Healthcare costs following falls and cataract surgery in older adults using Australian linked health data from 2012-2019.

OBJECTIVES: To investigate publicly funded healthcare costs according to faller status and the periods pre- and post-cataract surgeries, and identify factors associated with higher monthly costs in older people with bilateral cataract. METHODS: This prospective cohort study included community-dwelling older people aged 65 and over (between 2012 and 2019); at baseline participants had bilateral cataract and were waiting for cataract surgery in New South Wales (NSW) public hospitals. Participants were followed for 24 months. The study used self-reported and linked data (Medicare Benefits Schedule, Pharmaceutical Benefits Scheme, NSW Admitted Patient and Emergency Department Data Collections) to identify falls, cataract surgeries and healthcare costs incurred by the Australian and NSW Governments, all costs were inflated to 2018-19 Australian dollars (AUD). Median monthly healthcare costs were calculated for faller status (non-faller, non-medically treated faller, medically treated faller) and surgery periods (pre-surgery, post-first surgery, post-second surgery). Costs in the 30 days following a medically treated fall were estimated. A generalised linear model was used to investigate predictors of healthcare costs. RESULTS: During the median follow-up period of 24 months, 274 participants suffered 448 falls, with 95 falls requiring medical treatment. For medically treated falls, the mean cost in the 30 days after treatment was A$3779 (95% confidence interval $2485, $5074). Higher monthly healthcare costs were associated with a higher number of medications, being of the male sex, having one or more medically treated falls and having bilateral cataract surgery. After excluding the cost of cataract surgery, there were no significant differences in healthcare costs between the pre-cataract surgery, post-first eye cataract surgery and post-second eye cataract surgery periods. CONCLUSIONS: To our knowledge, this is the first study investigating publicly funded costs related to falls and cataract surgery in older people with bilateral cataract. This information enhances our understanding of healthcare costs in this group. The patterns in costs associated with falls can guide future government healthcare expenditure on falls treatment and prevention, including timely cataract surgery.

Diabetic Retinopathy Screening at the Point of Care (DR SPOC): detecting undiagnosed and vision-threatening retinopathy by integrating portable technologies within existing services.

INTRODUCTION: The aim of this study was to determine the prevalence of diabetic retinopathy (DR) in a low socioeconomic region of a high-income country, as well as determine the diagnostic utility of point-of-care screening for high-risk populations in tertiary care settings. RESEARCH DESIGN AND METHODS: This was a cross-sectional study of patients with diabetes attending foot ulcer or integrated care diabetes clinics at two Western Sydney hospitals (n=273). DR was assessed using portable, two-field, non-mydriatic fundus photography and combined electroretinogram/ pupillometry (ERG). With mydriatic photographs used as the reference standard, sensitivity and specificity of the devices were determined. Prevalence of DR and vision-threatening diabetic retinopathy (VTDR) were reported, with multivariate logistic regression used to identify predictors of DR. RESULTS: Among 273 patients, 39.6% had any DR, while 15.8% had VTDR, of whom 59.3% and 62.8% were previously undiagnosed, respectively. Non-mydriatic photography demonstrated 20.2% sensitivity and 99.5% specificity for any DR, with a 56.7% screening failure rate. Meanwhile, mydriatic photography produced high-quality images with a 7.6% failure rate. ERG demonstrated 72.5% sensitivity and 70.1% specificity, with a 15.0% failure rate. The RETeval ERG was noted to have an optimal DR cut-off score at 22. Multivariate logistic regression identified an eGFR of ≤29 mL/min/1.73 m2, HbA1c of ≥7.0%, pupil size of <4 mm diameter, diabetes duration of 5-24 years and RETeval score of ≥22 as strong predictors of DR. CONCLUSION: There is a high prevalence of vision-threatening and undiagnosed DR among patients attending high-risk tertiary clinics in Western Sydney. Point-of-care DR screening using portable, mydriatic photography demonstrates potential as a model of care which is easily accessible, targeted for high-risk populations and substantially enhances DR detection.

Associations between vision impairment and vision-related interventions on crash risk and driving cessation: systematic review and meta-analysis.

OBJECTIVES: To systematically investigate the associations between vision impairment and risk of motor vehicle crash (MVC) involvement, and evaluate vision-related interventions to reduce MVCs. DESIGN: Medline (Ovid), EMBASE and Global Health electronic databases were systematically searched from inception to March 2022 for observational and interventional English-language studies. Screening, data extraction and appraisals using the Joanna Briggs Institute appraisal tools were completed by two reviewers independently. Where appropriate, measures of association were converted into risk ratios (RRs) or ORs for meta-analysis. PARTICIPANTS: Drivers of four-wheeled vehicles of all ages with no cognitive declines. PRIMARY AND SECONDARY OUTCOMES: MVC involvement (primary) and driving cessation (secondary). RESULTS: 101 studies (n=778 052) were included after full-text review. 57 studies only involved older drivers (≥65 years) and 85 were in high-income settings. Heterogeneity in the data meant that most meta-analyses were underpowered as only 25 studies, further split into different groups of eye diseases and measures of vision, could be meta-analysed. The limited evidence from the meta-analyses suggests that visual field defects (four studies; RR 1.51 (95% CI 1.23, 1.85); p<0.001; I2=46.79%), and contrast sensitivity (two studies; RR 1.40 (95% CI 1.08, 1.80); p=0.01, I2=0.11%) and visual acuity loss (five studies; RR 1.21 (95% CI 1.02, 1.43); p=0.03, I2=28.49%) may increase crash risk. The results are more inconclusive for available evidence for associations of glaucoma (five studies, RR 1.27 (95% CI 0.67, 2.42); p=0.47; I2=93.48%) and cataract (two studies RR 1.15 (95% CI 0.97, 1.36); p=0.11; I2=3.96%) with crashes. Driving cessation may also be linked with glaucoma (two studies; RR 1.62 (95% CI 1.20, 2.19); p<0.001, I2=22.45%), age-related macular degeneration (AMD) (three studies; RR 2.21 (95% CI 1.47, 3.31); p<0.001, I2=75.11%) and reduced contrast sensitivity (three studies; RR 1.30 (95% CI 1.05, 1.61); p=0.02; I2=63.19%). Cataract surgery halved MVC risk (three studies; RR 0.55 (95% CI 0.34, 0.92); p=0.02; I2=97.10). Ranibizumab injections (four randomised controlled trials) prolonged driving in persons with AMD. CONCLUSION: Impaired vision identified through a variety of measures is associated with both increased MVC involvement and cessation. Cataract surgery can reduce MVC risk. Despite literature being highly heterogeneous, this review shows that detection of vision problems and appropriate treatment are critical to road safety. PROSPERO REGISTRATION NUMBER: CRD42020172153.

Patterns and determinants of incident cataract surgery in China from 2011 to 2015 using a nationally representative longitudinal database.

OBJECTIVES: To investigate incident cataract surgery and to investigate determinants of cataract surgery uptake in Chinese adults. DESIGN: This nationally representative longitudinal study recorded self-reported incident cataract surgery, and measured biological, clinical and socioeconomical characteristics at baseline and endline. SETTING: In the first stage, 150 county-level units were randomly chosen with a probability-proportional-to-size sampling technique from a sampling frame containing all county-level units. The sample was stratified by region and within region by urban district or rural county and per capita gross domestic product. The final sample of 150 counties fell within 28 provinces of China. PARTICIPANTS: Urban and rural Chinese persons aged 45 years and older. PRIMARY AND SECONDARY OUTCOME MEASURES: Incident cataract surgery (primary outcome) and the factors associated with incident cataract surgery (secondary outcome). RESULTS: Among 16 663 people enrolled in 2011, 13 705 (82.2%) attended follow-up in 2015. Among these, 167 (1.22%) reported incident cataract surgery. Those receiving surgery were significantly older (66.2±8.79 vs 58.3±9.18, p≤0.001) and more likely to report: illiteracy (44.9% vs 27.1%, p<0.001), poor baseline distance vision (49.7% vs 20.0%, p≤0.001), poor baseline near vision (37.1% vs 21.8%, p≤0.001), baseline visual impairment (15.6% vs 5.5%, p≤0.001), diabetes (12.0% vs 7.42%, p≤0.05) and higher baseline depression scores (9.7 vs 8.4 on a scale of 0-30, p≤0.05). In linear regression models, older age, worse distance vision, hypertension or diabetes, illiteracy and lower depression score were significantly associated with undergoing surgery. Results were similar in models including only persons aged ≥60 years, except that urban residence was also associated with surgery. When only those aged ≥60 years with poor vision were included, results were again the same, except that higher household expenditure was also associated with surgery. CONCLUSIONS: In China, cataract surgical rates remain low; underserved groups such as rural dwellers are less likely to receive cataract surgery.

Integration of hospital and community care for paediatric ophthalmology: A mixed-methods study.

BACKGROUND: To explore collaborative care models for paediatric eye care that integrate hospital and community-based care to address access blocks. METHODS: Sequential referrals to a tertiary paediatric ophthalmology clinic between April and October 2019 and subsequent encounters up until July 2020 at a major metropolitan public children's hospital in Sydney, Australia, were reviewed to identify those cases suitable for community care. Semi-structured phone interviews were conducted with eye health service providers, including ophthalmologists, orthoptists and optometrists, as well as service users to explore their perspectives on potential changes to service delivery. Qualitative data were analysed deductively using the Levesque model for access to healthcare and Consolidated Framework for Implementation Research (CFIR) to inform implementation strategies for future models of care. RESULTS: One-third of the 439 audited referrals (30.5%; 134/439) were identified as suitable for community management. Interviews revealed five themes relating to potential models of care, which would support and promote access: integrated health systems, standardised quality of care, interprofessional trust, multidisciplinary governance and patient-centred care. Key recommendations for future implementation included: (i) identifying and preparing clinical champions, (ii) conducting educational meetings, (iii) conducting local needs assessments and (iv) informing local opinion leaders. CONCLUSIONS: This audit highlights access blocks and poor targeting of referrals to tertiary paediatric ophthalmology services in a metropolitan hospital. Integration with community practitioners was identified as an acceptable way to streamline services, and strategies that may support successful implementation in this setting were identified.

Hypertensive retinopathy and cardiovascular disease risk: 6 population-based cohorts meta-analysis.

Background: The cardiovascular risk associated with different levels of hypertensive retinopathy, including mild, remains unclear. We performed an individual participant meta-analysis from 6 population-based cohort studies to determine the relationship of hypertensive retinopathy with incident cardiovascular outcomes. Methods: We identified cohort studies that objectively assessed hypertensive retinopathy from photographs, documented incident cardiovascular outcomes, and were population-based. Six studies contributed data from 11,013 individuals at baseline with 5-13 years follow-up. Participants were recruited if they had hypertension and did not have confounding conditions such as diabetic retinopathy. Main outcome measures were incident coronary heart disease (CHD), stroke and a composite endpoint of cardiovascular disease (CHD or stroke). Pooled estimates of incident risk ratios (IRR) were obtained after adjusting for age, gender, systolic blood pressure, serum total cholesterol, high density lipoprotein and smoking. Results: Among eligible participants with hypertension and without diabetes, there were 1018/9662 (10.5%) incident CHD events, 708/11,013 (6.4%) incident stroke events and 1317/9378 (14.0%) incident CVD events. Mild hypertensive retinopathy was associated with increased risk of CVD (IRR 1.13, 95% CI 1.00 to 1.27) and CHD (IRR 1.17, 95% CI 1.02 to 1.34) but not stroke; moderate hypertensive retinopathy was associated with increased risk of CVD (IRR 1.25 95% CI 1.02 to 1.53) but not stroke or CHD individually. Conclusions: In persons with hypertension, both mild and moderate hypertensive retinopathy were associated with higher CVD risk.

Feasibility of providing collaborative glaucoma care from a community optometry perspective: a mixed-methods assessment.

CLINICAL RELEVANCE: Despite evidence showing that optometry-led collaborative glaucoma care can be delivered at reduced cost compared to ophthalmology-based care without compromising patient outcomes, such models of care are not widely practiced in Australia. Ensuring glaucoma patients have equitable access to effective and cost-effective care is a matter of public health importance. BACKGROUND: This study examined the feasibility and business case assessment for providing glaucoma care from a community optometry perspective. METHODS: Nine optometrists were interviewed in a semi-structured format, focusing on the economic feasibility, barriers, and benefits of collaborative glaucoma care. The Consolidated Framework for Intervention Research was used for thematic data analysis. Costs and revenues associated with providing glaucoma care were sourced from the literature and interviews. A business case model assessing the profitability of glaucoma care in optometric practice was developed. RESULTS: Thematic analysis revealed concerns over financial viability such that current Medicare Benefits Schedule fees are not sufficient to justify the cost of running a community optometry glaucoma clinic. All participants received a supplementary source of revenue. This finding was confirmed by the business case assessment. Inter-professional trust was perceived to be a key barrier to initiation of collaborative care however was able to be overcome quickly upon commencement of a collaborative care relationship. Optometrists perceived that collaborative care was beneficial to all involved, including patients, ophthalmologists, optometrists, and health payers. There was a perception of a growing divide between clinical and retail optometry, which was thought by most participants to be appropriate. CONCLUSION: This study is the first to explore the feasibility and business case for community-based optometrists to provide collaborative glaucoma care in Australia. Our findings show that current public funding is insufficient to justify the business case to private optometry practice, despite being perceived by optometrists as beneficial to all involved.

Developing refractive management recommendations for patients undergoing cataract surgery: A Delphi study.

PURPOSE: Currently, there are no UK optometric guidelines regarding the pre and postoperative refractive management of patients undergoing cataract surgery. This study used a Delphi method to gain consensus on best practice. METHODS: Eighteen recommendations targeted areas of concern/variability in advice that were highlighted in an earlier focus group study of refractive management for patients who had received cataract surgery. These covered three topics: preoperative target refraction discussions, postoperative refractive management and driving advice postoperatively. The recommendations were then developed using evidence from optometry and ophthalmology clinical expertise and the research literature. Eighteen recommendations underwent a process of agreement and modification using a Delphi study consisting of a panel of 22 highly experienced optometrists (N = 11, 25 years mean clinical experience) and ophthalmologists (N = 11, 17 years mean clinical experience) who rated and commented upon the importance and feasibility of each recommendation. The responses were considered by the research team and the recommendations modified and/or removed prior to a second Delphi round of responses to a modified series of recommendations. Consensus of opinion was defined as greater than 80% of panellists 'agreed' or 'strongly agreed' on the recommendation for both importance and feasibility. RESULTS: Fourteen of the 18 recommendations reached consensus in the first round. A second round of the Delphi method saw 17 modified recommendations scored and commented upon by 20 clinicians. Fifteen recommendations reached consensus after two rounds of the Delphi method. CONCLUSIONS: Recommendations to guide the pre and postoperative refractive management of patients undergoing cataract surgery were agreed between highly experienced optometrists and ophthalmologists using a 2-round Delphi method. Patients would benefit from consistent target refraction discussions, postoperative refractive management and driving advice, and recommendations were of particular benefit to less experienced optometrists.

The true cost of hidden waiting times for cataract surgery in Australia.

Cataract surgery is a safe, effective and common elective procedure in Australia but access is inequitable. True waiting times for cataract care are undisclosed or inconsistently reported by governments. Estimates of true waiting times range from 4 to 30 months and have been extended during the coronavirus disease 2019 (COVID-19) pandemic. Comparative analysis revealed that reducing waiting periods from 12 to 3 months would result in estimated public health system cost savings of $6.6 million by preventing 50 679 falls. Investment in public cataract services to address current unmet needs would prevent avoidable vision impairment and associated negative consequences.

The incidence of falls after first and second eye cataract surgery: a longitudinal cohort study.

OBJECTIVE: To compare fall incidence, and visual acuity and refractive status, before surgery and after first and second eye cataract surgery. DESIGN, SETTING: Prospective observational study in eight tertiary referral ophthalmology clinics in public hospitals in Sydney, Melbourne, and Perth. PARTICIPANTS: People aged 65 years or more referred for bilateral age-related cataract surgery during 2013-16, followed for maximum of 24 months after study entry or until six months after second eye surgery, whichever was shorter. MAIN OUTCOME MEASURES: Primary outcome: age- and sex-adjusted incidence of falls. SECONDARY OUTCOMES: visual acuity and refractive error. RESULTS: The mean age of the 409 included participants was 75.4 years (SD, 5.4 years); 220 were women (54%). Age- and sex-adjusted fall incidence prior to surgery was 1.17 (95% CI, 0.95-1.43) per year, 0.81 (95% CI, 0.63-1.04) per year after first eye surgery, and 0.41 (95% CI, 0.29-0.57) per year after second eye surgery. For the 118 participants who underwent second eye surgery and participated in all follow-up visits, age- and sex-adjusted incidence before (0.80 [95% CI, 0.55-1.15] falls per year) and after first eye surgery (0.81 [95% CI, 0.57-1.15] falls per year) was similar, but was lower after second eye surgery (0.32 [95% CI 0.21-0.50] falls per year). Mean habitual binocular visual acuity (logMAR) was 0.32 (SD, 0.21) before surgery, 0.15 (SD, 0.17) after first eye surgery, and 0.07 (SD, 0.15) after second eye surgery. CONCLUSIONS: First eye surgery substantially improves vision in older people with cataract, but second eye surgery is required to minimise fall incidence. Timely cataract surgery for both eyes not only optimises vision in older people with cataract, but also reduces their risk of injury from falls.

Feasibility of Implementing Recommendations to Reduce Fall Risk in Older People: A Delphi Study.

SIGNIFICANCE: This study provides guidance for the implementation of recommendations for falls prevention in optometry practice, through synthesis with the optometrists' viewpoint as a major stakeholder. Educators and clinicians can adopt the revised recommendations and associated implementation strategies in this research for successful integration into optometric practice. PURPOSE: Recommendations for optometrists to help prevent falls in older patients were published in 2019 by Optometry Australia. This study used the Delphi technique to gain perspectives on the feasibility of implementing the recommendations in optometric practice. METHODS: A Delphi consensus process consisted of two rounds of anonymous questionnaires administered between October 2019 and February 2020. A panel of 12 optometrists scored and commented on the importance and feasibility of 28 recommendations based on a published evidence synthesis by Optometry Australia and a pilot Delphi round. Panelists were invited if they had at least 5-year experience in optometry practice and were involved in post-cataract surgery refractive management regularly in the past 12 months. RESULTS: Twenty-four recommendations reached consensus after the Delphi process. Recommendations that reached consensus but had low uptake in the panelists' practices were history taking about risk of falls and provision of advice to patients to seek professional home modification. Four recommendations did not reach consensus because they were perceived to be too prescriptive and less feasible to execute in real-world settings. To improve the compliance of patients to recommendations to reduce the risk of falls, panelists recommended involving patients in decision making and practice staff should be involved in falls prevention messaging. CONCLUSIONS: The Delphi panel supported the feasibility of most of the recommendations in optometric practice and provided suggestions to improve their implementation. Further research is needed to evaluate the implementation and benefits of these recommendations, designed to make optometric practice more effective in preventing patient falls.

Systematic review of diabetic eye disease practice guidelines: more applicability, transparency and development rigor are needed.

OBJECTIVES: To assess the quality of diabetic eye disease clinical practice guidelines. STUDY DESIGN AND SETTING: A systematic search of diabetic eye disease guidelines was conducted on six online databases and guideline repositories. Four reviewers independently rated quality using the Appraisal of Guidelines, Research, and Evaluation (AGREE II) instrument. Aggregate scores (%) for six domains and overall quality assessment were calculated. A "good quality" guideline was one with ≥60% score for "rigor of development" and in at least two other domains. RESULTS: Eighteen guidelines met the inclusion criteria, of which 13 were evidence-based guidelines (involved systematic search and grading of evidence). The median scores (interquartile range (IQR)) for "scope and purpose," "stakeholder involvement," "rigor of development," "clarity of presentation," "applicability" and "editorial independence" were 73.6% (54.2%-80.6%), 48.6% (29.2%-71.5%), 60.2% (30.9%-78.1%), 86.6% (76.7%-94.4%), 28.6% (18.0%-37.8%) and 60.2% (30.9%-78.1%), respectively. The median overall score (out of 7) of all guidelines was 5.1 (IQR: 3.7-5.8). Evidence-based guidelines scored significantly higher compared to expert-consensus guidelines. Half (n = 9) of the guidelines (all evidence-based) were of "good quality." CONCLUSION: A wide variation in methodological quality exists among diabetic eyecare guidelines, with nine demonstrating "good quality." Future iterations of guidelines could improve by appropriately engaging stakeholders, following a rigorous development process, including support for application in clinical practice and ensuring editorial transparency.

Quality of the Australian National Health and Medical Research Council's clinical practice guidelines for the management of diabetic retinopathy.

Clinical relevance: Understanding the quality of the commonly used clinical practice guidelines can help busy clinicians in selecting appropriate guidelines for evidence-based eye care for people with diabetes.Background: The National Health and Medical Research Council's (NHMRC) clinical practice guideline on diabetic retinopathy management has been widely used locally and internationally for over 10 years. However, the quality of this guideline has never been formally assessed. This study aimed to systematically evaluate the quality of the NHMRC guideline and compare it against other international guidelines.Methods: The 2008 NHMRC and another five established diabetic retinopathy management international guidelines (Scottish Intercollegiate Guidelines Network, 2017; American Academy of Ophthalmology, 2019; American Optometric Association, 2019; Royal College of Ophthalmologists, UK, 2013, and Canadian Ophthalmologic Society, 2012) were examined using the Appraisal of Guidelines, Research and Evaluation (AGREE II) instrument. Scoring by four independent reviewers was aggregated into six domain and overall rating scores. Consistency among the reviewers was assessed using intraclass correlation coefficient (ICC).Results: The AGREE II domain scores for the NHMRC guideline were: scope and purpose 72%, stakeholder involvement 64%, rigour of development 77%, clarity of presentation 96%, applicability 35%, and editorial independence 15%. The NHMRC guideline's overall score (5.3 of 7) was lower than that of most other guidelines. Compared to others, the NHMRC guideline scored well in clarity of presentation and rigour of development, but less well for editorial independence. The NHMRC guideline was the least current and a need to update it was recognised by all reviewers who identified key areas for improvement.Conclusion: The quality of the NHMRC guideline was comparable to most other established international guidelines. Several areas of strengths and weaknesses in this guideline were identified. Future updates should aim to improve transparency in development and applicability in clinical practice.

Falls prevention interventions for community-dwelling older people living in mainland China: a narrative systematic review.

BACKGROUND: Falls in community-dwelling older people have been recognised as a significant public health issue in China given the rapidly growing aged population. Although there are several reviews documenting falls prevention programs for community-dwelling older adults, no systematic reviews of the scope and quality of falls prevention interventions in Mainland China exist. Therefore, the aim of this study was to systematically review falls prevention interventions for community-dwelling older people living in Mainland China. METHODS: We systematically reviewed literature from Chinese and English databases. All types of randomised controlled trials (RCTs) and quasi-experimental studies published from 1st January 1990 to 30th September 2019 were included. Observational studies and studies in care facilities and hospitals were excluded. Narrative synthesis was performed to summarise the key features of all included studies. Quality assessment was conducted using the Cochrane Risk of Bias Tool and ROBINS-I tool for randomised and non-randomised studies respectively. RESULTS: A total of 1020 studies were found, and 101 studies were included in the analysis. Overall, very few high quality studies were identified, and there was insufficient rigor to generate reliable evidence on the effectiveness of interventions or their scalability. Most interventions were multiple component interventions, and most studies focused on outcomes such as self-reported falls incidence or awareness of falls prevention. CONCLUSION: There is an opportunity to undertake an evaluation of a rigorously-designed, large-scale falls prevention program for community-dwelling older people in Mainland China. To help mitigate the rising burden of falls in Mainland China, recommendations for future falls prevention interventions have been made. These include: (1) target disadvantaged populations; (2) incorporate personalised interventions; and (3) investigate the effectiveness of those under-explored interventions, such as psychological, social environment, management of urinary incontinence, fluid or nutrition therapy and surgery. The study results will also potentially provide a useful evidence base for other low-and-middle income countries in a similar situation.

Quality and targeting of new referrals for ocular complications of diabetes from primary care to a public hospital ophthalmology service in Western Sydney, Australia.

Patients with diabetes require regular examination for eye disease, usually in primary care settings. Guidelines recommend patients with at least moderate non-proliferative diabetic retinopathy (NPDR) be referred to an ophthalmologist for treatment; however, poorly targeted referrals lead to access blocks. The quality of new referrals associated with diabetes to a public ophthalmology service in Sydney, New South Wales, Australia, were assessed for referral completeness and targeting. A cross-sectional audit of medical records for new patients referred to Westmead Hospital Eye Clinic in 2016 was completed. Completeness of medical and ophthalmic information in referrals and subsequent patient diagnosis and management in 2016-17 was recorded. Sub-analyses were conducted by primary care referrer type (GP or optometrist). In total, 151 new retinopathy referrals were received; 12% were sent directly to a treatment clinic. Information was incomplete for diabetes status (>60%), medical (>50%) and ophthalmic indicators (>70%), including visual acuity (>60%). GP referrals better recorded medical, and optometrists (37%) ophthalmic information, but information was still largely incomplete. Imaging was rarely included (retinal photos <1%; optical coherence tomography <3%). Median appointment wait-time was 124 days; 21% of patients received treatment (laser or anti-vascular endothelial growth factor) at this or the following encounter. Targeting referrals for ocular complication of diabetes to public hospitals needs improvement. Education, feedback and collaborative care mechanisms should be considered to improve screening and referral in primary care.

The risk of vision loss in contact lens wear and following LASIK.

PURPOSE: To compare the risk of vision loss following contemporary laser-assisted in situ keratomileusis (LASIK) with different types and modality of use of contact lenses. METHODS: Data from a previously published study were used to derive the incidence of vision loss (≥ 2 line loss of best corrected spectacle acuity) following microbial keratitis for different contact lens types and wearing modality, stratified by duration of lens wear. A literature search on vision loss following LASIK was performed between 2003 and 2019. The prevalence of vision loss at six months post-surgery was captured from clinical trials published after 2003. A proportion meta-analysis was applied to derive the prevalence of vision loss following LASIK. A least-squares fitting of cumulative vision loss (P, /10 000 wearers) over time (t, years) using an exponential model estimated the years of contact lens wear to which the risk of vision loss with LASIK was equivalent. RESULTS: Vision loss following LASIK occurred in 66 (95% confidence interval [CI] 34-108) per 10 000 wearers. As a conservative estimate based on the lower confidence interval of the estimated equivalent years of contact lens wear, daily wear contact lenses and extended overnight silicone wear hydrogel contact lens need to be worn for 103 (95% [CI] 103-391) and 25 (95% [CI] 25-79) years respectively, to equal the rate of vision loss equivalent to a one-off LASIK procedure. CONCLUSIONS: The risk of vision loss to the individual is low with either contact lens wear or refractive surgery. Contact lens wear does not pose a higher risk of vision loss than LASIK surgery for the most common wear modalities.

Standardising the cataract referral process for public hospitals: perspectives of optometrists in New South Wales, Australia.

BACKGROUND: Previous research has shown that cataract surgery referral letters to major metropolitan public hospitals in New South Wales have insufficient detail to inform patient triage or apply prioritisation tools. This study aimed to canvass the views of optometrists working in New South Wales and the Australian Capital Territory (NSW/ACT) on standardising the referral process for public hospital cataract surgery. METHODS: An online survey was sent to all NSW/ACT members of Optometry Australia in October 2017. Respondents were asked to select clinical and personal information to be included on a referral template using a list of 25 items. Data were also gathered on preferences for the cataract referral process and sources of cataract referral guidelines. RESULTS: Two hundred and thirteen (response rate 13 per cent) optometrists completed the survey. There was close to universal support for inclusion of items like visual acuity (99 per cent), whereas other items had low support, including the date and details of previous refraction (26 per cent), history of falls (29 per cent) and health insurance status (29 per cent). Three-quarters of optometrists stated they would be willing to administer and report data from a patient survey about the functional impact of their cataract and level of visual disability. The preferred format of a standardised cataract referral template varied, although time efficiency and ease of completion were commonly cited reasons for preferences. Confirmation of receipt of referral from the public hospital, and a copy of the referral letter for the optometrist's records were also desirable. For the 61 per cent of respondents who reported accessing guidelines for cataract referral, 69 per cent stated the main source was Optometry NSW/ACT with fewer accessing guidelines directly from a public hospital or the NSW Health website. CONCLUSION: Optometrists' preferences will be useful to inform the design and implementation of a standardised cataract referral template.

Eye Injuries across history and the evolution of eye protection.

PURPOSE: To describe the history of eye injuries and the consequent evolution of eye protection. METHODS: A comprehensive search of Medline and the grey literature using the terms 'ocular trauma' and 'eye protection' or 'injury prevention' and 'history'. References were used to identify other relevant publications. Publications were classified according to the setting of eye injury: occupational, recreational or combat-related. RESULTS: Eye protection has been described in a wide range of sources, including in literature and art. With advances in eye protection material and design, as well as government and societal promotion of appropriate eye protection usage in the workplace, the epidemiology of ocular trauma has changed over time. In developed countries, the use of eye protection in the workplace has reduced the proportion of occupation-related eye injuries over the last century, with a higher proportion occurring during sports or at home. New protection devices and policies have evolved to meet this change. CONCLUSION: Vision loss has broad implications for the individual and for society and despite available prevention strategies, ocular trauma is a significant cause of preventable monocular and bilateral vision loss. The use of appropriate eye protection has reduced the burden of ocular trauma. History provides lessons for informing current eye protection and eye injury prevention strategies.

Routine preoperative medical testing for cataract surgery.

BACKGROUND: Cataract surgery is practiced widely, and substantial resources are committed to an increasing cataract surgical rate in low- and middle-income countries. With the current volume of cataract surgery and future increases, it is critical to optimize the safety and cost-effectiveness of this procedure. Most cataracts are performed on older individuals with correspondingly high systemic and ocular comorbidities. It is likely that routine preoperative medical testing will detect medical conditions, but it is questionable whether these conditions should preclude individuals from cataract surgery or change their perioperative management. OBJECTIVES: 1. To investigate the evidence for reductions in adverse events through preoperative medical testing2. To estimate the average cost of performing routine medical testing SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2018, Issue 6); Ovid MEDLINE; Embase.com; PubMed; LILACS BIREME, the metaRegister of Controlled Trials (mRCT) (last searched 5 January 2012); ClinicalTrials.gov and the WHO ICTRP. The date of the search was 29 June 2018, with the exception of mRCT which is no longer in service. We searched the references of reports from included studies for additional relevant studies without restrictions regarding language or date of publication. SELECTION CRITERIA: We included randomized clinical trials in which routine preoperative medical testing was compared to no preoperative or selective preoperative testing prior to age-related cataract surgery. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed abstracts to identify possible trials for inclusion. For each included study, two review authors independently documented study characteristics, extracted data, and assessed risk of bias. MAIN RESULTS: We identified three randomized clinical trials that compared routine preoperative medical testing versus selective or no preoperative testing for 21,531 cataract surgeries. The largest trial, in which 19,557 surgeries were randomized, was conducted in Canada and the USA. Another study was conducted in Brazil and the third in Italy. Although the studies had some issues with respect to performance and detection bias due to lack of masking (high risk for one study, unclear for two studies), we assessed the studies as at overall low risk of bias.The three randomized clinical trials included in this review reported results for 21,531 total cataract surgeries with 707 total surgery-associated medical adverse events, including 61 hospitalizations and three deaths. Of the 707 medical adverse events reported, 353 occurred in the pre-testing group and 354 occurred in the no-testing group (odds ratio (OR) 1.00, 95% confidence interval (CI) 0.86 to 1.16; high-certainty evidence). Most events were cardiovascular and occurred during the intraoperative period. Routine preoperative medical testing did not reduce the risk of intraoperative (OR 0.99, 95% CI 0.71 to 1.38) or postoperative ocular adverse events (OR 1.11, 95% CI 0.74 to 1.67) when compared to selective or no testing (2 studies; 2281 cataract surgeries; moderate-certainty evidence). One study evaluated cost savings, estimating the costs to be 2.55 times higher in those with preoperative medical testing compared to those without preoperative medical testing (1 study; 1005 cataract surgeries; moderate-certainty evidence). There was no difference in cancellation of surgery between those with preoperative medical testing and those with selective or no preoperative testing, reported by two studies with 20,582 cataract surgeries (OR 0.97, 95% CI 0.78 to 1.21; high-certainty evidence). No study reported outcomes related to clinical management changes (other than cancellation) or quality of life scores. AUTHORS' CONCLUSIONS: This review has shown that routine preoperative testing does not increase the safety of cataract surgery. Alternatives to routine preoperative medical testing have been proposed, including self administered health questionnaires, which could substitute for health provider histories and physical examinations. Such avenues may lead to cost-effective means of identifying those at increased risk of medical adverse events due to cataract surgery. However, despite the rare occurrence, adverse medical events precipitated by cataract surgery remain a concern because of the large number of elderly patients with multiple medical comorbidities who have cataract surgery in various settings. The studies summarized in this review should assist recommendations for the standard of care of cataract surgery, at least in low- and middle-income settings. Unfortunately, in these settings, medical history questionnaires may be useless to screen for risk because few people have ever been to a physician, let alone been diagnosed with any chronic disease.

Patient perspectives of cataract surgery: protocol and baseline findings of a cohort study.

BACKGROUND: Patient-reported outcome measures (PROMs) are becoming increasingly recognised as a key component in assessing the relative effectiveness of cataract surgery. This manuscript presents the protocol methodology and baseline characteristics of a prospective cohort study investigating patient-centred predictors of cataract surgery outcomes. METHODS: Patients with bilateral cataract (aged ≥ 50 years) scheduled for their first eye cataract surgery were recruited at four public hospitals and three private ophthalmology clinics in Sydney, Australia. Participants underwent a comprehensive assessment of clinical measures of vision (for example, visual acuity, contrast sensitivity) and PROMs prior to first eye surgery and three months after first and second eye surgery. The PROMs of interest included health-related quality of life, visual disability and satisfaction with vision. RESULTS: The characteristics of the baseline cohort of 359 participants are reported in this manuscript. Enrolment occurred over a two-year period with the majority recruited from urban public hospitals (96 per cent, n = 345). Health-related quality of life was scored highly (80 out of 100). Self-reported visual disability was considered within normal ranges compared to cataract populations in other high-income countries (-0.94 logits). Three-quarters of participants (n = 263/351) were dissatisfied with their pre-operative vision. CONCLUSIONS: There is a complex and wide range of patient-centred experiences prior to first eye cataract surgery in the public hospital setting. Gaining further insight into the patient perspective may allow eye health professionals to more appropriately time surgery, better manage patient expectations and provide direction for future prioritisation initiatives of cataract wait lists. Companion papers will follow, detailing results of surgery in terms of PROMs.