Worsening vision at age 4-5 in England post-COVID: Evidence from a large database of vision screening data.

PURPOSE: Myopia prevalence has increased in the UK at age 10-16y, but little is known about younger children. We hypothesise that if the 'myopia epidemic' is affecting young children, then there will be increasing rates of bilateral reduced unaided vision (V) at vision screenings of children 4-5 years of age. METHODS: Retrospective anonymised data from computerised vision screening at age 4-5 years were analysed from serial cross-sectional data. Refractive error is not assessed in UK vision screening, so vision was investigated. Data were only included from schools that screened every year from 2015/16 to 2021/22. The criterion used was unaided monocular logMAR (automated letter-by-letter scoring) vision >0.20 in both the right and left eyes, so as to maximise the chances of detecting bilateral, moderate myopia rather than amblyopia. RESULTS: Anonymised raw data were obtained for 359,634 screening episodes from 2075 schools. Once schools were excluded where data were not available for every year and data were cleaned, the final database comprised 110,076 episodes. The proportion (percentage and 95% CI) failing the criterion from 2015/16 to 2021/22 were 7.6 (7.2-8.0), 8.5 (8.1-8.9), 7.5 (7.1-7.9), 7.8 (7.4-8.2), 8.7 (8.1-9.2), 8.5 (7.9-9.0) and 9.3 (8.8-9.7), respectively. The slope of the regression line showed a trend for increasing rates of reduced bilateral unaided vision, consistent with increasing frequency of myopia (p = 0.06). A decreasing linear trendline was noted for children 'Under Professional Care'. CONCLUSIONS: For children 4-5 years of age, there were signs of reduced vision over the last 7 years in England. Consideration of the most likely causes support the hypothesis of increasing myopia. The increase in screening failures highlights the importance of eye care in this young population.

New Italian version of the Wilkins Rate of Reading Test: Materials for repeated-measure designs in optometry and neuropsychological research.

PURPOSE: To develop a series of equivalent passages of text in Italian, according to the principles of the Wilkins Rate of Reading Test (WRRT), suitable for both clinical examination and scientific research when equivalent stimuli are needed to compare performance in repeated-measure designs. METHOD: Fifteen high-frequency Italian words (matched for grammatical class and length to the English WRRT) were used to generate 15 different 10-line meaningless passages, according to the design principles of the English WRRT. Thirty-two healthy Italian-speaking higher education students read the passages aloud according to a fixed randomisation schedule. Performance was recorded digitally to measure reading speed and accuracy offline. Equivalence between the passages and the practice and fatigue effects for both reading speed and accuracy were examined as well as test-retest reliability. RESULTS: No significant difference in reading speed and accuracy was found between the passages. There was a significant practice effect on reading speed but not accuracy, with the first presented passage read significantly slower than the others. There was no evidence of a fatigue effect. Reading speed, the reference metric for the WRRT, showed good test-retest reliability. CONCLUSIONS: The passages of the Italian version of the WRRT were equivalent to each other. The practice effect suggests that familiarisation with the test (i.e., reading at least one matrix of words) should be carried out before consecutive/repeated reading of different passages for experimental or clinical purposes.

Referrals from community optometrists in England and their replies: A mixed methods study.

PURPOSE: Community optometrists, through routine eye examinations, identify patients with disease or ocular abnormalities requiring referral to the Hospital Eye Service. In many cases no reply to the referral letter is received, resulting in some patients being re-referred unnecessarily, potentially increasing the number of other patients who lose sight whilst on hospital waiting lists. This study investigated, qualitatively and quantitatively, factors influencing optometric referrals and replies. METHODS: The three-phase, sequential mixed methods study started with a literature review and qualitative phase, interviewing stakeholders to identify issues for exploration in subsequent phases. The second, quantitative phase, undertook documentary analysis of 349 patient referral records from three optometric practice modalities (domiciliary, independently owned, and corporate chain) in England. A final qualitative phase obtained views from stakeholders to explore unexplained findings from the first two phases. RESULTS: Phase 1 identified communication, financial, professional and technological issues for further exploration. In Phase 2, the referral rate was 22.2% for domiciliary provider, 2.1% for independent practice and 2.5% for the corporate chain, with the variation most likely explained by patient age and associated ophthalmic disease, illness and disability. The referral reply rate was 5.7% for domiciliary provider, 25.0% for independent practice and 4.9% for the corporate chain. The community optometrist remained unaware of the outcome of their referral in 72.8% of cases. Qualitative analyses indicate the main factors influencing referral reply rates are technology, the General Medical Practitioner, community optometrists' utility to and utility of the National Health Service and patient mobilisation. CONCLUSIONS: The low referral reply rate creates a break in the feedback loop required to raise the standard of referrals and avoid unnecessary re-referral. Of the factors identified that influence referral reply rates, technology is key in view of the increasing use of online referral platforms. Feedback to the referring optometrist should be embedded in such systems.

Randomised controlled trial of an accommodative support lens designed for computer users.

PURPOSE: Accommodative support (AS) lenses are a low add progressive addition spectacle lens designed to ease symptoms in computer vision syndrome (CVS). The study aims to investigate if (1) AS lenses improve CVS symptoms; (2) binocular/accommodative functions predict a benefit from AS lenses and (3) wearing AS lenses for six months impacts on binocular/accommodative functions. METHODS: Pre-presbyopic adults with symptoms of CVS (Computer Vision Syndrome Questionnaire, CVS-Q© , score ≥ 6) were randomly allocated to wear AS lenses or control single vision (SV) lenses. The CVS-Q© and a battery of optometric tests were applied at baseline and after three and six months. Participants and researchers were masked to participant group. After six months, the SV group were unmasked and changed to AS lenses and one week later asked to choose which they preferred. RESULTS: The change in CVS-Q© scores from baseline to six months did not differ significantly in the two groups. At the end of the one week period, when the control group wore the AS lenses, control group participants were significantly more likely to prefer AS lenses to SV lenses. No optometric functions correlated with the benefit from AS lenses. AS lenses did not have any adverse effects on binocular or accommodative function. CONCLUSIONS: In pre-presbyopic adults, there was no greater improvement in CVS-Q© scores in the group wearing AS lenses than in the control group. No adverse effects on optometric function (including accommodation) are associated with wearing AS lenses.

Referrals from community optometrists to the hospital eye service in England.

PURPOSE: In the UK, most referrals to the hospital eye service (HES) originate from community optometrists (CO). This audit investigates the quality of referrals, replies, and communication between CO and the HES. METHODS: Optometric referrals and replies were extracted from three practices in England. If no reply letter was found, the records were searched at each local HES unit, and additional replies or records copied. De-identified referrals, replies and records were audited by a panel against established standards to evaluate whether the referrals were necessary, accurate and directed to the appropriate professional. The referral rate (RR) and referral reply rate (RRR) were calculated. RESULTS: A total of 459 de-identified referrals were extracted. The RR ranged from 3.6%-8.7%. The proportion of referred patients who were seen in the HES unit was 63%-76%. From the CO perspective, the proportion of referrals for which they received replies ranged from 26%-49%. Adjusting the number of referrals for cases when it would be reasonable to expect an HES reply, RRR becomes 38%-62%. Patients received a copy of the reply in 3%-21% of cases. Referrals were made to the appropriate service in over 95% of cases, were judged necessary in 93%-97% and were accurate in 81%-98% of cases. The referral reply addressed the reason for the referral in 93%-97% and was meaningful in 94%-99% of cases. The most common conditions referred were glaucoma, cataract, anterior segment lesions, and neurological/ocular motor anomalies. The CO/HES dyad (pairing) in the area with the lowest average household income had the highest RR. CONCLUSIONS: In contrast with the Royal College of Ophthalmologists/College of Optometrists joint statement on sharing patient information, CO referrals often do not elicit a reply to the referring CO. Replies from the HES to COs are important for patient care, benefitting patients and clinicians, and minimising unnecessary HES appointments.

The relationship between unwarranted variation in optometric referrals and time since qualification.

PURPOSE: To investigate variation in optometric referral decision-making and the influence of experience and continuing education and training (CET). METHODS: To gain insight into unwarranted variation in referral activity in the United Kingdom (UK): (1) triage data were audited to investigate source of referral, provisional diagnosis, and outcome; (2) an online system was developed to present two sets of 10 vignettes, designed to avoid prompting answers. Participating optometrists completed 10 pre-CET vignettes, recording their tests and management decisions. The main group of participants chose whatever CET they wished over a 6-month period and then completed another 10 post-CET vignettes. A second group of newly-qualified optometrists completed the vignettes before and after a CET course intervention, followed by a third group of pre-registered optometrists with an intervention of 6-months experience of their pre-registration year. RESULTS: The audit identified 1951 optometric referrals and 158 optometrists (211 referrals were from general medical practitioners), with 122 of the 158 optometrists making fewer than ten referrals. Two newly-qualified optometrists generated 12.5% of the total referrals in the audit (N = 2162). Many suspect glaucoma referrals were based on a single suspect measurement resulting in a high discharge rate after community review, as did referrals for certain fundus-related appearances for which no treatment was indicated. The intervention of gaining CET points appeared to have no significant impact (p = 0.37) on referral decision-making, although this part of the study was underpowered. Self-selection bias was confirmed in the main group. When the main group and newly-qualified practitioners were compared, the number of referrals was negatively associated with time since qualification (p = 0.005). When all 20 referral decisions were compared, all optometrists referring more than 10 vignette patients came from a group of newly-qualified practitioners up to 2 years post-qualification. Pre-registered optometrists generally referred more appropriately than newly-qualified. Upon qualification, there was a significant increase in the number of sight tests undertaken per day (p = <0.0005). CONCLUSIONS: Gaining CET points alone is unlikely to significantly improve referral decision-making. Mentoring and targeted CET for the newly-qualified up to 2 years post-qualification should be considered. Ophthalmology replies to the referring newly-qualified optometrist are vital for moderating future referrals and developing clinical confidence.

Repeatability and comparison of clinical techniques for anterior chamber angle assessment.

PURPOSE: To assess the repeatability of gonioscopy, van Herick method and anterior segment Optical Coherence Tomography (AS-OCT) and determine the agreement between these techniques within a community optometry setting. METHODS: Gonioscopy, van Herick method and AS-OCT imaging were performed by an optometrist on two occasions, 1 month apart, on 80 subjects aged over 40 years recruited from community optometry practices. Anterior segment images were captured with a spectral domain OCT (Topcon 3D OCT-2000; wavelength 840 nm) set to the Anterior Segment (AS) mode. Eyes were graded as open or occludable for each method. AS-OCT images from both visits were graded by a second optometrist masked to the gonioscopy and van Herick method results, and the visit on which the images were acquired. Cohen's kappa (κ) was used to describe the intra-observer repeatability. Likelihood ratios, sensitivity and specificity of van Herick method and AS-OCT were calculated, using gonioscopy as the reference standard. RESULTS: Measurements were obtained from 80 eyes of 80 subjects. In four cases, AS-OCT images were un-gradable due to difficulty in locating the scleral spur. The repeatability of gonioscopy was fair κ = 0.29, while that of the van Herick method (κ = 0.54) and AS-OCT (κ = 0.47) were somewhat better. The van Herick method showed good sensitivity (visit 1: 75%, visit 2: 69%) and high specificity (visit 1: 88%, visit 2: 96%). The sensitivity of AS-OCT was fair (visit 1: 46%, visit 2: 25%), but specificity was high (visit 1: 87%. visit 2: 89%). CONCLUSION: Intra-observer repeatability was better for van Herick method and for AS-OCT than for gonioscopy, despite the latter being considered the gold standard method. The van Herick method appeared to be more sensitive than AS-OCT when identifying eyes at risk of angle closure. A standalone anterior segment OCT with a longer wavelength laser could afford better visualisation of the angle, and might therefore be expected to enable the examiner to make more precise classifications. These instruments are not widely used by optometrists in clinical practice in the UK at present.

Manufacturer changes lead to clinically important differences between two editions of the TNO stereotest.

PURPOSE: Stereoacuity tests used in clinical practice should be repeatable and reproducible. However, it has been observed in a clinical setting that new editions of the TNO stereotest appear to give different values from those obtained using previous versions. The purpose of the present research was to investigate this observation. METHODS: One hundred and twenty-one Dutch subjects, 88 (73%) females and 33 (27%) males, with an average age of 34.0 years (range 18-55) had their stereoacuity measured using two different versions of the TNO stereoacuity test (TNO 13 and TNO 15). The TNO was tested in a counterbalanced order so that consecutive subjects started with alternate editions to avoid bias. RESULTS: There was a significant difference (p < 0.001) between the median value for stereoacuity measured with TNO 13 (30 s of arc) and TNO 15 (60 s of arc). The bias between the two test versions was -0.23 Log arcseconds (95% limits of the differences: 0.15 to -0.60 Log arcseconds). CONCLUSION: This study reveals that results obtained with two different editions of a commonplace stereoacuity test are not comparable. New versions come on the market at regular intervals and the assumption that they will give the same results as previous versions may not be valid. Besides the statistically significant difference between the TNO 13 and TNO 15, the Bland-Altman plot also showed a considerable bias and the 95% limits of the differences between the TNO 13 and TNO 15 are more than two steps on the Log arcsecond scale. This difference between two editions of the TNO stereotests is not clinically acceptable and therefore it is inappropriate to use the two versions of the test interchangeably. It is important in both research and clinical records to specify the edition of the TNO test used.

Employee perception of a mandated helmet policy at Vail Resorts.

OBJECTIVE: The purpose of this study was to measure support for a mandated helmet policy among resort employees along with the impact of such a policy on job satisfaction, and additionally, to measure the prevalence of barriers to helmet use among this population. METHODS: In all, 728 Vail Resort employees were surveyed regarding their opinions on the helmet policy and on general helmet use. RESULTS: The majority of the 728 employees surveyed (66.5%; 95% CI: 63% to 70%) agreed with the helmet policy. Only 18% (95% CI: 16% to 21%) reported a negative effect on job satisfaction. Older employees (>25 years old) were more likely to disagree with the policy (odds ratio [OR] 3.1; 95% CI: 2.2 to 4.3) and report a negative effect on job satisfaction (OR 4.8; 95% CI: 3.0 to 7.6). Skiers were much more likely than snowboarders to report a negative effect on job satisfaction (OR 9.8; 95% CI: 5.2 to 18.1). Among resort employees, ski patrollers were more likely to disagree with the mandate (OR 9.8; 95% CI: 6.8 to 13.9) and report a negative effect on job satisfaction (OR 13.2; 95% CI: 8.3 to 21.). Forty-three percent of participants (95% CI: 39% to 46%) agreed with the statement that wearing a helmet encourages reckless behavior whereas 51.0% (95% CI: 47% to 54%) believed that wearing a helmet limits sensory perception. CONCLUSIONS: A mandatory helmet use policy was supported by most resort employees. However, ski patrollers and older, more experienced employees were more likely to report a negative effect on job satisfaction. Barriers to helmet use continue to persist in the ski industry and represent a target for further educational efforts.

A comparison of myopia control in European children and adolescents with defocus incorporated multiple segments (DIMS) spectacles, atropine, and combined DIMS/atropine.

PURPOSE: To evaluate the efficacy of a myopia control spectacle lens (DIMS) at slowing the progression of myopia in a population of European children in comparison with 0.01% atropine and combined DIMS and atropine. METHODS: The study was a non-randomised experimenter-masked prospective controlled observational study of individuals aged 6-18 years with progressing myopia but no ocular pathology. Participants were allocated, according to patient/parent choice, to receive 0.01% atropine eyedrops, DIMS (Hoya® MiyoSmart®) spectacles, combined atropine+DIMS or single vision spectacle lenses (control group). The key outcome variables, cycloplegic autorefraction spherical equivalent refraction (SER) and axial length (AL), were measured at baseline and after three, six, and 12 months. RESULTS: Of the 146 participants (mean age 10.3y ±3.2), 53 received atropine, 30 DIMS spectacles, 31 atropine+DIMS, and 32 single vision control spectacles. Generalized linear mixed model analysis revealed for SER, whilst controlling for age and SER at baseline, at each stage all treatment groups had significantly reduced progression compared with the control group (p<0.016). For AL, whilst controlling for baseline age and AL, at 6 and 12 months all treatment groups had significantly less progression than the control group (p<0.005). For SER only, in pairwise comparisons at 12 months the atropine+DIMS group had significantly reduced progression compared with the DIMS only and Atropine only groups (p<0.001). CONCLUSION: In a European population, DIMS and atropine are effective at reducing myopia progression and axial elongation in progressing myopia and are most successful at reducing myopia progression when used in combination.

A comparison of in-air and in-saline focimeter measurement of the back vertex power of spherical soft contact lenses.

PURPOSE: To compare the repeatability and validity of measurements of the back vertex power (BVP) of spherical soft contact lenses made in-air using the method specified in the International Standard (ISO 18369-3:2006) with the corresponding values when BVP was calculated from measurements made using a wet cell and focimeter method that is not approved by this Standard. METHODS: The BVP of 20 hydrogel and 20 silicone hydrogel lenses, with labelled powers ranging from +8.00 to -12.00 D, were measured with a focimeter by two operators on two occasions in-air in accordance with the relevant International Standard. Equivalent sets of measurements were made with the lenses immersed in-saline within a wet cell and their BVPs in-air were calculated. The validity of each method was assessed by comparing their results with an instrument that used the Hartmann method. RESULTS: The reliability results were generally a little better for the in-saline measurements than for the in-air measurements, although all reliability data demonstrated absolute values of mean errors (inter-operator and inter-session) that were <0.05 D for hydrogel lenses and <0.07 D for silicone hydrogel lenses. The in-air 95% confidence intervals were <0.45 D and <0.40 D for hydrogel and silicone hydrogel lenses, respectively and in-saline <0.39 and <0.31 D for hydrogel and silicone hydrogel lenses, respectively. The validity data revealed a relationship between measurement error and BVP for the in-air data (the focimeter overestimates the power of high plus and high minus lenses compared with the Hartmann instrument) and possibly a more complex relationship for the in-saline data. The 95% limits of agreement indicate better agreement for the in-saline validity data (-0.55 to +0.48 D for hydrogel lenses and -0.42 to +0.54 D for silicone hydrogel lenses) than those obtained in-air (-0.64 to +0.68 D for hydrogel lenses and -0.57 to +0.44 D for silicone hydrogel lenses). CONCLUSIONS: Using equipment readily available in a clinical setting, the wet cell method of measurement of the BVP of spherical soft contact lenses has been shown to provide results for reliability and validity that were at least as good as those obtained with the in-air method approved by the International Standard.

The development & evaluation of two vision screening tools for correctable visual loss in older people.

OBJECTIVES: In the UK, 20-50% of older people have undetected reduced vision and in most cases this results from correctable problems (refractive error and cataract). Many older people are not availing themselves of state-funded community optometric care. We assessed the efficacy of two vision screening instruments at detecting correctable visual problems and investigated the effect of optometric intervention on quality of life. METHODS: A computerised vision screener (CVS) was developed and refined after a preliminary study of 180 older people to include tests of: monocular presenting distance high contrast and low contrast visual acuities (VAs), binocular near acuities, and monocular visual fields. The modified CVS and a flip-chart vision screener (FVS) were evaluated on a second sample of 200 people aged 65+ (mean age 77 years). All participants in both studies were given an optometric eye examination, including high and low contrast VAs, refraction, binocular vision tests, tonometry, automated perimetry, and dilated fundoscopy including cataract grading and ARM grading. The target conditions were significant gain in monocular distance VA or binocular near VA with new refractive correction, significant cataract, or macular degeneration at risk of rapid progression. The Low Vision Quality of Life Questionnaire (LVQoL) was administered before and up to 3 months after testing. RESULTS: For the CVS, the best sensitivity (80.3%, 95% CI 72.4-86.4; specificity 66.7%, 95% CI 55.6-76.1) was obtained for a screener test combination of a fail on high contrast VA (>0.19 LogMAR) OR low contrast VA (>0.39 LogMAR) OR near VA (>N11.9). A screener test combination of high contrast VA OR near VA gave sensitivity of 79.5% (71.5-85.7) and specificity 67.9% (57-77.3). For the FVS, the best sensitivity was obtained for a test combination of a fail on high contrast VA OR low contrast VA OR near VA (sensitivity 82%, 95% CI 74.2-87.8; specificity 61.5%, 95% CI 50.4-71.6). A screener test combination of low contrast VA alone gave sensitivity of 75.4% (67.1-82.2) and specificity 76.9% (66.4-84.9). Significant improvements in LVQoL were found, with a significant correlation between gain in VA with new spectacles and improvement in LVQoL. CONCLUSIONS: The vision screeners are effective tools for detecting those with reduced vision. Further work is required to determine their effectiveness as a tool for encouraging older people to engage in regular eyecare.

Referrals from community optometrists to the hospital eye service in Scotland and England.

OBJECTIVES: This audit assesses communication between community optometrists (COs) and hospital eye service (HES) in Scotland and England. METHODS: Optometric referrals and replies were extracted from six practices in Scotland and England. If no reply was found, replies/records were copied from HES records. De-identified referrals, replies and records were audited against established standards, evaluating whether referrals were necessary, accurate and directed to the appropriate professional. The referral rate (RR) and referral reply rate (RRR) were calculated. RESULTS: From 905 de-identified referrals, RR ranged from 2.6 to 8.7%. From COs' perspective, the proportion of referrals for which they received replies ranged from 37 to 84% (Scotland) and 26 to 49% (England). A total of 88-96% of referrals (Scotland) and 63-76% (England) were seen in the HES. Adjusting for cases when it is reasonable to expect replies, RRR becomes 45-92% (Scotland) and 38-62% (England) with RRR significantly greater in Scotland (P = 0.015). Replies were copied to patients in 0-21% of cases. Referrals were to the appropriate service and judged necessary in ≥90% of cases in both jurisdictions. Accuracy of referral ranged from 89 to 97% (Scotland) and 81 to 98% (England). The reply addressed the reason for referral in 94-100% of cases (Scotland) and 93-97% (England) and was meaningful in 95-100% (Scotland) and 94-99% (England). CONCLUSIONS: Despite the interdisciplinary joint statement on sharing patient information, this audit highlights variable standard of referrals and deficits in replies to the referring COs, with one exception in Scotland. Replies from HES to COs are important for patient care, benefitting patients and clinicians and minimising unnecessary HES appointments.

Randomised controlled trial of intermittent photic stimulation for treating amblyopia in older children and adults.

The treatment of amblyopia is reviewed and it is noted that in addition to conventional 'passive treatment' in children with occlusion, it has been argued that 'active treatment' may be effective in older children and adults. Intermittent photic stimulation (IPS) is one such active treatment. In Study 1, we report a clinical audit of 21 patients treated with IPS, which demonstrated that the maximum improvement is reached after 6 half hour sessions. Study 2 is a double-masked randomised controlled trial comparing IPS with a control treatment in 30 participants aged 10-57 years. Using a sensitive staircase measure of visual acuity (VA), the IPS group improved by about one line (p = 0.0053). The mean improvement was significantly greater (unpaired t-test, p = 0.022) in the IPS group (mean 0.096; S.E.M. 0.029) than in the control group (mean 0.019; S.E.M. 0.022). The improvement occurred in participants with strabismic amblyopia, but not in those with anisometropic amblyopia. Follow up data after about 1 year showed that VA had regressed to pre-treatment levels. The results are discussed within the context of another development in active amblyopia therapy, perceptual learning. The literature on this therapy reveals improvements in VA of about 2.5 lines in older children and adults with anisometropic amblyopia. It is concluded that perceptual learning is likely a better treatment option than IPS for anisometropic amblyopes, and probably also for strabismic amblyopes although a randomised controlled trial is required. It is noted that the existence of effective treatments for adults does not detract from the need to treat amblyopia in younger children.