A prospective study on effectiveness of elevated intraocular pressure as a criterion for glaucoma referrals by optometric practitioners in Sweden.

PURPOSE: To evaluate the outcome of referrals for suspected glaucoma based on elevated intraocular pressure (IOP) made by optometric practitioners in Sweden. METHODS: This prospective study included 95 individuals referred to the Skåne University Hospital Malmö, Sweden, during 2019, by optometric practitioners, based on elevated IOP. Positive outcome was defined as a diagnosis of glaucoma, or a diagnosis of suspected glaucoma. Referral accuracy was analysed. Positive predictive values (PPV) of different hypothetical IOP and age thresholds were calculated. RESULTS: In 34% (95% CI: 24-43%) of the referrals, no eye disease was found. Intraocular pressure (IOP) was the only referral criterion in 77% (73/95). The PPV was 35% (95% CI: 25-45%) for all referrals, 27% (95% CI: 16-38%) for IOP-only referrals and 59% (95% CI: 36-82%) for referrals including additional findings. In IOP-only referrals, no definite diagnosis of glaucoma was made in any patients <45 years of age. Applying a theoretical age limit of ≥45 years with a hypothetical IOP limit of ≥25 mmHg in patients 45-69 years and of ≥22 mmHg in patients ≥70 years increased the PPV to 42% (95% CI: 27-57%). IOP-only referrals would have been reduced by 27% without missing any glaucoma cases. CONCLUSION: The overall predictive value of the referrals was poor. Glaucoma resources would have been used more effectively by increasing the required age for IOP-only referrals to ≥45 years in combination with different IOP thresholds for certain age groups.

Quality of 2019 American optometric association clinical practice guideline for diabetic eye care.

PURPOSE: The 2019 American Optometric Association (AOA) clinical practice guideline intends to assist optometrists in providing evidence-based eye care for people with diabetes. This technical report evaluated the methodological and reporting quality of the guideline. METHODS: Four independent reviewers appraised the 2014 and 2019 versions of the AOA's guideline using the AGREE II instrument. Average scaled scores across the six domains of the AGREE II and an overall independent score were calculated based on the formula provided. RESULTS: The 2019 guideline scored high (range: 75-93%) in all domains except for the domain of applicability (34%). In the domain of rigour of development, significant improvements were noted in the 2019 guideline (median score: 7.0, interquartile range (IQR): 6.0-7.0) compared to the 2014 guideline (median: 5.0, IQR: 4.0-6.0) (p < 0.0001). The appraisal of the guideline also identified room for further improvements, especially in relation to implementing the guideline. CONCLUSION: The overall and domain specific quality of the AOA 2019 guideline was high, however, improvement in its applicability domain is required. The findings of this study will aid uptake of the guideline and inform improvement efforts for other international optometric guidelines.

Clinical audit as an educative tool for optometrists: an intervention study in age-related macular degeneration.

PURPOSE: Age-related macular degeneration (AMD) is a major cause of vision loss. This study investigated whether performing clinical audit and receiving analytical performance feedback altered documentation of the AMD care provided by optometrists. METHODS: Australian optometrists were recruited and completed a survey about their demographics and confidence in AMD care, and a three-month audit of their practice records using an AMD audit tool (termed the pre-audit evaluation). After receiving analytical feedback, participants identified areas for improvement and re-audited their practices after three months to analyse changes in performance (termed the post-audit evaluation). Paired t-tests and Wilcoxon signed-rank tests, as appropriate, were used to compare pre- and post-audit data. RESULTS: Twenty optometrists, most practising in Victoria, Australia, completed the study. Participants primarily worked in corporate practice and/or rural settings and had a range of optometric experience (2-40 years). At baseline, participants felt confident in their: knowledge of AMD risk factors (65%), advice to patients about these factors (55%) and management of earlier stages of AMD (55%). Each clinician completed (median [IQR]): 15 [IQR: 10-19] and 12 [IQR: 8-16] audits of unique patient records, pre- and post-audit, respectively. Post-audit, average record documentation (per optometrist) improved for asking about: AMD family history (94% to 100%, p = 0.03), smoking status (21% to 58%, p < 0.01), diet (11% to 29%, p < 0.01) and nutritional supplementation (20% to 51%, p < 0.01). For clinical examination, compliance with documenting pinhole visual acuity, performing an in-office Amsler grid (upon indication) and using optical coherence tomography improved post-audit (p < 0.05). Accuracy of severity documentation improved for earlier stages of AMD (p < 0.05). For earlier stages of AMD, documentation of counselling about modifiable risk factors significantly improved post-audit (p < 0.05). Aspects well-performed pre-audit that did not change included documenting: medical histories (100% at both time points, p = 0.06) and retinal imaging (77% at both time points, p = 0.97). CONCLUSIONS: Self-audit with analytical feedback improved clinical record documentation of: AMD risk factors, clinical examination, AMD severity classification and management advice. These findings support a role for audit to improve optometric clinical care of AMD, as evidenced by improved documentation of the AMD care delivered.

The role of the disc damage likelihood scale in glaucoma detection by community optometrists.

PURPOSE: Recent guidelines recommend disc damage likelihood scale (DDLS) is recorded for all referrals of suspected glaucoma from community optometrists to hospital eye services (HES) in Scotland. This study aimed to determine whether lower DDLS grades were associated with higher rates of discharge at the first visit to HES. METHODS: A retrospective analysis of 618 consecutive new referrals from community optometrists to a university hospital glaucoma service. 65 (10.5%) included DDLS graded by the community optometrist. A comprehensive eye examination and optical coherence tomography (OCT) was performed in the hospital glaucoma clinic and first visit discharge rate (FVDR) for different grades of DDLS compared. The relationship between DDLS and retinal nerve fibre layer (RNFL) thickness on OCT was also examined. RESULTS: The FVDR for patients with DDLS recorded in the referral was 27.7% (18 of 65) compared to 25% (138 of 553) in those without DDLS (p = 0.631). The FVDR was 50% for those with a DDLS of 3 in the worse eye, decreasing to 32% and 21% for DDLS grades of 4 and 5 respectively. No patient with a DDLS ≥ 6 was discharged at the first visit and none with a DDLS < 4 (the cut off for consideration of referral in Scottish guidelines) were found to have glaucoma. There was a significant but weak inverse relationship between DDLS and RNFL thickness. The strongest relationship was with average RNFL thickness (r = -0.378, p < 0.01) followed by superotemporal (r = -0.359, p < 0.01) and inferotemporal (r = -0.353, p < 0.01) RNFL thickness. CONCLUSIONS: In patients referred to HES with DDLS information included, lower DDLS grading was associated with higher odds of being discharged at the first visit. DDLS grading by community optometrists had a poor correlation with RNFL thickness measured using OCT.

Competencies and training needs of the Portuguese optometrists - a national inquiry.

PURPOSE: The World Health Organization places the Optometrist as the primary eye care provider, clearly defining its competencies and scope of practice. In Portugal, there are no studies about Optometrists professional competencies and the profession remains unregulated. The aim of this study was to describe the Portuguese optometrists' professional competencies model and to identify possible training needs felt. METHODS: A questionnaire survey was carried out, with the Portuguese optometric population as target group, ascertaining the level of academic qualifications, the clinical procedures most frequently performed, the training needs felt and the confidence levels in the performance of certain procedures. RESULTS: The 444 validated surveys represent 28.41% of the study population, making it a representative sample. The validated sample had 78.8% of Graduates, 20.5% of Masters and 0.7% of PhDs in Optometry. CONCLUSIONS: The results of this study allowed us to conclude that the competences most frequently performed by Portuguese optometrists are a very reductive view of the internationally stipulated, based on Refraction, Basic Ocular Health Assessment, Contactology and Paediatric Optometry in School Age (>6 years old). The most important training needs occur at the level of Applied Ocular Pharmacology, Prismatic Prescription, Optometry in Special Needs Populations, Contactology in Special Cases, Low Vision and Clinical/Hospital Internship. Professional experience of 10 years or more and Master's/PhD qualifications give rise to more skills, higher levels of confidence and lower training needs. Higher frequency of execution of certain procedures translates into high levels of confidence and less training needs in the area.

Knowledge, perspectives and clinical practices of Australian optometrists in relation to childhood myopia.

BACKGROUND: The aim was to investigate the understanding of Australian optometrists in relation to myopia, its natural history and associations with vision-threatening ocular disease, self-reported clinical diagnosis and management approaches for childhood myopia, engagement with adult caregivers, and utilisation of information to guide practice. METHODS: An online survey was distributed to Australian optometrists (n = 4,124). Respondents provided information about their demographics (for example, gender, age, practice location and modality), myopia knowledge, self-reported practice behaviours relating to childhood myopia, the information and evidence base used to guide their practice, and perceived extent of adult caregiver engagement in making management decisions for myopic children. RESULTS: Completed surveys were returned by 239 optometrists (six per cent completed response rate). Most respondents demonstrated knowledge of the association between high myopia and retinal breaks, retinal detachment and primary open-angle glaucoma. Optometrists used a range of techniques to diagnose childhood myopia, with a preference for non-cycloplegic refractive measures. The most common approaches to management were single-vision distance and progressive addition spectacle lenses, despite most optometrists identifying orthokeratology, low-dose (0.01%) topical atropine and soft peripheral defocus contact lenses as three potentially more effective therapeutic interventions for modifying childhood myopia progression. Almost 90 per cent of respondents considered increasing time spent outdoors to be beneficial for reducing the rate of myopia progression. The main sources of information used to guide clinical practice were continuing education conferences and events, systematic reviews, and personal experience. Respondents perceived adult caregivers to generally be involved in myopia management decisions, and considered all aspects of myopia education as important. CONCLUSION: Current optometric practices reflect the inconclusive nature of several key aspects of the evidence for childhood myopia management. Australian optometrists appear aware of emerging evidence, but are not routinely adopting measures that have not yet received regulatory approval for modulating childhood myopia progression. Clinical guidelines may be of value for assisting practitioners in making clinical decisions based upon the current, best-available research evidence.

Standardising the cataract referral process for public hospitals: perspectives of optometrists in New South Wales, Australia.

BACKGROUND: Previous research has shown that cataract surgery referral letters to major metropolitan public hospitals in New South Wales have insufficient detail to inform patient triage or apply prioritisation tools. This study aimed to canvass the views of optometrists working in New South Wales and the Australian Capital Territory (NSW/ACT) on standardising the referral process for public hospital cataract surgery. METHODS: An online survey was sent to all NSW/ACT members of Optometry Australia in October 2017. Respondents were asked to select clinical and personal information to be included on a referral template using a list of 25 items. Data were also gathered on preferences for the cataract referral process and sources of cataract referral guidelines. RESULTS: Two hundred and thirteen (response rate 13 per cent) optometrists completed the survey. There was close to universal support for inclusion of items like visual acuity (99 per cent), whereas other items had low support, including the date and details of previous refraction (26 per cent), history of falls (29 per cent) and health insurance status (29 per cent). Three-quarters of optometrists stated they would be willing to administer and report data from a patient survey about the functional impact of their cataract and level of visual disability. The preferred format of a standardised cataract referral template varied, although time efficiency and ease of completion were commonly cited reasons for preferences. Confirmation of receipt of referral from the public hospital, and a copy of the referral letter for the optometrist's records were also desirable. For the 61 per cent of respondents who reported accessing guidelines for cataract referral, 69 per cent stated the main source was Optometry NSW/ACT with fewer accessing guidelines directly from a public hospital or the NSW Health website. CONCLUSION: Optometrists' preferences will be useful to inform the design and implementation of a standardised cataract referral template.

Accuracy of diagnosis of pterygium by optometrists and general practitioners in Australia.

BACKGROUND: It was the author's (LWH) observation that pterygium was frequently misdiagnosed by general practitioners that led to this study. The aim was to identify the rate of misdiagnosis of pterygium by optometrists and general practitioners based upon assessing referral accuracy to a single ophthalmologist (LWH). METHODS: This study involved a prospective case series from 25 March 2015 to 18 December 2018 in a tertiary referral practice specialising in pterygium. The accuracy of diagnosis of pterygium, based upon the content of the clinical referral, was undertaken for optometrists and general practitioners. The benchmark for diagnostic accuracy was the diagnosis made by the author (LWH) during a consultation in person by the author (LWH) using a hand-light examination and confirmed by slitlamp examination. RESULTS: A total of 1,511 consecutive patients were included in the study with 90/549 incorrectly diagnosed (16 per cent) by general practitioners and 14/962 (1.4 per cent) by optometrists. General practitioners were 13.28 times more likely to incorrectly diagnose a pterygium than optometrists (95% CI 7.48-23.57). Almost exclusively, the incorrect diagnosis made by general practitioners was naming a pinguecula, a pterygium. The same misdiagnosis was made by optometrists but far less frequently. CONCLUSION: General practitioners misdiagnosed pterygium far more often than optometrists which may reflect a reduction in training in eye health.

An Eye Tracking Analysis on Diagnostic Performance of Digital Fundus Photography Images between Ophthalmologists and Optometrists.

To investigate the parameters of eye movement between ophthalmologists and optometrists while diagnosing digital fundus photographs, sixteen participants (eight ophthalmologists and eight optometrists) were recruited in this study. Every participant's eye movement during diagnosis of a randomized set of fundus photographs displayed on an eye tracker were recorded. Fixation metrics (duration, count and rate) and scan path patterns were extracted from the eye tracker. These parameters of eye movement and correct diagnosis score were compared between both groups. Correlation analyses between fixation metrics and correct diagnosis score were also performed. Although fixation metrics between ophthalmologists and optometrists were not statistically different (p > 0.05), these parameters were statistically different when compared between different area of interests. Both participant groups had a similar correct diagnosis score. No correlation was found between fixation metrics and correct diagnosis score between both groups, except for total fixation duration and ophthalmologists' diagnosis score of diabetic retinopathy photographs. The ophthalmologists' scan paths were simpler, with larger saccades, and were distributed at the middle region of the photographs. Conversely, optometrists' scan paths were extensive, with shorter saccades covering wider fundus areas, and were accumulated in some unrelated fundus areas. These findings indicated comparable efficiency and systematic visual search patterns between both the groups. Understanding visual search strategy could expedite the creation of a novel training routine for interpretation of ophthalmic diagnostic imaging.

Anterior Chamber Angle Evaluation Using Gonioscopy: Consistency and Agreement between Optometrists and Ophthalmologists.

SIGNIFICANCE: In our intermediate-tier glaucoma care clinic, we demonstrate fair to moderate agreement in gonioscopy examination between optometrists and ophthalmologists, but excellent agreement when considering open versus closed angles. We highlight the need for increased consistency in the evaluation and recording of angle status using gonioscopy. PURPOSE: The consistency of gonioscopy results obtained by different clinicians is not known but is important in moving toward practice modalities such as telemedicine and collaborative care clinics. The purpose of this study was to evaluate the description and concordance of gonioscopy results among different practitioners. METHODS: The medical records of 101 patients seen within a collaborative care glaucoma clinic who had undergone gonioscopic assessment by two clinicians (one optometrist and either one general ophthalmologist [n = 50] or one glaucoma specialist [n = 51]) were reviewed. The gonioscopy records were evaluated for their descriptions of deepest structure seen, trabecular pigmentation, iris configuration, and other features. These were compared between clinicians (optometrist vs. ophthalmologist) and against the final diagnosis. RESULTS: Overall, 51.9 and 59.8% of angles were graded identically in terms of deepest visible structure when comparing between optometrist versus general ophthalmologist and optometrist versus glaucoma specialist, respectively. The concordance increased when considering ±1 of the grade (67.4 and 78.5%, respectively), and agreement with the final diagnosis was high (>90%). Variations in angle grading other than naming structures were observed (2.0, 30, and 3.9% for optometrist, general ophthalmologist, and glaucoma specialist, respectively). Most of the time, trabecular pigmentation or iris configuration was not described. CONCLUSIONS: Fair to moderate concordance in gonioscopy was achieved between optometrists and ophthalmologists in a collaborative care clinic in which there is consistent feedback and clinical review. To move toward unified medical records and a telemedicine model, improved consistency of record keeping and angle description is required.

Interventions to Mitigate Cognitive Biases in the Decision Making of Eye Care Professionals: A Systematic Review.

SIGNIFICANCE: Cognitive biases, systematic errors in thinking that impact a person's choices and judgments, can influence decision making at various points during patient care provision. These biases can potentially result in misdiagnoses, delayed clinical care, and/or patient mismanagement. A range of interventions exists to mitigate cognitive biases. There is a need to understand the relative efficacy of these interventions within the context of eye care practice. PURPOSE: The aim of this systematic review was to synthesize the evidence relating to interventions for mitigating cognitive biases associated with clinical decision making by eye care professionals. DATA SOURCES: Electronic databases (including Ovid MEDLINE, Embase, Scopus, PsycINFO) were searched from inception to October 2017 for studies investigating interventions intended to mitigate cognitive biases in the clinical decision making of eye care professionals. This review was undertaken in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guidelines. STUDY ELIGIBILITY CRITERIA: To ensure inclusion of all relevant literature, a wide range of study designs was eligible for inclusion, such as randomized controlled trials, nonrandomized trials, interrupted time series and repeated measures, controlled before-after studies, and qualitative studies that were a component of any of these quantitative study designs. STUDY APPRAISAL AND SYNTHESIS METHODS: Two review authors independently screened titles, abstracts, and full-text articles in duplicate, applying a priori eligibility criteria. RESULTS: After screening 2759 nonduplicate records, including full-text screening of 201 articles, no relevant studies were identified. CONCLUSIONS AND IMPLICATIONS OF FINDINGS: Given that cognitive biases can significantly impact the accuracy of clinical decision making and thus can have major effects on clinical care and patient health outcomes, the lack of studies identified in this systematic review indicates a critical need for research within the area of cognitive bias mitigation for decision making within eye care practice.

Treatment decisions of UK hospital optometrists and ophthalmologists in patients with nAMD: a vignette study.

PURPOSE: A vignette study to examine treatment decisions made by UK hospital optometrists in patients with neovascular age-related macular degeneration (nAMD) and the effect of optometrists' experience on agreement. METHODS: Patients with nAMD attending Manchester Royal Eye Hospital, Manchester, UK were identified as potential candidates for the case series of vignettes. The cases were chosen to reflect a varied case-mix with respect to difficulty as well as ensuring good quality of the images. Each vignette included a history summary consisting of the number of previous injections given and visual acuity measurements at baseline, the previous visit, and the current visit. Images were compiled to show baseline fundus photographs and ocular coherence tomography (OCT) images with the current visit images on which the treatment decision was to be made along with the images from the previous visit. Hospital optometrists were recruited and asked to complete the series of vignettes, deciding if treatment was required at that visit and how confident they felt with that decision. Their responses were compared to the reference standard created by a consensus of consultant ophthalmologists with a sub-speciality interest in medical retina. RESULTS: Regarding treatment decision for optometrists, the percentage correct value was 75% with the sensitivity being 75.6% (95% CI 70.1-80.3) and the specificity as 75.1% (95% CI 72.1-77.8). No statistically significant difference was found between differing levels of experience. However, there was a significant difference in confidence levels between groups. Potentially sight threatening decisions accounted for 6.4% of the optometrists' decisions, 3.5% were made with a high confidence rating suggesting no discussion with an ophthalmologist was required. CONCLUSIONS: Although the optometrists showed modest agreement with the reference standard in a series of cases that have higher than average complexity, the optometrists showed a similar amount of variability within their treatment decisions compared to the reference standard. The optometrists were therefore not inferior in their performance compared to the ophthalmologists and this can be seen as supporting evidence for their extended role within this clinical area. Experience did not have an effect on 'correct' treatment decisions although there was a statistically significant effect on increasing confidence of treatment decision.

Terapia visual: ¿En qué consiste y cuándo indicarla? / Vision therapy: what is it and when should it be indicated?

RESUMEN La terapia visual es un programa de ejercicios visuales personalizados, donde se realiza una estimulación neurofisiológica que nos permite desarrollar, mejorar e integrar las capacidades visuales. Esta serie de actividades específicas están pensadas para corregir problemas de visión. La terapia visual tiene como fin obtener una visión simple, nítida, confortable y eficaz. En la sociedad actual de la información y del conocimiento, donde hay un uso excesivo de la visión de cerca que provoca síntomas oculares como consecuencia del estrés visual, esta es una opción terapéutica a tener presente en sus diferentes variantes(AU)

ABSTRACT Vision therapy is a program of personalized visual exercises by which neurophysiological stimulation is provided to develop, improve and integrate visual capacities. It consists of a series of specific activities designed to correct vision problems. The purpose of vision therapy is to obtain single, neat, comfortable and efficient vision. In today's information and knowledge society, characterized by excessive use of near vision, leading to ocular symptoms resulting from visual stress, this is a therapy option to be taken into account in its various forms(AU)

Is there scope for expanding the optometrist's scope of practice in Singapore? - A survey of optometrists, opticians in Singapore.

PURPOSE: In Singapore, optometrists' roles are limited compared to their counterparts elsewhere. The purpose of the survey is to investigate optometrists' current roles, views on extended roles, self-reported primary eye care knowledge, needs for continuing professional education (CPE) and views on suitable modes for CPE. METHODS: Members of the Optometrist and Optician Board (OOB) were invited via email to take part in an anonymous online survey. The survey questions covered the following areas: current scope of practice, self-rated primary eye care knowledge, confidence in screening, co-managing minor eye conditions, CPE and referral behavior. RESULTS: A total of 230 optometrists completed the survey (response rate 30%). Their current roles were limited to diagnostic refraction (92%), colour vision assessment (65%), contact lens fitting and dispensing (62%) amongst others. The average self-rated score for primary eye care knowledge was 8.2 ± 1.4; score range 1-10 (1-Very poor, 10-Excellent). Self-rated confidence scores for screening for cataract, diabetic retinopathy, chronic glaucoma and age-related macular degeneration were 2.7 ± 1.5, 3.7 ± 1.9, 4.0 ± 1.9 and 3.8 ± 1.8, respectively. 71% of the optometrists felt that they should undertake regular CPE to improve their primary eye care knowledge. Blended learning (eLearning and traditional face-to-face lectures) (46.1%) was the most preferred mode for CPE delivery. CONCLUSION: Optometrists in Singapore represent a skilled underutilized primary eye care provider. Though their self-reported primary eye care knowledge is high, their confidence in screening and co-managing chronic eye conditions is low. Enabling them for extended primary eye care role would require further training. SIGNIFICANCE: Singapore ageing population has led to greater eye care demands. Task-shifting from ophthalmologists to optometrists has been proposed in the literature to handle this growing care demands. At this juncture, this study provides evidence based answers to issues revolving around optometrists' readiness for a role expansion in Singapore.

Accuracy of detection of patients with narrow angles by community optometrists in Scotland.

AIM: To examine the accuracy of referrals by community optometrists for suspected primary angle closure, including primary angle closure suspects, primary angle closure and primary angle closure glaucoma. METHODS: A retrospective review of 769 consecutive patients referred by community optometrists to the glaucoma clinic at a university hospital in Scotland. Ninety-five of 715 eligible subjects (13%) were referred due to suspected angle closure. All subjects had a comprehensive eye examination in the glaucoma clinic, including gonioscopy, with angle closure defined according to the International Society of Geographical and Epidemiological Ophthalmology classification as iridotrabecular contact over at least 270 degrees. RESULTS: Fifty-nine of 95 subjects referred due to suspected angle closure were confirmed to have an occludable angle, while 36 of 95 (38%) had open angles (positive predictive value = 62%). Of 620 patients referred to the glaucoma clinic for reasons other than narrow angles, 601 (97%) had open angles on gonioscopy and 19 (3%) had narrow angles. Using the 620 patients referred with 'open angles' as a control group, sensitivity was estimated as 76% and specificity 94%. Eleven of 95 (12%) patients referred for possible angle closure were discharged at the first visit compared to 156 of 620 (25%) referred to the glaucoma clinic for other reasons (p = 0.003). In a multivariable model, suspect angle closure detected by the optometrist (OR = 56.0, 95% CI 35.2-89.2, p < 0.001) and female gender (OR = 1.9, 95% CI 1.2-3.1, p = 0.008) were associated with increased odds of angle closure on gonioscopy. CONCLUSION: Community optometrists had good ability to detect eyes at risk of angle closure. There was also greater accuracy of referrals for suspected angle closure than for other glaucoma referrals.

Ophthalmologist and Optometrist Glaucoma Prescribing Patterns Based on 2015 Medicare Part D Data.

PURPOSE: To determine differences in prescribing patterns of glaucoma drugs between ophthalmologists and optometrists in terms of (1) the proportions of generics prescribed when brand-name drugs were also available, (2) the relative proportions of drugs prescribed within a drug class, and (3) the relative frequency of all glaucoma drugs prescribed. DESIGN: Cross-sectional study. PARTICIPANTS: All ophthalmologists and optometrists in the United States who prescribed any of the 36 drugs studied through Medicare Part D in 2015. METHODS: Outcome measures were calculated using Excel 2016 (Microsoft, Redmond, WA) based on the 2015 Medicare Part D Prescriber data. The total number of drug claims for 36 glaucoma drugs by all ophthalmologists and optometrists through Medicare Part D in 2015 was determined. These data were then used to calculate, for each drug class, the relative proportions of each drug prescribed by ophthalmologists and optometrists in addition to the proportion of claims that were for the generic drug when at least 1 brand-name alternative was available for both professions. RESULTS: The difference between ophthalmologists' and optometrists' proportions of claims that were for generics when at least 1 brand-name drug was available was generally less than 1%, with both professions' patients receiving primarily generic drugs. However, patients of both ophthalmologists and optometrists use relatively low proportions of generic betaxolol, brimonidine, travoprost, and bimatoprost (approximately 46%, 58%, 1%, and 0% of claims were for these generics, respectively, when compared with brand-name drugs for both ophthalmologists and optometrists). Within each drug class, ophthalmologists and optometrists generally chose the same drug. Overall, ophthalmologists prescribed a wider range of drugs, but both ophthalmologists and optometrists prescribed latanoprost most often. CONCLUSIONS: Ophthalmologists and optometrists exhibit similar clinical judgement when choosing a particular drug within a drug class. However, ophthalmologists tend to prescribe more drugs from a wider range of drug classes. Both ophthalmologists and optometrists could prescribe more generic betaxolol, brimonidine, travoprost, and bimatoprost, though generic bimatoprost only became available in 2015.

The impact of SIGN glaucoma guidelines on false-positive referrals from community optometrists in Central Scotland.

BACKGROUND: Since the introduction of National Institute for Health and Care Excellence glaucoma guidelines 2009, the number of referrals from community optometrists to hospital eye services has increased across the UK, resulting in increase in first visit discharge rates (FVDRs). AIM: To assess the impact of Scottish Intercollegiate Guidelines Network (SIGN) 144 on quality of referrals from community optometrists. METHODOLOGY: A retrospective study of patient records who attended as new adult glaucoma referrals to clinics in Princess Alexandra Eye Pavilion, Edinburgh, and in Greater Glasgow and Clyde, was carried out across October-November 2014 (group 1) and September-October 2016 (group 2), before and after the introduction of SIGN 144. The primary outcome of this study is FVDRs. A secondary outcome is the extent of compliance to referral recommendations by SIGN guidelines. RESULTS: Three hundred and twelve and 325 patients were included in groups 1 and 2, respectively. There was a significant decline in FVDRs between these two periods from 29.2% to 19.2%. (p=0.004) (OR 0.58 (95%CI 0.40 to 0.84)). Post-SIGN guidelines, 87% of referrals were compliant to SIGN referral criteria while 13% remained non-compliant. The main reasons for non-compliance were no repeatable visual field defects (42.0%) and referrals due to high intraocular pressure were either not repeated or not interpreted in the context of age and central corneal thickness (36.8%). CONCLUSION: Patients referred after the introduction of SIGN guidelines were 33.5% less likely to be discharged at the first visit. Although compliance to most recommendations in SIGN guidelines has improved, there is still a need to improve adherence to referral criteria.

Glaucoma management in primary care: barriers perceived by optometrists in Scotland.

PURPOSE: Over the next 10 years, the prevalence of glaucoma in the United Kingdom (UK) is predicted to rise by 22%,(The Way Forward: Glaucoma, The Royal College of Ophthalmologists, London, 2017) posing a considerable challenge to already overstretched hospital eye services. To help address this problem, services traditionally offered in hospital such as managing stable glaucoma patients, could be transferred to community optometrists. The aim of this study was to identify whether optometrists in Scotland have an interest in managing primary open angle glaucoma (POAG) in primary care and to assess perceived barriers. METHODS: All optometrists on the NHS Education Scotland (NES) database were invited to participate in an online survey over a 7-week period. Optometrists were asked if they had an interest in being accredited to manage POAG in the community and a free text question was used to elicit perceived barriers. Responders with an interest in managing POAG were invited to take part in two further rounds of electronic surveying, using a modified Delphi approach, with the aim of reaching a consensus on perceived barriers. RESULTS: Two hundred and ninety-nine of 1566 optometrists (19%) responded to the survey. 229 (79%) expressed an interest in managing patients with POAG in primary care. The most commonly perceived barriers after two rounds of Delphi surveying were remuneration (29%), communication with secondary care (18%), perceived ophthalmology resistance (13%), training (11%) and capacity (10%). Multivariate regression revealed fewer years in practice and comfort using and interpreting results of pachymetry were associated with higher odds of interest in managing glaucoma in the community. CONCLUSIONS: Among survey responders, there was significant interest from community optometrists to being accredited to manage POAG in primary care. A collaborative approach between primary and secondary care will be required to address the concerns of community optometrists in any future expansion of their role in glaucoma management.

Compliance With Primary Open-angle Glaucoma and Primary Open-angle Glaucoma Suspect Preferred Practice Patterns in a Retail-based Eye Clinic.

PURPOSE: To determine the level of adherence to the American Academy of Ophthalmology preferred practice pattern (PPP) guidelines for quality primary open-angle glaucoma (POAG) and POAG suspect (POAGS) care among retail-based optometrists. METHODS: Patients with a diagnosis of POAG or POAGS who participated in a telemedicine pilot project were included. Patients' charts were evaluated for 15 elements of PPP guidelines for glaucoma care. Results were further stratified by number of follow-up visits and diagnosis. RESULTS: Of 360 identified patients, 10 elements were documented in over 98%. Documentation of the remaining 5 components was as follows: dilated fundus examination 91.1%, central corneal thickness (CCT) 88.6%, visual field 78.9%, gonioscopy 47.5%, and target intraocular pressure (IOP) 15.6%. in total, 32.8% of patients were seen once, whereas the remaining 67.2% had multiple visits. In patients with multiple visits, providers were more likely to document systemic history (100.0% vs. 97.5%; P=0.0346), review of systems (100.0% vs. 97.5%; P=0.0346), gonioscopy (60.0% vs. 22.0%; P<0.001), CCT (94.2% vs. 77.1%; P<0.001), visual field (97.5% vs. 40.7%; P<0.001), and target IOP (22.4% vs. 1.7%; P<0.001) compared with single visit patients. In stratifying results by diagnosis, POAG patients more often received visual field testing (92.7% vs. 68.9%; P<0.001) and had an established target IOP (35.1% vs. 1.4%; P<0.001) compared with POAGS patients. CONCLUSIONS: Compliance with PPP guidelines for glaucoma care was very high for most elements but lower for performing dilated fundus examination, CCT, visual field, gonioscopy, and target IOP. This study highlights deficiencies in care likely to hamper the detection of glaucoma progression.