Characterization of ocular surface symptoms from optometric practices in North America.

PURPOSE: This study characterized ocular symptoms typical of dry eye in an unselected optometric clinical population in the United States and Canada. METHODS: Self-administered dry eye questionnaires, one for non-contact lens wearers (dry eye questionnaire) and one for contact lens wearers (contact lens dry eye questionnaire), were completed at six clinical sites in North America. Both questionnaires included categoric scales to measure the prevalence, frequency, diurnal severity, and intrusiveness of nine ocular surface symptoms. The questionnaires also asked how much these ocular symptoms affected daily activities and contained questions about computer use, medications, and allergies. The examining doctors, who were masked to questionnaire responses, recorded a nondirected dry eye diagnosis for each patient, based on their own diagnostic criteria. RESULTS: The dry eye questionnaires were completed by 1,054 patients. The most common ocular symptom was discomfort, with 64% of non--contact lens wearers and 79% of contact lens wearers reporting the symptom at least infrequently. There was a diurnal increase in the intensity of many symptoms, with symptoms such as discomfort, dryness, and visual changes reported to be more intense in the evening. The 22% percent of non-contact lens wearers and 15% of contact lens wearers diagnosed with dry eye (most in the mild to moderate categories) reported symptoms at a greater frequency than those not diagnosed with dry eye. CONCLUSIONS: Our results show that symptoms of ocular irritation and visual disturbances were relatively common in this unselected clinical population. The intensity of many ocular symptoms increased late in the day, which suggested that environmental factors played a role in the etiology of the symptoms.

Optimal clinical management of eye problems: the role of optometrists in managed care plans.

BACKGROUND: Recent developments in the education and licensure of optometrists have created new opportunities for more-efficient provision of eye care. This study was conducted to determine the extent to which optometrists provided various kinds of eye care independently in managed care organizations. We compared optometric practices in health plans located in states in which the legal authority of optometrists was limited, to optometric practices in plans situated in states in which optometric licensure permitted broader prescribing authority. The volume and nature of referrals to ophthalmologists were assessed in relation to state law and organizational protocols. METHODS: A 15-item patient encounter form was developed and completed for all patients examined by the optometrists at each site during a 4-week period in 1998. Specific conditions were selected and criteria developed to help determine whether referrals to ophthalmologists were appropriate, or if they could have been managed by the optometrist These referrals were assessed by an independent panel of four optometrists. RESULTS: This study documented that optometrists provide a substantial range of eye care, and their individual scope of practice is influenced not only by legal boundaries, but also by financial and organizational factors found within managed care organizations. The pattern of referrals to ophthalmologists helped indicate the extent to which optometrists were underutilized or used appropriately in various settings. CONCLUSIONS: There is no single reliable predictor of whether optometrists will be used at the highest level of their abilities and scope of license. Although state licensure sets the overall parameters for care, optometric practice in managed care plans may be modified by internal protocols and organizational factors.

Optometry as practiced in health plans within different state jurisdictions.

This study was conducted to determine how managed care plans use optometrists to provide vision and eye care. The study documents the variety of optometric practice patterns found within six health plans in several states, each having different organizational characteristics, professional staffing patterns, and payment arrangements, and each regulated by dissimilar state licensure laws. A 15-item patient encounter form was developed and completed for all patients examined by the optometrists at each site during a four-week period. The instrument included information on patient demographics, medical/ocular history, reason for the visit, procedures performed, diagnosis, therapy provided, ocular medications prescribed, prognosis, disposition, referrals, and duration of the visit. A variety of patterns were found, some of which did not necessarily closely follow the legal boundaries of optometric care. This study documented that optometrists provide a substantial volume and range of vision care, and their scope of practice is influenced by legal, financial, and organizational factors. In some plans, optometrists' skills were underutilized relative to their legal authority in certain situations; in others, creative, cooperative arrangements extended the benefits of optometry beyond the existent practice laws. Licensure is certainly a major influence on the scope of practice of health providers. This study revealed, however, that licensure alone does not appear to be the only determinant of use, delegation, and division of labor among health professionals, and that organizational factors seem to play a very significant role.

Comparison of clinical techniques to assess the near accommodative response.

Assessment of the accommodative response (AR) is an essential part of the optometric examination. This study compared a number of clinical procedures for determining the AR with the findings of an objective infrared autorefractor. First, the AR to a 2.5 D binocular stimulus was measured by dynamic retinoscopy (neutralization being obtained both with lenses and by varying the working distance), dynamic cross-cylinder (with and without fogging lenses), and a near red-green duochrome test. Second, the response to a monocular 2.5 D stimulus was examined using dynamic retinoscopy (neutralizing with lenses), dynamic cross-cylinder, and the red-green duochrome. Third, the monocular AR was examined with both red-green and blue-yellow near duochrome tests. Under binocular conditions, the mean ARs for all the tests were clinically equivalent. However, comparison with the findings from the objective autorefractor indicated that dynamic retinoscopy (where neutralization was obtained by varying the working distance) showed the closest agreement, whereas the two dynamic cross-cylinder procedures exhibited the greatest variability. For the monocular condition, the mean lag of accommodation observed with the autorefractor was significantly less than that observed with dynamic retinoscopy, the dynamic cross-cylinder, or the red-green duochrome. However, the blue-yellow near duochrome test did not provide a valid estimation of the AR. It is concluded that the technique of dynamic retinoscopy where the working distance is varied to obtain a neutral reflex should be the method of choice for the clinical assessment of the AR, because this procedure does not require the introduction of supplementary lenses, which may themselves alter the AR.

Multi-meridional keratometry.

During conventional keratometry, the two principal meridia are identified and measurements of the anterior corneal curvature determined along these orientations. However, in cases of corneal irregularity, the principal meridia may be difficult to identify. Accordingly, the present study sought to evaluate two alternative procedures which do not require identification of the principal meridia. Instead, measurements of anterior corneal curvature were determined along either three or four preselected meridia and subsequently converted into the standard format for measurements of anterior corneal curvature. The study was performed on 25 visually normal subjects and the results compared with conventional two meridian keratometry findings. No significant differences were observed between the mean findings for the three and four meridian techniques. Furthermore, both procedures gave comparable results to the conventional two meridian method. Accordingly, multi-meridional keratometry may be valuable in cases of irregular astigmatism, for example produced by keratoconus or scarred corneas, since measurements can be obtained without the necessity for identification of the principal meridia.