy the challenge of fitting GPs, although fitting takes longer than soft lens fitting. There is a difference in attitude between longer qualified and more recently qualified ECPs. Longer qualified ECPs more frequently reported enjoyment of the fitting challenges, recommended GP lenses to patients and were less likely to believe that GP lenses were becoming obsolete. ECPs are in strong agreement on the ocular health advantages of fitting GPs. They do not feel specialist equipment is generally needed, although some reported a topographer to be advantageous. The large majority of ECPs do not have access to the specialist equipment they perceive to be normally associated with GP fitting (radiuscope, V-gauge). They believe that initial fitting discomfort of GP fitting is a major drawback to their fitting, and while they feel this greatly improves with adaptation, they do not feel it reaches soft lens wear comfort. A total of 30.3% of ECPs feel it is clinically acceptable to use topical anaesthetic during GP fitting, but only 1.4% of ECPs regularly do so. CONCLUSIONS: ECPs are aware of the benefits that GP lenses provide in terms of ocular health. They find GPs take longer to fit, but they enjoyed the challenge of fitting, which suggests that they are not lacking in clinical skill, nor any specialist equipment. However, they are unhappy with initial patient comfort, and are not yet prepared to use topical anaesthetics during initial fitting. As a consequence, ECPs believe that GP lenses are becoming obsolete. Negative practitioner attitudes toward various aspects of GP fitting may mean fewer recommendations to patients and reduced GP prescribing.

[Recent developments on the scientific research in optometry and visual science in China].

The current text reviewed the situation of the scientific research in the field of Optometry and visual sciences in the recent 5 to 6 years in our country. It showed the advancement and achievement in the myopic fundamental research and the application research of visual science. In addition, it also analyzed the guidance of research in solving the clinical visual issues and the significance of community service of research in eye care in public. This text indicated by the concrete current situation and the result data of research that the biology and optics, the double property of the eye endowed the distinguished feature to the research in Ophthalmology and Optometry, and that the cross cooperation of multidisciplinary promoted the innovation in the fields of Optometry and visual research. In future, the fields of Optometry and visual science in China will face up to more and more anticipations of the original and systematic research. The prophylaxis and treatment of myopia would be still a long-term and rough exploration theme in these fields.

Could telehealth help eye care practitioners adapt contact lens services during the COVID-19 pandemic?

The COVID-19 pandemic has necessitated government-imposed restrictions on social interactions and travel. For many, the guidance has led to new ways of working, most notably a shift towards working remotely. While eye care practitioners (ECPs) may continue to provide urgent or emergency eye care, in many cases the travel restrictions present a unique challenge by preventing conventional face-to-face examination. Telephone triage provides a useful starting point for establishing at-risk and emergency patients; but patient examination is central to contact lens patient care. The indeterminate period over which conventional practice will be suspended, and the risk that resumption of 'normal' practice could be impeded by a potential secondary peak in COVID-19 cases, hastens the need for practitioners to adapt their delivery of eyecare. Specifically, it is prudent to reflect upon supportive evidence for more comprehensive approaches to teleoptometry in contact lens practice. Smartphone based ocular imaging is an area which has seen considerable growth, particularly for imaging the posterior eye. Smartphone imaging of the anterior eye requires additional specialised instrumentation unlikely to be available to patients at home. Further, there is only limited evidence for self-administered image capture. In general, digital photographs, are useful for detection of gross anterior eye changes, but subtle changes are less discernible. For the assessment of visual acuity, many electronic test charts have been validated for use by practitioners. Research into self-administered visual acuity measures remains limited. The absence of a comprehensive evidence base for teleoptometry limits ECPs, particularly during this pandemic. Knowledge gaps ought to be addressed to facilitate development of optometry specific evidence-based guidance for telecare. In particular, advances in ocular self-imaging could help move this field forwards.

Photorefraction of eyes: history and future prospects.

A brief history of photorefraction, i.e., the refraction of eyes by photography or computer image capture, is given. The method of photorefraction originated from an optical scheme for secret communication across the Berlin wall. This scheme used a lens whose focus about infinity was modulated by a movable reflecting surface. From this device, it was recognized that the vertebrate eye was such a reflector and that its double-pass pointspread could be used to compute its degree of defocus. Subsequently, a second, totally independent invention, more accurately termed "photoretinoscopy," used an eccentric light source and obtained retinoscopic-like images of the reflex in the pupil of the subject's eyes. Photoretinoscopy has become the preferred method of photorefraction and has been instantiated in a wide variety of devices used in vision screening and research. This has been greatly helped by the parallel development of computer and digital camera technology. It seems likely that photorefractive methods will continue to be refined and may eventually become ubiquitous in clinical practice.

Cortical visual impairment: new directions.

Cortical visual impairment is the leading cause of bilateral low vision in children in the U.S., yet very little research is being performed to find new diagnostic measures and treatments. Dr. Velma Dobson pioneering work on visual assessments of developmentally delayed children stands out as highly significant in this field. Future research will assess new diagnostic measures, including advanced imaging techniques. In addition, research will evaluate methods to prevent, treat, and rehabilitate infants and children afflicted with this condition.