Glaucoma Agreement in New Zealand (GAINZ).

CLINICAL RELEVANCE: With an ageing population, ophthalmologists are becoming burdened with glaucoma management, and patient care can be delayed. Therefore, the use of optometrists in glaucoma management can help alleviate the burden. BACKGROUND: The ageing population and subsequent rise of glaucoma prevalence are putting a strain on the public health system in New Zealand. Glaucoma collaborative care between optometrists and ophthalmologists has been gaining support with the aim to reduce this burden on ophthalmologists. There has been little investigation of the agreement in care and management of mild-to-moderate severity glaucoma patients by optometrists and ophthalmologists. METHODS: One hundred and three glaucomatous eyes were used in a survey where clinical history and examination, intraocular pressures (IOPs), visual field testing and optical coherence tomography (OCT) imaging were evaluated for glaucoma progression and decision-making regarding subsequent management by four participants. Two participants were glaucoma-credentialled optometrists (Group 1), and the other two were glaucoma specialists (Group 2). RESULTS: With respect to glaucoma progression, Spearman coefficients identified strong agreement between the two groups for IOP, visual fields and overall status and moderate agreement for OCT imaging. A confusion matrix was used to analyse management and found 80% ± 10% agreement between the two groups. Review periods gave an agreement of 55% ± 20% between the two groups. CONCLUSION: There was strong agreement in the assessment of glaucoma progression between the two groups. The 80% level of agreement for subsequent management between the two groups is comparable to other published reports. These results provide some reassurance that a collaborative care system can perform safely and as intended.

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.

An analysis of glaucoma repeat measures assessment results: Are core competencies enough?

PURPOSE: The need to validate core competency skills in qualified optometrists wishing to take part in extended roles in glaucoma care has been questioned. This analysis examines the ability of qualified optometrists to perform relevant core competency skills under standardised objective assessment conditions to explore whether such validation is justified. It also investigates if there are associations between performance, gender and length of time since qualification. METHODS: Anonymised data from the Cardiff University assessment programme for the Wales Optometry Postgraduate Education Centre (WOPEC) Local Optical Committee Support Unit glaucoma referral filtering and monitoring pathway delivered between January 2017 and March 2020 were analysed. Results were combined with demographic data from the General Optical Council register of optometrists in the UK to investigate associations between performance and practitioner characteristics, namely length of time since qualification and gender. RESULTS: The assessment results of 2215 optometrists practising in England (approximately 15% of all UK registered optometrists and 30% of all optometrists registered in England) were analysed. Failure rates for first time assessment in each of five objective structured clinical examination style practical assessments were 8.5% (van Herick); 8.8% (slit lamp binocular indirect ophthalmoscopy); 10.1% (Goldmann applanation tonometry calibration); 21.9% (Goldmann applanation tonometry) and 23.3% (case scenario interpretation and management). There were either no associations or at most very weak associations between performance and practitioner characteristics. CONCLUSIONS: Our results suggest that these competencies are not universally present in optometrists practising in England and that ongoing training and assessment of these competencies is justified for entry into extended roles. There are no meaningful associations between performance in these assessments and gender or time since qualification.

Point-of-care tools to support optometric care provision to people with age-related macular degeneration: A randomised, placebo-controlled trial.

PURPOSE: Age-related macular degeneration (AMD) is a leading cause of vision impairment. This randomised placebo-controlled trial investigated whether point-of-care tools can improve optometrists' AMD knowledge and/or care provision. METHODS: Australian optometrists (n = 31) completed a demographics survey and theoretical AMD case study multiple-choice questions (MCQs) to assess their confidence in AMD care provision and AMD knowledge. Participants were then randomly assigned to one of three point-of-care tools (online 'Classification of Age-related macular degeneration and Risk Assessment Tool' (CARAT), paper CARAT, or 'placebo') to use when providing care to their subsequent 5-10 AMD patients. Participants self-audited the compliance of their AMD care to best practice for these patients, and a similar number of consecutive patients seen prior to enrolment. Post-intervention, participants retook the AMD knowledge MCQs and confidence survey. RESULTS: A total of 29 participants completed the study. At the study endpoint, clinical confidence relative to baseline improved with the paper CARAT, relative to placebo, for knowledge of AMD risk factors, asking patients about these factors and referring for medical retinal sub-specialist care. There were no between-group differences for the change in AMD knowledge scores. Considering record documentation for patients with any AMD severity, there were no significant between-group differences for documenting patient risk factors, AMD severity, clinical examination techniques or management. In a sub-analysis, the change from baseline in compliance for documenting discussions about patient smoking behaviours for early AMD patients was higher with use of the online CARAT relative to placebo (p = 0.04). For patients with intermediate AMD, the change from baseline in documenting the risk of progression to late AMD was greater among practitioners who used the paper CARAT, relative to placebo (p = 0.04). CONCLUSIONS: This study demonstrates that point-of-care clinical tools can improve practitioner confidence and aspects of the documentation of AMD clinical care by optometrists as assessed by self-audit.

Scope of practice of optometrists working in the UK Hospital Eye Service: Second national survey.

PURPOSE: As the landscape in ophthalmology and related commissioning continues to change, there is a pressing need to re-evaluate the current scope of practice of hospital optometrists working within secondary care in the UK. We aim to establish if the skills or services delivered by optometrists have changed to meet varying demands, and to better understand what changes in practice may have arisen as a result of COVID-19. METHOD: A survey developed from that used in 2015 was disseminated to 129 optometry Hospital Eye Service (HES) leads in September 2020, including questions on department workforce; core services; extended roles; procedures undertaken within extended roles; level of autonomy; arrangements for prescribing; training and accreditation, and service changes in response to COVID-19. RESULTS: Ninety responses were received (70% response rate) from within England (76%), Scotland (22%) and Northern Ireland (2%). Whole time equivalents within units ranged from 0.4-79.2 (median of 2.5). In comparison to the 2015 survey, there was an increase in the proportion of units delivering extended roles, with glaucoma (88%) remaining the most common extended role, and new areas of practice in uveitis (21%) and vitreoretinal (13%) services. There was increased use of independent prescribing (67%) in comparison to 18% in 2015 and there was an increase in optometrists delivering laser interventions. In response to COVID-19, optometrists were increasingly delivering telephone consultations and there were new collaborations between primary and secondary care. CONCLUSIONS: Optometrists' scope of practice continues to develop in the HES with an increased variety of roles and an apparent increase in the number of units employing optometrists, often working in roles historically performed by medical practitioners. Such changes appear necessary in recovery and transformation within ophthalmology, alongside wider optometry changes arising at the interface of primary and secondary care.

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.

Interocular conflict from a monocular augmented reality display: Impact of visual characteristics on performance.

In monocular see-through augmented reality systems, each eye is stimulated differently by a monocular image that is superimposed on the binocular background. This can impair binocular fusion, due to interocular conflict. As a function of visual characteristics, the latter can have a greater or lesser impact on user comfort and performance. This study tested several visual characteristics of a binocular background and a monocular element during an exposure that reproduced the interocular conflict induced by a monocular see-through near-eye display. The aim was to identify which factors impact the user's performance. Performance was measured as target tracking and event detection, identification, fixation time, and latency. Our results demonstrate that performance is a function of the binocular background. Furthermore, exogenous attentional stimulation, in the form of a pulse with different levels of contrast applied to the monocular display, appears to preserve performance in most background conditions.

Measurement of visual acuity with a digital eye chart: optotypes, presentation modalities and repeatability

Purpose: Digital or computerised eye charts are becoming standard in the examination of visual acuity. Each instrument allows the selection of different optotypes, presentation modalities, and crowding. The aim of this study was to examine the differences in visual acuity (VA) measurement using a digital eye chart, comparing different optotypes and procedures, together with an evaluation of the repeatability of the measurement.MethodsTwo groups of 52 participants aged between 18 and 31 years participated in the study. In the first experiment, VA thresholds were measured using LEA Symbols, Tumbling E, and Landolt Rings in monocular and binocular conditions using single line presentation and QUEST presentation. In the second experiment, we have compared all modalities of presentation together with a paper eye-chart and test the repeatability.ResultsThe results showed that thresholds for LEA Symbols are low. The modality of presentation affects these thresholds. For Landolt Rings and Tumbling E, the QUEST procedure gave significantly better thresholds than line presentation, while this difference was absent for LEA Symbols. In comparing all modalities of presentation, single letter and line presentation showed similar values, slightly better than block presentation. Paper eye-charts showed better values of VA. Repeatability and agreement were good for all presentations, but best for QUEST.ConclusionsThe QUEST modality of presentation provides a better threshold than line presentation except for LEA Symbols. Examiners using digital eye charts must take into account that not all modalities of presentation and optotypes are equivalent and give different VA thresholds. Specific thresholds need to be used for each optotype and presentation modality. (AU)

Reducing the Global Burden of Myopia by Delaying the Onset of Myopia and Reducing Myopic Progression in Children: The Academy's Task Force on Myopia.

In 2019, the American Academy of Ophthalmology (AAO) created the Task Force on Myopia in recognition of the substantial global increases in myopia prevalence and its associated complications. The Task Force, led by Richard L. Abbott, MD, and Donald Tan, MD, comprised recognized experts in myopia prevention and treatment, public health experts from around the world, and organization representatives from the American Academy of Family Physicians, American Academy of Optometry, and American Academy of Pediatrics. The Academy's Board of Trustees believes that myopia is a high-priority cause of visual impairment, warranting a timely evaluation and synthesis of the scientific literature and formulation of an action plan to address the issue from different perspectives. This includes education of physicians and other health care providers, patients and their families, schools, and local and national public health agencies; defining health policies to ameliorate patients' access to appropriate therapy and to promote effective public health interventions; and fostering promising avenues of research.

Assessing the use of a smartphone app to teach eye screening to opticians.

INTRODUCTION: Torch-light Eye Screening Test (TEST) is a simple eye screening technique designed for use by opticians to look for common anterior segment eye conditions. The TEACHES-Learning Electronic Module (TEACHES-LEM) is an e-learning platform that was developed to teach opticians to perform TEST. The objective of this study was to compare the effectiveness of TEACHES-LEM with face-to-face training (F2FT) in the training and assessment of knowledge among opticians. METHODS: Participants were randomly assigned in this experimental study to receive either the intervention group ((TEACHES-LEM, n = 60) or the control group (F2FT, n = 57). The conceptual knowledge of TEST was assessed with a 20-item clinical scenario-based multiple choice question (MCQ) test before and after teaching (immediately post-teaching and 1-month post-teaching). The MCQ test was developed by three ophthalmologists to give face validity. RESULTS: The pre-teaching test scores (TS), indicating prior knowledge, were comparable in both groups (10.02 ± 2.79 versus 10.40 ± 4.17, p = 0.563, independent t test). The mean immediate post teaching score for TEACHES-LEM was 13.3 ± 4.01 versus 12.3 ± 3.29 in the F2FT group (p = 0.170, independent t test). The mean post 1-month teaching score for TEACHES-LEM and F2FT groups were also comparable, 14.5 ± 4.19 versus 13.4 ± 3.90 respectively (p = 0.295, independent t test), indicating non-inferiority of TEACHES to F2FT. CONCLUSION: The TEACHES-LEM e-learning tool is as effective as F2FT in teaching opticians to perform TEST. It is an alternative to face-to-face teaching in delivering knowledge and assessment. The obviation for physical contact will make it a useful teaching tool during the COVID-19 pandemic period.

Routine slit lamp examination procedures: A risk for severe acute respiratory syndrome coronavirus 2 infection to eye care professionals.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a highly infectious coronavirus, has been rapidly spreading after its surge in China in December 2019. It is currently a global pandemic. A myriad of transmission routes have been documented, however established thus far, are respiratory droplet, contact and airborne transmissions. Susceptible persons at proximity, usually within 1-2 m, to infected persons are largely at risk of being infected. Unfortunately, health workers usually evaluate patients within this distance. Eye care professionals (ECPs) are faced with a higher risk scenario of being infected as they undertake routine clinical eye examination procedures at a close face-to-face proximity to patients, which place them at a high risk of respiratory droplets and aerosolised particles, particularly from asymptomatic and pre-symptomatic carriers. The slit lamp examination procedure is typically at a distance of between 0.25 m and 0.5 m. While undertaking certain procedures on the slit lamp, such as gonioscopy and slit lamp indirect ophthalmoscopy, the ECP holds the accessory lenses either directly on the patient's eye or at about 5-10 cm from the patient's face, respectively. The authors found it pertinent to articulate this narrative review article to guide slit lamp examination practice by ECPs during routine ophthalmic evaluation, with a view to reducing the spread of SARS-CoV-2 to ECPs. In conclusion, ECPs are at increased risk of infection due to high-risk scenarios for routine slit lamp examination procedures of the eye. Adherence to standard precautionary measures with slit lamp use is highly recommended.

Assesment of the QuickSee wavefront autorefractor for characterizing refractive errors in school-age children.

PURPOSE: To assess the performance of an open-view binocular handheld aberrometer (QuickSee) for diagnosing refractive errors in children. METHODS: 123 school-age children (9.9 ± 3.3 years) with moderate refractive error underwent autorefraction (AR) with a standard desktop device and subjective refraction (SR), with or without cycloplegia to determine their eyeglass prescription. Measurements with QuickSee (QS) were taken in 62 of these patients without cycloplegia (NC), and in 61 under cycloplegia (C). Differences in refraction values (AR vs SR vs QS) as well as the visual acuity (VA) achieved by the patients with each method (QS vs SR) were used to evaluate the performance of the device in measuring refractive error. RESULTS: The spherical equivalent refraction obtained by QS agreed within 0.5 D of the SR in 71% (NC) and 70% (C) of the cases. Agreement between the desktop autorefractor and SR for the same threshold was of 61% (NC) and 77% (C). VA resulting from QS refractions was equal to or better than that achieved by SR procedure in 77% (NC) and 74% (C) of the patients. Average improvement in VA with the QS refractions was of 8.6 and 13.4 optotypes for the NC and C groups respectively, while the SR procedure provided average improvements of 8.9 (NC) and 14.8 (C) optotypes. CONCLUSIONS: The high level of agreement between QuickSee and subjective refraction together with the VA improvement achieved in both study groups using QuickSee refractions suggest that the device is a useful autorefraction tool for school-age children.

Validation of the Clouclip and utility in measuring viewing distance in adults.

PURPOSE: To validate the Clouclip, a continuously measuring objective rangefinder, and examine viewing behaviours during various near tasks in non-myopic and myopic adults. METHODS: In experiment 1, five Clouclip devices were utilised. An infrared camera was used to visualise and measure infrared beam size and angle. Repeatability for distance tracking was assessed from 5 to 120 cm in 5 cm increments. Accuracy of distance tracking was investigated for paper and iPad targets, spatial integration was calculated, effects of target tilt were determined and light measurements were compared to a lux meter. In experiment 2, viewing behaviour was assessed in 41 subjects (21 non-myopic, 20 myopic) during four 15-min near tasks; (1) passive reading of printed material, (2) active writing on printed material, (3) passive viewing on an electronic device and (4) active engagement on an electronic device. Working distance was compared between tasks and refractive error groups. RESULTS: Clouclip distance tracking showed good repeatability, with a mean difference of 0.34 cm and limits of agreement of ±2.0 cm. Clouclip-measured and actual distances were highly correlated for paper and electronic targets from 5 to 120 cm, with mean differences and limits of agreement of 3.96 ± 13.78 cm and 4.48 ± 8.92 cm, respectively; variability increased for distances >100 cm. Tracking ability increased with larger target sizes; tracking was accurate when the target occupied 1.5%-20.3% of tracking beam area, depending on distance and with target tilt up to ±60 degrees. Clouclip- and lux meter-measured ambient illumination were highly correlated for a wide range of intensities (r = 0.96, p < 0.001), but with greater variability for intensities >20 000 lux. The Clouclip infrared beam was measured to have a diameter of 25.6 ± 2.2° and a downward angle of 10.3 ± 0.5°. For subject testing, viewing distance was significantly closer for active and passive printed tasks (29.5 ± 6.7 cm and 33.2 ± 8.8 cm, respectively) than for active and passive electronic tasks (35.4 ± 8.0 cm and 40.8 ± 10.4 cm, respectively), with no differences between refractive error groups (p = 0.88). CONCLUSIONS: The Clouclip performed well in measuring near and intermediate distances and could distinguish between indoor (<1000 lux) and outdoor (>1000 lux) illumination. A closer working distance was observed for printed tasks compared to those on an iPad, with no difference in viewing distance between non-myopic and myopic adults.

Gamification, serious games and action video games in optometry practice / Gamificación, juegos serios y videojuegos de acción en la práctica optométrica

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Delisted routine eye examinations for nonrefractive eye conditions: a comparative analysis.

BACKGROUND: In 2004, Ontario delisted routine eye examinations for people aged 20-64 years, potentially encouraging patients seeking eye care to visit government-insured primary care providers (PCPs) rather than optometrists whose services had been deinsured. We investigated if utilization of PCP services for nonrefractive eye conditions increased after 2004 among Ontarians who were affected by the delisting. METHODS: We conducted a comparative analysis of the utilization of PCP services for nonrefractive eye conditions in Ontario using administrative data from 2000 to 2014. We included participants without a visit to government-insured optometrists or ophthalmologists in the year before the study year; we excluded participants with existing diabetes. Changes in utilization before and after delisting were statistically assessed using segmented regression analysis in subgroups stratified by age, sex, rurality and neighbourhood income. RESULTS: A significant increase in utilization of PCP services for nonrefractive ocular diagnoses after 2004 was documented among people affected by the delisting: 17.8% (95% confidence interval [CI] 17.0% to 18.7%) for people aged 20-39 years and 11.6% (95% CI 10.6% to 12.5%) for people aged 40-64 years. This corresponds to an increase in the number of patients who visited PCPs for nonrefractive ocular diagnoses of 10 690 (95% CI 321 to 21 059) for people aged 20-39 years and 20 682 (95% CI -94 to 41 457) for people aged 40-64 years. Among people aged 65 years and older (an age group not affected by the delisting), utilization of PCP services for nonrefractive ocular diagnoses was stable (p = 0.95) throughout the study period. Changes in utilization of PCP services for nonocular diagnoses were nonsignificant among people aged 0-19, 40-64 and 65 years and older. INTERPRETATION: After delisting, utilization of the services of government-funded PCPs for nonrefractive ocular diagnoses significantly increased among Ontarians affected by the delisting. The impact on ocular outcomes and the cost-effectiveness of increased use of PCPs for ocular management warrants further investigation and policy-makers' consideration.