Developing realistic benchmarks for glaucoma care delivery.

CLINICAL RELEVANCE: Realistic benchmarks can serve as comparators for optometrists wishing to engage in clinical practice audits of their glaucoma care. BACKGROUND: The iCareTrack study established the appropriateness of glaucoma care delivery through clinical record audits of Australian optometry practices. Benchmarks required for monitoring and improving glaucoma care delivery do not exist. This study developed realistic benchmarks for glaucoma care and then benchmarked the performance of practices from the iCareTrack study to establish aspects of care that warrant attention from quality improvement initiatives. METHODS: Benchmarks were developed from the pre-existing iCareTrack dataset using the Achievable Benchmarks of Care (ABC) method. The iCareTrack study had audited the appropriateness of glaucoma care delivery against 37 clinical indicators for 420 randomly sampled glaucoma patient records from 42 Australian optometry practices. The four-step ABC method calculates benchmarks based on the top 10% of best-performing practices adjusted for low patient encounter numbers. iCareTrack results were compared to the benchmarks to explore the distribution of practices that were at, above or below benchmark. RESULTS: Benchmarks were developed for 34 of 37 iCareTrack indicators. For 26 (of 34) indicators, the benchmarks were at or above 90% appropriateness. The benchmarks for 14 (of 34) iCareTrack indicators were met by more than 80% of eligible practices, indicating excellent performance. Some aspects of glaucoma care such as peripheral anterior angle assessment, applanation tonometry, and visual field assessment appeared to be delivered sub-optimally by optometrists when compared to the benchmarks. CONCLUSION: This study established benchmarks for glaucoma care delivery in optometry practices that reflect realistic and top achievable performance. The large number of indicators with benchmarks above 90% confirmed that glaucoma care can and should be delivered by optometrists at very high levels of appropriateness. Benchmarking identified pockets of sub-optimal performance that can now be targeted by quality improvement initiatives.

Clinical indicators for diabetic eyecare delivered by optometrists in Australia: a Delphi study.

CLINICAL RELEVANCE: Valid and updated clinical indicators can serve as important tools in assessing and improving eyecare delivery. BACKGROUND: Indicators for diabetic eyecare in Australia were previously developed from guidelines published before 2013 and then used to assess the appropriateness of care delivery through a nationwide patient record card audit (the iCareTrack study). To reflect emerging evidence and contemporary practice, this study aimed to update clinical indicators for optometric care for people with type 2 diabetes in Australia. METHODS: Forty-five candidate indicators, including existing iCareTrack and new indicators derived from nine high-quality evidence-based guidelines, were generated. A two-round modified Delphi process where expert panel members rated the impact, acceptability, and feasibility of the indicators on a 9-point scale and voted for inclusion or exclusion of the candidate indicators was used. Consensus on inclusion was reached when the median scores for impact, acceptability, and feasibility were ≥7 and >75% of experts voted for inclusion. RESULTS: Thirty-two clinical indicators with high acceptability, impact and feasibility ratings (all median scores: 9) were developed. The final indicators were related to history taking (n = 12), physical examination (n = 8), recall period (n = 5), referral (n = 5), and patient education/communication (n = 2). Most (14 of 15) iCareTrack indicators were retained either in the original format or with modifications. New indicators included documenting the type of diabetes, serum lipid level, pregnancy, systemic medications, nephropathy, Indigenous status, general practitioner details, pupil examination, intraocular pressure, optical coherence tomography, diabetic retinopathy grading, recall period for high-risk diabetic patients without retinopathy, referral of high-risk proliferative retinopathy, communication with the general practitioner, and patient education. CONCLUSION: A set of 32 updated diabetic eyecare clinical indicators was developed based on contemporary evidence and expert consensus. These updated indicators inform the development of programs to assess and enhance the eyecare delivery for people with diabetes in Australia.

Dendritic Cell Density and Morphology Can Be Used to Differentiate Vernal Keratoconjunctivitis from Allergic Conjunctivitis.

The aim of the study was to compare the distribution of corneal and conjunctival epithelial dendritic cells (DCs) in vernal keratoconjunctivitis (VKC), allergic conjunctivitis (AC), and non-allergic controls to examine if the allergy type causes differences in immune cell activation. The prospective study included 60 participants: 20 with VKC, 20 with AC, and 20 non-allergic controls. In vivo confocal microscopy was performed on the right eye. The locations scanned included the corneal centre, inferior whorl, corneal periphery, corneal limbus, and bulbar conjunctiva. The DCs were counted manually, and their morphology was assessed for the largest cell body size, the presence of dendrites, and the presence of long and thick dendrites. The DC density was higher in VKC and AC compared to non-allergic group at all locations (p ≤ 0.01) except at the inferior whorl. The DC density in VKC participants was significantly higher than in AC at the limbus (p < 0.001) but not at other locations. Both the AC and the VKC group had larger DC bodies at the corneal periphery and limbus compared to the non-allergic group (p ≤ 0.03). The study found a higher proportion of participants with DCs exhibiting long dendrites at both the corneal periphery in AC (p = 0.01) and at the corneal centre, periphery, and limbus in VKC, compared to the non-allergic group (p ≤ 0.001). In conclusion, a higher DC density at the limbus may be a marker of more severe VKC. DCs with larger cell bodies and a greater proportion of participants with DCs displaying long dendrites can be potential markers to differentiate allergy from non-allergy, and more severe forms of allergy from milder forms.

TFOS Lifestyle: Impact of contact lenses on the ocular surface.

Several lifestyle choices made by contact lens wearers can have adverse consequences on ocular health. These include being non-adherent to contact lens care, sleeping in lenses, ill-advised purchasing options, not seeing an eyecare professional for regular aftercare visits, wearing lenses when feeling unwell, wearing lenses too soon after various forms of ophthalmic surgery, and wearing lenses when engaged in risky behaviors (e.g., when using tobacco, alcohol or recreational drugs). Those with a pre-existing compromised ocular surface may find that contact lens wear exacerbates ocular disease morbidity. Conversely, contact lenses may have various therapeutic benefits. The coronavirus disease-2019 (COVID-19) pandemic impinged upon the lifestyle of contact lens wearers, introducing challenges such as mask-associated dry eye, contact lens discomfort with increased use of digital devices, inadvertent exposure to hand sanitizers, and reduced use of lenses. Wearing contact lenses in challenging environments, such as in the presence of dust and noxious chemicals, or where there is the possibility of ocular trauma (e.g., sport or working with tools) can be problematic, although in some instances lenses can be protective. Contact lenses can be worn for sport, theatre, at high altitude, driving at night, in the military and in space, and special considerations are required when prescribing in such situations to ensure successful outcomes. A systematic review and meta-analysis, incorporated within the review, identified that the influence of lifestyle factors on soft contact lens dropout remains poorly understood, and is an area in need of further research. Overall, this report investigated lifestyle-related choices made by clinicians and contact lens wearers and discovered that when appropriate lifestyle choices are made, contact lens wear can enhance the quality of life of wearers.

TFOS Lifestyle - Evidence quality report: Advancing the evaluation and synthesis of research evidence.

Evidence-based practice is a dominant paradigm in healthcare that emphasizes the importance of ensuring the translation of the best available, relevant research evidence into practice. An Evidence Quality Subcommittee was established to provide specialized methodological support and expertise to promote rigorous and evidence-based approaches for the Tear Film and Ocular Surface Society (TFOS) Lifestyle Epidemic reports. The present report describes the purpose, scope, and activity of the Evidence Quality Subcommittee in the undertaking of high-quality narrative-style literature reviews, and leading prospectively registered, reliable systematic reviews of high priority research questions, using standardized methods for each topic area report. Identification of predominantly low or very low certainty evidence across the eight systematic reviews highlights a need for further research to define the efficacy and/or safety of specific lifestyle interventions on the ocular surface, and to clarify relationships between certain lifestyle factors and ocular surface disease. To support the citation of reliable systematic review evidence in the narrative review sections of each report, the Evidence Quality Subcommittee curated topic-specific systematic review databases and relevant systematic reviews underwent standardized reliability assessment. Inconsistent methodological rigor was noted in the published systematic review literature, emphasizing the importance of internal validity assessment. Based on the experience of implementing the Evidence Quality Subcommittee, this report makes suggestions for incorporation of such initiatives in future international taskforces and working groups. Content areas broadly relevant to the activity of the Evidence Quality Subcommittee, including the critical appraisal of research, clinical evidence hierarchies (levels of evidence), and risk of bias assessment, are also outlined.

Blink Rate Measured In Situ Decreases While Reading From Printed Text or Digital Devices, Regardless of Task Duration, Difficulty, or Viewing Distance.

Purpose: To compare blinking measured in situ during various tasks and examine relationships with ocular surface symptoms. The day-to-day repeatability of the blink rate and interblink interval was assessed. Methods: Twenty-four students (28.6 ± 6.3 years; 8 male and 16 female) completed six reading tasks (printed text, laptop, TV, smartphone, smartphone at 50% brightness, smartphone with complex text), and two nonreading tasks (conversation, walking) in a randomized cross-over study. Ocular surface symptoms and clinical signs were assessed. The blink rate and interblink interval were measured using a wearable eye tracking headset. Blink parameters were compared across tasks and time (linear mixed model and post hoc comparisons with Bonferroni correction). Associations between blinking, symptoms, ocular surface, and clinical signs were assessed (Spearman's correlation). The smartphone reading task was completed twice to determine the coefficient of repeatability. Results: The blink rate was lower (mean 10.7 ± 9.7 blinks/min) and the interblink interval longer (mean 9.6 ± 8.7 seconds) during all reading tasks compared with conversation (mean 32.4 ± 12.4 blinks/min; 1.5 ± 0.6 seconds) and walking (mean 31.3 ± 15.5 blinks/min; 1.9 ± 1.3s) (P < 0.001). There were no significant differences in blink parameters between any of the reading tasks or between conversation and walking. Changes in blinking occurred within 1 minute of starting the task. No associations were evident between blink rate or interblink interval and ocular surface symptoms or signs. The coefficient of repeatability was ±12.4 blinks/min for blink rate and ±18.8 seconds for interblink interval. Conclusions: Spontaneous blinking can be measured reliably in situ. The blink rate was decreased and the interblink interval increased during reading compared with conversation and walking. Changes in blinking were immediate, sustained, and not associated with ocular surface symptoms or signs.

Increased dendritic cell density and altered morphology in allergic conjunctivitis.

BACKGROUND: Corneal and conjunctival epithelial dendritic cells (DC) have an established role in vernal keratoconjunctivitis, however, their role in more prevalent forms of allergic eye disease remains unclear. This study evaluated corneal and conjunctival epithelial DC density, morphology, and distribution observed using in vivo confocal microscopy (IVCM) in allergic conjunctivitis. METHODS: In this prospective, observational study, 66 participants (mean age 36.6 ± 12.0 years, 56% female): 33 with allergic conjunctivitis and 33 controls were recruited. IVCM was performed at the corneal centre, inferior whorl, corneal periphery, corneal limbus, and temporal bulbar conjunctiva. DC were counted and their morphology was assessed as follows: largest cell body size, presence of dendrites, and presence of long and thick dendrites. Mixed model analysis (DC density) and non-parametric tests (DC morphology) were used. RESULTS: DC density was higher in allergic participants at all locations (p ≤ 0.01), (corneal centre median (IQR) 21.9 (8.7-50.9) cells/mm2 vs 13.1 (2.8-22.8) cells/mm2; periphery 37.5 (15.6-67.2) cells/mm2 vs 20 (9.4-32.5) cells/mm2; limbus 75 (60-120) cells/mm2 vs 58.1 (44.4-66.2) cells/mm2; conjunctiva 10 (0-54.4) cells/mm2 vs 0.6 (0-5.6) cells/mm2, but not at the inferior whorl 21.9 (6.2-34.4) cells/mm2 vs 12.5 (1.9-37.5) cells/mm2, p = 0.20. At the corneal centre, allergic participants had larger DC bodies (p = 0.02), a higher proportion of DC with dendrites (p = 0.02) and long dendrites (p = 0.003) compared to controls. CONCLUSIONS: Corneal and conjunctival DC density was increased, and morphology altered in allergic conjunctivitis. These findings imply that the ocular surface immune response was upregulated and support an increased antigen-capture capacity of DC in allergic conjunctivitis.

Dendritiform immune cells with reduced antigen-capture capacity persist in the cornea during the asymptomatic phase of allergic conjunctivitis.

BACKGROUND: Increased density and altered morphology of dendritic cells (DC) in the cornea and conjunctiva occur during active allergic conjunctivitis. This study investigated whether inflammation (characterised by altered DC density and morphology) persists during the symptom-free phase of allergic conjunctivitis. METHODS: Twenty participants (age 43.3 ± 14.3 years, 55% female) assessed during their active (symptomatic) phase of allergic conjunctivitis were re-examined during the asymptomatic phase. Ocular allergy symptoms and signs were evaluated during both phases, and five ocular surface locations (corneal centre, inferior whorl, corneal periphery, corneal limbus, and bulbar conjunctiva) were examined using in vivo confocal microscopy (HRT III). DC were counted manually, and their morphology was assessed for cell body size, presence of dendrites, presence of long dendrites and presence of thick dendrites using a grading system. Mixed model analysis (DC density) and non-parametric tests (DC morphology) were used to examine differences between phases. RESULTS: DC density at corneal locations did not change between the active and asymptomatic phases (p ≥ 0.22). However, corneal DC body size was smaller and fewer DC presented with long dendrites during the asymptomatic phase (p ≤ 0.02). In contrast, at the bulbar conjunctiva, DC density was reduced during the asymptomatic phase compared to the active phase (p = 0.01), but there were no changes in DC morphology. CONCLUSIONS: Dendritiform immune cell numbers persist in the cornea during the symptom-free phase of allergic conjunctivitis, whereas conjunctival DC appear to return to a baseline state. The morphology of these persisting corneal DC suggests their antigen-capture capacity is reduced during the asymptomatic phase.

Enhancing the appropriateness of eyecare delivery: the iCaretrack approach.

Optometrists play an integral role in primary eyecare services, including prevention, diagnosis, and management of acute and chronic eye conditions. Therefore, it remains essential that the care they provide be timely and appropriate to ensure the best patient outcomes and optimal utilisation of resources. However, optometrists continuously face many challenges that can affect their ability to provide appropriate care (i.e., the care in line with evidence-based clinical practice guidelines). To address any resulting evidence-to-practice gaps, programs are needed that support and enable optometrists to adopt and utilise the best evidence in clinical practice. Implementation science is a field of research that can be applied to improving the adoption and maintenance of evidence-based practices in routine care, through systematic development and application of strategies or interventions to address barriers to evidence-based practice. This paper demonstrates an approach using implementation science to enhance optometric eyecare delivery. A brief overview of the methods used to identify existing gaps in appropriate eyecare delivery is presented. An outline of the process used to understand the behavioural barriers responsible for such gaps follows, involving theoretical models and frameworks. The resulting development of an online program for optometrists to enhance their capability, motivation, and opportunity to provide evidence-based eyecare is described, using the Behaviour Change Model and co-design methods. The importance of and methods used in evaluating such programs are also discussed. Finally, reflections on the experience and key learnings from the project are shared. While the paper focuses on experiences in improving glaucoma and diabetic eyecare in the Australian optometry context, this approach can be adapted to other conditions and contexts.

Diurnal changes and topographical distribution of ocular surface epithelial dendritic cells in humans, and repeatability of density and morphology assessment.

PURPOSE: Dendritic cells (DC) play a crucial role in ocular surface defence. DC can be visualised in vivo by confocal microscopy but have not yet been fully characterised in humans. This study investigated the diurnal variation, topographical distribution and repeatability of DC density and morphology measurements. METHODS: In vivo confocal microscopy (IVCM) was conducted on 20 healthy participants (mean age 32.7 ± 6.4 years, 50% female) at baseline and repeated after 30 minutes, 2, 6 and 24 h. Images were captured at the corneal centre, inferior whorl, corneal periphery, limbus and bulbar conjunctiva. DC were counted manually, and their morphology was assessed for cell body size, presence of dendrites, and presence of long and thick dendrites. Mixed-model analysis, non-parametric analyses, Bland and Altman plots, coefficient of repeatability (CoR) and kappa were used. RESULTS: There were no significant changes in DC density (p ≥ 0.74) or morphology (p > 0.07) at any location over the 24-h period. The highest DC density was observed at the corneal limbus followed by the peripheral cornea (p < 0.001), with the lowest density at the corneal centre, inferior whorl and bulbar conjunctiva. Most DC at the corneal periphery, limbus and bulbar conjunctiva had larger cell bodies compared with the corneal centre (p ≤ 0.01), and the presence of long dendrites was observed mostly at non-central locations. Day-to-day CoR for DC density ranged from ±28.1 cells/mm2 at the corneal centre to ±56.4 cells/mm2 at the limbus. Day-to-day agreement of DC morphology determined by kappa ranged from 0.5 to 0.95 for cell body size, 0.60 to 0.95 for presence of dendrites, and 0.55 to 0.80 for the presence of long dendrites at various locations. CONCLUSIONS: No diurnal changes are apparent in corneal or conjunctival DC. Substantial topographical differences exist in DC density and morphology. IVCM provides good repeatability of DC density and acceptable agreement of DC morphology.

Corneal epithelial dendritic cells, tear neuropeptides and corneal nerves continue to be affected more than 12 months after LASIK.

PURPOSE: LASIK causes corneal nerve damage and may affect the neuro-immune crosstalk. This study examined the effects of LASIK on corneal epithelial dendritic cells (CEDC) density and morphology and explored their relationships with corneal nerves and tear neuropeptides. A grading system was developed to assess CEDC morphology. METHODS: Intra- and inter-observer repeatability of the CEDC morphology grading system was established using kappa (κ). In vivo confocal microscope images of the central cornea were captured from 20 participants who had undergone LASIK 12-16 months earlier and 20 controls (age 18-32 years, 55%F). CEDC density was counted manually, and CEDC morphology was assessed using a new grading system. CEDC sub-types (contacting nerves [CEDCc] and not contacting nerves [CEDCnc]) were also assessed. Differences in CEDC density and morphology were examined using mixed models and chi-squared test. Relationships between CEDC and corneal nerve parameters and tear substance P were explored using Spearman's correlation. RESULTS: Excellent intra- and inter-observer repeatability was demonstrated for the grading system (κ = 0.82-0.97). In post-LASIK participants, CEDC density was lower compared with controls (5 [0-34] vs. 21 [7-77] cells/mm2 ; p = 0.01), and the proportion of CEDC with thick dendrites was higher (55%-73% vs. 11%-21%, p < 0.003). Higher tear substance P levels were associated with higher CEDC density (rho = 0.48, p = 0.003). Fewer nerve interconnections were observed in participants in whom CEDC had dendrites (p = 0.03). CEDC sub-types followed a similar pattern to CEDC. CONCLUSIONS: The findings suggest that CEDC may remain altered more than 12 months post-LASIK. The association with substance P suggests a role for CEDC in corneal neurogenic inflammation.

Smartphone gaming induces dry eye symptoms and reduces blinking in school-aged children.

PURPOSE: Smartphone use by children is rising rapidly, but its ocular surface impact is unknown. This study examined the effect of smartphone use on blinking, symptoms, and tear function in children. METHODS: Prospective intervention study where 36 children aged 6-15years (14 M:22 F) played games on a smartphone continuously for one hour. Symptoms (SANDE, IOSS, NRS) and tear film (lipid layer thickness, tear secretion, stability) were assessed before and after gaming. Blink rate and interblink interval were measured in situ using an eye tracking headset, before (during conversation) and continuously throughout gaming. Symptoms and tear film changes were examined using paired t-tests. Changes in blinking throughout one hour were examined using repeated measures ANOVA, post-hoc comparisons with Bonferroni correction. Associations examined using Pearson bivariate correlation. Significance level was 0.05. RESULTS: Symptoms worsened following one hour smartphone gaming (SANDE + 8.2units, p = 0.01; IOSS + 1.3units, p < 0.001; NRS-average +6.3units, p = 0.03; NRS-comfort +7.6units, p = 0.04; NRS-tiredness +10.1units, p = 0.01), but tear film remained unchanged. Blink rate reduced from 20.8 blinks/min to 8.9 blinks/min (p < 0.001) and interblink interval increased from 2.9 s to 8.7 s (p = 0.002) within the first minute of gaming relative to baseline conversation, and this effect remained unchanged throughout one hour of gaming. CONCLUSIONS: Smartphone use in children results in dry eye symptoms and immediate and sustained slowing of blinking, with no change in tear function evident up to one hour. Given the ubiquitous use of smartphones by children, future work should examine whether effects reported herein persist or get worse over a longer term causing cumulative damage to the ocular surface.

Level of appropriate primary diabetic eyecare delivered and achievable in optometry practices in Australia.

CLINICAL RELEVANCE: Current levels of appropriateness for primary diabetic eyecare delivered by Australian optometrists are presented along with realistic targets (benchmarks) for quality improvement. The demonstrated methods can be used in practice evaluation and benchmarking of other clinical practice areas and settings. BACKGROUND: To examine the appropriateness of diabetic eye-care delivery and establish achievable benchmarks of care (ABCs) for optometry practices in Australia. METHOD: In a retrospective audit, clinical records of patients with type-II diabetes obtained from a randomly selected nationally representative sample of optometry practices were assessed against evidence-based clinical indicators. Appropriate care is defined as care delivered in compliance with the indicators. The ABC for each indicator was calculated as the average performance for the top 10% of optometry practices after Bayesian adjustment to account for a low number of eligible records. RESULTS: The audit of 420 randomly selected patient records from 42 practices against 12 clinical indicators showed an overall appropriateness of 69% (95% confidence interval (CI) 66%, 73%) for overall diabetic eye care. While a high level of appropriateness was identified for recall period (93%, 95% CI 85%, 100%) and referral (100%, 95% CI 38%, 100%), larger gaps existed in history taking (46%, 95% CI 44%, 52%), dilated fundus examination (80%, 95% CI 76%, 84%) and iris examination (0%, 95% CI 0%, 56%). The ABCs for 8 of 12 indicators were 100%, and the remaining three indicators had ABCs above 80%. An ABC for the iris examination indicator could not be calculated owing to the low number of eligible patient record cards. CONCLUSIONS: This study demonstrated a systematic process of practice evaluation and benchmarking in optometry practices. The diabetic eye care delivered by Australian optometrists was largely appropriate; however, improvement opportunities exist for history taking and physical examination. The ABCs demonstrate that excellence in primary diabetic eye care is attainable and will serve as an important tool in future initiatives to reduce the identified evidence-to-practice gaps.

Blinking and normal ocular surface in school-aged children and the effects of age and screen time.

PURPOSE: Baseline ocular surface characteristics in children require investigation. This study characterised blinking and relationships with ocular symptoms, tear film and digital device use. METHODS: 45 children aged 6-15 years (56% female) participated in a cross-sectional study. Ocular surface symptoms (Instant Ocular Symptoms Survey, Dry Eye Questionnaire 5, Symptoms Assessment in Dry Eye, Ocular Surface Disease Index, Ocular Comfort Index and Numerical Rating Scale) and clinical indices (lipid layer thickness, tear secretion and stability, meibomian gland) were assessed. Blink rate and interblink interval were measured in situ using a wearable eye-tracking headset (Pupil Labs GmbH, Germany). Associations between blinking, ocular surface, age, and digital device use (bivariate and partial correlations) and between automated and manually counted blink rate (Bland & Altman) were examined. RESULTS: Mean blink rate and interblink interval were 20.5±10.5 blinks/min and 2.9±1.9 s during conversation. There was no difference between automated and manual blink rate (p=0.78) and no relationship between blinking and digital device use, age or sex. Mean group symptoms were within normal range and not associated with clinical measurements including blinking. Greater tear volume was associated with a faster blink rate (r=0.46, p=0.001) and shorter interblink interval (r=-0.36, p=0.02). Older age was associated with improved tear volume (r=0.37, p=0.01) and stability (r=0.38, p=0.01). CONCLUSIONS: Blinking characterised in situ was not impacted by age or habitual digital device use. A faster blink rate was associated with greater tear volume but not symptoms. Improved tear function was found with age suggesting that the ocular surface continues to develop through childhood.

Smoke and the eyes: A review of the harmful effects of wildfire smoke and air pollution on the ocular surface.

Wildfires are occurring worldwide with greater frequency and intensity. Wildfires, as well as other sources of air pollution including environmental tobacco smoke, household biomass combustion, agricultural burning, and vehicular emissions, release large amounts of toxic substances into the atmosphere. The ocular surface is constantly exposed to the ambient air and is hence vulnerable to damage from air pollutants. This review describes the detrimental effects of wildfire smoke and air pollution on the ocular surface and resultant signs and symptoms. The latest relevant evidence is synthesised and critically evaluated. A mechanism for the pathophysiology of ocular surface damage will be proposed considering the existing literature on respiratory effects of air pollution. Current strategies to reduce human exposure to air pollutants are discussed and specific possible approaches to protect the ocular surface and manage air pollution induced ocular surface damage are suggested. Further avenues of research are suggested to understand how acute and chronic air pollution exposure affects the ocular surface including the short and long-term implications.

The appropriateness of and barriers to glaucoma care delivery by Australian optometrists.

CLINICAL RELEVANCE: Establishing the level of appropriateness and barriers to glaucoma care delivery by Australian optometrists are important first steps in developing tailored interventions aimed at improving glaucoma care delivery. BACKGROUND: To determine the appropriateness of and barriers to glaucoma care by optometrists. METHODS: A mixed method study was conducted. Phase I was a retrospective cross-sectional medical record audit that assessed glaucoma care appropriateness against 37 clinical indicators from a nationally representative sample of 42 optometry practices. In Phase II, focus groups and interviews involving 31 optometrists explored audit findings to identify barriers to appropriate glaucoma care. Barriers were analysed by deductive and inductive qualitative analysis. Saliency analysis was used to identify key domains that influence glaucoma care. RESULTS: Appropriate glaucoma care was delivered for 63% (95% CI 61%, 64%) of the 420 patient encounters audited. Appropriate care was delivered above 80% for most (57%) indicators, while 14 (38%) indicators were delivered below 60% appropriateness. Good compliance to appropriate care was noted for key indicators of intraocular pressure measurement (90%, 95% CI 87%, 93%) and optic nerve head/retinal nerve fibre layer imaging (78%, 95% CI 74%, 82%). Important barriers identified were beliefs about expected outcomes, lack of perceived relevancy, time constraints, poor organisational culture, knowledge gaps, focusing on some aspects of glaucoma care to the detriment of others, the complexity of glaucoma care, information recall, and social norms. CONCLUSION: Glaucoma care was appropriate in most patient encounters, with opportunity to improve some aspects of history taking and physical examinations. Barriers to glaucoma care were diverse, existing at both the practitioner and organisational levels. These findings provide direction for the development of a tailored improvement intervention.

Multiple things going on at the same time: determinants of appropriate primary diabetic eyecare delivery.

PURPOSE: A recent nationwide medical record audit of optometry practices has identified an evidence-to-practice gap in primary diabetic eyecare delivery. This study aimed to explore the determinants (barriers and enablers) to appropriate diabetic eyecare delivery in Australia. METHODS: A qualitative study involving focus-group discussions and interviews of a purposeful sample of Australian optometrists was conducted. Participants were asked about the perceived barriers to adherence to four underperforming clinical indicators related to primary diabetic eyecare identified by the recent national optometry practice audit. The Theoretical Domain Framework was used for thematic analysis and coding salience to identify key behavioural determinants. RESULTS: Optometrists participated in eight focus groups (n = 27) and individual interviews (n = 4). The most salient barriers were related to Environmental resources (e.g., limited chair time); Beliefs about consequences (e.g., lack of perceived importance); Knowledge (e.g., poor understanding); Professional role/identity (e.g., the perceived role of optometry in care process); Social influences (e.g., the influence of senior optometrists) and Intentions (e.g., apathy). Key enablers were Environmental resources (e.g., electronic record system and practice aids); Knowledge (e.g., keeping up with knowledge/professional development); reinforcements (e.g., fear of legal actions) and behavioural regulations (e.g., self-monitoring/audit). CONCLUSIONS: This study shows that the evidence-to-practice gap in primary diabetic eyecare delivery in Australia can be attributed in part to several interconnected factors related to optometrists' individual capability and motivation as well as the social and practice environment within which they sit. These behavioural determinants will inform the design of an intervention to improve the appropriateness of primary diabetic eyecare delivery.

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

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

Knowledge translation for the everyday optometrist.

A gap exists between best evidence and actual clinical care provided to patients. The advent of evidence-based practice was meant to address this gap by providing practitioners with a method to search, evaluate and incorporate evidence into practice. However, the gap continues to exist. The health research fields of knowledge translation and implementation science have evolved over the last few decades to assist practitioners in embedding research findings and best evidence into routine practice. Knowledge translation seeks to improve public health outcomes by facilitating the movement of best evidence from the bench to clinical practice. Implementation science is the study of methods to integrate research findings and evidence-based practice into routine practice. This literature review aims to revisit the concepts of evidence-based practice and to introduce knowledge translation and implementation science by exploring their roles and influences in the delivery of appropriate glaucoma care by optometrists.