327 research outputs found
Role of advanced technology in the detection of sight-threatening eye disease in a UK community setting.
Background/aims: To determine the performance of combinations of structural and functional screening tests in detecting sight-threatening eye disease in a cohort of elderly subjects recruited from primary care. Methods: 505 subjects aged ≥60 years underwent frequency doubling technology (FDT) perimetry, iVue optical coherence tomography (iWellness and peripapillary retinal nerve fibre layer (RNFL) scans) and intraocular pressure with the Ocular Response Analyzer, all performed by an ophthalmic technician. The reference standard was a full ophthalmic examination by an experienced clinician who was masked to the index test results. Subjects were classified as presence or absence of sight-threatening eye disease (clinically significant cataract, primary open-angle glaucoma, intermediate or advanced age-related macular degeneration and significant diabetic retinopathy). Univariate and multivariate logistic regression analyses were used to determine the association between abnormal screening test results and the presence of sight-threatening eye disease. Results: 171 subjects (33.8%) had one or more sight-threatening eye diseases. The multivariate analysis found significant associations with any of the target conditions for visual acuity of <6/12, an abnormal FDT and peripapillary RNFL thickness outside the 99% normal limit. The sensitivity of this optimised screening panel was 61.3% (95% CI 53.5 to 68.7), with a specificity of 78.8% (95% CI 74.0 to 83.1), a positive predictive value of 59.5% (95% CI 53.7 to 65.2) and an overall diagnostic accuracy of 72.9% (95% CI 68.8 to 76.8). Conclusions: A subset of screening tests may provide an accurate and efficient means of population screening for significant eye disease in the elderly. This study provides useful preliminary data to inform the development of further larger, multicentre screening studies to validate this screening panel
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Multi-stakeholder perspectives of locally commissioned enhanced optometric services
OBJECTIVES: To explore views of all stakeholders (patients, optometrists, general practitioners (GPs), commissioners and ophthalmologists) regarding the operation of community-based enhanced optometric services.
DESIGN: Qualitative study using mixed methods (patient satisfaction surveys, semi-structured telephone interviews and optometrist focus groups).
SETTING: A minor eye conditions scheme (MECS) and glaucoma referral refinement scheme (GRRS) provided by accredited community optometrists.
PARTICIPANTS: 189 patients, 25 community optometrists, 4 glaucoma specialist hospital optometrists (GRRS), 5 ophthalmologists, 6 GPs (MECS), 4 commissioners.
RESULTS: Overall, 99% (GRRS) and 100% (MECS) patients were satisfied with their optometrists' examination. The vast majority rated the following as 'very good'; examination duration, optometrists' listening skills, explanations of tests and management, patient involvement in decision-making, treating the patient with care and concern. 99% of MECS patients would recommend the service. Manchester optometrists were enthusiastic about GRRS, feeling fortunate to practise in a 'pro-optometry' area. No major negatives were reported, although both schemes were limited to patients resident within certain postcode areas, and some inappropriate GP referrals occurred (MECS). Communication with hospitals was praised in GRRS but was variable, depending on hospital (MECS). Training for both schemes was valuable and appropriate but should be ongoing. MECS GPs were very supportive, reporting the scheme would reduce secondary care referral numbers, although some MECS patients were referred back to GPs for medication. Ophthalmologists (MECS and GRRS) expressed very positive views and widely acknowledged that these new care pathways would reduce unnecessary referrals and shorten patient waiting times. Commissioners felt both schemes met or exceeded expectations in terms of quality of care, allowing patients to be seen quicker and more efficiently.
CONCLUSIONS: Locally commissioned schemes can be a positive experience for all involved. With appropriate training, clear referral pathways and good communication, community optometrists can offer high-quality services that are highly acceptable to patients, health professionals and commissioners
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A qualitative study of stakeholder views regarding participation in locally commissioned enhanced optometric services
Objectives: To explore the views of optometrists, general practitioners (GPs) and ophthalmologists regarding the development and organisation of community-based enhanced optometric services.
Design: Qualitative study using free-text questionnaires and telephone interviews.
Setting: A minor eye conditions scheme (MECS) and a glaucoma referral refinement scheme (GRRS) are based on accredited community optometry practices.
Participants: 41 optometrists, 6 ophthalmologists and 25 GPs.
Results: The most common reason given by optometrists for participation in enhanced schemes was to further their professional development; however, as providers of ‘for-profit’ healthcare, it was clear that participants had also considered the impact of the schemes on their business. Lack of fit with the ‘retail’ business model of optometry was a frequently given reason for non-participation. The methods used for training and accreditation were generally thought to be appropriate, and participating optometrists welcomed the opportunities for ongoing training. The ophthalmologists involved in the MECS and GRRS expressed very positive views regarding the schemes and widely acknowledged that the new care pathways would reduce unnecessary referrals and shorten patient waiting times. GPs involved in the MECS were also very supportive. They felt that the scheme provided an ‘expert’ local opinion that could potentially reduce the number of secondary care referrals.
Conclusions: The results of this study demonstrated strong stakeholder support for the development of community-based enhanced optometric services. Although optometrists welcomed the opportunity to develop their professional skills and knowledge, enhanced schemes must also provide a sufficient financial incentive so as not to compromise the profitability of their business
Noncontact Screening Methods for the Detection of Narrow Anterior Chamber Angles
PURPOSE: Comparing diagnostic accuracy of biomicroscope techniques (van Herick and Smith's tests, evaluating limbal and central anterior chamber depth, respectively) and advanced imaging (Visante OCT and Pentacam) for detection of gonioscopically narrow anterior chamber angles (ACAs).
METHODS: A total of 78 subjects with narrow or open ACAs underwent four index tests, performed on both eyes by examiners masked to other test results. Diagnostic performance was compared with gonioscopy, using International Society of Geographical and Epidemiological Ophthalmology (ISGEO) definition of primary angle closure and a classification based on clinical opinion of occludability. Data were analyzed using both the eye and the individual as unit of analysis. Sensitivity, specificity, and partial area under the receiver operating characteristic curve (AUROC) were generated.
RESULTS: Using the eye as the unit of analysis, the van Herick grading cutoff of 25% or less and ISGEO gonioscopic classification achieved 80% (confidence interval [CI] 65 to 89) sensitivity and 92% specificity (CI 80 to 97) for narrow angle detection, with specificity reaching 97% (CI 87 to 100) for a cutoff of less than or equal to 15%. Notably, with a gonioscopic classification based on clinical opinion of occludability, van Herick (≤25%) together with Smith's test (≤2.50 mm) detected 100% of narrow angle subjects. Of the three Pentacam parameters, anterior chamber volume achieved highest test sensitivity of 85% (CI 70 to 94) using the ISGEO definition. Visante OCT ACA had greatest partial AUROC at 90% specificity, also yielding sensitivity and specificity greater than 85% using the Youden-derived cutoff of less than or equal to 20.7°and ISGEO definition.
CONCLUSIONS: Van Herick test and Visante OCT ACA exhibited best discrimination between narrow and open angles both alone, and in combination. Van Herick test affords advantages over Visante OCT, showing potential for identifying individuals who may benefit from further gonioscopic assessment in a case-finding or screening setting
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Seeing new opportunities to help smokers quit: A UK national survey of optometrist delivered smoking cessation behavioural support interventions
Background: Smoking is a risk factor for various eye conditions. Brief smoking cessation interventions have demonstrated effectiveness when delivered by a range of healthcare professionals. Optometrists are well-placed in the community to advise otherwise healthy smokers to quit, yet remain relatively neglected in smoking cessation research and policy. In a national survey, this study investigated self-reported practices of UK optometrists for delivering brief tobacco smoking cessation interventions to patients. Methods: A randomly selected sample of 1,200 optometrists out of the 9000 optometrists registered on the UK College of Optometrists database were invited to complete a 40-item, web-based survey assessing: training related to smoking cessation; current practice [i.e. the proportion of patients to which components of very brief advice (Ask, Advise, Assist) and other evidence-based smoking cessation behaviour change techniques were delivered]; and barriers/enablers to intervention delivery. Results: In total, 408 (34%) responses were received. Most (83%) optometrists received no training in practical skills for delivering smoking cessation support. A third (34%) routinely assessed smoking status. Fewer self-reported advising smokers to quit (22%), offering assistance (via referral to dedicated services) (3%), or advice on smoking cessation medications (2%). Perceived barriers included insufficient knowledge/training (81%) and time (65%). Optometrists were more likely to assess and advise on smoking cessation if they practised in Scotland (χ²(2)=32.95, p<0.001), an independent optometry practice (χ²(1)=4.27, p=0.39), or had received smoking cessation training χ²(1)=13.1, p<0.001). Conclusions: Substantial gaps exist in UK optometrists' current smoking cessation training and practice. Evidence-based training resources are needed to support the implementation of smoking cessation interventions into routine optometry practice. Implications: Optometrists are well placed in the community to delivery brief advice interventions to a large population of smokers. This survey provides a comprehensive description of current UK optometry practice related to the provision of evidence-based brief tobacco smoking cessation interventions to patients. Although optometrists perceive advising on smoking cessation as part of their role, numerous substantial gaps in current practice and training remain which need to be addressed through targeted interventions to increase implementation
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Diagnostic accuracy of technologies for glaucoma case-finding in a community setting
DESIGN: Cross-sectional, observational, community-based study.
PARTICIPANTS: A total of 505 subjects aged ≥60 years recruited from a community setting using no predefined exclusion criteria.
METHODS: Subjects underwent 4 index tests conducted by a technician unaware of subjects' ocular status. FDT and MMDT were used in suprathreshold mode. iVue OCT measured ganglion cell complex and retinal nerve fiber layer (RNFL) thickness. Reference standard was full ophthalmic examination by an experienced clinician who was masked to index test results. Subjects were classified as POAG (open drainage angle, glaucomatous optic neuropathy, and glaucomatous field defect), glaucoma suspect, ocular hypertension, or non-POAG/nonocular hypertension.
MAIN OUTCOME MEASURES: Test performance evaluated the individual as the unit of analysis. Diagnostic accuracy was assessed using predefined cutoffs for abnormality, generating sensitivity, specificity, and likelihood ratios. Continuous data were used to derive estimates of sensitivity at 90% specificity and partial area under the receiver operating characteristic curve (AUROC) plots from 90% to 100% specificity.
RESULTS: From the reference standard examination, 26 subjects (5.1%) had POAG and 32 subjects (6.4%) were glaucoma suspects. Sensitivity (95% confidence interval) at 90% specificity for detection of glaucoma suspect/POAG combined was 41% (28-55) for FDT, 35% (21-48) for MMDT, and 57% (44-70) for best-performing OCT parameter (inferior quadrant RNFL thickness); for POAG, sensitivity was 62% (39-84) for FDT, 58% (37-78) for MMDT, and 83% (68-98) for inferior quadrant RNFL thickness. Partial AUROC was significantly greater for inferior RNFL thickness than visual-function tests (P < 0.001). Post-test probability of glaucoma suspect/POAG combined and definite POAG increased substantially when best-performing criteria were combined for FDT or MMDT, iVue OCT, and ORA.
CONCLUSIONS: Diagnostic performance of individual tests gave acceptable accuracy for POAG detection. Low specificity of visual-function tests precludes their use in isolation, but case detection improves by combining RNFL thickness analysis with visual function tests
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Impact of the Manchester Glaucoma Enhanced Referral Scheme on NHS costs
Objectives: Glaucoma filtering schemes such as the Manchester Glaucoma Enhanced Referral Scheme (GERS) aim to reduce the number of false positive cases referred to Hospital Eye Services. Such schemes can also have wider system benefits, as they may reduce waiting times for other patients. However, previous studies of the cost consequences and wider system benefits of glaucoma filtering schemes are inconclusive. We investigate the cost consequences of the Manchester GERS. Design: Observational study. Methods: A cost analysis from the perspective of the National Health Service (NHS) was conducted using audit data from the Manchester GERS. Results: 2405 patients passed through the Manchester GERS from April 2013 to November 2016. 53.3% were not referred on to Manchester Royal Eye Hospital (MREH). Assuming an average of 2.3 outpatient visits to MREH were avoided for each filtered patient, the scheme saved the NHS approximately £2.76 per patient passing through the scheme. Conclusion: Our results indicate that glaucoma filtering schemes have the potential to reduce false positive referrals and costs to the NHS
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Clinical safety of a minor eye conditions scheme in England delivered by community optometrists
Objective The aim of this study was to monitor the activity and evaluate the clinical safety of a minor eye conditions scheme (MECS) conducted by accredited community optometrists in Lambeth and Lewisham, London.
Methods and analysis Optometrists underwent an accredited training programme, including attendance at hospital eye services (HES) clinics. Patients who satisfied certain inclusion criteria were referred to accredited MECS optometrists by their general practitioners (GPs) or could self-refer. Data were extracted from clinical records. A sample of MECS clinical records was graded to assess the quality of the MECS optometrists’ clinical management decisions. Referrals to the HES were assessed by the collaborating ophthalmologists and feedback was provided.
Results A total of 2123 patients (mean age 47 years) were seen over 12 months. Two-thirds of the patients (67.3%) were referred by their GP. The most common reasons for patients needing a MECS assessment were ‘red eye’ (36.7% of patients), ‘painful white eye’ (11.1%), ‘flashes and floaters’ (10.2%); 8.7% of patients had a follow-up appointment. Of the patients seen, 75.1% were retained in the community, 5.7% were referred to their GP and 18.9% were referred to the HES. Of the HES referrals, 49.1% were routine, 22.6% urgent and 28.3% emergency. Of the records reviewed, 94.5% were rated as appropriately managed; 89.2% of the HES referrals were considered appropriate.
Conclusion The findings of this study indicate that optometrists are in a good position to work very safely within the remits of the scheme and to assess risk
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Repeatability and agreement of central corneal thickness measurements with a new handheld non-contact pachymeter
Purpose
To compare the repeatability of central corneal thickness (CCT) measurements taken with a new handheld pachymeter (Occuity PM1 pachymeter) and to assess its agreement with ultrasound biometry and two commercially available optical biometers in participants with normal eyes.
Methods
Three consecutive CCT measurements of the right eye of 105 participants with normal corneas were acquired by the PM1 pachymeter, Lenstar LS 900 and Oculus Pentacam HR in a random order. This was followed by three measurements with a handheld ultrasound pachymeter (UP) (Pachmate 2). Repeatability and the repeatability limit were calculated for each device and Bland–Altman limits of agreement (LoA) were determined for the PM1 pachymeter compared to the other devices.
Results
The mean CCT (±SD) was 551.04 ± 33.43, 558.62 ± 31.46, 549.41 ± 31.00 and 539.73 ± 29.50 μm for the PM1 pachymeter, UP, Lenstar and Pentacam, respectively. The repeatability limits (expressed as the within subject SD for repeat measurements) were 14.02, 13.68, 4.99 and 9.90 μm, respectively. The closest agreement was between the PM1 and Lenstar (mean difference = −1.63 μm with LoA 10.72 μm below and 13.97 μm above the readings obtained with the Lenstar). The PM1 underestimated CCT compared to UP (mean difference = 7.58 μm, LoA 24.63 μm below and 9.47 μm above UP). The agreement was lowest between the PM1 and Pentacam (mean difference = −11.30 μm, LoA between 4.29 and 26.89 μm).
Conclusions
The PM1 pachymeter shows excellent precision for CCT measurements across a range of corneal thicknesses in normal eyes and provides a safe and easy-to-use alternative to ultrasound pachymetry
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Evaluation of a minor eye conditions scheme delivered by community optometrists
BACKGROUND: The establishment of minor eye conditions schemes (MECS) within community optometric practices provides a mechanism for the timely assessment of patients presenting with a range of acute eye conditions. This has the potential to reduce waiting times and avoid unnecessary referrals to hospital eye services (HES).
OBJECTIVE: To evaluate the clinical effectiveness, impact on hospital attendances and patient satisfaction with a minor eye service provided by community optometrists.
METHODS: Activity and outcome data were collected for 12 months in the Lambeth and Lewisham MECS. A patient satisfaction questionnaire was given to patients at the end of their MECS appointment. A retrospective difference-in-differences analysis of hospital activity compared changes in the volume of referrals by general practitioners (GPs) from a period before (April 2011-March 2013) to after (April 2013-March 2015) the introduction of the scheme in Lambeth and Lewisham relative to a neighbouring area (Southwark) where the scheme had not been commissioned. Appropriateness of case management was assessed by consensus using clinical members of the research team.
RESULTS: A total of 2123 patients accessed the scheme. Approximately two-thirds of patients (67.5%) were referred by their GP. The commonest reasons for patients attending for a MECS assessment were 'red eye' (36.7% of patients), 'painful white eye' (11.1%) and 'flashes and floaters' (10.2%). A total of 64.1% of patients were managed in optometric practice and 18.9% were referred to the HES; of these, 89.2% had been appropriately referred. First attendances to HES referred by GPs reduced by 26.8% (95% CI -40.5% to -13.1%) in Lambeth and Lewisham compared to Southwark.
CONCLUSIONS: The Lambeth and Lewisham MECS demonstrates clinical effectiveness, reduction in hospital attendances and high patient satisfaction and represents a successful collaboration between commissioners, local HES units and primary healthcare providers
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