Agreement between optometrists and ophthalmologists on clinical management decisions for patients with glaucoma.

BACKGROUND/AIMS: Although optometrists have become an accepted part of the team in many hospital glaucoma clinics, their decision making ability has not been assessed formally. This study aims to document the accuracy and safety of clinical work undertaken by optometrists in the hospital setting by investigating their management decisions on follow up of patients with glaucoma. METHODS: Four optometrists and three medical clinicians examined 50 patients each. Clinical findings were recorded as usual in the hospital records but management decisions were documented separately on a specially designed data collection form. Subsequently, the patient records and clinical findings were reviewed retrospectively and independently by two consultant ophthalmologists, who were masked to the management decisions of the optometrists and medical clinicians. The consultants' management decisions were then compared with those made by the optometrists and medical clinicians. Percentage agreements were computed together with kappa (kappa), or weighted kappa, statistics where appropriate. RESULTS: Agreement between consultants and optometrists was 55% (kappa = 0.33) for evaluation of visual field status, 79% (kappa = 0.67) for medical management, 72-98% for other aspects of patient management, and 78% (weighted kappa = 0.35) for scheduling of next clinic appointment. Very similar levels of agreement were found between consultants and medical clinicians. CONCLUSION: Agreement between optometrists and consultants, in glaucoma clinical decision making, was at least as good as that between medical clinicians and consultants. Within an appropriate environment, optometrists can safely work as part of the hospital glaucoma team in outpatient clinics.

Low vision services for vision rehabilitation in the United Kingdom.

AIM: Little is known about the distribution and methods of delivery of low vision services across the United Kingdom. The purpose of this study was to determine the type and location of low vision services within the UK. METHODS: Survey by means of a 29 point postal questionnaire, followed when necessary by a five point telephone questionnaire. All known potential providers of low vision services (n = 2539) including hospitals (n = 277), optician/optometry practices (n = 1683), social services (n = 177), voluntary groups (n = 190), specialist teachers (n = 205), and universities (n = 6) were surveyed. For each service provider, the type, magnitude, and geographical location were determined. The distribution of services across the United Kingdom and the ratio of providers to population density of people with a visual impairment were mapped using the Geographic Information System (GIS). RESULTS: Data were obtained on 1945 (77%) service providers: 1679 (66%) responded to the postal questionnaire and 266 (11%) to the telephone questionnaire. Of all respondents, 59% (n = 1135) offer some form of help to people with a visual disability, of which 26% (n = 497) only sell magnifiers and 33% (n = 638) provide low vision services. It is estimated that in total just under 155,000 low vision consultations are offered annually, the bulk of which are provided by hospital eye departments. The distribution was geographically uneven and there appears to be scarcity in some areas. CONCLUSION: When compared to the probable number of people with a visual impairment in the UK there are apparent inadequacies in service provision in terms of distribution, magnitude, and coordination. The results highlight a need to review current services.

An optometrist's role of co-management in a hospital glaucoma clinic.

In recent years, optometrists have started to work in some clinical roles in hospital medical clinics. This paper outlines the current working practice in a typical glaucoma clinic at Moorfields Eye Hospital NHS Trust and goes on to establish the ability of an optometrist working with a team of ophthalmologists. In this study, 54 patients (n = 108 eyes) were recruited and clinically assessed by an optometrist. Subsequently, a research fellow (i.e. ophthalmologist) assessed the same patients independently. The results were compared in order to determine the accuracy of the optometrist's evaluation and proposed management. This paper considers the costs of employing personnel by reviewing the salaries of optometrists and medical assistants. Although nurses have started to work alongside ophthalmologists, and orthoptists may be considering such work, it is not within the scope of this paper to consider either of these groups. If optometrists are to become an accepted part of a glaucoma clinical team, consideration needs to be given to the training and experience they receive.

An extended role for the hospital optometrist.

The management of patients within shared care programmes would seem to have significant benefits in terms of individuals' convenience, addressing resource needs and expanding professional horizons. To date, these schemes have typically concentrated on the monitoring of patients with diabetes and glaucoma. At Moorfields Eye Hospital, we attempted to develop the role of the hospital optometrist by establishing a study to evaluate the clinical appraisal of new referrals in a busy out-patient clinic. The results showed a high level of diagnostic accuracy which suggests that the role of hospital optometrists may be successfully extended to include some aspects of patient evaluation not typically undertaken.

Use of scrolled text in a scanning laser ophthalmoscope to assess reading performance at different retinal locations.

A new technique is described for assessing reading performance using a scanning laser ophthalmoscope. Letters of different sizes and contrasts were projected onto specific retinal locations of normal and low vision observers. Successive letters were scrolled in a horizontal direction at different speeds through a 'window'. Throughout the experiments the subjects' fundus and the retinal location of the stimuli could be visualized. With this scanning laser ophthalmoscope text-scrolling computer program the subject does not search for adjacent letters, and because the eye is held relatively stationary the tedious eye movement analysis incurred in other studies is reduced. Five retinal areas were investigated in two normal observers. The percentage of letters correctly identified decreased with eccentricity, increased velocity of the text and reduced text contrast. The reading performance of two patients, one with age-related macular degeneration and the other with juvenile macular disease, was investigated. Decrements in performance were related to morphology of the lesions.