An investigation of barriers and enablers to community eye care for children in England: A qualitative descriptive study.

PURPOSE: Research suggests that there are challenges in the accessibility of eye care for children in England. This study explores the barriers and enablers to eye examinations for children under 5 years of age from the perspective of community optometrists in England. METHODS: Optometrists working in community settings were invited to participate in virtual focus group discussions using an online platform based on a topic guide. The discussions were audio-recorded, transcribed and thematically analysed. Themes were derived from the focus group data based on the study aim and research question. RESULTS: Thirty optometrists participated in the focus group discussions. The overarching themes identified as barriers to eye examinations for young children in a community setting were as follows: 'Time and Money', 'Knowledge, Skills and Confidence', 'Awareness and Communication', 'Range of Attitudes' and 'Clinical Setting'. The key themes for enabling eye examinations for young children were as follows: 'Improving behaviour', 'Enhancing training and education', 'Enhancing eye care services', 'Raising awareness', 'Changes in professional bodies' and 'Balancing commercial pressures and health care'. CONCLUSION: Time, money, training and equipment are perceived by optometrists as key factors in providing an eye examination for a young child. This study identified a need for improved training and robust governance related to eye examinations for young children. There is a need for change within eye care service delivery such that all children, regardless of age and ability, are examined regularly, and by conducting these examinations, optometrists remain confident.

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.

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.

Interventions for myopia control in children: a living systematic review and network meta-analysis.

BACKGROUND: Myopia is a common refractive error, where elongation of the eyeball causes distant objects to appear blurred. The increasing prevalence of myopia is a growing global public health problem, in terms of rates of uncorrected refractive error and significantly, an increased risk of visual impairment due to myopia-related ocular morbidity. Since myopia is usually detected in children before 10 years of age and can progress rapidly, interventions to slow its progression need to be delivered in childhood. OBJECTIVES: To assess the comparative efficacy of optical, pharmacological and environmental interventions for slowing myopia progression in children using network meta-analysis (NMA). To generate a relative ranking of myopia control interventions according to their efficacy. To produce a brief economic commentary, summarising the economic evaluations assessing myopia control interventions in children. To maintain the currency of the evidence using a living systematic review approach.  SEARCH METHODS: We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register), MEDLINE; Embase; and three trials registers. The search date was 26 February 2022.  SELECTION CRITERIA: We included randomised controlled trials (RCTs) of optical, pharmacological and environmental interventions for slowing myopia progression in children aged 18 years or younger. Critical outcomes were progression of myopia (defined as the difference in the change in spherical equivalent refraction (SER, dioptres (D)) and axial length (mm) in the intervention and control groups at one year or longer) and difference in the change in SER and axial length following cessation of treatment ('rebound').  DATA COLLECTION AND ANALYSIS: We followed standard Cochrane methods. We assessed bias using RoB 2 for parallel RCTs. We rated the certainty of evidence using the GRADE approach for the outcomes: change in SER and axial length at one and two years. Most comparisons were with inactive controls. MAIN RESULTS: We included 64 studies that randomised 11,617 children, aged 4 to 18 years. Studies were mostly conducted in China or other Asian countries (39 studies, 60.9%) and North America (13 studies, 20.3%). Fifty-seven studies (89%) compared myopia control interventions (multifocal spectacles, peripheral plus spectacles (PPSL), undercorrected single vision spectacles (SVLs), multifocal soft contact lenses (MFSCL), orthokeratology, rigid gas-permeable contact lenses (RGP); or pharmacological interventions (including high- (HDA), moderate- (MDA) and low-dose (LDA) atropine, pirenzipine or 7-methylxanthine) against an inactive control. Study duration was 12 to 36 months. The overall certainty of the evidence ranged from very low to moderate. Since the networks in the NMA were poorly connected, most estimates versus control were as, or more, imprecise than the corresponding direct estimates. Consequently, we mostly report estimates based on direct (pairwise) comparisons below. At one year, in 38 studies (6525 participants analysed), the median change in SER for controls was -0.65 D. The following interventions may reduce SER progression compared to controls: HDA (mean difference (MD) 0.90 D, 95% confidence interval (CI) 0.62 to 1.18), MDA (MD 0.65 D, 95% CI 0.27 to 1.03), LDA (MD 0.38 D, 95% CI 0.10 to 0.66), pirenzipine (MD 0.32 D, 95% CI 0.15 to 0.49), MFSCL (MD 0.26 D, 95% CI 0.17 to 0.35), PPSLs (MD 0.51 D, 95% CI 0.19 to 0.82), and multifocal spectacles (MD 0.14 D, 95% CI 0.08 to 0.21). By contrast, there was little or no evidence that RGP (MD 0.02 D, 95% CI -0.05 to 0.10), 7-methylxanthine (MD 0.07 D, 95% CI -0.09 to 0.24) or undercorrected SVLs (MD -0.15 D, 95% CI -0.29 to 0.00) reduce progression.  At two years, in 26 studies (4949 participants), the median change in SER for controls was -1.02 D. The following interventions may reduce SER progression compared to controls: HDA (MD 1.26 D, 95% CI 1.17 to 1.36), MDA (MD 0.45 D, 95% CI 0.08 to 0.83), LDA (MD 0.24 D, 95% CI 0.17 to 0.31), pirenzipine (MD 0.41 D, 95% CI 0.13 to 0.69), MFSCL (MD 0.30 D, 95% CI 0.19 to 0.41), and multifocal spectacles  (MD 0.19 D, 95% CI 0.08 to 0.30). PPSLs (MD 0.34 D, 95% CI -0.08 to 0.76) may also reduce progression, but the results were inconsistent. For RGP, one study found a benefit and another found no difference with control. We found no difference in SER change for undercorrected SVLs (MD 0.02 D, 95% CI -0.05 to 0.09). At one year, in 36 studies (6263 participants), the median change in axial length for controls was 0.31 mm. The following interventions may reduce axial elongation compared to controls: HDA (MD -0.33 mm, 95% CI -0.35 to 0.30), MDA (MD -0.28 mm, 95% CI -0.38 to -0.17), LDA (MD -0.13 mm, 95% CI -0.21 to -0.05), orthokeratology (MD -0.19 mm, 95% CI -0.23 to -0.15), MFSCL (MD -0.11 mm, 95% CI -0.13 to -0.09), pirenzipine (MD -0.10 mm, 95% CI -0.18 to -0.02), PPSLs (MD -0.13 mm, 95% CI -0.24 to -0.03), and multifocal spectacles (MD -0.06 mm, 95% CI -0.09 to -0.04). We found little or no evidence that RGP (MD 0.02 mm, 95% CI -0.05 to 0.10), 7-methylxanthine (MD 0.03 mm, 95% CI -0.10 to 0.03) or undercorrected SVLs (MD 0.05 mm, 95% CI -0.01 to 0.11) reduce axial length. At two years, in 21 studies (4169 participants), the median change in axial length for controls was 0.56 mm. The following interventions may reduce axial elongation compared to controls: HDA (MD -0.47mm, 95% CI -0.61 to -0.34), MDA (MD -0.33 mm, 95% CI -0.46 to -0.20), orthokeratology (MD -0.28 mm, (95% CI -0.38 to -0.19), LDA (MD -0.16 mm, 95% CI -0.20 to  -0.12), MFSCL (MD -0.15 mm, 95% CI -0.19 to -0.12), and multifocal spectacles (MD -0.07 mm, 95% CI -0.12 to -0.03). PPSL may reduce progression (MD -0.20 mm, 95% CI -0.45 to 0.05) but results were inconsistent. We found little or no evidence that undercorrected SVLs (MD -0.01 mm, 95% CI -0.06 to 0.03) or RGP (MD 0.03 mm, 95% CI -0.05 to 0.12) reduce axial length. There was inconclusive evidence on whether treatment cessation increases myopia progression. Adverse events and treatment adherence were not consistently reported, and only one study reported quality of life. No studies reported environmental interventions reporting progression in children with myopia, and no economic evaluations assessed interventions for myopia control in children. AUTHORS' CONCLUSIONS: Studies mostly compared pharmacological and optical treatments to slow the progression of myopia with an inactive comparator. Effects at one year provided evidence that these interventions may slow refractive change and reduce axial elongation, although results were often heterogeneous. A smaller body of evidence is available at two or three years, and uncertainty remains about the sustained effect of these interventions. Longer-term and better-quality studies comparing myopia control interventions used alone or in combination are needed, and improved methods for monitoring and reporting adverse effects.

ANTECEDENTES: La miopía es un defecto de refracción frecuente, en el que el alargamiento del globo ocular hace que los objetos lejanos aparezcan borrosos. La creciente prevalencia de la miopía es un problema de salud pública mundial cada vez mayor, en cuanto a tasas de defectos de refracción no corregidos y un significativamente mayor riesgo de discapacidad visual debido a la morbilidad ocular relacionada con la miopía. Dado que la miopía se suele detectar en niños antes de los 10 años y puede evolucionar rápidamente, las intervenciones para frenar su avance se deben realizar en la infancia. OBJETIVOS: Evaluar la eficacia comparativa de las intervenciones ópticas, farmacológicas y ambientales para frenar la progresión de la miopía en niños mediante un metanálisis en red (MAR). Generar una clasificación relativa de las intervenciones de control de la miopía en función de su eficacia. Elaborar un breve comentario económico que resuma las evaluaciones económicas de las intervenciones de control de la miopía en niños. Mantener la vigencia de la evidencia mediante un enfoque de revisión sistemática continua. MÉTODOS DE BÚSQUEDA: Se realizaron búsquedas en CENTRAL (que contiene el Registro de ensayos del Grupo Cochrane de Salud ocular y de la visión [Cochrane Eyes and Vision]), MEDLINE; Embase; y en tres registros de ensayos. La fecha de búsqueda fue el 26 de febrero de 2022. CRITERIOS DE SELECCIÓN: Se incluyeron ensayos controlados aleatorizados (ECA) de intervenciones ópticas, farmacológicas y ambientales para retrasar la progresión de la miopía en niños de hasta 18 años. Los desenlaces fundamentales fueron la progresión de la miopía (definida como la diferencia en el cambio del equivalente esférico de la refracción [EER, dioptrías (D)] y la longitud axial [mm] en los grupos de intervención y control al año o más) y la diferencia en el cambio del EER y la longitud axial tras el cese del tratamiento ("rebote"). OBTENCIÓN Y ANÁLISIS DE LOS DATOS: Se utilizaron los métodos Cochrane estándar. El sesgo se evaluó mediante la herramienta RoB 2 en el caso de los ECA paralelos. La certeza de la evidencia se calificó mediante el método GRADE para los desenlaces: cambio del EER y la longitud axial al año y a los dos años. La mayoría de las comparaciones se realizaron con controles inactivos. RESULTADOS PRINCIPALES: Se incluyeron 64 estudios que asignaron al azar a 11 617 niños de cuatro a 18 años de edad. Los estudios se realizaron principalmente en China u otros países asiáticos (39 estudios; 60,9%) y Norteamérica (13 estudios; 20,3%). Cincuenta y siete estudios (89%) compararon intervenciones de control de la miopía (gafas multifocales, gafas periféricas plus [PPSL por sus siglas en inglés], gafas monofocales [SVL por sus siglas en inglés] subcorregidas, lentes de contacto multifocales blandas [MFSCL por sus siglas en inglés], ortoqueratología, lentes de contacto rígidas permeables al gas [RGP por sus siglas en inglés]); o intervenciones farmacológicas (incluidas atropina a dosis alta, media y baja, pirenzipina o 7­metilxantina) contra un control inactivo. La duración de los estudios fue de 12 a 36 meses. La certeza global de la evidencia varió entre muy baja y moderada. Debido a que las redes del MAR estaban mal conectadas, la mayoría de las estimaciones versus control fueron tan imprecisas o más que las correspondientes estimaciones directas. En consecuencia, a continuación se presentan principalmente estimaciones basadas en comparaciones directas (por pares). Al año, en 38 estudios (6525 participantes analizados), la mediana del cambio del EER para los controles fue de ­0,65 D. Las siguientes intervenciones podrían reducir la progresión del EER en comparación con los controles: atropina a dosis alta (diferencia de medias [DM] 0,90 D; intervalo de confianza [IC] del 95%: 0,62 a 1,18), atropina a dosis media (DM 0,65 D; IC del 95%: 0,27 a 1,03), atropina a dosis baja (DM 0,38 D; IC del 95%: 0,10 a 0,66), pirenzipina (DM 0,32 D; IC del 95%: 0,15 a 0,49), MFSCL (DM 0,26 D; IC del 95%: 0,17 a 0,35), PPSL (DM 0,51 D; IC del 95%: 0,19 a 0,82) y gafas multifocales (DM 0,14 D; IC del 95%: 0,08 a 0,21). Por el contrario, hubo poca o ninguna evidencia de que las RGP (DM 0,02 D; IC del 95%: ­0,05 a 0,10), la 7­metilxantina (DM 0,07 D; IC del 95%: ­0,09 a 0,24) o las SVL subcorregidas (DM ­0,15 D; IC del 95%: ­0,29 a 0,00) redujeran la progresión. A los dos años, en 26 estudios (4949 participantes), el cambio medio del EER para los controles fue de ­1,02 D. Las siguientes intervenciones podrían reducir la progresión del EER en comparación con los controles: atropina a dosis alta (DM 1,26 D; IC del 95%: 1,17 a 1,36), atropina a dosis media (DM 0,45 D; IC del 95%: 0,08 a 0,83), atropina a dosis baja (DM 0,24 D; IC del 95%: 0,17 a 0,31), pirenzipina (DM 0,41 D; IC del 95%: 0,13 a 0,69), MFSCL (DM 0,30 D; IC del 95%: 0,19 a 0,41) y gafas multifocales (DM 0,19 D; IC del 95%: 0,08 a 0,30). Las PPSL (DM 0,34 D; IC del 95%: ­0,08 a 0,76) también podrían reducir la progresión, pero los resultados no fueron consistentes. Para las RGP, un estudio encontró un efecto beneficioso y otro no encontró diferencias con el control. No se observaron diferencias en el cambio del EER para las SVL subcorregidas (DM 0,02 D; IC del 95%: ­0,05 a 0,09). Al año, en 36 estudios (6.263 participantes), el cambio medio en la longitud axial de los controles fue de 0,31 mm. Las siguientes intervenciones podrían reducir la elongación axial en comparación con los controles: atropina a dosis alta (DM ­0,33 mm; IC 95%: ­0,35 a 0,30), atropina a dosis media (DM ­0,28 mm; IC 95%: ­0,38 a ­0,17), atropina a dosis baja (DM ­0,13 mm; IC 95%: ­0,21 a ­0,05), ortoqueratología (DM ­0,19 mm; IC 95%: ­0,23 a ­0,15), MFSCL (DM ­0,11 mm; IC del 95%: ­0,13 a ­0,09), pirenzipina (DM ­0,10 mm; IC del 95%: ­0,18 a ­0,02), PPSL (DM ­0,13 mm; IC del 95%: ­0,24 a ­0,03) y gafas multifocales (DM ­0,06 mm; IC del 95%: ­0,09 a ­0,04). Se encontró poca o ninguna evidencia de que las RGP (DM 0,02 mm; IC del 95%: ­0,05 a 0,10), la 7­metilxantina (DM 0,03 mm; IC del 95%: ­0,10 a 0,03) o las SVL subcorregidas (DM 0,05 mm; IC del 95%: ­0,01 a 0,11) reduzcan la longitud axial. A los dos años, en 21 estudios (4169 participantes), la mediana del cambio en la longitud axial de los controles fue de 0,56 mm. Las siguientes intervenciones podrían reducir la elongación axial en comparación con los controles: atropina a dosis alta (DM ­0,47 mm; IC del 95%: ­0,61 a ­0,34), atropina a dosis media (DM ­0,33 mm; IC del 95%: ­0,46 a ­0,20), ortoqueratología (DM ­0,28 mm; IC del 95%: ­0,38 a ­0,19), atropina a dosis baja (DM ­0,16 mm; IC del 95%: ­0,20 a ­0,12), MFSCL (DM ­0,15 mm; IC del 95%: ­0,19 a ­0,12) y gafas multifocales (DM ­0,07 mm; IC del 95%: ­0,12 a ­0,03). Las PPSL podrían reducir la progresión (DM ­0,20 mm; IC del 95%: ­0,45 a 0,05), pero los resultados no fueron consistentes. Se encontró poca o ninguna evidencia de que las SVL subcorregidas (DM ­0,01 mm; IC del 95%: ­0,06 a 0,03) o las RGP (DM 0,03 mm; IC del 95%: ­0,05 a 0,12) reduzcan la longitud axial. No hubo evidencia concluyente sobre si el abandono del tratamiento aumenta la progresión de la miopía. Los eventos adversos y la adherencia al tratamiento no se comunicaron de forma consistente, y solo un estudio informó sobre la calidad de vida. Ningún estudio proporcionó información sobre intervenciones ambientales que informaran sobre la progresión en niños con miopía y ninguna evaluación económica analizó intervenciones para el control de la miopía en niños. CONCLUSIONES DE LOS AUTORES: La mayoría de los estudios compararon tratamientos farmacológicos y ópticos para enlentecer la progresión de la miopía con un comparador inactivo. Los efectos al año demostraron que estas intervenciones podrían ralentizar el cambio refractivo y reducir el alargamiento axial, aunque a menudo los resultados fueron heterogéneos. El conjunto de evidencia disponible a los dos o tres años fue más escaso, y persiste la incertidumbre sobre el efecto sostenido de estas intervenciones. Se necesitan estudios a más largo plazo y de mejor calidad que comparen las intervenciones para el control de la miopía utilizadas solas o en combinación, así como métodos mejorados de seguimiento y notificación de los efectos adversos.

Influence of location, season and time of day on the spectral composition of ambient light: Investigation for application in myopia.

PURPOSE: Given the possible role of spectral composition of light and myopia, this study aimed at investigating the variation in the spectral composition of ambient light in different (a) outdoor/indoor locations, (b) time of a day and (c) seasons. METHODS: The spectral power distribution (SPD), categorised into short (380-500 nm), middle (505-565 nm) and long wavelengths (625-780 nm), was recorded using a handheld spectrometer at three outdoor locations ('open playground', 'under shade of tree' and 'canopy') and three indoor locations ('room with multiple windows', 'closed room' and 'closed corridor'). Readings were taken at five different time points (3-h intervals between 6:30 and 18:00 hours) on two days, each during the summer and monsoon seasons. RESULTS: The overall median SPD (IQR [25th-75th percentile] W/nm/m2 ) across the three outdoor locations (0.11 [0.09, 0.12]) was 157 times higher than that of the indoor locations (0.0007 [0.0001, 0.001]). Considerable locational, diurnal and seasonal variation was observed in the distribution of the median SPD value, with the highest value being recorded in the 'open playground' (0.27 [0.21, 0.28]) followed by 'under shade of tree' (0.083 [0.074, 0.09]), 'canopy' (0.014 [0.012, 0.015]) and 'room with multiple windows' (0.023 [0.015, 0.028]). The relative percentage composition of short, middle and long wavelengths was similar in both the outdoor and indoor locations, with the proportion of middle wavelengths significantly higher (p < 0.01) than short and long wavelengths in all the locations, except 'canopy'. CONCLUSION: Irrespective of variation in SPD values with location, time, day and season, outdoor locations always exhibited significantly higher spectral power than indoor locations. The relative percentage composition of short, middle and long wavelengths of light was similar across all locations. These findings establish a foundation for future research to understand the relationship between spectral power and the development of myopia.

Development and validation of a 'MyLyt' wearable light tracking device.

PURPOSE: We developed a clip-on light tracker (MyLyt) for estimating light exposure in real time. This study aimed at validating and investigating the feasibility of using MyLyt in children and adults. METHOD: The study was conducted in two phases. Phase 1 involved validation against a factory-calibrated digital lux meter in three separate conditions: controlled environmental set-up, outdoors and indoors where intra-test (two measurements by the same tracker), inter-test (measurements among trackers) and inter-device (MyLyt tracker and lux meter) validations were conducted. Phase 2 involved a feasibility study where MyLyt was used in a real-world setting by 21 adults and 8 children. Participants were asked to log their real-time movements in an 'activity diary', which were correlated with the lux levels measured by the tracker. RESULTS: A strong positive correlation and non-significant difference in the recorded mean illuminance levels were observed during intra-test (inter-class correlation: 1.00, p = 0.99), inter-test (0.91-1.00, p > 0.15) and inter-device (0.91-1.00, p > 0.56) validation in all three testing conditions (p > 0.49), except the indoor location. While the lux level measured by MyLyt was significantly higher than that of the lux meter (p < 0.01) in the indoor locations, differences were minimal and clinically insignificant. A Bland-Altman plot showed a minimal mean difference (95% limits of agreement) between the MyLyt tracker and lux meter in all three conditions (controlled environmental set-up: 641 [-949, 2230], outdoor: 74 [-2772, 2920] and indoor: -35 [-151, 80] lux). Phase 2 validation showed an expected illuminance level against the corresponding location with high sensitivity (97.8%) and specificity (99%) to accurately differentiate between outdoor and indoor locations. CONCLUSION: The MyLyt tracker showed good repeatability, strong correlation and comparable values with the lux meter in the three tested conditions, making it suitable for tracking light exposure patterns for both research and clinical purposes.

Refractive prescribing for preschool children by optometrists in England.

PURPOSE: Correction of refractive error in children is important for visual and educational development. The aim of this questionnaire-based study was to explore paediatric refractive correction by optometrists in England. METHODS: An online questionnaire was piloted and distributed to optometrists in England. The questionnaire asked about respondents' characteristics (such as type of practice), management of refractive error in 1- and 3-year-old children and sources of information used as a basis for decisions on prescribing refractive error in children. RESULTS: Two hundred and ninety-three questionnaires were returned, although only 139 (47%) were fully completed. In an average month, about half of respondents examined no children between 0 and 2 years of age, and about half examined no more than five children aged 3-4 years. A significant proportion indicated they would refer children aged 1 or 3 years with refractive error and no other signs or symptoms into the hospital eye service. Almost a quarter would prescribe in full or in part an isometropic refractive correction of +2.00 D for a 3-year-old (within the normal range) with no other signs or symptoms, suggesting a degree of unnecessary prescribing. Almost all would act in cases of clinically significant refractive error. Respondents made similar use of their colleagues, optometric or postgraduate/continuing education, professional guidance and peer-reviewed research as sources of evidence on which to base decisions about prescribing for paediatric refractive errors. Most reported 'never' or 'rarely' using Cochrane reviews. CONCLUSIONS: These results suggest optometrists often defer management of paediatric refractive error to the hospital eye service, with implications in terms of underutilisation of community optometric expertise and burden on the National Health Service. In some cases, the results indicate a mismatch between respondents' reported management and existing guidance/guidelines on paediatric prescribing.

Systematic review and meta-analysis on the agreement of non-cycloplegic and cycloplegic refraction in children.

OBJECTIVE: To determine the diagnostic agreement of non-cycloplegic and cycloplegic refraction in children. METHOD: The study methodology followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Electronic databases were searched for comparative studies exploring refraction performed on children under non-cycloplegic and cycloplegic conditions. There was no restriction on the year of publication; however, only publications in the English language were eligible. Inclusion criteria consisted of children aged ≤12 years, any degree or type of refractive error, either sex and no ocular or binocular co-morbidities. The QUADAS-2 tool was used to evaluate the risk of bias. Meta-analysis was conducted to synthesise data from all included studies. Subgroup and sensitivity analyses were undertaken for those studies with a risk of bias. RESULTS: Ten studies consisting of 2724 participants were eligible and included in the meta-analysis. The test for overall effect was not significant when comparing non-cycloplegic Plusoptix and cycloplegic autorefractors (Z = 0.34, p = 0.74). The pooled mean difference (MD) was -0.08 D (95% CI -0.54 D, +0.38 D) with a prediction interval of -1.72 D to +1.56 D. At less than 0.25 D, this indicates marginal overestimation of myopia and underestimation of hyperopia under non-cycloplegic conditions. When comparing non-cycloplegic autorefraction with a Retinomax and Canon autorefractor to cycloplegic refraction, a significant difference was found (Z = 9.79, p < 0.001) and (Z = 4.61, p < 0.001), respectively. DISCUSSION: Non-cycloplegic Plusoptix is the most useful autorefractor for estimating refractive error in young children with low to moderate levels of hyperopia. Results also suggest that cycloplegic refraction must remain the test of choice when measuring refractive error ≤12 years of age. There were insufficient data to explore possible reasons for heterogeneity. Further research is needed to investigate the agreement between non-cycloplegic and cycloplegic refraction in relation to the type and level of refractive error at different ages.

Public health for paediatricians: 15-minute guide to identify and address food insecurity.

Food insecurity is a major problem in the UK. It has been both highlighted and exacerbated by the COVID-19 pandemic, and particularly affects children and young people (CYP). The effects of inadequate nutrition manifest themselves in all stages of child development and adversely affect health and educational outcomes. Healthcare professionals working with CYP can address food insecurity at individual, local community, organisational and national levels. The government plays an important role in monitoring and responding to food insecurity, supporting CYP most in need.This paper summarises how food insecurity can be identified and approached by healthcare professionals in clinical consultations, including the use of screening tools and awareness of risk factors that signpost family food insecurity. Examples of services and clinician-assisted referrals to support vulnerable patients are provided, alongside suggested methods to implement further education for the multidisciplinary healthcare team.

Time spent outdoors as an intervention for myopia prevention and control in children: an overview of systematic reviews.

PURPOSE: Outdoor light exposure is considered a safe and effective strategy to reduce myopia development and aligns with existing public health initiatives to promote healthier lifestyles in children. However, it is unclear whether this strategy reduces myopia progression in eyes that are already myopic. This study aims to conduct an overview of systematic reviews (SRs) reporting time spent outdoors as a strategy to prevent myopia or slow its progression in children. METHODS: We searched the Cochrane Library, EMBASE, MEDLINE and CINAHL from inception to 1 November 2020 to identify SRs that evaluated the association between outdoor light exposure and myopia development or progression in children. Outcomes included incident myopia, prevalent myopia and change in spherical equivalent refraction (SER) and axial length (AL) to evaluate annual rates of myopia progression. The methodological quality and risk of bias of included SRs were assessed using the AMSTAR-2 and ROBIS tools, respectively. RESULTS: Seven SRs were identified, which included data from 47 primary studies with 63,920 participants. Pooled estimates (risk or odds ratios) consistently demonstrated that time outdoors was associated with a reduction in prevalence and incidence of myopia. In terms of slowing progression in eyes that were already myopic, the reported annual reductions in SER and AL from baseline were small (0.13-0.17 D) and regarded as clinically insignificant. Methodological quality assessment using AMSTAR-2 found that all reviews had one or more critical flaws and the ROBIS tool identified a low risk of bias in only two of the included SRs. CONCLUSION: This overview found that increased exposure to outdoor light reduces myopia development. However, based on annual change in SER and AL, there is insufficient evidence for a clinically significant effect on myopia progression. The poor methodological quality and inconsistent reporting of the included systematic reviews reduce confidence in the estimates of effect.

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.

Categorising high-cost high-need children and young people.

OBJECTIVES: To describe the characteristics of high-cost high-need children and young people (CYP) (0-24 years) in England. METHODS: Retrospective observational study using data from the Clinical Practice Research Database linked to Hospital Episode Statistics in 2014/2015 and 2015/2016. Healthcare utilisation of primary and secondary care services were calculated, and costs were estimated using Healthcare Resource Group for secondary care and Personal Social Services Research Unit for primary care. High-cost high-need CYP were defined as the top 5% of users by cost. RESULTS: 3891 of 73 392 CYP made up the top 5% that were classified as high-cost high-need, and this group accounted for 54% of total annual costs. In this population, 7.3% were males <5 years and 11.0% were females 20-24 years. Inpatient care (acute) accounted for 63% of known spending in high-cost high-need patients. Total mean monthly cost per patient was 22.7 times greater in the high-cost high-need group compared with all other patients (£4417 vs £195). 29% of CYP in the high-cost high-need group in 2014/2015 were also classified as high-cost high-need in the following year. CONCLUSIONS: These findings indicate the importance of further understanding and anticipating trends in CYP health spending to optimise care, reduce costs and inform new models of care. This includes integrated services, a further look into societal factors in reducing health inequalities and a particular focus of mental health services, the demand of which increases with age.

How accessible is primary eye care for children in England?

PURPOSE: Good vision during childhood is vital for visual, educational, and social development. Previous research highlights challenges in the accessibility of eye care for children. This study investigates the accessibility of primary eye care for young children with typical development and those with autism in England. METHODS: A telephone survey was conducted using four hypothetical scenarios (a child aged 1, 3, 5 years and a 13-year-old with autism). Four hundred community optometric practices (100 different practices for each scenario) were contacted to explore the availability of an eye examination. The caller acted as a parent, asking about the availability of an eye examination for their child and raising concerns regarding the child. Key barriers and enablers to the accessibility of primary eye care were identified through an analysis of qualitative information. RESULTS: Of the 400 practices, only three (<1%) stated that they do not perform eye examinations on children. Fifty-six practices (14%) stated that they would examine a child at any age, the remainder (n = 341, 85%) specifying a minimum age at which they would perform eye examinations on children. Lack of 'communication' from the child and 'equipment' were identified as barriers to accessing eye care for young children. Eye care for children with autism was enabled by factors related to adaptability and appointment time. CONCLUSION: Our results suggest that communication and a lack of appropriate equipment for examining children are potential barriers to accessing primary eye care. No clear barriers were identified for an older child with autism. Eye examinations are more accessible for older children in these scenarios (aged 5 with typical development and 13 years with autism) than younger children (aged 1 and 3 years old). While the UK General Ophthalmic Services (GOS) terms do not permit contract holders to exclude categories of patients from a GOS eye exam, our findings suggest this is taking place.

Inter-optometrist variability of IOP measurement for modern tonometers and their agreement with Goldmann Applanation Tonometry.

Clinical relevance: Accuracy of tonometers is of vital importance in the detection and treatment of glaucoma.Background: This study investigates: agreement in intraocular pressure measurements between three tonometers and Goldmann applanation tonometry (GAT); inter-optometrist agreement for each tonometer; intra-optometrist agreement for GAT; association between central corneal thickness (CCT) and IOP measurements with each tonometer.Methods: IOP was measured using: CT-1P Non-Contact Tonometer (NCT) (Topcon Corporation, Tokyo, Japan), Pulsair IntelliPuff (Keeler Ltd., Windsor, UK) and Icare rebound tonometer (Icare, Helsinki, Finland) by two optometrists in a random order. Two GAT readings were obtained by each optometrist in a randomised masked manner. Mean differences, and 95% limits of agreement (LoA) for each measurement were calculated. CCT was measured by CT-1P pachymeter.Results: Forty-one participants' IOPs were measured. Mean differences (95% LoA) between NCT, Pulsair, Icare compared to GAT for one optometrist were: 0.8 (-5.4 to 6.9) mmHg, -1.7 (-8.2 to 4.8) mmHg, -1.6 (-9.0 to 5.9) mmHg. Mean differences (95% LoA) in inter-optometrist agreement for GAT, NCT, Pulsair and Icare were: 0.3 (-6.7 to 7.3) mmHg, 0.4 (-2.1 to 2.9) mmHg, -0.9 (-3.6 to 1.9) mmHg and -0.2 (-4.9 to 4.5) mmHg, respectively. Mean differences (95% LoA) for intra-optometrist agreement for GAT were 0.2 (4.3 to -4.7) mmHg and 0.1 (3.6 to -3.9) mmHg for each optometrist, respectively. There was a weak positive association between CCT and both GAT (r2 = 0.11) and NCT (r2 = 0.12).Conclusion: Pulsair and Icare may measure IOP lower than GAT. Mean differences for inter-optometrist agreement for all tonometers were < 1 mmHg; Pulsair showed a statistically significant difference. Intra-optometrist agreement for GAT was good. IOP measurements taken by two community optometrists are comparable using tonometers used in community practice.

Use of standardised patients in optometry training.

Clinical relevance: The ability to articulate clinical findings to patients through effective communication is a key skill in all health-care professions.Background: Unannounced standardised patients (SPs) are successful in measuring quality of clinical care provided by qualified optometrists but have not been used in optometry training. Final-year undergraduate optometry students examine members of the public during primary care clinics observed by visiting clinical tutors (VCTs) who provide individualised feedback, highlighting areas for improvement. This pilot study investigates whether unannounced SPs can be used as an additional resource providing enhanced feedback on communication skills in undergraduate optometry education.Methods: Two SPs received intensive training on reporting on students eye examinations and communication skills through completion of pre-designed checklists for each patient encounter. Each SP presented 16 times as an unannounced patient for routine eye examinations. SPs' comments on communication skills of 32 students during 32 examinations was compared to feedback from 10 VCTs. SPs' performance was monitored to ensure consistency. Evaluation of differences in quality and quantity of feedback provided by SPs and VCTs was performed using thematic analysis and chi-squared tests. Student feedback on the use of SPs was obtained on completion of the study.Results: Qualitative thematic analysis revealed six overarching themes emerging from 64 sets of feedback. SPs gave significantly more feedback, both positive comments and comments with recommendations, than VCTs for the (a) total number of comments for each theme (p = 0.0000) and (b) detail and depth of these comments. Students reported that SPs commented on aspects of communication (e.g., establishing rapport and body language) not noted by VCTs.Conclusions: Unannounced SPs can provide enhanced feedback on communication skills to final-year undergraduate optometry students. Students greatly valued VCTs feedback; however, they felt SPs commented on elements of communication not noted by VCTs.