Referrals to ophthalmology: optometric and general practice comparison

Assessment of optometrists' referral accuracy and contributing factors: A review

PURPOSE

In the UK, ophthalmology has the highest number of outpatient appointments within the National Health Service. False-positive referrals from primary care are one of the main factors contributing to the oversubscription of hospital eye services (HESs). We reviewed the accuracy of referrals originating from primary care optometrists and contributing factors, such as condition type and years since registration.

RECENT FINDINGS

Of the 31 studies included in the review, 22 were retrospective analyses of referrals and appointments at the HES. Eight were prospective studies, and one used online clinical vignettes. Seven assessed the accuracy of referrals for all ocular conditions. The remaining studies focused on glaucoma (n = 11), cataracts (n = 7), emergency conditions (n = 4), neovascular age-related macular degeneration (n = 1) and paediatric binocular vision (n = 1). The diagnostic agreement for suspected emergency ocular conditions was the lowest, with only 21.1% of referrals considered to require urgent attention in one study. For glaucoma, the first-visit discharge rate was high (16.7%-48%). Optometrist referral accuracy was overall 18.6% higher than General Medical Practitioners'; however, the two mainly referred different ocular conditions. Female optometrists made more false-positive referrals than males (p = 0.008). The proportion of false positives decreased by 6.2% per year since registration (p < 0.001).

SUMMARY

There was significant variation in referral accuracy across different ocular conditions, partly due to differences when defining accurate referrals. Optometrists working in primary care are generally more limited in their resources than the HES. Thus, choosing the cautious option of referral when they are unsure could be in the patients' best interests. The possible effect of increased use of advanced imaging on referrals requires evaluation. Although interventions such as refinement schemes have been put in place, these vary across regions, and their approaches such as virtual referral triaging may reduce unnecessary HES face-to-face appointments and promote communication between primary and secondary care.

Strengthening Saudi Arabia's Primary Health Care through an e-Referral System: A Case Study

Health systems are becoming more complex, regulatory bodies are increasing their vigilance, and reimbursement practices are shifting toward value, making closing the referral loop an imperative for patient safety, regulatory oversight, and financial viability. The aim of this study was to examine the referral pattern in PHC services and whether a significant variation exists among them based on geographic accessibility to a referred hospital. This was a cross-sectional retrospective study that included all sequentially referred patients between 1 January 2019 and 30 December 2021. A pre-initiative comparison could not be performed, as previous data on the traditional referral system could not be collected. The primary outcome measures considered in this study were the referral rate, and the proportion of the documented appointment date. The healthcare facilities’ geographic locations and data of the hospital departments to which the patients were referred were also available. Between 2019 and 2021, the hospital received 52,143 referrals from the 9 designated PHC centres covering 34 districts. In the PHC centres located within the ≤13 km zone, 1 in every 14 patients were referred to the hospital, whereas 1 in every 20 patients visited PHC centres outside this zone. Since the introduction of the Ehalati e-referral system, the number of documented appointment schedules of the referred patients has improved over time by 16.1% (from 79.6% to 95.7%, p < 0.001). Ophthalmologic (17.1%) and dental services (15.4%) received the most referrals among all other specialties, whereas the referral rate for cardiology services was the lowest (2.5%). The documented appointment scheduling record of referred patients has improved significantly since the introduction of the Ehalati e-referral system. However, the results of this study indicate that the proximity of PHC centres to specialised hospitals is more likely associated with higher referral and documented appointment scheduling rates. Strategies that improve scheduling, decrease variation among clinics, and improve patient access will likely improve the closing rates of the referral loop.

Review of referrals reveal the impact of referral content on the triage and management of ophthalmology wait lists

OBJECTIVES

Many chronic eye conditions are managed within public hospital ophthalmology clinics resulting in encumbered wait lists. Integrated care schemes can increase system capacity. In order to direct implementation of a public hospital-based integrated eye care model, this study aims to evaluate the quality of referrals for new patients through information content, assess triage decisions of newly referred patients and evaluate the consistency of referral content for new patients referred multiple times.

DESIGN

A retrospective and prospective review of all referral forms for new patients referred to a public hospital ophthalmology clinic between January 2016 and September 2017, and September 2017 and August 2018, respectively.

SETTING

A referral-only public hospital ophthalmology clinic in metropolitan Sydney, Australia.

PARTICIPANTS

418 new patients on existing non-urgent wait lists waiting to be allocated an initial appointment, and 528 patients who were newly referred.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was the information content of referrals for new patients. The secondary outcomes were triage outcomes for new incoming referrals, and the number of new patients with multiple referrals.

RESULTS

Of the wait-listed referrals, 0.2% were complete in referral content compared with 9.8% of new incoming referrals (p<0.001). Of new incoming referrals, 56.7% were triaged to a non-urgent clinic. Multiple referrals were received for 49 patients, with no change in the amount of referral content.

CONCLUSIONS

Most referrals were incomplete in content, leading to triage based on limited clinical information. Some new patients were referred multiple times with their second referral containing a similar amount of content as their first. Lengthy wait lists could be prevented by improving administrative processes and communication between the referral centre and referrers. The future implementation of an integrated eye care model at the study setting could sustainably cut wait lists for patients with chronic eye conditions.

Referrals from community optometrists to the hospital eye service in Scotland and England

Objectives

This audit assesses communication between community optometrists (COs) and hospital eye service (HES) in Scotland and England.

Methods

Optometric referrals and replies were extracted from six practices in Scotland and England. If no reply was found, replies/records were copied from HES records. De-identified referrals, replies and records were audited against established standards, evaluating whether referrals were necessary, accurate and directed to the appropriate professional. The referral rate (RR) and referral reply rate (RRR) were calculated.

Results

From 905 de-identified referrals, RR ranged from 2.6 to 8.7%. From COs’ perspective, the proportion of referrals for which they received replies ranged from 37 to 84% (Scotland) and 26 to 49% (England). A total of 88–96% of referrals (Scotland) and 63–76% (England) were seen in the HES. Adjusting for cases when it is reasonable to expect replies, RRR becomes 45–92% (Scotland) and 38–62% (England) with RRR significantly greater in Scotland (P = 0.015). Replies were copied to patients in 0–21% of cases. Referrals were to the appropriate service and judged necessary in ≥90% of cases in both jurisdictions. Accuracy of referral ranged from 89 to 97% (Scotland) and 81 to 98% (England). The reply addressed the reason for referral in 94–100% of cases (Scotland) and 93–97% (England) and was meaningful in 95–100% (Scotland) and 94–99% (England).

Conclusions

Despite the interdisciplinary joint statement on sharing patient information, this audit highlights variable standard of referrals and deficits in replies to the referring COs, with one exception in Scotland. Replies from HES to COs are important for patient care, benefitting patients and clinicians and minimising unnecessary HES appointments.

Analysis of UK eye casualty presentations

CLINICAL RELEVANCE

Optometrists upskilling and participating in enhanced optometric schemes has the potential to improve service accessibility and alleviate pressure on hospital eye services.

BACKGROUND

There is a growing demand for eye care in the UK with rising hospital attendances thought to be due in part to an ageing population and a shift in behaviour to favour emergency secondary care.

METHODS

Records of first-time presentations to the eye casualty department at the County Hospital (Wye Valley NHS Trust), Hereford, UK, over a month were analysed retrospectively and sequentially. The proportion of patients from optometrist referrals with conditions potentially requiring pharmacological intervention, that could have been retained within community optometry by an independent prescriber, was assessed. For general practitioner and self-referrals, the reasons for visit were compared to the Minor Eye Conditions Service criteria for inclusion. Patient conditions reviewed at the hospital following their initial presentation were grouped according to those who could have been discharged to a commissioned optometric service.

RESULTS

The records of 421 patients were organised by the source of referral and condition diagnosed by the hospital practitioner. Thirty-three percent of optometrist referrals could have been managed by an independent prescribing optometrist. Ninety-two percent of patients presenting from general practitioner referrals and 83 percent of self-referrals could have been assessed via the local optometric scheme. Sixty-six percent of patients attending hospital for follow-up could have been seen within the community.

CONCLUSION

The present analysis highlights the value of commissioned local optometric community services to address acute ocular symptoms and the value of an independent prescribing qualification in helping to further alleviate the burden on hospital emergency eye services. The large number of self-referrals suggests that the general public needs to be further educated on services that are available at a community optometry level.

The Effect of Government-Uninsured Optometric Services on the Use of Primary Care Providers

INTRODUCTION

Eye care in many countries is provided by optometrists, ophthalmologists, primary care providers (PCPs, including family physicians and pediatricians) and emergency department (ED) physicians. In the province of Prince Edward Island (PEI), Canada, optometric services are not government-insured, while services provided by other eye care providers are government-insured. Clinics of optometrists, PCPs and ED physicians are widely distributed across the island. Clinics of ophthalmologists however are concentrated in the capital city Charlottetown.

PURPOSE

To investigate if more patients visited government-insured PCPs and EDs for eye care when local optometric services are government-uninsured and government-insured ophthalmologists are potentially distant.

METHODS

From PEI physician billing database, we identified all patients with an ocular diagnosis from 2010-2012 using International Classification of Diseases, 9th Revision (ICD-9) codes. The utilization of government-insured PCPs and EDs in five geographical regions was assessed utilizing patients' residential postal code. Of the five regions, Prince was the region farthest from the capital Charlottetown.

RESULTS

Compared to utilization of government-insured PCPs for ocular diagnoses in Charlottetown (13.5% in 2010, 95% confidence interval [CI] 12.9-14.0%), the utilization in Prince (22.4% in 2010, 95% CI 21.7-23.1%) was nearly double (p<0.05). The utilization of ED physicians for ocular diagnoses was similarly double in Prince (8.8%, 95% CI 8.3-9.3%) versus Charlottetown (4.1%, 95% CI 3.8-4.5%). The utilization of ophthalmologists however was significantly lower in Prince (43%, 95% CI 41.4-42.9%) versus Charlottetown (56.3%, 95% CI 55.6-57.1%). Similar trends remained throughout 2010-2012.

CONCLUSION

When optometric services are government-uninsured and government-insured ophthalmologist services are geographically distant, ocular patients utilized PCPs and ED physicians more frequently. Due to different levels of training and available equipment for eye examinations among PCPs, ED physicians and optometrists, the quality of eye care and cost-effectiveness of increased use of PCPs and ED physicians for ocular management warrant further investigation.

TRIAL REGISTRATION

Not applicable.

New digital models of care in ophthalmology, during and beyond the COVID-19 pandemic

COVID-19 has led to massive disruptions in societal, economic and healthcare systems globally. While COVID-19 has sparked a surge and expansion of new digital business models in different industries, healthcare has been slower to adapt to digital solutions. The majority of ophthalmology clinical practices are still operating through a traditional model of ‘brick-and-mortar’ facilities and ‘face-to-face’ patient–physician interaction. In the current climate of COVID-19, there is a need to fuel implementation of digital health models for ophthalmology. In this article, we highlight the current limitations in traditional clinical models as we confront COVID-19, review the current lack of digital initiatives in ophthalmology sphere despite the presence of COVID-19, propose new digital models of care for ophthalmology and discuss potential barriers that need to be considered for sustainable transformation to take place.

Danish teleophthalmology platform reduces optometry referrals into the national eye care system

Objective

The purpose of this study was to evaluate the stratification of follow-up and referral pathways after implementation of a systematic cloud-based electronic-referral teleophthalmological service for optometry-initiated ocular posterior segment disease referrals to the Danish national eye care system.

Methods and Analysis

A retrospective cohort study was conducted in the period from 1 August 2018 to 31 July 2019. Patients with suspected ocular posterior segment disease reviewed by the telemedical ophthalmology service were included. The service stratified patients into the categories: no need for follow-up, follow-up by optometrist, follow-up by the telemedical service and referral to the national Danish eye care service.

Results

From a pool of 386 361 customers, 9938 patients were enrolled into this study. 19.5% of all patients were referred to the Danish national eye care system, while 80.5% of the patients in the telemedical service were not, in the period from 1 August 2018 to 31 July 2019. 14.4% of the optometrist referrals did not need any follow-up, while a majority of 66.1% needed some follow-up either by the optometrist themselves or within the telemedical service.

Conclusion

Optometrist posterior segment disease referrals can be considerably reduced with a risk stratified approach and optimal use of technology. New models can improve and streamline the healthcare system.

Predictors of narrow angle detection rate-a longitudinal study of Massachusetts residents over 1.7 million person years

BACKGROUND/OBJECTIVES

To determine the predictors of narrow angle detection in a United States population-based cohort.

MATERIALS AND METHODS

This was a retrospective cohort study using the Massachusetts All-Payer Claims Database. Demographic information of all patients and eye care provider information during the years 2011-2015 were extracted from Massachusetts All Payers Claims Data. All payers who received eye care during 1/1/2012-12/31/2015 without any previous eye visit during 2011 were included in the analyses. Laser peripheral iridotomy was identified by Current Procedural Terminology code 66761. Narrow angle detection was defined as the diagnosis of narrow angles by diagnosis code followed by a laser peripheral iridotomy procedure. Different predictors of narrow angle detection were evaluated using Kaplan-Meier curves with the log rank and Cox regression modeling.

RESULTS

A total of 1,082,144 patients were included. The hazard ratio of narrow angle detection increased with age compared to the reference group of 0-10 years: 21-30 years of age (hazard ratio = 4.5), 31-40 (10.5), 41-50 (27.9), 51-60 (46.1), 61-70 (68.4), 71-80 (56.8) (all p < 0.0002), was 1.47 times higher in women and 1.85 times higher if evaluated by ophthalmologists compared to optometrists, after controlling for provider × time interaction.

CONCLUSION

Older age and female sex are associated with narrow angles. The rate of narrow angle detection was significantly higher if patients are seen by ophthalmologists compared to optometrists only. Evaluation with an ophthalmologist may be important for patients at high risks for developing primary angle closure glaucoma.

Clinical outcomes of the Centre for Eye Health: an intra-professional optometry-led collaborative eye care clinic in Australia

Clinical relevance: This novel clinical model is the first of its kind in Australia and was designed to help reduce unnecessary referrals into overburdened public systems by utilising pre-existing community-based resources.Background: The Centre for Eye Health (CFEH) is an intra-professional optometry-led care clinic offering an alternative pathway to traditional ophthalmology-based pathways (public hospital clinics or private practices) for 'at-risk' patients requiring ocular imaging, diagnostic and management services. This study evaluates the CFEH integrated eye-care model in the identification of chronic eye diseases within the community.Methods: A retrospective random clinical audit of over 750 medical records of patients referred to the CFEH between July 2016 and June 2019 was conducted. Demographics of patients, referral type, final diagnosis and recommended management plans were extracted from this subset. Clinic key performance indicators (referral turnaround time, and net cost per patient appointment) were also extracted.Results: Of the 755 referrals associated with the audited records, 77.4% resulted in the identification of patients with or at-risk of developing eye diseases with 73.5% of this cohort requiring ongoing monitoring at CFEH or referral to ophthalmology. Although the CFEH model is not designed to diagnose or manage acute conditions, 1.5% of patients in this pathway required same day ophthalmological or medical intervention. The cost per patient was equivalent to hospital eye departments costs.Conclusion: This integrated care pathway has the potential to reduce unnecessary referrals from optometrists to hospital ophthalmological service by offering a safe and effective alternate pathway. The majority of patients seen within this pathway were able to be monitored within optometry-led services. This is a unique clinical model utilising inter-professional referrals within optometry which has the potential to reduce preventable blindness within the community through the early detection of eye diseases.

Referrals from community optometrists to the hospital eye service in England

PURPOSE

In the UK, most referrals to the hospital eye service (HES) originate from community optometrists (CO). This audit investigates the quality of referrals, replies, and communication between CO and the HES.

METHODS

Optometric referrals and replies were extracted from three practices in England. If no reply letter was found, the records were searched at each local HES unit, and additional replies or records copied. De-identified referrals, replies and records were audited by a panel against established standards to evaluate whether the referrals were necessary, accurate and directed to the appropriate professional. The referral rate (RR) and referral reply rate (RRR) were calculated.

RESULTS

A total of 459 de-identified referrals were extracted. The RR ranged from 3.6%-8.7%. The proportion of referred patients who were seen in the HES unit was 63%-76%. From the CO perspective, the proportion of referrals for which they received replies ranged from 26%-49%. Adjusting the number of referrals for cases when it would be reasonable to expect an HES reply, RRR becomes 38%-62%. Patients received a copy of the reply in 3%-21% of cases. Referrals were made to the appropriate service in over 95% of cases, were judged necessary in 93%-97% and were accurate in 81%-98% of cases. The referral reply addressed the reason for the referral in 93%-97% and was meaningful in 94%-99% of cases. The most common conditions referred were glaucoma, cataract, anterior segment lesions, and neurological/ocular motor anomalies. The CO/HES dyad (pairing) in the area with the lowest average household income had the highest RR.

CONCLUSIONS

In contrast with the Royal College of Ophthalmologists/College of Optometrists joint statement on sharing patient information, CO referrals often do not elicit a reply to the referring CO. Replies from the HES to COs are important for patient care, benefitting patients and clinicians, and minimising unnecessary HES appointments.

Assessing the effect of Independent Prescribing for community optometrists and referral rates to Hospital Eye Services in Scotland

INTRODUCTION

Since 2010, General Ophthalmic Services (GOS) legislation and Independent Prescribing (IP) enable community optometrists to manage primary eye conditions. No studies have assessed the effect of IP. We wished to determine the distribution of IP optometrists and associated hospital referral rates across Scotland.

METHODS

In 2019, FOI requests (General Optical Council and NHS Education Scotland) identified all registered IP optometrists in Scotland and their registered postcodes. Data regarding community eye examinations and referrals to HES since 2010 were gathered via Information Services Division of NHS Scotland.

RESULTS

As of March 2019, there were 278 IP optometrists in Scotland (278/1189; 23.4%). Two hundred eighteen IP optometrists work in 293 practices across 11 of Scotland's 14 health boards. There was a strong correlation (r = +0.96) between population density and number of IP optometrists. Fifty-six percent of IP optometrists work in the two most deprived quintiles. Since IP's introduction, there has been a marked increase in anterior segment supplementary visits (+290%). Optometry referrals to GPs have reduced by 10.5%, but referrals to HES have increased by 118% (to 96,315). There was no correlation between quantity of IP optometrists and referral rates to HES (r = -0.06, 95% CI -0.64 to 0.56, p = 0.86).

CONCLUSIONS

This is the first analysis of IP optometrists and associated referral rates in Scotland. Despite good geographical distribution and increased supplementary attendances, optometric referrals to HES have doubled and continue to rise. We propose a ratio of primary, supplementary, non-referral and referral rates to discern the true impact of IP versus non-IP community optometric behaviour.

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.

Delayed attendance at routine eye examinations is associated with increased probability of general practitioner referral: a record linkage study in Northern Ireland

PURPOSE

To investigate relationships between health and socio-economic status with delayed attendance at routine eye examinations and risk of subsequent general practitioner (GP) referral in Northern Ireland.

METHODS

We constructed a cohort of 132 046 community dwelling individuals aged ≥60 years, drawing contextual information from the 2011 Northern Ireland Census. Using linked administrative records of routine eye examinations between 2009 and 2014, we calculated 311 999 examination intervals. Multinomial models were used to estimate associations between contextual factors and examination interval (classified into three groups: early recall, on-time, delayed attendance). Associations between examination interval and referral risk were estimated using logistic regression.

RESULTS

Delayed attendance was recorded for 129 857 (41.6%) examination intervals, 53 759 (17.2%) delayed by ≥6 months. Female sex, poor general or mental health were each associated with delay, as were longer distances to optometry services among those aged ≥70 years (longest vs shortest: Relative Risk Ratio = 1.21 [1.14, 1.28]). Low income and residence in social housing were associated with reduced delay risk. There were 3347 (3.5%) and 11 401 (5.3%) GP referrals in the 60-69 and ≥70 years age groups respectively. Delayed attendance was associated with increased referral risk in both groups (Odds Ratios: 60-69 years = 1.30 [1.04, 1.61]; ≥70 years = 1.07 [1.01, 1.13]).

CONCLUSIONS

Poor health and longer distances to optometry services were associated with delayed attendance at routine eye examinations but low income was not. Delayed attendance was associated with increased GP referral risk, indicative of missed opportunities to detect potentially serious eye conditions.

Accuracy of a Popular Online Symptom Checker for Ophthalmic Diagnoses

Importance

Because more patients are presenting with self-guided research of symptoms, it is important to assess the capabilities and limitations of these available health information tools.

Objective

To determine the accuracy of the most popular online symptom checker for ophthalmic diagnoses.

Design, Setting, and Participants

In a cross-sectional study, 42 validated clinical vignettes of ophthalmic symptoms were generated and distilled to their core presenting symptoms. Cases were entered into WebMD symptom checker by both medically trained and nonmedically trained personnel blinded to the diagnosis. Output from the symptom checker, including the number of symptoms, ranking and list of diagnoses, and triage urgency were recorded. The study was conducted on October 13, 2017. Analysis was performed between October 15, 2017, and April 30, 2018.

Main Outcomes and Measures

Accuracy of the top 3 diagnoses generated by the online symptom checker.

Results

The mean (SD) number of symptoms entered was 3.6 (1.6) (range, 1-8). The median (SD) number of diagnoses generated by the symptom checker was 26.8 (21.8) (range, 1-99). The primary diagnosis by the symptom checker was correct in 11 of 42 (26%; 95% CI, 12%-40%) cases. The correct diagnosis was included in the online symptom checker's top 3 diagnoses in 16 of 42 (38%; 95% CI, 25%-56%) cases. The correct diagnosis was not included in the symptom checker's list in 18 of 42 (43%; 95% CI, 32%-63%) cases. Triage urgency based on the top diagnosis was appropriate in 7 of 18 (39%; 95% CI, 14%-64%) emergent cases and 21 of 24 (88%; 95% CI, 73%-100%) nonemergent cases. Interuser variability for the correct diagnosis being in the top 3 listed was at least moderate (Cohen κ = 0.74; 95% CI, 0.54-0.95).

Conclusions and Relevance

The most popular online symptom checker may arrive at the correct clinical diagnosis for ophthalmic conditions, but a substantial proportion of diagnoses may not be captured. These findings suggest that further research to reflect the real-life application of internet diagnostic resources is required.

Referral Patterns in Neuro-Ophthalmology

BACKGROUND

Neuro-ophthalmologists specialize in complex, urgent, vision- and life-threatening problems, diagnostic dilemmas, and management of complex work-ups. Access is currently limited by the relatively small number of neuro-ophthalmologists, and consequently, patients may be affected by incorrect or delayed diagnosis. The objective of this study is to analyze referral patterns to neuro-ophthalmologists, characterize rates of misdiagnoses and delayed diagnoses in patients ultimately referred, and delineate outcomes after neuro-ophthalmologic evaluation.

METHODS

Retrospective chart review of 300 new patients seen over 45 randomly chosen days between June 2011 and June 2015 in one tertiary care neuro-ophthalmology clinic. Demographics, distance traveled, time between onset and neuro-ophthalmology consultation (NOC), time between appointment request and NOC, number and types of providers seen before referral, unnecessary tests before referral, referral diagnoses, final diagnoses, and impact of the NOC on outcome were collected.

RESULTS

Patients traveled a median of 36.5 miles (interquartile range [IQR]: 20-85). Median time from symptom onset was 210 days (IQR: 70-1,100). Median time from referral to NOC was 34 days (IQR: 7-86), with peaks at one week (urgent requests) and 13 weeks (routine requests). Median number of previous providers seen was 2 (IQR: 2-4; range:0-10), and 102 patients (34%) had seen multiple providers within the same specialty before referral. Patients were most commonly referred for NOC by ophthalmologists (41% of referrals). Eighty-one percent (242/300) of referrals to neuro-ophthalmology were appropriate referrals. Of the 300 patients referred, 247 (82%) were complex or very complex; 119 (40%) were misdiagnosed; 147 (49%) were at least partially misdiagnosed; and 22 (7%) had unknown diagnoses. Women were more likely to be at least partially misdiagnosed-108 of 188 (57%) vs 39 of 112 (35%) of men (P < 0.001). Mismanagement or delay in care occurred in 85 (28%), unnecessary tests in 56 (19%), unnecessary consultations in 64 (22%), and imaging misinterpretation in 16 (5%). Neuro-ophthalmologists played a major role in directing treatment, such as preserving vision, preventing life-threatening complications, or avoiding harmful treatment in 62 (21%) patients.

CONCLUSIONS

Most referrals to neuro-ophthalmologists are appropriate, but many are delayed. Misdiagnosis before referral is common. Neuro-ophthalmologists often prevent vision- and life-threatening complications.

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.

Accuracy of vision technicians in screening ocular pathology at rural vision centres of southern India

BACKGROUND

There is paucity of data on the inter-observer agreement and diagnostic accuracy between a primary-care technician (vision technician) and an ophthalmologist. Hence, the current study was conducted to assess the accuracy of vision technicians, to screen potentially sight-threatening ocular conditions at rural vision centres of southern India and their agreement with an ophthalmologist.

METHODS

In July to August 2010, patients presenting to seven vision centres in Adilabad district (Andhra Pradesh) were selected and screened in a masked manner by seven vision technicians followed by an examination by a consultant ophthalmologist. Agreement was assessed between vision technicians and the ophthalmologist for screening of potential sight-threatening ocular conditions and decisions for referral. The ophthalmologist's findings were considered as the reference standard.

RESULTS

Two hundred and seventy-nine patients were enrolled at seven vision centres with a mean age of 32.9 ± 21.8 years. Agreement for screening of ocular pathology was 0.82 (95 per cent CI, 0.8-0.83). There was excellent agreement for cataract (0.97; 95 per cent CI, 0.93-1), refractive error (0.98; 95 per cent CI, 0.96-1), corneal pathology (1.0; 95 per cent CI, 1.0-1.0) and other anterior segment pathology (0.95; 95 per cent CI, 0.9-1); the agreement was moderate to fair for detection of glaucoma suspects (0.43; 95 per cent CI, 0.28-0.60) and retinal pathology (0.39; 95 per cent CI, 0.14-0.63). Sensitivity for screening of anterior segment pathology was 94.6-100 per cent. There was a fair to moderate sensitivity for glaucoma suspect; 35.6 per cent (95 per cent CI, 21.9-51.2) and retinal pathology 26.3 per cent (95 per cent CI, 9.2-51.2). Specificity for screening of ocular pathology was 98.2 to 100 per cent. The kappa (κ) agreement for referral for any pathology was 0.82 (0.8-0.83) CONCLUSION: As there is good agreement between the vision technicians and the ophthalmologist for screening and referral of anterior segment pathology but moderate to fair for glaucoma suspects and retinal pathology, vision technicians would be a good resource at the primary level to screen for anterior segment pathology; however, they may need further training to detect posterior segment pathology.

The Prevalence of Visual Impairment in People with Dementia (the PrOVIDe study): a cross-sectional study of people aged 60–89 years with dementia and qualitative exploration of individual, carer and professional perspectives

Background

The prevalence of visual impairment (VI) and dementia increases with age and these conditions may coexist, but few UK data exist on VI among people with dementia.

Objectives

To measure the prevalence of eye conditions causing VI in people with dementia and to identify/describe reasons for underdetection or inappropriate management.

Design

Stage 1 – cross-sectional prevalence study. Stage 2 – qualitative research exploring participant, carer and professional perspectives of eye care.

Setting

Stage 1 – 20 NHS sites in six English regions. Stage 2 – six English regions.

Participants

Stage 1 – 708 participants with dementia (aged 60–89 years): 389 lived in the community (group 1) and 319 lived in care homes (group 2). Stage 2 – 119 participants.

Interventions

Stage 1 gathered eye examination data following domiciliary sight tests complying with General Ophthalmic Services requirements and professional guidelines. Cognitive impairment was assessed using the Standardised Mini-Mental State Examination (sMMSE) test, and functional ability and behaviour were assessed using the Bristol Activities of Daily Living Scale and Cambridge Behavioural Inventory – Revised. Stage 2 involved individual interviews (36 people with dementia and 11 care workers); and separate focus groups (34 optometrists; 38 family and professional carers).

Main outcome measures.

VI defined by visual acuity (VA) worse than 6/12 or worse than 6/18 measured before and after refraction.

Results

Stage 1 – when participants wore their current spectacles, VI prevalence was 32.5% [95% confidence interval (CI) 28.7% to 36.5%] and 16.3% (95% CI 13.5% to 19.6%) for commonly used criteria for VI of VA worse than 6/12 and 6/18, respectively. Of those with VI, 44% (VA < 6/12) and 47% (VA < 6/18) were correctable with new spectacles. Almost 50% of remaining uncorrectable VI (VA < 6/12) was associated with cataract, and was, therefore, potentially remediable, and one-third was associated with macular degeneration. Uncorrected/undercorrected VI prevalence (VA < 6/12) was significantly higher in participants in care homes (odds ratio 2.19, 95% CI 1.30 to 3.73;p < 0.01) when adjusted for age, sex and sMMSE score. VA could not be measured in 2.6% of group 1 and 34.2% of group 2 participants (p < 0.01). The main eye examination elements (excluding visual fields) could be performed in > 80% of participants. There was no evidence that the management of VI in people with dementia differed from that in older people in general. Exploratory analysis suggested significant deficits in some vision-related aspects of function and behaviour in participants with VI. Stage 2 key messages – carers and care workers underestimated how much can be achieved in an eye examination. People with dementia and carers were unaware of domiciliary sight test availability. Improved communication is needed between optometrists and carers; optometrists should be informed of the person’s dementia. Tailoring eye examinations to individual needs includes allowing extra time. Optometrists wanted training and guidance about dementia. Correcting VI may improve the quality of life of people with dementia but should be weighed against the risks and burdens of undergoing examinations and cataract surgery on an individual basis.

Limitations

Sampling bias is possible owing to quota-sampling and response bias.

Conclusions

The prevalence of VI is disproportionately higher in people with dementia living in care homes. Almost 50% of presenting VI is correctable with spectacles, and more with cataract surgery. Areas for future research are the development of an eye-care pathway for people with dementia; assessment of the benefits of early cataract surgery; and research into the feasibility of specialist optometrists for older people.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Clinical Competency of 1-Year Trained Vision Technicians in Andhra Pradesh, India

PURPOSE

To assess clinical competency of 1-year trained vision technicians (VTs) in detecting and referring causes of visual impairment in India.

METHODS

Eye examination results and management plans for 328 patients examined by 24 VTs in 24 vision centers of LV Prasad Eye Institute in Andhra Pradesh were compared with those of a standard optometrist who examined the same patients. Eye examinations included retinoscopy and subjective refraction, slit lamp examination, applanation tonometry and undilated direct ophthalmoscopy. Data were analyzed for level of concordance in retinoscopy, spectacle prescription, disease detection and referral.

RESULTS

VTs demonstrated moderate to good levels of agreement in refraction, disease detection and referral. Sensitivity and specificity for ocular pathology identification were 77.4% (95% confidence interval, CI, 69.4-84.2%) and 86.6% (95% CI 81.1-91.1%), respectively. The highest sensitivity was demonstrated in detecting significant cataract (91.5%) and refractive error (83.0%). VT spectacle prescriptions were accurate 76% of the time for mean spherical equivalent and 65% of the time for astigmatism. VT sensitivity in detecting posterior segment abnormalities was low (18.5%) resulting in failure to detect retinal conditions such as diabetic retinopathy and maculopathy. Despite lack of recognition of the specific pathology, referral decisions were correct in 78.4% of cases.

CONCLUSION

VTs in India competently detect and manage or refer the two most common causes of visual impairment; uncorrected refractive error and cataract. Over two-thirds of patients received accurate and appropriate services from VTs, suggesting that they are a useful and competent cadre for rural and remote eye care.

A review of 1000 referrals to Walsall's hospital eye service

BACKGROUND

Referrals to ophthalmology are predominantly made from general practitioners (GPs) and optometrists. These two groups of referrers receive differing types and levels of training and are equipped with different instrumentation. The purpose of this study was to determine whether the quality of referrals to the hospital eye service (HES) differs between GPs and optometrists in Walsall.

METHODS

Referrals into the HES were identified from Q1 2014 retrospectively until 1000 notes had been reached. Each record was scrutinized using a standard template. Data were analysed and summary statistics produced including positive predictive values and interobserver agreement.

RESULTS

We achieved our target of auditing 1000 records. The false-positive rate (patients being discharged from HES with a 'normal vision' diagnosis) was 7.7% of referrals from GPs and 6.2% of referrals from optometrists. Concordance between referred condition and diagnosed condition at HES between optometrists and ophthalmologists was 76.1%, and between GPs and ophthalmologists was 67.2%.

CONCLUSIONS

In view of findings from this study, it is important for commissioners in the new reconfigured National Health Service to ensure that enhanced ophthalmic services are commissioned only on the basis of hard evidence sourced from local data rather than opinion or on data from another geographical area.

Assessment of referrals to the hospital eye service by optometrists and GPs in Bradford and Airedale

PURPOSE

To investigate the content of referrals to a hospital eye department and describe differences between referring clinician (optometrist or GP) and referral formats.

METHODS

A random sample of 433 new referrals to Bradford Royal Infirmary hospital eye service (HES) during 2007 and 2008 were retrospectively analysed.

RESULTS

Three hundred and eleven referrals (72%) were from optometric practice and 122 (28%) from general practice. Optometric referrals were mainly for cataract and posterior capsular opacification (27%), glaucoma or suspect glaucoma (20%) and diabetic retinopathy (10%).

CONCLUSIONS

The proportion of referrals to the hospital eye service from optometrists appears to be increasing (1988: 39%, 1999: 48%, present study 72%). GPs mainly refer patients with anterior segment disorders, particularly lid lesions, based on direct observation and symptoms. Optometrists refer patients with a wide range of ocular diseases and include fundus observations and visual acuity measurements in their referrals. There is a need to inform optometrists of what content is required in a referral to the HES from GOS sight tests, at least for the common referral conditions such as age-related cataract and suspect open-angle glaucoma. Referral forms specifically designed for these commonly referred conditions are likely to improve referral quality.