Initial experience in self-monitoring of intraocular pressure.

Background/aims: Diurnal variation in intraocular pressure (IOP) is a routine assessment in glaucoma management. Providing patients the opportunity to perform self-tonometry might empower them and free hospital resource. We previously demonstrated that 74% of patients can use the Icare® HOME tonometer. This study further explores Icare® HOME patient self-monitoring. Methods: Patients were trained by standard protocol to use the Icare® HOME rebound tonometer. Patient self-tonometry was compared to Goldmann applanation tonometry (GAT) over one clinical day. Following this, each patient was instructed to undertake further data collection that evening and over the subsequent two days. Results: Eighteen patients (35 eyes) participated. Good agreement was demonstrated between GAT and Icare® HOME for IOPs up to 15 mm Hg. Above this IOP the Icare® tended to over-read, largely explained by 2 patients with corneal thickness >600 um. The mean peak IOP during ‘clinic hours’ phasing was 16.7 mm Hg and 18.5 mm Hg (p = 0.24) over three days. An average range of 5.0, 7.0 and 9.8 mm Hg was shown during single day clinic, single day home and three day home phasing respectively (p =<0.001). The range of IOP was lower in eyes with prior trabeculectomy (6.1 mm Hg vs 12.2 mm Hg). All patients undertook one reading in the early morning at home with an average of 4.8 readings during, and 3.1 readings after office hours. Conclusions: This small study shows that self-tonometry is feasible. The findings from home phasing demonstrated higher peak and trough IOPs, providing additional clinical information. Home phasing is a viable alternative. The cost-effectiveness of this approach has yet to be addressed

Blue-light filtering spectacle lenses for visual performance, sleep, and macular health in adults

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To assess whether blue-light filtering spectacle lenses impart effects on visual function, provide protection to the macula, or both. We will also examine potential effects on the sleep-wake cycle

Nutrition and Eye Health

Diet is a key lifestyle factor that can have long-term effects on ocular health [...]

Evaluation of a new rebound tonometer for self-measurement of intraocular pressure

Background/aims To compare the accuracy of self-obtained, partner-obtained and trainer-obtained measurements using the handheld Icare Home rebound tonometer with Goldmann applanation tonometry (GAT), and to evaluate the acceptability to subjects of Icare Home measurement. Methods 76 subjects were trained to use Icare Home for self-measurement using a standardised protocol. A prespecified checklist was used to assess the ability of a subject to perform self-tonometry. Accuracy of Icare Home self-measurement was compared with GAT using one eye per subject, randomly selected. Bland-Altman difference analysis was used to compare Icare Home and GAT intraocular pressure (IOP) estimates. Acceptability of self-tonometry was evaluated using a questionnaire. Results 56 subjects (74%, 95% CI 64 to 84) were able to correctly perform self-tonometry. Mean bias (95% limits of agreement) was 0.3 mm Hg (−4.6 to 5.2), 1.1 mm Hg (−3.2 to 5.3) and 1.2 mm Hg (−3.9 to 6.3) for self-assessment, partner-assessment and trainer-assessment, respectively, suggesting underestimation of IOP by Icare Home tonometry. Differences between GAT and Icare Home IOP were greater for central corneal thickness below 500 µm and above 600 µm than data points within this range. Acceptability questionnaire responses showed high agreement that the self-pressure device was easy to use (84%), the reading was quick to obtain (88%) and the measurement was comfortable (95%). Conclusions Icare Home tonometry can be used for self-measurement by a majority of trained subjects. IOP measurements obtained using Icare Home tonometry by self-assessment and third party-assessment showed slight underestimation compared with GAT

A Critical Appraisal of National and International Clinical Practice Guidelines Reporting Nutritional Recommendations for Age-Related Macular Degeneration: Are Recommendations Evidence-Based?

Eye care professionals should have access to high quality clinical practice guidelines that ideally are underpinned by evidence from robust systematic reviews of relevant research. The aim of this study was to identify clinical guidelines with recommendations pertaining to dietary modification and/or nutritional supplementation for age-related macular degeneration (AMD), and to evaluate the overall quality of the guidelines using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument. We also mapped recommendations to existing systematic review evidence. A comprehensive search was undertaken using bibliographic databases and other electronic resources for eligible guidelines. Quality appraisal was undertaken to generate scores for each of the six AGREE II domains, and mapping of extracted nutritional recommendations was performed for systematic reviews published up to March 2017. We identified 13 national and international guidelines, developed or updated between 2004 and 2019. These varied substantially in quality. The lowest scoring AGREE II domains were for 'Rigour of Development', 'Applicability' (which measures implementation strategies to improve uptake of recommendations), and 'Editorial Independence'. Only four guidelines used evidence from systematic reviews to support their nutritional recommendations. In conclusion, there is significant scope for improving current Clinical Practice Guidelines for AMD, and guideline developers should use evidence from existing high quality systematic reviews to inform clinical recommendations

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

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

Trends in diabetic retinopathy screening attendance and associations with vision impairment attributable to diabetes in a large nationwide cohort

AIMS: To investigate diabetic retinopathy screening attendance and trends in certified vision impairment caused by diabetic eye disease. METHODS: This was a retrospective study of attendance in three urban UK diabetic eye screening programmes in England. A survival analysis was performed to investigate time from diagnosis to first screen by age and sex. Logistic regression analysis of factors influencing screening attendance during a 15-month reporting period was conducted, as well as analysis of new vision impairment certifications (Certificate of Vision Impairment) in England and Wales from 2009 to 2019. RESULTS: Of those newly registered in the Routine Digital Screening pathway (n = 97 048), 80% attended screening within the first 12 months and 88% by 36 months. Time from registration to first eye screening was longer for people aged 18-34 years, and 20% were unscreened after 3 years. Delay in first screen was associated with increased risk of referable retinopathy. Although 95% of participants (n = 291 296) attended during the 15-month reporting period, uptake varied considerably. Younger age, social deprivation, ethnicity and duration of diabetes were independent predictors of non-attendance and referable retinopathy. Although the last 10 years has seen an overall reduction in vision impairment certification attributable to diabetic eye disease, the incidence of vision impairment in those aged <35 years was unchanged. CONCLUSIONS: Whilst the majority of participants are screened in a timely manner, there is considerable variation in uptake. Young adults, have sub-optimal attendance, and levels of vision impairment in this population have not changed over the last 10 years. There is an urgent need to explore barriers to/enablers of attendance in this group to inform policy initiatives and tailored interventions to address this issue

Trends in diabetic retinopathy screening attendance and associations with vision impairment attributable to diabetes in a large nationwide cohort

AIMS: To investigate diabetic retinopathy screening attendance and trends in certified vision impairment caused by diabetic eye disease. METHODS: This was a retrospective study of attendance in three urban UK diabetic eye screening programmes in England. A survival analysis was performed to investigate time from diagnosis to first screen by age and sex. Logistic regression analysis of factors influencing screening attendance during a 15-month reporting period was conducted, as well as analysis of new vision impairment certifications (Certificate of Vision Impairment) in England and Wales from 2009 to 2019. RESULTS: Of those newly registered in the Routine Digital Screening pathway (n = 97 048), 80% attended screening within the first 12 months and 88% by 36 months. Time from registration to first eye screening was longer for people aged 18-34 years, and 20% were unscreened after 3 years. Delay in first screen was associated with increased risk of referable retinopathy. Although 95% of participants (n = 291 296) attended during the 15-month reporting period, uptake varied considerably. Younger age, social deprivation, ethnicity and duration of diabetes were independent predictors of non-attendance and referable retinopathy. Although the last 10 years has seen an overall reduction in vision impairment certification attributable to diabetic eye disease, the incidence of vision impairment in those aged <35 years was unchanged. CONCLUSIONS: Whilst the majority of participants are screened in a timely manner, there is considerable variation in uptake. Young adults, have sub-optimal attendance, and levels of vision impairment in this population have not changed over the last 10 years. There is an urgent need to explore barriers to/enablers of attendance in this group to inform policy initiatives and tailored interventions to address this issue