What are the experiences of teleophthalmology in optometric referral pathways? A qualitative interview study with patients and clinicians.

OBJECTIVE: Implementing teleophthalmology into the optometric referral pathway may ease the current pressures on hospital eye services caused by over-referrals from some optometrists. This study aimed to understand the practical implications of implementing teleophthalmology by analysing lived experiences and perceptions of teleophthalmology in the optometric referral pathway for suspected retinal conditions. DESIGN: Qualitative in-depth interview study SETTING: Fourteen primary care optometry practices and four secondary care hospital eye services from four NHS Foundation Trusts across the UK. PARTICIPANTS: We interviewed 41 participants: patients (17), optometrists (18), and ophthalmologists (6) who were involved in the HERMES study. Through thematic analysis, we collated and present their experiences of implementing teleophthalmology. RESULTS: All participants interviewed were positive towards teleophthalmology as it could enable efficiencies in the referral pathway and improve feedback and communication between patients and healthcare professionals. Concerns included setup costs for optometrists and anxieties from patients about not seeing an ophthalmologist face to face. However, reducing unnecessary visits and increasing the availability of resources and capacity were seen as significant benefits. CONCLUSIONS: Overall, we report positive experiences of implementing teleophthalmology into the optometric referral pathway for suspected retinal conditions. Successful implementation will require appropriate investment to set up and integrate new technology and remunerate services, and continued evaluation to ensure timely feedback to patients and between healthcare professionals is received. TRIAL REGISTRATION NUMBER: ISRCTN18106677.

Situation analysis on the integration of refractive error services provided by optometrists into the national health services in Kenya.

INTRODUCTION: Even though the burden of uncorrected refractive error could potentially be addressed through innovative and cost-effective approaches, integration of the services into the National Health Services (NHS) is desirable. However, minimal information exists on the current situation warranting the need for evidence about the integration of refractive error service provided by optometrists into the national health services in Kenya. METHODS: A situation analysis of the Kenyan refractive error services provided by optometrists within the NHS was undertaken based on access to service delivery, service coverage, and human resource. A strengths, weaknesses, opportunities, and threats analysis was undertaken based on the existent evidence to identify the core factors that could potentially facilitate or hinder the integration of refractive error services provided by optometrists within the National Health Services. The proportion of optometrists to be integrated in the NHS was estimated based on the minimum ratios recommended by the World Health Organization. RESULTS: A section of tertiary and secondary healthcare facilities in Kenya have specific services to address refractive errors within the NHS with most facilities lacking such services. Treatment of refractive error occurs at the level of eye care general services. There are 11,547 health facilities offering primary care services in Kenya. However, none of them offers refractive error services and only a section of facilities offering county health referral services provides eye care services which is limited to refraction without provision of spectacles. The existing workforce comprises of ophthalmologists, optometrists and ophthalmic clinical officers, together with nurses and other general paramedical assistants. Optometrists, ophthalmologists and ophthalmic clinical officers are allowed to undertake refraction. However, optometrists majorly practices in the private sector. Centralization of eye care services in urban areas, weak referral systems, and a shortage in the workforce per population was observed. CONCLUSIONS: The Kenyan NHS should advocate for primary care and reorient the current hospital-based delivery approach for refractive error services. This is attributed to the fact that provision of refractive error services at primary care remains effective and efficient and could translate to early detection of other ocular conditions. The existing human resources in the eye health ecosystem in Kenya should maximize their efforts towards addressing uncorrected refractive error and optometrists should be integrated into the NHS.

Diagnostic decisions of specialist optometrists exposed to ambiguous deep-learning outputs.

Artificial intelligence (AI) has great potential in ophthalmology. We investigated how ambiguous outputs from an AI diagnostic support system (AI-DSS) affected diagnostic responses from optometrists when assessing cases of suspected retinal disease. Thirty optometrists (15 more experienced, 15 less) assessed 30 clinical cases. For ten, participants saw an optical coherence tomography (OCT) scan, basic clinical information and retinal photography ('no AI'). For another ten, they were also given AI-generated OCT-based probabilistic diagnoses ('AI diagnosis'); and for ten, both AI-diagnosis and AI-generated OCT segmentations ('AI diagnosis + segmentation') were provided. Cases were matched across the three types of presentation and were selected to include 40% ambiguous and 20% incorrect AI outputs. Optometrist diagnostic agreement with the predefined reference standard was lowest for 'AI diagnosis + segmentation' (204/300, 68%) compared to 'AI diagnosis' (224/300, 75% p = 0.010), and 'no Al' (242/300, 81%, p = < 0.001). Agreement with AI diagnosis consistent with the reference standard decreased (174/210 vs 199/210, p = 0.003), but participants trusted the AI more (p = 0.029) with segmentations. Practitioner experience did not affect diagnostic responses (p = 0.24). More experienced participants were more confident (p = 0.012) and trusted the AI less (p = 0.038). Our findings also highlight issues around reference standard definition.

Keratoconus Management in the Community: A Survey of Optometrists.

OBJECTIVES: Defining the patterns of practice and referral criteria of optometrists within New Zealand to investigate the diagnosis and management of keratoconus. METHODS: Optometrists recruited through the New Zealand Association of Optometrists, Cornea and Contact Lens Society of New Zealand, and private practices were invited to complete an anonymous survey. RESULTS: Responses were received from 168 optometrists (representing 20.0% of the optometrist population). Half (48%) of optometrists had ≥15 years of experience, and 22% prescribed soft contact lenses daily, whereas only 6.4% prescribed rigid gas-permeable (RGP) lenses daily. The main barriers to prescribing RGPs were experience with fitting, low market demand, and patient discomfort. When referring to an ophthalmologist, 41% reported referring on progression of corneal parameters, 27% on initial diagnosis, 21% at no set time, and 10% with a reduction in visual acuity. Most optometrists (64%) would refer for possible surgery when visual acuity dropped between 6/9 and 6/12. Optometrists with greater experience were more likely to prescribe RGP lenses and co-manage patients with ophthalmologists. Ownership of a corneal imaging unit suggested an increased likelihood of prescribing RGP lenses but did not alter referral patterns. CONCLUSION: This survey provides an overview of current practice and highlights the importance of optometrists in the diagnosis and management of keratoconus. There was a significant discrepancy in keratoconus management, regarding optical correction modality and referral criteria for ophthalmology review. Further interdisciplinary work is required between optometry and ophthalmology to standardize referral guidelines and enhance visual outcomes.

Diagnostic accuracy of community optometrists for age-related macular degeneration using colour fundus photographs: A pilot evaluation.

PURPOSE: The accurate diagnosis of age-related macular degeneration (AMD) represents an important step in delaying and preventing vision loss and achieving optimal patient care. Therefore, this pilot study aimed to estimate the diagnostic accuracy of community optometrists for identifying AMD using colour fundus photographs (CFPs) to support sample size calculations for subsequent definitive studies. METHODS: Five practising community optometrists were invited to classify a total of 1023 CFPs for the (1) presence of AMD, and, if applicable, (2) stage of AMD (early/intermediate/late geographic atrophy/late neovascular AMD). Diagnosis by referral centre clinicians formed the reference standard. Diagnostic accuracy was assessed by the area under the receiver operating characteristic curve (aROC). Sensitivity, specificity, positive and negative predictive values were also calculated. RESULTS: Of the 1023 CFPs included in the study, 226 images were of AMD and 797 images were of other ocular conditions or no abnormal findings. Participating community optometrists had a mean (SD) age of 30.2 (8.9) years, 60.0% (3/5) were female and the mean number of years practising in primary eye care was 5.4 (5.4) years. Community optometrists demonstrated excellent performance for diagnosing AMD, with an aROC of 0.86 (95% CI 0.83 to 0.89), sensitivity of 84.5% (95% CI 79.1 to 89.0) and specificity of 88.0% (95% CI 85.5 to 90.1). The aROC (95% CI) for diagnosing early, intermediate, late geographic atrophy and late neovascular AMD was 0.82 (0.73 to 0.91), 0.76 (0.72 to 0.81), 0.69 (0.49 to 0.90) and 0.55 (0.34 to 0.75), respectively. CONCLUSIONS: These results justify the need for an appropriately powered definitive study to assess community clinicians' diagnostic accuracy for AMD.

Criterios de referencia y barreras para la atención de personas con baja visión en Santander / Criteria for referral and barriers to care for people with low vision in Santander

Objetivo: Identificar criterios de derivación y barreras percibidas por los optómetras para la rehabilitación de personas con baja visión en Santander. Métodos: Estudio de corte transversal que incluyó 82 optómetras de municipios de Santander, seleccionados mediante muestreo intencionado. Se diseñó un cuestionario con 36 preguntas para recolectar los datos que son reportados empleando estadística descriptiva. Resultados: El 47,5 % de los profesionales tiene claro el nivel de agudeza visual para clasificar a una persona con baja visión. Las principales barreras identificadas para el acceso a servicios de baja visión fueron: el proceso de derivación dentro del sistema de salud es engorroso (74,39 %), falta de servicios cerca (57,31 %) y considerar que los pacientes no pueden pagar las ayudas (48,78 %). Discusión: Es necesario fortalecer la formación de los optómetras para mejorar los procesos de identificación, atención y rehabilitación. Conclusiones: Es importante ubicar como prioritaria la discapacidad visual en Santander, para así robustecer la red de atención en salud.

Objective: To identify referral criteria and barriers perceived by optometrists for the rehabilitation of people with low vision in Santander. Methods: Cross-sectional study, which included 82 optometrists from municipalities of Santander, selected by purposive sampling. A questionnaire with 36 questions was designed to collect data that are reported using descriptive statistics. Results: A total of 47.5% of the professionals are clear about the level of visual acuity to classify a person with low vision. The main barriers identified for access to low vision services were: the referral process within the health system is cumbersome (74.39%), lack of services nearby (57.31%) and considering that patients cannot afford the aids (48.78%). Discussion: It is necessary to strengthen the training of optometrists to improve the processes of identification, care and rehabilitation. Conclusions: It is important to prioritize visual impairment in Santander in order to strengthen the health care network.

Nd:YAG Laser Capsulotomy: Efficacy and Outcomes Performed by Optometrists.

SIGNIFICANCE: An increasing number of optometrists are performing Nd:YAG laser capsulotomy procedures; however, there is limited published information on the outcomes of these procedures. PURPOSE: This study aimed to assess the efficacy and safety of capsulotomy procedures performed by optometrists. METHODS: Subjects diagnosed with posterior capsule opacification causing reduced vision and subjective visual complaints were recruited for this study. A baseline examination was performed to ensure that the subjects met all the necessary criteria. The procedure was performed by a licensed doctor of optometry at six different clinics, and each subject was monitored for visual outcome and any potential complications. RESULTS: Subjects' Snellen visual acuity improved from an average of 20/40 to 20/23 ( P < .001) with no complications of increased intraocular pressure, inflammation, visually significant lens pitting, macular edema, or retinal detachment. Of 78 subjects who responded to a post-procedure survey, 77 (99%) reported subjective improvement in vision after capsulotomy. CONCLUSIONS: Based on the outcomes of this study, YAG laser capsulotomies are effective treatments to improve patient vision that can be safely and effectively performed by optometrists.

Evaluating Access to Laser Eye Surgery by Driving Times Using Medicare Data and Geographical Mapping.

Importance: Recently, several states have granted optometrists privileges to perform select laser procedures (laser peripheral iridotomy, selective laser trabeculoplasty, and YAG laser capsulotomy) with the aim of increasing access. However, whether these changes are associated with increased access to these procedures among each state's Medicare population has not been evaluated. Objective: To compare patient access to laser surgery eye care by estimated travel time and 30-minute proximity to an optometrist or ophthalmologist. Design, Setting, and Participants: This retrospective cohort database study used Medicare Part B claims data from 2016 through 2020 for patients accessing new patient or laser eye care (laser peripheral iridotomy, selective laser trabeculoplasty, YAG) from optometrists or ophthalmologists in Oklahoma, Kentucky, Louisiana, Arkansas, and Missouri. Analysis took place between December 2021 and March 2023. Main Outcome and Measures: Percentage of each state's Medicare population within a 30-minute travel time (isochrone) of an optometrist or ophthalmologist based on US census block group population and estimated travel time from patient to health care professional. Results: The analytic cohort consisted of 1 564 307 individual claims. Isochrones show that optometrists performing laser eye surgery cover a geographic area similar to that covered by ophthalmologists. Less than 5% of the population had only optometrists (no ophthalmologists) within a 30-minute drive in every state except for Oklahoma for YAG (301 470 [7.6%]) and selective laser trabeculoplasty (371 097 [9.4%]). Patients had a longer travel time to receive all laser procedures from optometrists than ophthalmologists in Kentucky: the shortest median (IQR) drive time for an optometrist-performed procedure was 49.0 (18.4-71.7) minutes for YAG, and the the longest median (IQR) drive time for an ophthalmologist-performed procedure was 22.8 (12.1-41.4) minutes, also for YAG. The median (IQR) driving time for YAG in Oklahoma was 26.6 (12.2-56.9) for optometrists vs 22.0 (11.2-40.8) minutes for ophthalmologists, and in Arkansas it was 90.0 (16.2-93.2) for optometrists vs 26.5 (11.8-51.6) minutes for ophthalmologists. In Louisiana, the longest median (IQR) travel time to receive laser procedures from optometrists was for YAG at 18.5 (7.6-32.6) minutes and the shortest drive to receive procedures from ophthalmologists was for YAG at 20.5 (11.7-39.7) minutes. Conclusions and Relevance: Although this study did not assess impact on quality of care, expansion of laser eye surgery privileges to optometrists was not found to lead to shorter travel times to receive care or to a meaningful increase in the percentage of the population with nearby health care professionals.

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.

Survey of the Faculty Status of Optometrists at Academic Medical Centers in the United States.

SIGNIFICANCE: This is the first study of the prevalence and faculty status of optometrists practicing at academic medical centers in the United States. PURPOSE: This study aimed to quantify the number of optometrists at academic medical centers, along with faculty rank and post-doctoral training programs. METHODS: The official Web sites of academic medical centers and schools of medicine in the United States were examined during the 2021 to 2022 academic year to identify departments of ophthalmology and collect faculty profiles of employed optometrists. Institutional data were cross-referenced and analyzed by geographic distribution. Data were gathered from the Association of Schools and Colleges of Optometry and Accreditation Council on Optometry Education to identify post-graduate training programs in optometry. RESULTS: A total of 192 academic medical centers were identified, of which 121 (63.02%) had a residency or fellowship program in ophthalmology and/or optometry. One hundred twenty-five (65.10%) of these institutions had at least one staff optometrist. Seven hundred eighteen optometrists were found at these institutions, representing 1.83% of the 39,205 practicing optometrists estimated in the United States. Of the 718 optometrists, 369 (51.39%) held an academic appointment at a medical school. The most common academic rank was assistant professor (184 [25.63%]), followed by instructor (138 [19.22%]), associate professor (34 [4.74%]), and full professor (13 [1.81%]). The distribution of academic rank was similar across all regions but varied between institutions as to whether all, some, or none of the optometric faculty were appointed by a medical school. Of 296 optometry residency programs in the United States, 21 (7.09%) were at an academic medical center. Of 15 optometric fellowship programs in the United States, 3 (20%) were at an academic medical center. Of the 192 institutions in this study, 22 (11.46%) had a post-doctoral optometric training program. CONCLUSIONS: This study shows the distribution of academic rank and post-doctoral training programs for optometrists at academic medical centers.

The MOLES system to guide the management of melanocytic choroidal tumours: can optometrists apply it?

CLINICAL RELEVANCE: Although melanocytic choroidal tumours of the choroid are a common eye pathology, no standardised protocol exists for their management in the community. BACKGROUND: Choroidal naevi are found in approximately 6% of the adult White population, whereas choroidal melanomas are rare, with an annual incidence of 5-10/million/year. Multimodal imaging has advanced the understanding of malignancy imaging biomarkers, but distinguishing between a small melanoma and naevus remains difficult and an algorithm for their management by community practitioners has not been uniformly adopted. One of the authors (BD) devised the MOLES scoring system, which indicates malignancy likelihood according to mushroom shape, orange pigment, large size, enlargement, and subretinal fluid. When applied by ocular oncologists, the system accurately distinguishes choroidal naevi from melanomas. The aim of this study was to evaluate whether community optometrists can appropriately manage patients with melanocytic choroidal tumours using this system. METHODS: Clinical images of 25 melanocytic choroidal tumours were presented in an online survey, including colour fundus photographs, fundus autofluorescence, optical coherence tomography, and B-scan ultrasound images. Using the MOLES system, 39 optometrists diagnosed tumours as naevus or probable melanoma and decided between community monitoring and ophthalmologist referral. Responses were compared to MOLES grading of the same clinical images by ocular oncologists. RESULTS: Using MOLES, optometrists correctly identified 389/406 probable melanomas (95.8% sensitivity) and 331/516 choroidal naevi (64.1% specificity); correctly referred 773/778 tumours to an ophthalmologist (99.4% sensitivity); and correctly managed 80/144 lesions (55.6% specificity) in the community. CONCLUSION: Optometrists safely applied the MOLES scoring system in this survey. Further measures are indicated to reduce choroidal naevi over-referral and evaluate MOLES system usage in clinical optometric practice, where some imaging modalities may not be readily available.

The paediatric optometry alignment program - a model of interprofessional collaborative eyecare.

CLINICAL RELEVANCE: Collaboration  between hospital-based ophthalmology and community-based optometry could pave the way to improve access to paediatric eyecare services. BACKGROUND: The Paediatric Optometry Alignment Program (POAP) began in 2016 as a proof-of-concept pilot project that aimed to improve access to specialist paediatric ophthalmology services. If found to be effective at improving patient access, and the quality of care acceptable to patients and professionals then the strategic intent was to upscale the programme to  serve as a model for paediatric eye care in the community. METHODS: Temporal observational trend analysis was used to review ophthalmology clinic appointment waitlists prior and post POAP pilot project commencement. Family satisfaction with post-discharge care was surveyed in a purposive sample of 30 patients.  Aligned optometrists in the program pilot (n = 97) were invited to complete an online survey (response rate 46%; n = 45). RESULTS: The percentage of children waiting longer than clinically recommended fell from 72% to 36%. Sixty-seven percent  of surveyed families had attended a community optometrist as recommended, and all rated the optometry experience from good to excellent.  Participating optometrists reported high levels of satisfaction with involvement in the program, and increased confidence and involvement in paediatric eye care delivery. The need to improve formal transfer  of clinical information was identified. CONCLUSION: Facilitated integrated care between community-based optometrists and a hospital-based ophthalmology department can improve access for tertiary care services, with high satisfaction for families and participating community-based optometrists.

Analysis of cataract referrals from community optometrists and general practitioners and subsequent clinic visit outcomes in a university hospital in the west of Ireland.

BACKGROUND: Studies published from hospitals in other countries have reported rates of between 69 and 90% of cataract referrals being listed for surgery (1-3). This potentially represents unnecessary outpatient appointments, time off work and transport costs for patients and carers (2). AIMS: Our first primary endpoint was to assess the number of cataract referrals listed for surgery. Our second primary endpoint was to assess the number of cataract referrals which included the following: (i) that visual loss from the cataract resulted in a detrimental effect on the patient's lifestyle, (ii) that the patient was willing to have surgery and (iii) that the patient was symptomatic from their cataract. METHODS: This project followed the Declaration of Helsinki. This was a retrospective study. RESULTS: Between February 2021 and February 2022, 198 patients were seen in Mr. PM's cataract clinic. Overall, 129 patients (67.5%) were listed for cataract surgery. Forty-seven referrals (23.7%) reported that the cataract was having a detrimental effect on the patient's life and these patients were more likely to be listed for surgery (93.6% vs. 59.2%, p = 0.00). Twenty-five referrals (12.6%) reported that the patient was willing to undergo surgery and these patients were more likely to be listed for surgery (88% vs. 64.8%, p = 0.02). A total of 130 referrals (65.7%) reported that the patient was symptomatic from their cataract and these patients were more likely to be listed for surgery (81.5% vs. 38.3%, p = 0.00). CONCLUSIONS: It is possible that an appropriately focussed referral form will aid in triaging cataract referrals and potentially reduce unnecessary appointments.

Point-of-care tools to support optometric care provision to people with age-related macular degeneration: A randomised, placebo-controlled trial.

PURPOSE: Age-related macular degeneration (AMD) is a leading cause of vision impairment. This randomised placebo-controlled trial investigated whether point-of-care tools can improve optometrists' AMD knowledge and/or care provision. METHODS: Australian optometrists (n = 31) completed a demographics survey and theoretical AMD case study multiple-choice questions (MCQs) to assess their confidence in AMD care provision and AMD knowledge. Participants were then randomly assigned to one of three point-of-care tools (online 'Classification of Age-related macular degeneration and Risk Assessment Tool' (CARAT), paper CARAT, or 'placebo') to use when providing care to their subsequent 5-10 AMD patients. Participants self-audited the compliance of their AMD care to best practice for these patients, and a similar number of consecutive patients seen prior to enrolment. Post-intervention, participants retook the AMD knowledge MCQs and confidence survey. RESULTS: A total of 29 participants completed the study. At the study endpoint, clinical confidence relative to baseline improved with the paper CARAT, relative to placebo, for knowledge of AMD risk factors, asking patients about these factors and referring for medical retinal sub-specialist care. There were no between-group differences for the change in AMD knowledge scores. Considering record documentation for patients with any AMD severity, there were no significant between-group differences for documenting patient risk factors, AMD severity, clinical examination techniques or management. In a sub-analysis, the change from baseline in compliance for documenting discussions about patient smoking behaviours for early AMD patients was higher with use of the online CARAT relative to placebo (p = 0.04). For patients with intermediate AMD, the change from baseline in documenting the risk of progression to late AMD was greater among practitioners who used the paper CARAT, relative to placebo (p = 0.04). CONCLUSIONS: This study demonstrates that point-of-care clinical tools can improve practitioner confidence and aspects of the documentation of AMD clinical care by optometrists as assessed by self-audit.

Investigating target refraction advice provided to cataract surgery patients by UK optometrists and ophthalmologists.

PURPOSE: To determine whether UK optometrists and ophthalmologists provide target refraction advice to patients prior to cataract surgery, and when this should first be discussed. METHODS: Optometrists and ophthalmologists were asked to complete a survey of two clinical vignettes (both older patients with cataract; a pre-operative myope who routinely read without glasses and a patient using a monovision approach), plus multiple choice and short answer questions either using hard copy or online. RESULTS: Responses were obtained from 437 optometrists and 50 ophthalmologists. Optometrists who reported they would provide target refraction advice were more experienced (median 22 years) than those who would leave this to the Hospital Eye Service (median 10 years). The former group reported it was in the patients' best interest to make an informed decision as they had seen many myopic patients who read uncorrected pre-operatively, and were unhappy that they could no longer do so after surgery. Inexperienced optometrists reported that they did not want to overstep their authority and left the decision to the ophthalmologist. The ophthalmologists estimated their percentage of emmetropic target refractions over the last year to have been 90%. CONCLUSION: Currently, some long-term myopes become dissatisfied after cataract surgery due to an emmetropic target refraction that leaves them unable to read without glasses as they did prior to surgery. Although experienced optometrists are aware of this and attempt to discuss this issue with patients, less experienced optometrists tend not to. This suggests that target refraction needs greater exposure in university training and continuing professional development. To provide patients with the knowledge to make informed decisions regarding their surgery, we suggest an agreed protocol within funded direct referral schemes of initial target refraction discussions by optometrists to introduce the idea of refractive outcomes and outline options, with further discussion with the ophthalmologist to clarify understanding.

Validity of Hand Held Fundus Camera by Optometrist using Slit lamp 90D bio microscopy as a reference standard for screening of Diabetes Retinopathy.

OBJECTIVE: To find out the validity of hand-held fundus camera by optometrist using slit lamp 90D biomicroscopy as reference standard for screening of diabetes retinopathy. METHODS: The observational cross-sectional study was conducted at the diabetic clinic of Al-Ibrahim Eye Hospital, Karachi, from August 2020 to May 2021, and comprised diabetics of either gender aged >16 years visiting the outpatient department. Un-dilated fundus photograph of both eyes were taken with non-mydriatic fundus camera. Pupils were then mid-dilated with one drop of tropicamide 1% before capturing retinal images by handheld fundus camera by another optometrist. Both the optometrists identified and recorded the presence and absence of diabetic retinopathy. Subsequently, a retinal specialist examined the fundus with slit lamp 90 D biomicroscopy. Data was analysed using SPSS 23. RESULTS: Of the 500 subjects, 291(58.2%) were males and 209(41.8%) were females. The overall mean age was 54.49±9.16 years (range: 16-83 years). Of the 1000 eyes, fundus was not readable in 130(13%) by hand-held fundus camera, 296(29.6%) eyes by non-mydriatic fundus camera and 76(7.6%) eyes by slit lamp. Sensitivity and specificity of hand-held fundus camera compared to non-mydriatic fundus camera was 89.86% and 80.36%, respectively. In comparison with slit lamp, the sensitivity was 91.71% and specificity was 71.10%. Kappa statistic for diabetic retinopathy detection by hand-held fundus camera versus non-mydriatic fundus camera was 0.705, indicating substantial agreement. Kappa statistic for diabetic retinopathy detection with hand-held fundus camera with semi-dilated pupil was found to be a valid screening tool in the hand of optometrist for preliminary screening of diabetic retinopathy. CONCLUSIONS: Handheld fundus camera with semi-dilated pupil was found to be a valid screening tool in the hand of optometrist for preliminary screening of diabetic retinopathy.

Acute community ophthalmology services provided by independent prescribing optometrists supporting hospital eye services during the COVID-19 outbreak.

BACKGROUND: Specialised Independent Prescribing (IP) community optometrists provided acute eye care during the COVID-19 crisis ensuring that over-stretched hospital emergency eye care was supported, therefore local overall urgent eye care provision was not affected. SUBJECTS/METHODS: Number of cases seen by hospital Rapid Access Clinic (RAC) between January 2020 and June 2020 were compared to number of cases seen by IP optometrists in community Acute Primary Care Ophthalmology Service (APCOS) during the same time period. Specifically, comparisons were made between the number of cases seen in RAC and the number of cases seen by APCOS during the period before COVID-19 emergency (January-March 2020) and for a similar timeframe thereafter (April-June 2020). Numbers treated by APCOS alone and those referred to RAC were also determined. The change in case numbers between the different healthcare settings was also studied. RESULTS: Increase in cases seen by APCOS between April (n = 391) and June (n = 641). Number of cases seen by RAC declined from 652 in March to 372 in April, increasing to 610 by June. This was still below maximum number of monthly cases seen by RAC pre-lockdown in January (861). Most of the cases seen by APCOS were managed in the community with 4% referred to RAC. CONCLUSIONS: Ophthalmology services delivered by IP specialised optometrists can safely and efficiently treat and manage the vast majority of urgent cases and mitigate the reduced capacity within hospital emergency eye clinics. Our experience provides insights into care pathways for urgent eye cases in the future.

Selective laser trabeculoplasty (SLT) performed by optometrists-enablers and barriers to a shift in service delivery.

BACKGROUND/OBJECTIVES: To explore the acceptability, training requirements, enablers and barriers of optometrist-delivered SLT. SUBJECTS/METHODS: Optometrists, fellowship and consultant grade ophthalmologists, hospital managers and patients were interviewed using pre-defined topic guides. Interviews were audio-recorded, transcribed, and subjected to thematic analysis. Overarching themes were defined by the study aims and the topic guides; subthemes were derived from the interview data. RESULTS: Sixty-six participants (three managers, eight glaucoma specialist consultant ophthalmologists, seven clinical glaucoma fellows, 12 optometrists (two of them performing SLT), two ophthalmic nurses and 34 patients) participated in the study. Overarching themes (and subthemes) were: necessity of non-medical SLT delivery, clinical practice and training, advantages, disadvantages, concerns, challenges, community delivery of SLT, patient values and other healthcare professionals that could also deliver SLT. CONCLUSIONS: Certain clinical pre-requisites, such as gonioscopy and independent prescribing rights, were perceived as necessary for undertaking SLT training. An optometrist-delivered SLT service was expected to benefit the NHS, but there was an identified need of a standardised training scheme and robust governance. Patients were accepting of an optometrist-delivered SLT service in the hospital eye service.