Investigation of current guidelines for prescribing spectacles to children using a modified Delphi approach and the AGREE II tool.

PURPOSE: This study aimed to identify clinical guidelines that provide recommendations on prescribing refractive error correction in children, evaluate the overall quality of these guidelines using the Appraisal of Guidelines for REsearch and Evaluation II (AGREE II) tool and subsequently gain consensus on the prescribing recommendations from high-quality guidelines using the modified Delphi technique. METHODS: A comprehensive search for prescribing guidelines was conducted using databases and professional websites. The quality appraisal of eligible guidelines was undertaken by scoring the six AGREE II domains. Subsequently, the modified Delphi technique was used by 10 experts (sub-specialist optometrists, ophthalmologists and orthoptists) to gain consensus on the prescribing recommendation statements extracted from guidelines that had been identified as high quality. Three rounds were conducted in which agreement of these statements were scored using a 9-point Likert scale with a free-text option for any additional comments. RESULTS: Five eligible guidelines were identified. The AGREE II tool demonstrated that the guidelines varied substantially in quality, with only one guideline identified as being of high quality. A total of 168 prescribing statements were reviewed in the Delphi procedure. Of these, 95 statements reached expert consensus as being appropriate prescribing recommendations. CONCLUSION: There is significant scope for improving current guidelines for prescribing refractive error correction in children. We used the modified Delphi technique to find points of agreement on prescribing recommendations to support professionals prescribing refractive error correction in children. We recommend that further work is needed to address gaps in the guidelines.

The potential for using entrustable professional activities in assessing optometric clinical competence.

Qualifications required to practise optometry seek to provide assurance that those completing them have the necessary competencies to be safe and effective clinicians. Often, this assurance is gained via high stakes assessments such as objective structured clinical examinations. This paper introduces entrustable professional activities (EPAs) as a potential alternative approach to assessing optometric clinical competence. Entrustable professional activities are defined in the context of optometric practice and the potential advantages and challenges of using them are outlined.

Challenges and impact of COVID-19 lockdown on Indian optometry practice: A survey-based study

PURPOSE: The Indian government announced a nationwide lockdown as a preventive measure to control the prevailing COVID-19 pandemic. This survey was developed and conducted to assess the impact of lockdown on Indian optometry practice. METHODS: A survey questionnaire was designed and circulated across the optometrists practicing in India through multiple social media platforms. All the data were extracted and only valid response were analyzed and reported. RESULTS: A total of 691 optometrists participated in the survey. Most of the participants (22.25%) were in private practice followed by academics (14.89%). Among the valid responses collected, it was found that 43.37% of the respondents were consulting patients during the lockdown. Of these, 27.17% of optometrists were examining infectious cases and 48.68% were examining all the patients who came for consultation. Approximately 50.94% of the participated optometrist had begun telephonic/e‑mail/video consultations. In addition, 64.48% reported that optometrists were at an equal risk of clinching COVID‑19 on comparison with other domains during patient examination. Nearly 30.44% respondents felt that optometrists would face challenges in approaching the patient post COVID-19 considering the close working distance. CONCLUSION: A proportion of optometrist have switched to some form of teleconsultation in order to aid patients during this prevailing pandemic. Regulatory bodies should issue appropriate guidelines regarding the safe optometry practice for the betterment of both patient and practitioners during face-to-face

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Effects of Quality Improvement Education in Diabetic Retinopathy on Routine Clinical Practice Patterns of Optometrists.

SIGNIFICANCE: Optometrists play a preventive role in diabetic care by detecting early signs of diabetic retinopathy (DR), a leading cause of blindness in adults. This study demonstrates that additional training can improve optometrists' ability to assess the presence and severity of DR in individuals with diabetes. PURPOSE: This study aimed to determine the impact of a quality improvement intervention involving education, assessment, and feedback on improving the evaluation and referral patterns of optometrists with regard to their patients with diabetes. METHODS: A pre-interventional and post-interventional analysis of optometrist practices was conducted through a retrospective chart review of diabetic patient encounters from July 2018 to March 2019. Dilated fundus examination (DFE) documentation, follow-up scheduling, referral practices, and usage of various imaging modalities were collected from patient records. Concordance of DR severity recordings between DFE findings, assessment and plan notes, and International Classification of Diseases codes was calculated. RESULTS: After intervention, the proportion of optometrists who conducted a DFE significantly increased from 79.5 (95% confidence interval [CI], 77.3 to 81.7%) to 84.4% (95% CI, 82.4 to 86.4%). In addition, the rate of improper follow-up instructions decreased from 13.8 (95% CI, 12.0 to 15.7%) to 10.8% (95% CI, 9.2 to 12.6%), and the decrease was significant (P = .02). Although overall referrals decreased from 19.8 (95% CI, 17.6 to 21.9%) to 14.6% (95% CI, 12.6 to 16.5%), optometrists were as likely to refer to retinal specialists. Finally, concordance between documented DFE findings, assessment and plan notes, and International Classification of Diseases codes significantly increased from 78.8 (95% CI, 76.5 to 81.0%) to 88.7% (95% CI, 86.9 to 90.4%). CONCLUSIONS: Providing optometrists education in screening and assessing DR is effective in improving diabetic patient care.

Centro de optometría y centro de refracción: norma técnica No. 12-2020­DRACES / Optometry Center and Refraction Center: Technical Standard No. 12-2020 ­ DRACES

Un poco apagada la tinta del documento y dificulta un poco la lectura DRACES [Departamento de Regulación, Acreditación y Control de Establecimientos de Salud] Este documento tiene como objeto "la regulación, autorización y control de los centros de optometría y centro de refracción, en concordancia con el Reglamento para la Regulación, Autorización, Acreditación y Control de Establecimientos de Atención para la Salud, Acuerdo Gubernativo No. 376-2007." Es de carácter obligatorio. Contiene además, las definiciones de los conceptos relacionados al tema principal, además de la infraestructura que deberá tener cada centro, incluidos el equipo y recurso humano y técnico.

COVID-19 guidelines for optometry and optical services post-lockdown.

The COVID-19 pandemic has caused disruption in everyone's lives globally. Optometrists, being primary health care professionals are at a higher risk of infection in their practices during these testing times. Optometrists and optical store owners need practically implementable guidelines as lockdown gets lifted in various parts of our country. As these practices gear up to provide eye examination and vision correction to people, they need to take necessary precautions to avoid any cross contaminations. Optometry Council of India guidelines were circulated among optometry and optical associations and among experts in various optometry specialty. A consensus among various bodies were arrived. These guidelines provide recommendation for optical and optometry practices.

A Review of the Use of Confidence Intervals for Bland-Altman Limits of Agreement in Optometry and Vision Science.

SIGNIFICANCE: Confidence intervals are still seldom reported for Bland-Altman 95% limits of agreement. When they are reported, 50% of articles use approximate methods and 50% use exact methods. PURPOSE: Bland-Altman limits of agreement can be unreliable estimates, especially for small sample sizes. However, authors seldom use confidence intervals for limits of agreement. This article reviews their use in Optometry and Vision Science. METHODS: A keyword search for "Bland," "Altman," "Bland-Altman," "LoA," and "limits of agreement" was conducted on the Optometry and Vision Science website within a time range from January 2016 to December 2018. RESULTS: Fifty articles were reported or were judged to use Bland-Altman analysis; sample sizes ranged from 3 to 2072. Eight of these article reported confidence limits for limits of agreement, four of which used exact methods and four used Bland and Altman's approximate method. CONCLUSIONS: Use of confidence intervals for limits of agreement has increased in Optometry and Vision Science but is far from universal. To assist researchers in calculating exact confidence limits for Bland-Altman limits of agreement, spreadsheets are included for performing the calculations and generating Bland-Altman plots with the confidence intervals included.

Understanding Infection Prevention Practices in Optometry Clinics.

SIGNIFICANCE: The Los Angeles County Department of Public Health investigated an outbreak of epidemic keratoconjunctivitis secondary to adenovirus linked to a single optometry clinic between June and July 2017. Suboptimal infection prevention practices were identified in the implicated clinic. PURPOSE: The purpose of this study was to determine infection prevention practices in optometry clinics within Los Angeles County. METHODS: A 17-question survey on infection prevention practices among a sample of optometry providers in the county was conducted by the Los Angeles County Department of Public Health. The survey was administered via e-mails sent to a local optometric society's Listserv and in person at a local continuing education event for optometrists. The results were analyzed and are represented as percentages. RESULTS: There were 42 responses, 20 via the online survey (response rate, 15%) and 22 via the in-person survey (response rate, 22%). More than half had no written hand-hygiene policy (58.5%, n = 24/41), 46.2% (n = 18/39) did not wear gloves while examining patients with eye drainage, and about half (48.6%, n = 18/37) did not use droplet precautions for patients with respiratory symptoms. The vast majority used multidose eye-drop vials (92.5%, n = 37/40), but 41.6% (n = 15/36) did not discard the vial if the tip came into contact with conjunctiva/skin/environmental surface. To ensure a clean tonometer for each patient, the majority (68.4%, n = 26/38) used 70% isopropyl alcohol, 47.4% (n = 18/38) used noncontact tonometers, and 23.6% (n = 9/38) used disposable tips (answers not mutually exclusive); none used bleach. CONCLUSIONS: Our data highlight several areas of concern in the practice of standard or transmission-based precautions in the sampled population. First, hand-hygiene policies are not well enforced. Second, personal protective equipment is not appropriately used while examining potentially infectious patients. Third, eye-drop vials are not consistently discarded if contaminated with eye secretions. Lastly, a large proportion of surveyed practices use inadequate disinfection techniques of tonometers.

Examination Practices and Referral of Patients With Diabetic Retinopathy by Optometrists in Routine Clinical Care.

BACKGROUND AND OBJECTIVE: To analyze the examination practices and referral of patients with diabetic retinopathy (DR) by optometrists in routine clinical care. PATIENTS AND METHODS: Diabetic patient records from 2012 to 2018 were retrospectively reviewed for documentation of dilated fundus exam (DFE), imaging, follow-up appointments, and referrals. Concordance between clinical exam and coding was also analyzed. RESULTS: For 97.8% of encounters, DFE was performed, the patient was referred for DFE, or DFE was scheduled for follow-up. When DFE was performed at the initial visit, this resulted in referral of 19.8% of patients to an ophthalmologist. Imaging was obtained occasionally, with fundus photos in 2.6% and optical coherence tomography in 14.5% of encounters. Concordance of DR grading between exam and coding was 78.8%. Recommended follow-up times were incorrect based on DR severity level in 13.8% of encounters. CONCLUSION: Although DFE was performed reliably by optometrists, utilization of imaging, DR grading and coding, and appropriate follow-up periods could be improved. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:608-612.].

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.

"I can see fine": patient knowledge of eye care.

PURPOSE: To learn more about the perceptions and attitudes toward eye care of members of the public - in particular, their knowledge of the purpose, components and providers of eye examinations, their ability to self-monitor ocular status and their awareness of major sight threatening eye conditions. METHODS: This study used the qualitative research strategy, grounded theory. Participants were recruited via poster and social media. Two researchers, one with optometric knowledge and one without, moderated seven 60- to 90-min, semi-structured focus group discussions, which were audiotaped and transcribed. Participants also completed a short demographic questionnaire. Three researchers employed constant comparative coding strategies to identify common themes within the focus group transcripts. The number of participants represented by identified themes were tracked and themes were listed in order of decreasing frequency. RESULTS: Focus groups included 25 participants (nine male, 16 female), ranging in age from 18 to 71 years (mean: 41.7). Five themes related to eye care awareness were identified: eye examination purpose, test procedure identification, eye care professional roles, asymptomatic eye disease awareness, and significant eye disease awareness. Perceived eye examination purposes were vision/prescription priority with some eye health knowledge, comprehensive evaluation of visual system, and vision/prescription only. Most participants who responded could correctly identify the use of an eye chart and a phoroptor; fewer were able to do the same for a direct ophthalmoscope and slit lamp biomicroscope. Less than a quarter of participants could accurately identify the roles of all three major eye care providers. Trauma was the most commonly mentioned risk for vision loss, followed by diabetes and infection. Participants' knowledge appeared most often to have been obtained from personal experience rather than as the result of any systematic educational initiative. CONCLUSIONS: This study found notable gaps in knowledge of eye care and sight risks. If these gaps result in fewer eye examinations, they potentially contribute to increased risk of vision loss due to later stage detection. The results provide motivation for further study and development of effective public health education strategies.

Optometric infection control guidelines assessing patients with methicillin-resistant Staphylococcus aureus.

The purpose of this scoping review was to present the state of research regarding optometric infection control guidelines for the assessment of patients with methicillin-resistant Staphylococcus aureus (MRSA) and to identify any areas requiring further research. Twelve articles were carefully chosen for review. Data extracted included information regarding appropriate handwashing methods (five articles), indications for use of personal protective equipment (one article), management of surfaces that come in contact with an MRSA-infected person (three articles), recommendations for patient appointment scheduling/seating (three articles) and suggestions for staff training (three articles). The results of the review demonstrated that there exist many gaps in the literature regarding comprehensive optometric-specific infection control guidelines. Further research regarding appropriate handwashing methods, equipment disinfection techniques, extent and breadth of staff training and indications for use of personal protective equipment is required to better understand what precautions must be taken in an optometric setting when encountering patients with MRSA.

Quality indicators in a community optometrist led cataract shared care scheme.

PURPOSE: Cataract shared care schemes involving community optometrists show wide variation in practice. We report on defined key performance indicators (KPIs) which improve accountability between stakeholders. METHODS: In this prospective study over nine months at a UK public hospital, we evaluated the outcomes of consecutive direct cataract referrals from community optometrists against two KPIs agreed under a service-level agreement between the Hospital Eye Service and community optometrists: (1) 85% of patients listed for cataract listing at first consultation; and (2) 90% postoperative feedback return rate on patients discharged to community optometrists. A detailed analysis on referral triage, surgical listing and postoperative form return rate is reported in this study. RESULTS: A total of 733 direct cataract referrals were received using a designated referral form of which 86% were listed for cataract surgery. The predominant reason for not listing was a failure to reach the visual threshold set by the local clinical commissioning guidelines. Out of 569 cataract surgical episodes, 402 (71%) patients were discharged on the same day of surgery to community optometrist follow up. Completed postoperative feedback was returned from 374 patients (93%). CONCLUSION: Direct cataract referrals from accredited community optometrists led to a majority of patients receiving a definitive clinical decision during first consultation. Postoperative community follow up reduced hospital visits and allowed for convenient consultation closer to home following uncomplicated cataract surgery. A service-level agreement with an accreditation scheme measured against KPIs enhances the accountability of stakeholders involved in the cataract shared care scheme.

Reply to Letter to the Editor by Griffiths et al. commenting on Evans & Allen: Letter to the Editor concerning «A systematic review of controlled trials on visual stress using intuitive overlays or colorimeter» / Respuesta a la carta al editor de Griffiths et al., como comentario al documento de Evans & Allen: Carta al Editor en relación a «Revisión sistemática de ensayos controlados sobre estrés visual utilizando filtros intuitivos o colorímetro»

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Improving services for glaucoma care in Nigeria: implications for policy and programmes to achieve universal health coverage.

Glaucoma in Africa is sometimes referred to as the silent thief of sight. In Nigeria, glaucoma is common, it is serious, ophthalmologists face many constraints in managing it, people do not even know they have it until it is advanced, patients do not understand or comply with treatment after they are diagnosed and the poor are more likely to be glaucoma blind. Available evidence indicates that the health system in Nigeria is failing to meet the needs of patients with glaucoma. Based on evidence, we propose future directions for improving services for glaucoma care in Nigeria, and the implications for policy and programmes to control glaucoma blindness, using a health system-oriented approach. Three complementary strategies are required: (i) strengthening clinical services for glaucoma-by developing models of glaucoma care, improving clinical treatment options, making medicines and equipment available, financing glaucoma care and training eye care workers; (ii) introducing initiatives for earlier detection of glaucoma in the clinic and approaches in the community and (iii) strengthening health system governance. Glaucoma is a complex disease to manage and addressing it as a public health problem is challenging. However, we need to change the paradigm to recognise that glaucoma is a potentially avoidable cause of blindness in Africa.

A Delphi study to develop practical diagnostic guidelines for visual stress (pattern-related visual stress).

PURPOSE: Visual stress (VS) is characterised by symptoms of visual perceptual distortions and eyestrain when viewing text, symptoms that are alleviated by individually prescribed coloured filters. A recent review supports the existence of VS and its treatment, but noted that controversy remains, in part due to inconsistencies in the diagnosis of the condition. The present paper reviews the diagnostic criteria for VS in the literature and reports a Delphi analysis of the criteria currently used in clinical practice. METHODS: Twenty-six eyecare practitioners were invited to participate in a Delphi study. They were selected because they were frequent prescribers of precision tinted lenses. In the first round they were sent a list of the indicators for which there is literature to suggest a relevance in the diagnosis of VS. The practitioners were invited to rank the indicators and add any additional criteria they use in diagnosis. In the second round a revised list was circulated, including items added from the responses in the first round. RESULTS: The respondents included optometrists, orthoptists and opticians. In the first round the response rate was 85%. Ninety-one percent of those who participated in the first round also responded in the second round. Strong indicators in the second round included the symptom of words moving when reading, voluntary use of an overlay for a prolonged period, improved performance of ≥15% with an overlay on the Wilkins Rate of Reading test, and an abnormally high score on the Pattern Glare Test. CONCLUSIONS: The strongest diagnostic criteria are combined in a diagnostic tool. This is proposed as a guide for clinical practice and further research.

Effectiveness of UK optometric enhanced eye care services: a realist review of the literature.

PURPOSE: UK demographic and legislative changes combined with increasing burdens on National Health Service manpower and budgets have led to extended roles for community optometrists providing locally-commissioned enhanced optometric services (EOS). This realist review's objectives were to develop programme theories that implicitly or explicitly explain quality outcomes for eye care provided by optometrists via EOS and to test these theories by investigating the effectiveness of services for cataract, glaucoma, and primary eye care. METHODS: The review protocol was published on PROSPERO, and RAMESES publication standards were followed. Programme theories were formulated via scoping literature searches and expert consultation. The searching process involved all relevant electronic databases and grey literature, without restrictions on study design. Data synthesis focussed on questioning the integrity of each theory by considering supportive and refuting evidence from the source literature. RESULTS: Good evidence exists for cataract, glaucoma and primary eye care EOS that: with appropriate training, accredited optometrists manage patients commensurate with usual care standards; genuine partnerships can exist between community and hospital providers for cataract and glaucoma EOS; patient satisfaction with all three types of service is high; cost-effectiveness of services is unproven for cataract and primary eye care, while glaucoma EOS cost-effectiveness depends on service type; contextual factors may influence service success. CONCLUSIONS: The EOS reviewed are clinically effective and provide patient satisfaction but limited data is available on cost-effectiveness.

A Comparison of Spectacles Purchased Online and in UK Optometry Practice.

PURPOSE: To compare spectacles bought online with spectacles from optometry practices. METHODS: Thirty-three participants consisting of single vision spectacle wearers with either a low (N = 12, mean age 34 ± 14 years) or high prescription (N = 11, mean age 28 ± 9 years) and 10 presbyopic participants (mean age 59 ± 4 years) wearing progressive addition lenses (PALs) purchased 154 pairs of spectacles online and 154 from UK optometry practices. The spectacles were compared via participant-reported preference, acceptability, and safety; the assessment of lens, frame, and fit quality; and the accuracy of the lens prescriptions to international standard ISO 21987:2009. RESULTS: Participants preferred the practice spectacles (median ranking 4th, IQR 1-6) more than online (6th, IQR 4-8; Mann-Whitney U = 7345, p < 0.001) and practice PALs (median ranking 2nd, IQR 1-4) were particularly preferred (online 6.5th, IQR 4-9, Mann-Whitney U = 455, p < 0.001). Of those deemed unacceptable and unsafe, significantly more were bought online (unacceptable: online 43/154 vs. practice 15/154, Fisher's exact p = 0.0001; unsafe: online 14/154 vs. practice 5/154, Fisher's exact p = 0.03). CONCLUSIONS: Participants preferred spectacles from optometry practice rather than those bought online, despite lens quality and prescription accuracy being similar. A greater number of online spectacles were deemed unsafe or unacceptable because of poor spectacle frame fit, poor cosmetic appearance, and inaccurate optical centration. This seems particularly pertinent to PAL lenses, which are known to increase falls risk. Recommendations are made to improve both forms of spectacle provision.

Evaluations of refraction competencies of ophthalmic technicians in Mozambique.

PURPOSE: Ophthalmic technicians (OT) work at health facilities in Mozambique and are trained to provide primary and secondary eye care services including basic refraction. This study was designed to assess OT competence and confidence in refraction, and investigate whether an upskilling programme is effective in developing their competence and confidence at refraction. METHODS: Thirty-one trainee OTs and 16 qualified OTs were recruited to the study. A background questionnaire was administered to determine the demographic profile of the OTs. A confidence levels questionnaire explored their self-reported skills. Clinical competencies were assessed in relation to knowledge (theory exam) and clinical skills (patient exams). 11 OTs were upskilled and the clinical evaluations carried out post training. RESULTS: Initial evaluations demonstrated that confidence and competence levels varied depending on the OTs training (location and duration), and their location of work (clinical load, availability of equipment and other eye care personnel). The qualified OTs were more competent than trainee OTs in most of the evaluations. Post upskilling results demonstrated significant positive impact on confidence and competence levels. CONCLUSION: These evaluations identified factors affecting the refraction competencies of the OTs and demonstrated that upskilling is effective in improving confidence and competence levels for refraction. They demonstrate the need for a refraction competency framework. The overarching aim of this research was to inform the development of a nationwide programme of OT mentoring, upskilling and leading to the establishment of clinical competency standards for the new OT curricula, relevant to the professional demands.