A revolution in Welsh low vision service provision

Confidence in low vision rehabilitation and attitudes towards further learning: A survey of UK optometrists

PURPOSE

Optometrists are well positioned to help expand low vision (LV) services and improve their availability and accessibility. Determinants of participation in LV service provision must be well understood to facilitate successful service expansion. This survey aimed to investigate optometrists' professional confidence in the delivery of LV services and attitudes towards further learning.

METHODS

An online survey was emailed to a sample of College of Optometrists members. Respondents rated their confidence in different areas of core optometric practice; confidence in LV was compared with confidence in other areas. Respondents also rated their confidence in undertaking multiple tasks involved in LV service delivery and in routine optometric practice; confidence was compared between optometrists who do and do not work in a LV service. Attitudes towards learning more about assessing and supporting patients with a vision impairment (VI) were recorded.

RESULTS

The survey received 451 recorded responses (15.1% response rate). Optometrists who do not work in a LV service reported significantly lower confidence in LV than in other areas of core optometric practice, whereas optometrists who work in a LV service reported significantly higher confidence in LV than in other areas. Additionally, optometrists who do not work in a LV service reported significantly lower confidence in all tasks involved in LV service delivery than optometrists who work in a LV service (p < 0.001 for all tasks). Approximately 80% of respondents were interested in learning more about assessing and supporting patients with a VI.

CONCLUSIONS

Optometrists who do not work in a LV service have relatively low confidence in LV, which could contribute to low motivation to participate in LV service provision. There is sizeable interest in learning more about assessing and supporting patients with a VI, which could help to increase motivation to participate in LV service provision.

Essential components of rehabilitation services provided to visually impaired people

CLINICAL RELEVANCE

This study was conducted to determine the essential components in the delivery of vision rehabilitation services. The findings could be useful in the planning of vision rehabilitation services by optometrists or health managers.

BACKGROUND

Appropriate models of delivering vision rehabilitation services are a challenge for service providers worldwide. Studies have not revealed the key characteristics of a suitable model for delivering vision rehabilitation services. This study investigated the viewpoints of the key informants for identifying the most important components of a suitable model for delivering vision rehabilitation services.

METHODS

Semi-structured in-depth interviews were conducted with 19 participants including managers and service providers in Iran. All the interviews were recorded and transcribed verbatim. An inductive framework analysis approach was used to analyse the data. Qualitative analysis was done using the MAXQDA 10 software.

RESULTS

Four main themes emerged from the data, including creating maximum access (three subcategories: screening for visual impairment, creating a stepped-model for service delivery, and public and professional awareness of vision rehabilitation services), early intervention (two sub-categories: timely identification of people at the onset of disability and starting off with counselling services), need for financial support (two subcategories: providing affordable visual aid equipment and insurance coverage), and informed and skilled personnel (two subcategories: training vision rehabilitation specialists and familiarity of the rehabilitation staff with the rehabilitation program).

CONCLUSION

This study identified the key features of an appropriate model for providing vision rehabilitation services to blind and visually impaired people from the viewpoints of key informants who were experienced in providing vision rehabilitation services. The findings have valuable implications for policy-making and planning for vision rehabilitation services by the health system.

Demographics, referral patterns and management of patients accessing the Welsh Eye Care Service

Background

The Primary Eyecare Acute Referral Service (PEARS) and the Wales Eye Health Examination (WEHE) operate as enhanced optometry services for patients residing in Wales, enabling the examination of a patient presenting with an acute eye problem (PEARS) or the examination of patients at higher risk of eye disease (WEHE). The purpose of the study is to assess the demographics of patients accessing these services, referral patterns and clinical management in one Health Board in Wales (Aneurin Bevan University Health Board).

Methods

Information from 2302 patients accessing the services was prospectively collected. The following information was obtained: type of examination (PEARS or WEHE), patient age, gender, self-referral or general practitioner (GP) referral and clinical management (no further action, monitor by optometrist or ophthalmic medical practitioner [OMP], refer to the Hospital Eye Service [HES], or refer to GP).

Results

There were 1791 (77.8 %) PEARS examinations and 511 (22.2 %) WEHE. There were 1379 (59.9 %) females with a mean age of 58.61 (±19.75) and 923 (40.1 %) males with a mean age of 56.11 (±20.42). The majority of patients were self-referrals compared to GP-referrals (1793 [77.9 %] versus 509 [22.1 %] respectively). Sub-analysis indicated similar numbers of self-referrals compared to GP-referrals for the WEHE only (297 [58.1 %] versus 214 [41.9 %] respectively) but greater numbers of self-referrals for the PEARS examinations only (1496 [83.5 %] versus 295 [16.5 %] respectively). For management, 75 % of patients were monitored by their optometrist or OMP, 17 % required referral to the HES and 8 % required referral to their GP.

Conclusions

Higher numbers of females accessed both PEARS and WEHE services and the majority of patients self-referred. These findings have important implications for public health campaigns both for targeting specific groups (e.g. male patients) and increasing awareness among GPs.

The Depression in Visual Impairment Trial (DEPVIT): trial design and protocol

BACKGROUND

The prevalence of depression in people with a visual disability is high but screening for depression and referral for treatment is not yet an integral part of visual rehabilitation service provision. One reason for this may be that there is no good evidence about the effectiveness of treatments in this patient group. This study is the first to evaluate the effect of depression treatments on people with a visual impairment and co morbid depression.

METHODS /DESIGN

The study is an exploratory, multicentre, individually randomised waiting list controlled trial. Participants will be randomised to receive Problem Solving Therapy (PST), a 'referral to the GP' requesting treatment according to the NICE's 'stepped care' recommendations or the waiting list arm of the trial. The primary outcome measure is change (from randomisation) in depressive symptoms as measured by the Beck's Depression Inventory (BDI-II) at 6 months. Secondary outcomes include change in depressive symptoms at 3 months, change in visual function as measured with the near vision subscale of the VFQ-48 and 7 item NEI-VFQ at 3 and 6 months, change in generic health related quality of life (EQ5D), the costs associated with PST, estimates of incremental cost effectiveness, and recruitment rate estimation.

DISCUSSION

Depression is prevalent in people with disabling visual impairment. This exploratory study will establish depression screening and referral for treatment in visual rehabilitation clinics in the UK. It will be the first to explore the efficacy of PST and the effectiveness of NICE's 'stepped care' approach to the treatment of depression in people with a visual impairment.

TRIAL REGISTRATION

ISRCTN46824140.

The effect of low vision rehabilitation in diabetic eye disease: a randomised controlled trial protocol

PURPOSE

Current research highlights a rising incidence of diabetes and its complications. Diabetic retinopathy is the leading cause of blindness within the working-age population of the United Kingdom. Increasing severity of retinopathy is associated with reduced visual function and participation in daily living. Only 8% of those referred to Moorfields Eye Hospital's low vision clinic have diabetic eye disease, a value less than prevalence figures for diabetes would predict. The lack of evidence for effectiveness of low vision intervention in this patient group could be responsible. Therefore, in line with CONSORT guidance, we present the methodology of the first randomised controlled trial to quantify the effect of low vision rehabilitation on people with diabetic eye disease.

METHODS

One hundred participants were recruited into four retinopathy severity groups based on their diagnosis according to the English National Screening Programme Grading Protocol. Participants were randomised to either immediate intervention (1-2 weeks after enrollment) or delayed (control) intervention (3 months after enrollment). Intervention was a standard low vision assessment performed in a hospital clinic. The Activity Inventory (AI), was administered to all participants by telephone within 1 week of enrollment (before any intervention) and repeated at 3 and 6 months.

RESULTS

One hundred participants (Type 1: 28, Type 2: 72; male: 62, female 38) have been recruited. Median habitual distance acuity was 0.19 logMAR (6/9, 20/30), with an interquartile range of 0.06-0.30 logMAR (6/7.5-6/12, 20/25-20/40). AI responses were scored by Rasch analysis, providing a measure of visual ability. Median baseline visual ability was 1.64 logits, with an interquartile range of 0.60-3.75 logits. Difference in mean change in visual ability between intervention groups will be assessed 3 months (primary outcome) and 6 months (secondary outcome) after enrollment.

CONCLUSIONS

This is the first randomised controlled trial investigating the effectiveness of low vision rehabilitation for people with diabetic eye disease. With recruitment already complete, it is hoped this work will be the first step in guiding referral criteria for those with diabetic eye disease into the low vision service.

The newly established primary care based Welsh Low Vision Service is effective and has improved access to low vision services in Wales

AIM

The aim of this study was to determine whether the new, primary care based, Welsh Low Vision Service (WLVS) improved access to low vision services in Wales and was effective.

METHOD

The impact of the WLVS was determined by measuring the number of low vision appointments; travel time to the nearest service provider; and waiting times for low vision services for 1 year before, and for 1 year after, its establishment. Change in self-report visual function (using the 7 item NEI-VFQ), near visual acuity, patient satisfaction and use of low vision aids were used to determine the effectiveness of the service.

RESULTS

Following instigation of the WLVS, the number of low vision assessments increased by 51.7%, the waiting time decreased from more than 6 months to less than 2 months for the majority of people, and journey time to the nearest service provider reduced for 80% of people. Visual disability scores improved significantly (p < 0.001) by 0.79 logits and 97.42% patients found the service helpful.

CONCLUSIONS

The extension of low vision rehabilitation services into primary care identified a considerable unmet burden of need as evidenced by the substantial increase in the number of low vision assessments provided in Wales. The new service is effective and exhibits improved access.

An exploratory qualitative study of equity and the social care needs of visually impaired older people in England

This article describes the findings of a small study of the ways in which social care practitioners describe their assessment practice with visually impaired older people in England. The study interviewed 14 social care staff in three local authorities that had different organizational arrangements for assessments. Using a vignette method, the study explored staff's definitions of social care needs. Possible differences between the practice of specialists in visual impairment and those who were not working or trained specifically in the area of visual impairment are explored, as is the context of policy assessments for social care services. The potential impact of differences and context on equity is discussed.

Measuring low vision service outcomes: Rasch analysis of the seven-item National Eye Institute Visual Function Questionnaire

PURPOSE

To describe a short, functional visual disability instrument capable of measuring the outcomes of a government funded country-wide multicenter low vision service in Wales and to determine if postal implementation might lead to response bias.

METHODS

Seven items from the National Eye Institute Visual Function Questionnaire (NEI VFQ), which have previously been shown to be responsive to low vision service intervention, were incorporated into a postal questionnaire which was given to patients before they attended the all Wales Low Vision Service. Rasch analysis was used to describe the instrument's psychometric properties.

RESULTS

Rasch analysis of 490 completed questionnaires showed that all seven questions worked together to form a unidimensional scale. By combining the first two response categories, category utilization and targeting was improved. There were no significant differences in the age (p = 0.29), gender (p = 0.75), distance binocular Visual Acuity (VA; p = 0.86), living situation (p = 0.34) or prevalence of macular degeneration (p = 0.31) between those who returned a completed questionnaire and those who did not.

CONCLUSIONS

The seven-item National Eye Institute Visual Function Questionnaire is an appropriate and precise outcome measure that is acceptable to patients and easy to administer. It measures aspects of near, reading, and distance visual disability that have been shown to be amenable to low vision service provision and, therefore, it should be highly responsive to this intervention and facilitate inter-service assessment. We found no evidence to suggest that postal implementation results in response bias. The instrument is an appropriate measure of patient based outcomes for a large-scale, multicenter low vision service.

Quality of life and visual rehabilitation: an observational study of low vision in three general practices in West Glamorgan

AIM

To survey low vision in an urban population and assess impact on quality of life, rehabilitation and support.

METHODS

In a cross-sectional population survey, 66 patients were identified from databases of three general practices and surveyed by investigator administered questionnaire. Main outcome measures were ocular diagnoses, (US) National Eye Institute Visual Function-Questionnaire (NEI-VFQ) scores assessing visual and nonvisual disability, eligibility for, awareness and receipt of rehabilitation and support.

RESULTS

Of 24,420 individuals on the lists of the three study practices, we found 101 registered as blind or partially sighted (prevalence 0.41%). A total of 66 patients participated with ocular diseases of age-related macular degeneration 39 (59%), glaucoma 11 (17%), diabetic retinopathy two (3%), retinitis pigmentosa two (3%), and 12 (18%) 'others'. Better eye visual acuity was counting fingers or worse in 32 (48.5%). NEI-VFQ scores were poor-overall mean 41.5% (SD 23.5). In all, 80% had a social services home visit with one-third of these still in contact. In all, 66% had undergone a low vision aid assessment and 57.6% of these used their aid. The awareness and receipt of benefits arising from registration as visually impaired were lower than for other supportive measures available for reasons unrelated to vision. None had a guide dog.

CONCLUSIONS

We found expected patterns of low vision but poorer levels of function and support that may reflect age and deprivation in a population failed by the current systems for identification, registration, and rehabilitation based on legislation overtaken by demographic change and social provision independent of visual status.

Low vision service models in Alberta: innovation, collaboration, and future opportunities

As Alberta's population ages over the next 20 years, the number of older adults experiencing age-related blindness or vision loss is likely to at least double. To prevent a crisis in low vision service provision, we need to build upon, and extend, existing partnerships between the CNIB and ophthalmologists, optometrists, government policy makers, and other service providers. Future service models for low vision rehabilitation should also emphasize interventions such as counselling and peer support that enhance quality of life. With thoughtful planning, adequate funding, and involvement of all stakeholders, Alberta has the potential to become a world leader in the field of low vision treatment and rehabilitation.