What are the causes of non-tolerance to new spectacles and how can they be avoided?

PURPOSE: To investigate non-tolerance cases from several UK practices to determine their likely causes and how they might have been avoided. METHODS: Patient complaint and refraction data were collected from non-tolerance recheck examinations. For one practice, clinical data were also collected retrospectively to investigate the quality of the eye examinations. RESULTS: Data for 279 rechecks were gathered from 10 practices and a recheck frequency of 2.3% was found. The mean patient age was 60 (SD 16) years, with cylinder changes responsible for 38% of prescription-related causes of rechecks, overplusing or underminusing 26%, and underplusing or overminusing just 11%. An assessment of 242 recheck corrections found that 40% were unsatisfactory (e.g., failed to address initial or recheck symptoms, N = 45) and retrospective analysis of 217 case records showed many limitations (e.g., 61% or 28% recorded no uncorrected or habitual visual acuity (VA) at either initial examination or recheck). CONCLUSIONS: Given that overplus-underminus was a much bigger proportion of prescription-related cases than overminus-underplus (26% vs. 11%), the refraction mantra of "maximum plus for maximum VA" should be balanced by increased teaching of the problems of overplusing and underminusing, and the use of prescribing guidelines. In addition, continuing professional development regarding the basics of the recheck examination, refraction, visual acuity and prism determination is needed. Changes of oblique cylinders should be carefully considered in older patients as this is a common cause of non-tolerance. In addition, if the "if it ain't broke, don't fix it" and related maxims had been applied to all patients who were asymptomatic at the original examination, one third of all non-tolerance cases could have been avoided. Finally, it would seem appropriate for practices to develop a system to deal better with non-tolerance cases. Perhaps an experienced clinician should examine all patients with non-tolerance and provide feedback to the original clinician.

A prospective evaluation of the clinical safety and effectiveness of a COVID-19 Urgent Eyecare Service across five areas in England.

PURPOSE: Although urgent primary eye care schemes exist in some areas of England, their current safety is unknown. Accordingly, the aim of the present study was to quantify the clinical safety and effectiveness of a COVID-19 Urgent Eyecare Service (CUES) across Luton, Bedford, Hull, East Riding of Yorkshire and Harrogate. METHODS: Consenting patients with acute onset eye problems who had accessed the service were contacted to ascertain what the optometrist's recommendation was, whether this worked, if they had to present elsewhere and how satisfied they were with the CUES. RESULTS: A total of 27% (170/629) and 6.3% (28/445) of patients managed virtually and in person, respectively, did not have their acute eye problem resolved. Regression analysis revealed that patients who attended a face-to-face consultation were 4.66 times more likely to be correctly managed [Exp (ß) = 5.66], relative to those solely managed virtually. Optometrists' phone consultations failed to detect conditions such as stroke, intracranial hypertension, suspected space occupying lesions, orbital cellulitis, scleritis, corneal ulcer, wet macular degeneration, uveitis with macular oedema and retinal detachment. Of referrals to hospital ophthalmology departments, in total, 19% were false-positives. Patients, however, were typically very satisfied with the service. Uptake was associated with socioeconomic status. CONCLUSION: The present study found that a virtual assessment service providing optometrist tele-consultations was not effective at resolving patients' acute-onset eye problems. The range and number of pathologies missed by tele-consultations suggests that the service model in the present study was detrimental to patient safety. To improve this, optometrists should follow evidence based guidance when attempting to manage patients virtually, or in person. For example, patients presenting with acute-onset symptoms of flashing lights and/or floaters require an urgent dilated fundus examination. Robust data collection on service safety is required on an ongoing basis.

A needs assessment for a minor eye condition service within Leeds, Bradford and Airedale, UK.

BACKGROUND: There are a number of limitations to the present primary eye care system in the UK. Patients with minor eye conditions typically either have to present to their local hospital or GP, or face a charge when visiting eye care professionals (optometrists). Some areas of the UK have commissioned enhanced community services to alleviate this problem; however, many areas have not. The present study is a needs assessment of three areas (Leeds, Airedale and Bradford) without a Minor Eye Conditions Service (MECS), with the aim of determining whether such a service is clinically or economically viable. METHOD: A pro forma was developed for optometrists and practice staff to complete when a patient presented whose reason for attending was due to symptoms indicative of a problem that could not be optically corrected. This form captured the reason for visit, whether the patient was seen, the consultation funding, the outcome and where the patient would have presented to if the optometrists could not have seen them. Optometrists were invited to participate via Local Optical Committees. Results were submitted via a Google form or a Microsoft Excel document and were analysed in Microsoft Excel. RESULTS: Seventy-five percent of patients were managed in optometric practice. Nine and 16% of patients required subsequent referral to their General Practitioner or hospital ophthalmology department, respectively. Should they not have been seen, 34% of patients would have presented to accident and emergency departments and 59% to their general practitioner. 53% of patients paid privately for the optometrist appointment, 28% of patients received a free examination either through use of General Ophthalmic Service sight tests (9%) or optometrist good will (19%) and 19% of patients did not receive a consultation and were redirected to other providers (e.g. pharmacy, accident and emergency or General Practitioner). 88% of patients were satisfied with the level of service. Cost-analyses revealed a theoretical cost saving of £3198 to the NHS across our sample for the study period, indicating cost effectiveness. CONCLUSIONS: This assessment demonstrates that a minor eye condition service in the local areas would be economically and clinically viable and well received by patients.

A proposed minimum data set for international primary care optometry: a modified Delphi study.

PURPOSE: To identify a minimum list of metrics of international relevance to public health, research and service development which can be extracted from practice management systems and electronic patient records in primary optometric practice. METHODS: A two stage modified Delphi technique was used. Stage 1 categorised metrics that may be recorded as being part of a primary eye examination by their importance to research using the results from a previous survey of 40 vision science and public health academics. Delphi stage 2 then gauged the opinion of a panel of seven vision science academics and achieved consensus on contentious metrics and methods of grading/classification. RESULTS: A consensus regarding inclusion and response categories was achieved for nearly all metrics. A recommendation was made of 53 metrics which would be appropriate in a minimum data set. CONCLUSIONS: This minimum data set should be easily integrated into clinical practice yet allow vital data to be collected internationally from primary care optometry. It should not be mistaken for a clinical guideline and should not add workload to the optometrist. A pilot study incorporating an additional Delphi stage prior to implementation is advisable to refine some response categories.

Can data in optometric practice be used to provide an evidence base for ophthalmic public health?

PURPOSE: The purpose of this paper is to investigate the potential of using primary care optometry data to support ophthalmic public health, research and policy making. METHODS: Suppliers of optometric electronic patient record systems (EPRs) were interviewed to gather information about the data present in commercial software programmes and the feasibility of data extraction. Researchers were presented with a list of metrics that might be included in an optometric practice dataset via a survey circulated by email to 102 researchers known to have an interest in eye health. Respondents rated the importance of each metric for research. A further survey presented the list of metrics to 2000 randomly selected members of the College of Optometrists. The optometrists were asked to specify how likely they were to enter information about each metric in a routine sight test consultation. They were also asked if data were entered as free text, menus or a combination of these. RESULTS: Current EPRs allowed the input of data relating to the metrics of interest. Most data entry was free text. There was a good match between high priority metrics for research and those commonly recorded in optometric practice. CONCLUSIONS: Although there were plenty of electronic data in optometric practice, this was highly variable and often not in an easily analysed format. To facilitate analysis of the evidence for public health purposes a UK based minimum dataset containing standardised clinical information is recommended. Further research would be required to develop suitable coding for the individual metrics included. The dataset would need to capture information from all sectors of the population to ensure effective planning of any future interventions.

Dizziness, but not falls rate, improves after routine cataract surgery: the role of refractive and spectacle changes.

PURPOSE: To determine whether dizziness and falls rates change due to routine cataract surgery and to determine the influence of spectacle type and refractive factors. METHODS: Self-reported dizziness and falls were determined in 287 patients (mean age of 76.5 ± 6.3 years, 55% females) before and after routine cataract surgery for the first (81, 28%), second (109, 38%) and both eyes (97, 34%). Dizziness was determined using the short-form of the Dizziness Handicap Inventory. Six-month falls rates were determined using self-reported retrospective data. RESULTS: The number of patients with dizziness reduced significantly after cataract surgery (52% vs 38%; χ(2) = 19.14(,) p < 0.001), but the reduction in the number of patients who fell in the 6-months post surgery was not significant (23% vs 20%; χ(2) = 0.87, p = 0.35). Dizziness improved after first eye surgery (49% vs 33%, p = 0.01) and surgery on both eyes (58% vs 35%, p < 0.001), but not after second eye surgery (52% vs 45%, p = 0.68). Multivariate logistic regression analyses found significant links between post-operative falls and change in spectacle type (increased risk if switched into multifocal spectacles). Post-operative dizziness was associated with changes in best eye visual acuity and changes in oblique astigmatic correction. CONCLUSIONS: Dizziness is significantly reduced by first (or both) eye cataract surgery and this is linked with improvements in best eye visual acuity, although changes in oblique astigmatic correction increased dizziness. The lack of improvement in falls rate may be associated with switching into multifocal spectacle wear after surgery.

Multimodal optogenetic neural interfacing device fabricated by scalable optical fiber drawing technique.

We present a novel approach to the design and manufacture of optrodes for use in the biomedical research field of optogenetic neural interfacing. Using recently developed optical fiber drawing techniques that involve co-drawing metal/polymer composite fiber, we have assembled and characterized a novel optrode with promising optical and electrical functionality. The fabrication technique is flexible, scalable, and amenable to extension to implantable optrodes with high-density arrays of multiple electrodes, waveguides, and drug delivery channels.

Addressing inequalities in eye health with subsidies and increased fees for General Ophthalmic Services in socio-economically deprived communities: a sensitivity analysis.

OBJECTIVES: Poor knowledge of eye health, concerns about the cost of spectacles, mistrust of optometrists and limited geographical access in socio-economically deprived areas are barriers to accessing regular eye examinations and result in low uptake and subsequent late presentation to ophthalmology clinics. Personal Medical Services (PMS) were introduced in the late 1990 s to provide locally negotiated solutions to problems associated with inequalities in access to primary care. An equivalent approach to delivery of optometric services could address inequalities in the uptake of eye examinations. STUDY DESIGN: One-way and multiway sensitivity analyses. METHODS: Variations in assumptions were included in the models for equipment and accommodation costs, uptake and length of appointments. The sensitivity analyses thresholds were cost-per-person tested below the GOS1 fee paid by the NHS and achieving break-even between income and expenditure, assuming no cross-subsidy from profits from sales of optical appliances. RESULTS: Cost per test ranged from £ 24.01 to £ 64.80 and subsidy required varied from £ 14,490 to £ 108,046. Unused capacity utilised for local enhanced service schemes such as glaucoma referral refinement reduced the subsidy needed. CONCLUSIONS: In order to support the financial viability of primary eye care in socio-economically deprived communities, income is required from additional subsidies or from sources other than eye examinations, such as ophthalmic or other optometric community services. This would require a significant shift of activity from secondary to primary care locations. The subsidy required could also be justified by the utility gain from earlier detection of preventable sight loss.

Longitudinal strain with speckle-tracking echocardiography predicts electroanatomic substrate for ventricular tachycardia in nonischemic cardiomyopathy patients.

Background: Longitudinal strain (LS) derived from speckle-tracking echocardiography (STE) corresponds to regions of scar in ischemic cardiomyopathy. Objective: We investigated if regional LS abnormalities correlate with scar location and scar burden, identified using high-density electroanatomic mapping (EAM) in nonischemic cardiomyopathy (NICM). Methods: Fifty NICM patients with ventricular tachycardia (VT) underwent echocardiography; multilayer (endocardial, midmyocardial, and epicardial) regional LS and global LS (GLS) were evaluated prior to EAM for detection of low-voltage scar. Patients were divided into 3 groups by EAM left ventricular scar location: (1) anteroseptal (group 1, n = 20); (2) inferolateral (group 2, n = 20); and (3) epicardial scar (group 3; n = 10). We correlated (1) location of scar to regional LS and (2) regional strain and GLS to scar percentage. Results: Regional LS abnormalities correlated with EAM scar in all groups. Segmental impaired LS and low voltage on EAM demonstrated concordance with scar in ∼75% or its border zone in 25% of segments. In groups 1 and 2, endocardial GLS showed a strong linear correlation with endocardial bipolar scar percentage (r = 0.79, 0.75 for groups 1 and 2, respectively; P < .001), whereas midmyocardial GLS correlated with unipolar scar percentage (r = 0.82, 0.78 for groups 1 and 2, respectively; P < .001). In group 3, epicardial regional LS and GLS correlated with epicardial bipolar scar percentage (r = 0.72, P < .001). Conclusion: Regional abnormalities on LS predict scar location on EAM mapping in patients with NICM. Moreover, global and regional LS correlate with scar percentage. STE could be used as a noninvasive tool for localizing and quantifying scar prior to EAM.

Assessment of referrals to the hospital eye service by optometrists and GPs in Bradford and Airedale.

PURPOSE: To investigate the content of referrals to a hospital eye department and describe differences between referring clinician (optometrist or GP) and referral formats. METHODS: A random sample of 433 new referrals to Bradford Royal Infirmary hospital eye service (HES) during 2007 and 2008 were retrospectively analysed. RESULTS: Three hundred and eleven referrals (72%) were from optometric practice and 122 (28%) from general practice. Optometric referrals were mainly for cataract and posterior capsular opacification (27%), glaucoma or suspect glaucoma (20%) and diabetic retinopathy (10%). CONCLUSIONS: The proportion of referrals to the hospital eye service from optometrists appears to be increasing (1988: 39%, 1999: 48%, present study 72%). GPs mainly refer patients with anterior segment disorders, particularly lid lesions, based on direct observation and symptoms. Optometrists refer patients with a wide range of ocular diseases and include fundus observations and visual acuity measurements in their referrals. There is a need to inform optometrists of what content is required in a referral to the HES from GOS sight tests, at least for the common referral conditions such as age-related cataract and suspect open-angle glaucoma. Referral forms specifically designed for these commonly referred conditions are likely to improve referral quality.

Exploring the effect of optometrist practice type on NHS funded sight test outcome.

PURPOSE: The United Kingdom (UK) National Health Service (NHS) currently provides sight tests at no cost to patients for all those aged <16 or ≥60. Some 'at-risk' patients and those in receipt of means-tested benefits are eligible for a NHS sight test between the ages of 16 and 60. In the UK, community optometrists typically either work in independent or national chain practices (multiples). The present study aims to explore whether practice type has any association with sight test outcome. As sight tests are essential in detecting early childhood visual problems, we also aim to explore children's first sight tests. METHOD: Data from 664,480 NHS sight test claims submitted in Essex from April 2015 to September 2016 were analysed using regression analysis. Practice type (multiple, independent) and children's first sight test were examined with respect to socio-economic status (SES, based on index of multiple deprivation rankings), age and sight test outcome. RESULTS: The median age for a first NHS sight test was 6 years old and was clinically independent of SES. Children's first sight tests typically resulted in neither a spectacle prescription being issued nor an onwards referral. Patients that attend multiples are significantly more likely to receive a new prescription, relative to no prescription, compared to a patient attending an independent (p<.001). CONCLUSIONS: Inequalities in sight test outcome appear to exist with differing type of practice (independent or multiple). Choice of practice type appears to be influenced by SES. Children have their first sight test at a later age than recommended.

Analysis of muscle tissue in vivo using fiber-optic autofluorescence and diffuse reflectance spectroscopy.

SIGNIFICANCE: Current methods for analyzing pathological muscle tissue are time consuming and rarely quantitative, and they involve invasive biopsies. Faster and less invasive diagnosis of muscle disease may be achievable using marker-free in vivo optical sensing methods. AIM: It was speculated that changes in the biochemical composition and structure of muscle associated with pathology could be measured quantitatively using visible wavelength optical spectroscopy techniques enabling automated classification. APPROACH: A fiber-optic autofluorescence (AF) and diffuse reflectance (DR) spectroscopy device was manufactured. The device and data processing techniques based on principal component analysis were validated using in situ measurements on healthy skeletal and cardiac muscle. These methods were then applied to two mouse models of genetic muscle disease: a type 1 neurofibromatosis (NF1) limb-mesenchyme knockout (Nf1Prx1 - / - ) and a muscular dystrophy mouse (mdx). RESULTS: Healthy skeletal and cardiac muscle specimens were separable using AF and DR with receiver operator curve areas (ROC-AUC) of >0.79. AF and DR analyses showed optically separable changes in Nf1Prx1 - / - quadriceps muscle (ROC-AUC >0.97) with no differences detected in the heart (ROC-AUC <0.67), which does not undergo gene deletion in this model. Changes in AF spectra in mdx muscle were seen between the 3 week and 10 week time points (ROC-AUC = 0.96) and were not seen in the wild-type controls (ROC-AUC = 0.58). CONCLUSION: These findings support the utility of in vivo fiber-optic AF and DR spectroscopy for the assessment of muscle tissue. This report highlights that there is considerable scope to develop this marker-free optical technology for preclinical muscle research and for diagnostic assessment of clinical myopathies and dystrophies.

Development and Validation of the Vision-Related Dizziness Questionnaire.

PURPOSE: To develop and validate the first patient-reported outcome measure (PROM) to quantify vision-related dizziness. Dizziness is a common, multifactorial syndrome that causes reductions in quality of life and is a major risk factor for falls, but the role of vision is not well understood. METHODS: Potential domains and items were identified by literature review and discussions with experts and patients to form a pilot PROM, which was completed by 335 patients with dizziness. Rasch analysis was used to determine the items with good psychometric properties to include in a final PROM, to check undimensionality, differential item functioning, and to convert ordinal questionnaire data into continuous interval data. Validation of the final 25-item instrument was determined by its convergent validity, patient, and item-separation reliability and unidimensionality using data from 223 patients plus test-retest repeatability from 79 patients. RESULTS: 120 items were originally identified, then subsequently reduced to 46 to form a pilot PROM. Rasch analysis was used to reduce the number of items to 25 to produce the vision-related dizziness or VRD-25. Two subscales of VRD-12-frequency and VRD-13-severity were shown to be unidimensional, with good psychometric properties. Convergent validity was shown by moderately good correlations with the Dizziness Handicap Inventory (r = 0.75) and good test-retest repeatability with intra-class correlation coefficients of 0.88. CONCLUSION: VRD-25 is the only PROM developed to date to assess vision-related dizziness. It has been developed using Rasch analysis and provides a PROM for this under-researched area and for clinical trials of interventions to reduce vision-related dizziness.

Improving energy efficiency of electrochemical blackwater disinfection through sequential reduction of suspended solids and chemical oxygen demand.

Onsite reuse of blackwater requires removal of considerable amounts of suspended solids and organic material in addition to inactivation of pathogens. Previously, we showed that electrochemical treatment could be used for effective pathogen inactivation in blackwater, but was inadequate to remove solids and organics to emerging industry standards. Further, we found that as solids and organics accumulate with repeated recycling, electrochemical treatment becomes less energetically sustainable. Here, we describe a pilot study in which concentrated blackwater is pretreated with ultrafiltration and granular activated carbon prior to electrochemical disinfection, and show that this combination of treatments removes 75-99% of chemical oxygen demand, 92-100% of total suspended solids, and improves the energy efficiency of electrochemical blackwater treatment by an order of magnitude.

Exploring the effect of optometrist practice type on NHS funded sight test outcome

PURPOSE: The United Kingdom (UK) National Health Service (NHS) currently provides sight tests at no cost to patients for all those aged <16 or ≥60. Some 'at-risk' patients and those in receipt of means-tested benefits are eligible for a NHS sight test between the ages of 16 and 60. In the UK, community optometrists typically either work in independent or national chain practices (multiples). The present study aims to explore whether practice type has any association with sight test outcome. As sight tests are essential in detecting early childhood visual problems, we also aim to explore children's first sight tests. METHOD: Data from 664,480 NHS sight test claims submitted in Essex from April 2015 to September 2016 were analysed using regression analysis. Practice type (multiple, independent) and children's first sight test were examined with respect to socio-economic status (SES, based on index of multiple deprivation rankings), age and sight test outcome. RESULTS: The median age for a first NHS sight test was 6 years old and was clinically independent of SES. Children's first sight tests typically resulted in neither a spectacle prescription being issued nor an onwards referral. Patients that attend multiples are significantly more likely to receive a new prescription, relative to no prescription, compared to a patient attending an independent (p < .001). CONCLUSIONS: Inequalities in sight test outcome appear to exist with differing type of practice (independent or multiple). Choice of practice type appears to be influenced by SES. Children have their first sight test at a later age than recommended

No disponible

Levels of state and trait anxiety in patients referred to ophthalmology by primary care clinicians: a cross sectional study.

PURPOSE: There is a high level of over-referral from primary eye care leading to significant numbers of people without ocular pathology (false positives) being referred to secondary eye care. The present study used a psychometric instrument to determine whether there is a psychological burden on patients due to referral to secondary eye care, and used Rasch analysis to convert the data from an ordinal to an interval scale. DESIGN: Cross sectional study. PARTICIPANTS AND CONTROLS: 322 participants and 80 control participants. METHODS: State (i.e. current) and trait (i.e. propensity to) anxiety were measured in a group of patients referred to a hospital eye department in the UK and in a control group who have had a sight test but were not referred. Response category analysis plus infit and outfit Rasch statistics and person separation indices were used to determine the usefulness of individual items and the response categories. Principal components analysis was used to determine dimensionality. MAIN OUTCOME MEASURE: Levels of state and trait anxiety measured using the State-Trait Anxiety Inventory. RESULTS: State anxiety scores were significantly higher in the patients referred to secondary eye care than the controls (p<0.04), but similar for trait anxiety (p>0.1). Rasch analysis highlighted that the questionnaire results needed to be split into "anxiety-absent" and "anxiety-present" items for both state and trait anxiety, but both subscales showed the same profile of results between patients and controls. CONCLUSIONS: State anxiety was shown to be higher in patients referred to secondary eye care than the controls, and at similar levels to people with moderate to high perceived susceptibility to breast cancer. This suggests that referral from primary to secondary eye care can result in a significant psychological burden on some patients.