Providing capacity in glaucoma care using trained and accredited optometrists: A qualitative evaluation

INTRODUCTION

The role of optometrists in glaucoma within primary and secondary care has been well described. Whilst many studies examined safety and clinical effectiveness, there is a paucity of qualitative research evaluating enablers and barriers for optometrists delivering glaucoma care. The aims of this study are to investigate qualitatively, and from a multi-stakeholder perspective whether optometric glaucoma care is accepted as an effective alternative to traditional models and what contextual factors impact upon their success.

METHODS

Patients were recruited from clinics at Manchester Royal Eye Hospital and nationally via a Glaucoma UK registrant database. Optometrists, ophthalmologists, and other stakeholders involved in glaucoma services were recruited via direct contact and through an optometry educational event. Interviews and focus groups were recorded and transcribed anonymously, then analysed using the framework method and NVivo 12.

RESULTS

Interviews and focus groups were conducted with 38 participants including 14 optometrists and 6 ophthalmologists (from all 4 UK nations), and 15 patients and 3 commissioners/other stakeholders. Themes emerging related to: enablers and drivers; challenges and barriers; training; laser; professional practice; the role of other health professionals; commissioning; COVID-19; and patient experience.

CONCLUSION

Success in developing glaucoma services with optometrists and other health professionals is reliant on multi-stakeholder input, investment in technology and training, inter-professional respect and appropriate time and funding to set up and deliver services. The multi-stakeholder perspective affirms there is notable support for developing glaucoma services delivered by optometrists in primary and secondary care, with caveats around training, appropriate case selection and clinical responsibility.

Risk of Falls and Fractures in Individuals With Cataract, Age-Related Macular Degeneration, or Glaucoma

Importance

Three leading disease causes of age-related visual loss are cataract, age-related macular degeneration (AMD), and glaucoma. Although all 3 eye diseases have been implicated with falls and fracture risk, evidence is mixed, with the contribution of different eye diseases being uncertain.

Objective

To examine whether people with cataract, AMD, or glaucoma have higher risks of falls or fractures than those without.

Design, Setting, and Participants

This cohort study was a population-based study in England using routinely collected electronic health records from the Clinical Practice Research Datalink (CPRD) GOLD and Aurum primary care databases with linked hospitalization and mortality records from 2007 to 2020. Participants were people with cataract, AMD, or glaucoma matched to comparators (1:5) by age, sex, and general practice. Data were analyzed from May 2021 to June 2023.

Exposures

For each eye disease, we estimated the risk of falls or fractures using separate multivariable Cox proportional hazards regression models.

Main Outcomes

Two primary outcomes were incident falls and incident fractures derived from general practice, hospital, and mortality records. Secondary outcomes were incident fractures of specific body sites.

Results

A total of 410 476 people with cataract, 75 622 with AMD, and 90 177 with glaucoma were matched (1:5) to 2 034 194 (no cataract), 375 548 (no AMD), and 448 179 (no glaucoma) comparators. The mean (SD) age was 73.8 (11.0) years, 79.4 (9.4) years, and 69.8 (13.1) years for participants with cataract, AMD, or glaucoma, respectively. Compared with comparators, there was an increased risk of falls in those with cataract (adjusted hazard ratio [HR], 1.36; 95% CI, 1.35-1.38), AMD (HR, 1.25; 95% CI, 1.23-1.27), and glaucoma (HR, 1.38; 95% CI, 1.35-1.41). Likewise for fractures, there were increased risks in all eye diseases, with an HR of 1.28 (95% CI, 1.27-1.30) in the cataract cohort, an HR of 1.18 (95% CI, 1.15-1.21) for AMD, and an HR of 1.31 (95% CI, 1.27-1.35) for glaucoma. Site-specific fracture analyses revealed increases in almost all body sites (including hip, spine, forearm, skull or facial bones, pelvis, ribs or sternum, and lower leg fractures) compared with matched comparators.

Conclusions and Relevance

The results of this study support recognition that people with 1 or more of these eye diseases are at increased risk of both falls and fractures. They may benefit from improved advice, access, and referrals to falls prevention services.

Multi-resolution Correlative Ultrastructural and Chemical Analysis of Carious Enamel by Scanning Microscopy and Tomographic Imaging

Caries, a major global disease associated with dental enamel demineralization, remains insufficiently understood to devise effective prevention or minimally invasive treatment. Understanding the ultrastructural changes in enamel is hampered by a lack of nanoscale characterization of the chemical spatial distributions within the dental tissue. This leads to the requirement to develop techniques based on various characterization methods. The purpose of the present study is to demonstrate the strength of analytic methods using a correlative technique on a single sample of human dental enamel as a specific case study to test the accuracy of techniques to compare regions in enamel. The science of the different techniques is integrated to genuinely study the enamel. The hierarchical structures within carious tissue were mapped using the combination of focused ion beam scanning electron microscopy with synchrotron X-ray tomography. The chemical changes were studied using scanning X-ray fluorescence (XRF) and X-ray wide-angle and small-angle scattering using a beam size below 80 nm for ångström and nanometer length scales. The analysis of XRF intensity gradients revealed subtle variations of Ca intensity in carious samples in comparison with those of normal mature enamel. In addition, the pathways for enamel rod demineralization were studied using X-ray ptychography. The results show the chemical and structural modification in carious enamel with differing locations. These results reinforce the need for multi-modal approaches to nanoscale analysis in complex hierarchically structured materials to interpret the changes of materials. The approach establishes a meticulous correlative characterization platform for the analysis of biomineralized tissues at the nanoscale, which adds confidence in the interpretation of the results and time-saving imaging techniques. The protocol demonstrated here using the dental tissue sample can be applied to other samples for statistical study and the investigation of nanoscale structural changes. The information gathered from the combination of methods could not be obtained with traditional individual techniques.

Time-Lapse In Situ 3D Imaging Analysis of Human Enamel Demineralisation Using X-ray Synchrotron Tomography

Caries is a chronic disease that causes the alteration of the structure of dental tissues by acid dissolution (in enamel, dentine and cementum) and proteolytic degradation (dentine and cementum) and generates an important cost of care. There is a need to visualise and characterise the acid dissolution process on enamel due to its hierarchical structure leading to complex structural modifications. The process starts at the enamel surface and progresses into depth, which necessitates the study of the internal enamel structure. Artificial demineralisation is usually employed to simulate the process experimentally. In the present study, the demineralisation of human enamel was studied using surface analysis carried out with atomic force microscopy as well as 3D internal analysis using synchrotron X-ray tomography during acid exposure with repeated scans to generate a time-lapse visualisation sequence. Two-dimensional analysis from projections and virtual slices and 3D analysis of the enamel mass provided details of tissue changes at the level of the rods and inter-rod substance. In addition to the visualisation of structural modifications, the rate of dissolution was determined, which demonstrated the feasibility and usefulness of these techniques. The temporal analysis of enamel demineralisation is not limited to dissolution and can be applied to other experimental conditions for the analysis of treated enamel or remineralisation.

Synchrotron X-ray Studies of the Structural and Functional Hierarchies in Mineralised Human Dental Enamel: A State-of-the-Art Review

Hard dental tissues possess a complex hierarchical structure that is particularly evident in enamel, the most mineralised substance in the human body. Its complex and interlinked organisation at the Ångstrom (crystal lattice), nano-, micro-, and macro-scales is the result of evolutionary optimisation for mechanical and functional performance: hardness and stiffness, fracture toughness, thermal, and chemical resistance. Understanding the physical-chemical-structural relationships at each scale requires the application of appropriately sensitive and resolving probes. Synchrotron X-ray techniques offer the possibility to progress significantly beyond the capabilities of conventional laboratory instruments, i.e., X-ray diffractometers, and electron and atomic force microscopes. The last few decades have witnessed the accumulation of results obtained from X-ray scattering (diffraction), spectroscopy (including polarisation analysis), and imaging (including ptychography and tomography). The current article presents a multi-disciplinary review of nearly 40 years of discoveries and advancements, primarily pertaining to the study of enamel and its demineralisation (caries), but also linked to the investigations of other mineralised tissues such as dentine, bone, etc. The modelling approaches informed by these observations are also overviewed. The strategic aim of the present review was to identify and evaluate prospective avenues for analysing dental tissues and developing treatments and prophylaxis for improved dental health.

Driving and exceptional cases: Supporting relicensing evaluation in patients whose visual fields fail to meet standards

PURPOSE

The UK Driver and Vehicle Licensing Agency's (DVLA) visual field criteria mean that homonymous defects close to fixation are not usually acceptable for driving. Here, we illustrate cases where patients with field defects failing to meet standards had their licences revoked but subsequently were permitted to drive again through exceptional case provisions.

METHODS

Clinical assessment of two patients with homonymous loss: a 62-year-old man (PWT) with a dense left upper homonymous quadrantanopia secondary to a right occipital lobe stroke and a 48-year-old woman (JC), only aware of right upper homonymous quadrantanopia following routine primary care assessment and subsequently attributed to left middle cerebral artery stroke from perinatal intracranial haemorrhage.

RESULTS

PWT's Esterman test showed a significant central defect failing to meet the standard. His subsequent ophthalmic examination was otherwise unremarkable with excellent visual functions. Clinical evidence was provided supporting his relicensing application, and in time, a practical DVLA driving assessment indicated adaptation had been successful, and his licence was restored. JC's defect also failed to meet the standard, and her licence was revoked. Her ophthalmic examination was otherwise unremarkable, and her condition was attributed to a nonprogressive, isolated perinatal event. The DVLA accepted supporting clinical evidence; her subsequent practical driving assessment demonstrated successful adaptation and her licence was also restored.

CONCLUSIONS

Conventional visual field tests are not necessarily predictive of real-world driving performance, with drivers' adaptive strategies not being accommodated. In the UK, individuals with visual field loss failing to meet the standard may be eligible for relicensing as exceptional cases if specific criteria can be met. For exceptional cases potentially licensable under these criteria, the DVLA requires clinician support and a satisfactory practical driving assessment. Similar provisions exist internationally. Clinicians need to be aware of the role they may play in such scenarios.

Evaluation of the Manchester COVID-19 Urgent Eyecare Service (CUES)

INTRODUCTION

Pressure on capacity in ophthalmology alongside the coronavirus (COVID-19) pandemic led to the development of the COVID-19 Urgent Eyecare Service (CUES), allowing patients to receive a prompt ophthalmic consultation, including remotely. The aim of this study was to conduct a service evaluation of CUES in Manchester.

METHODS

Data were collected both prospectively and retrospectively from both primary and secondary care over an 8-week period from June to August 2020.

RESULTS

In primary care CUES in Greater Manchester (GM) 2461 patients were assessed, with a majority self-referring to the service (68.7%, n = 1844). 91.7% of cases initially screened for CUES were deemed eligible and given a telemedicine appointment in GM; 53.3% of these cases required face-to-face consultation. 14.3% of cases seen within in GM CUES (351 out of 2461) were provisionally referred to secondary care. Contemporaneously the main provider emergency eyecare department (EED) attendances were reduced by 37.7% per month between April and December 2020 inclusive, compared to the same months in 2019. Patients attending a CUES face-to-face assessment were more likely to have a diagnosis in agreement with secondary care, compared to patients referred in from telemedicine assessment only (P < 0.05).

CONCLUSION

This evaluation of CUES demonstrates a high level of primary care activity alongside a sustained reduction in EED cases. The case-mix of patients seen within EED following referral appears to be of a less benign nature than those cases seen prior to the introduction of CUES.

Scope of practice of optometrists working in the UK Hospital Eye Service: Second national survey

Purpose

As the landscape in ophthalmology and related commissioning continues to change, there is a pressing need to re‐evaluate the current scope of practice of hospital optometrists working within secondary care in the UK. We aim to establish if the skills or services delivered by optometrists have changed to meet varying demands, and to better understand what changes in practice may have arisen as a result of COVID‐19.

Method

A survey developed from that used in 2015 was disseminated to 129 optometry Hospital Eye Service (HES) leads in September 2020, including questions on department workforce; core services; extended roles; procedures undertaken within extended roles; level of autonomy; arrangements for prescribing; training and accreditation, and service changes in response to COVID‐19.

Results

Ninety responses were received (70% response rate) from within England (76%), Scotland (22%) and Northern Ireland (2%). Whole time equivalents within units ranged from 0.4–79.2 (median of 2.5). In comparison to the 2015 survey, there was an increase in the proportion of units delivering extended roles, with glaucoma (88%) remaining the most common extended role, and new areas of practice in uveitis (21%) and vitreoretinal (13%) services. There was increased use of independent prescribing (67%) in comparison to 18% in 2015 and there was an increase in optometrists delivering laser interventions. In response to COVID‐19, optometrists were increasingly delivering telephone consultations and there were new collaborations between primary and secondary care.

Conclusions

Optometrists’ scope of practice continues to develop in the HES with an increased variety of roles and an apparent increase in the number of units employing optometrists, often working in roles historically performed by medical practitioners. Such changes appear necessary in recovery and transformation within ophthalmology, alongside wider optometry changes arising at the interface of primary and secondary care.

Defining stable glaucoma: a Delphi consensus survey of UK optometrists with a specialist interest in Glaucoma

BACKGROUND

Increasing demand on hospital services has led to the development of alternative community-based services, often run by optometrists for monitoring 'stable' and low-risk glaucoma patients.

METHODS

An online Delphi exercise was undertaken to derive a consensus definition of 'stable glaucoma' amongst optometrists with a special interest in glaucoma. Participants were asked to score their agreement for various clinical parameters. Results from each round were used to inform subsequent rounds.

RESULTS

31 optometrists participated in the study. 100%, 77%, and 68% completion rates were achieved over three rounds respectively. Consensus was reached for 7 parameters: Stability should be defined over a period of 36-48 months, summary measure Visual Field (VF), and/or Trend Analysis should be used to assess VF stability. Two or more decibel (dB) of change of VF mean deviation (MD) is considered unstable. Intraocular pressure (IOP) should be below a target defined by the patient's clinician or a fixed-percentage reduction compared to the presenting IOP. No treatment change during the stability assessment period is considered stable. Imaging with Ocular Coherence Topography Retinal Nerve Fibre Layer (OCT RNFL) assessment should be used to define glaucoma stability. Overview by a glaucoma consultant was considered important for glaucoma monitoring schemes.

CONCLUSION

This Delphi exercise has generated a consensus definition for glaucoma stability by UK Optometrists with a specialist interest in glaucoma. This consensus definition can be used to inform the selection of suitable patients from hospital services for transfer to monitoring in community-based 'stable' optometry run glaucoma clinics.

1

PURPOSE

Describe the development, delivery, acceptability and evaluation of a modular training programme for community-based, non-medical practitioners monitoring patients with quiescent neovascular age related macular degeneration (QnAMD). Also, report on a qualitative process evaluation conducted during the pilot phase of a randomised control trial (the FENETRE Study) exploring patient and practitioner acceptability of community-based QnAMD care relative to hospital-based care.

METHODS

Learning outcomes from The College of Optometrists' Medical Retina higher qualifications and the Royal College of Ophthalmologists' Common Clinical Competency Framework were used to develop a competency framework for QnAMD care. Training was delivered online, comprising six asynchronous lectures followed by two synchronous case-based discussion webinars, with an accredited assessment of 24 case vignettes. An anonymous evaluation survey was conducted with the first two FENETRE cohorts (n = 38). Separately, we undertook a qualitative process evaluation, sampling purposively in four hospitals and five community-based practices, interviewing nine patients and eight practitioners.

RESULTS

Survey responses (n = 26) showed community optometrists were very satisfied (n = 12; 46%) or satisfied (n = 14; 54%) with the training; feedback reflected by qualitative process evaluation data. Overall, optometrists also felt either confident (n = 15; 58%) or very confident (n = 8; 31%) in conducting AMD monitoring appointments following training, a finding also corroborated by interview data from optometrists participating in the initial pilot phase roll-out. Optometrists identified patient convenience and alleviating pressures in hospital care as the primary reasons for acceptability of community pathways. Data from patients entering community practices suggested they largely found this at least as safe and convenient as hospital care, although some patients randomised to hospital care perceived that as safer.

CONCLUSION

This pilot study has shown the development and implementation of a collaborative community monitoring model is feasible, with satisfaction from community optometrists for training and accreditation, and broad acceptance for the pathway by both patients and practitioners.

Acid-induced demineralisation of human enamel as a function of time and pH observed using X-ray and polarised light imaging

Acid-induced enamel demineralisation affects many individuals either by exposure to acidic diets, acidic gas pollution (dental erosion) or to dental plaque acids (dental caries). This study aimed to develop in situ X-ray and light imaging methods to determine progression of enamel demineralisation and the dynamic relationship between acid pH and mineral density. Hourly digital microradiograph time-lapse sequences showed the depth of enamel demineralisation in 500 µm thick sections progressed with time from the surface towards the dentine following a power-law function, which was 21% faster than the lateral demineralisation progression after exposure for 85 h to lactic acid (10%, pH 2.2). The minimum greyscale remaining (mineral content) within the induced enamel lesion followed an exponential decay, while the accumulated total greyscale loss with time was linear, which showed a constant anisotropic mineral release within the enamel architecture. This 85 h demineralisation method studied by polarised light microscopy time-lapse sequences showed that once the demineralisation front reached the enamel Hunter-Schreger bands, there was preferential demineralisation along those bands. Mineral density loss was linear with increasing pH acidity between pH 5.2 and pH 4.0 (with 0.4 pH increments) when incubated over a 3-week period exposed to 0.5% lactic acid. At pH 4.0, there was complete mineral loss in the centre of the demineralised area after the 3-week period and the linear function intercepted the x-axis at ~ pH 5.5, near the critical pH for hydroxyapatite (HAp). These observations showed how intrinsic enamel structure and pH affected the progression of demineralisation. STATEMENT OF SIGNIFICANCE: Hydroxyapatite crystallites (HAp) in human enamel dissolve when exposed to an acidic environment but little is known about how the intrinsic structures in enamel and pH influence the demineralisation kinetics. We have developed a time-lapse in situ microradiography method to quantify microscopic anisotropic mineral loss dynamics in response to an acid-only caries model. Correlation with polarised light microscopy time-lapse sequences showed that larger structures in enamel also influence demineralisation progression as demineralisation occurred preferentially along the Hunter-Schreger bands (decussating prismatic enamel). The pH-controlled enamel mineral release in a linear manner quantifying the relationship between HAp orientation and acid solubility. These findings should direct the development of improved anti-demineralisation/ remineralisation treatments to retain/ restore the natural intrinsic enamel structure.

The minipig as a potential model for pedicle screw fixation: morphometry and mechanics

Background

While there are several different animal models for use in the characterization of spinal fixation, none have emerged as a definitive model for comparative studies in spinal fixation methods. The purpose of this study is to establish morphometric data of porcine vertebrae and to characterize the feasibility of pedicle screw fixation in porcine spines for potential comparative human study.

Methods

Four spines from 45 to 50 kg Hanford minipigs were cleaned of soft tissue and analyzed by computed tomography and dual-energy x-ray absorptiometry. Two 5 × 30-mm pedicle screws were placed in each vertebra and tested to failure using a combined moment-load protocol.

Results

Pedicle widths were measured from L6-T5. Widths ranged from 7.15 mm (T6) to 9.24 mm (T14). Posterior cortex to anterior cortex depth ranged from 25.9 to 32.6 mm. Mean bone mineral density was 1.0665 g/cm² (range 1.139–1.016). Force-to-failure demonstrated mean 1171.40 N (+ 115.34).

Conclusion

Our baseline morphometric and compositional data demonstrate that porcine vertebrae can serve as a useful model for comparative studies due to their similar pedicle widths and bone mineral density to the human vertebra. This biomechanical data could provide a baseline comparison for future studies. This study also suggests that the minipig could be a suitable model for comparative studies due to similarities in pedicle width and bone mineral density to the human vertebrae.

Clinical effectiveness of the Manchester Glaucoma Enhanced Referral Scheme

Background

Glaucoma referral filtering schemes have operated in the UK for many years. However, there is a paucity of data on the false-negative (FN) rate. This study evaluated the clinical effectiveness of the Manchester Glaucoma Enhanced Referral Scheme (GERS), estimating both the false-positive (FP) and FN rates.

Method

Outcome data were collected for patients newly referred through GERS and assessed in ‘usual-care’ clinics to determine the FP rate (referred patients subsequently discharged at their first visit). For the FN rate, glaucoma suspects deemed not requiring referral following GERS assessment were invited to attend for a ‘reference standard’ examination including all elements of assessment recommended by National Institute for Health and Care Excellence (NICE) by a glaucoma specialist optometrist. A separate 33 cases comprising randomly selected referred and non-referred cases were reviewed independently by two glaucoma specialist consultant ophthalmologists to validate the reference standard assessment.

Results

1404 patients were evaluated in GERS during the study period; 651 (46.3%) were referred to the Hospital Eye Service (HES) and 753 (53.6%) were discharged. The FP rate in 307 assessable patients referred to the HES was 15.5%. This study reviewed 131 (17.4%) of those patients not referred to the HES through the GERS scheme; 117 (89.3%) were confirmed as not requiring hospital follow-up; 14 (10.7%) required follow-up, including 5 (3.8%) offered treatment. Only one patient (0.8%) in this sample met the GERS referral criteria and was not referred (true FN). There were no cases of missed glaucoma or non-glaucomatous pathology identified within our sample.

Conclusion

The Manchester GERS is an effective glaucoma filtering scheme with a low FP and FN rate.

In situ monitoring and analysis of enamel demineralisation using synchrotron X-ray scattering

Dental caries is one of the most common chronic diseases that affect human teeth. It often initiates in enamel, undermining its mechanical function and structural integrity. Little is known about the enamel demineralisation process caused by dental caries in terms of the microstructural changes and crystallography of the inorganic mineral phase. To improve the understanding of the carious lesion formation process and to help identify efficient treatments, the evolution of the microstructure at the nano-scale in an artificially induced enamel erosion region was probed using advanced synchrotron small-angle and wide-angle X-ray scattering (SAXS and WAXS). This is the first in vitro and time-resolved investigation of enamel demineralisation using synchrotron X-ray techniques which allows in situ quantification of the microstructure evolution over time in a simulated carious lesion. The analysis revealed that alongside the reduction of mineral volume, a heterogeneous evolution of hydroxyapatite (HAp) crystallites (in terms of size, preferred orientation and degree of alignment) could be observed. It was also found that the rate and direction of dissolution depends on the crystallographic orientation. Based on these findings, a novel conceptual view of the process is put forward that describes the key structural parameters in establishing high fidelity ultrastructure-based numerical models for the simulation of the enamel demineralisation process.

STATEMENT OF SIGNIFICANCE

Hydroxyapatite (HAp) crystallites in the enamel dissolve during dental caries although little is known about the structural-chemical relationships that control the dynamic demineralisation process. For the first time this work investigated the in situ evolution of nano-scale morphology and the spatial distribution of ultrastructural HAp crystallites of human enamel during demineralisation in simulated caries. Advanced synchrotron SAXS and WAXS techniques showed that the heterogeneous evolution of crystallites (size, preferred orientation and degree of alignment) could be attributed to crystallographic-orientation-dependent anisotropic dissolution. Hence we propose a novel conceptual schematic diagram to describe the demineralisation process. These findings have important implications for understanding the detailed mechanisms of enamel demineralisation and provide insight into potential enamel remineralisation that could restore structural integrity and function.

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.

Acceptability and use of glaucoma virtual clinics in the UK: a national survey of clinical leads

Objective

The purpose of this paper is to describe the findings of a national survey that aimed to estimate the proportion of Hospital Eye Service (HES) units using glaucoma virtual clinics, to determine how these services differ and to gauge clinicians’ views and opinions on the safety and acceptability of this model of care compared with usual care.

Methods and analysis

This 12-question survey was disseminated nationally to 92 clinical lead consultant ophthalmologists using SurveyMonkey.

Results

The response rate was 45.7%. There were 21 out of the total 42 respondents (50.0%) who were based at an NHS Trust where glaucoma virtual clinics were already being used and a further 9 (21.4%) were planning to establish one. Clinical leads largely rated efficiency and patient safety to be at least equivalent to usual care (92.9%) and 81.0% perceived glaucoma virtual clinics to be acceptable to patients. The main reasons for not running glaucoma virtual clinics were insufficient staff (71.4%) and inadequate space (47.6%). The majority of those running virtual clinics used this model of care for ‘lower risk’ patients such as ocular hypertensives (90.5%) and glaucoma suspects.

Conclusion

Glaucoma virtual clinics are employed by a large proportion of HES units, with many seeking to develop such services. Clinical leads largely rate efficiency, patient safety and the perception of patient acceptability to be at least equivalent to usual care.

Soft, adhesive (+) alpha tocopherol phosphate planar bilayers that control oral biofilm growth through a substantive antimicrobial effect

'Soft' nanomaterials have the potential to produce substantive antibiofilm effects. The aim of this study was to understand the oral antimicrobial activity of soft nanomaterials generated from alpha-tocopherol (α-T) and alpha-tocopherol phosphate (α-TP). (+) α-TP formed planar bilayer islands (175 ± 21 nm, -14.9 ± 3.5 mV) in a Trizma® buffer, whereas (+) α-T formed spherical liposomes (563 ± 1 nm, -10.5 ± 0.2 mV). The (+) α-TP bilayers displayed superior Streptococcus oralis biofilm growth retardation, a more substantive action, generated a superior adsorption to hydroxyapatite and showed an enhanced inhibition of multi-species bacterial saliva biofilm growth (38 ± 7μm vs 58 ± 18 μm, P ˂ 0.05) compared to (+) α-T. Atomic force microscopy data indicated that the ability of the 'soft' α-TP nanomaterials to transition into planar bilayer structures upon contact with interfaces facilitated their adhesive properties and substantive antimicrobial effects.

Glaucoma, dementia, and the "precipice of care": transitions between states of medication adherence

PURPOSE

"She wouldn't remember. Even when I go through, and she's decided to go to bed, I'll say I'll come and do her drops. If I didn't say that, they wouldn't be done." Dementia is widely considered as a key factor in whether patients take their medication as prescribed. However, few studies have examined the effect of dementia on medication management strategies for glaucoma including how patient and carer needs impact adherence and long-term prognosis. We report findings from a qualitative grounded theory study incorporating the views of patients, carers, and healthcare professionals.

METHODS

Eighty-three semistructured interviews were conducted with 35 patients, 22 lay carers, and nine healthcare professionals across sites in Wales and Scotland. These explored understanding of eye drop regimens, barriers, and facilitators to drop administration, as well as attitudes toward glaucoma, dementia, and other comorbidities.

RESULTS

Using Pound's synthesis of adherence behavior, we identified categories of active and passive acceptance of medicines, alongside modification or rejection of eye drop regimens. In relation to dementia, participants highlighted transitions between such categories, with a shift from active to passive acceptance commonly reported. This loss of self-medicating capability was referred to as the precipice of care, where entwinement of multiple conditions (eg, heart disease, glaucoma, and dementia) and sociocultural influences (eg, living alone) contributed to accelerated health declines. That said, numerous factors mitigated this, with a key role being the lay carer. Spouses and family members often acted as the monitor of eye drops for patients, seeking intervention when any behavioral changes influenced their administration.

CONCLUSION

Though dementia was associated with progression toward the precipice of care, factors such as communication with healthcare professionals appeared to affect patient adherence. Recommendations for healthcare practice include better recording of dementia diagnoses and integrating eye drops into preexisting routines.

Topically Applied Epsilon-Aminocaproic Acid Reduces Blood Loss and Length of Hospital Stay After Total Knee Arthroplasty

Perioperative blood loss after total knee arthroplasty (TKA) affects postoperative recovery. Tranexamic acid is safe and efficient in reducing blood loss without increasing thromboembolic events. Epsilon-aminocaproic acid (ε-ACA) is less expensive than and as safe as tranexamic acid. Its efficiency when locally applied in TKA is unknown. The authors retrospectively followed 240 consecutive patients treated by 1 surgeon with TKA from January 2012 to August 2016. From January 2013 to May 2015, the authors topically applied 5 g of ε-ACA to the open wound after tourniquet release and before closure (ε-ACA-after-tourniquet-release group). From August 2015 to August 2016, the authors topically applied 5 g of ε-ACA intraoperatively to the open wound 3 minutes before tourniquet release (ε-ACA-before-tourniquet-release group). The last 80 patients not receiving ε-ACA (control group), the 80 patients in the ε-ACA-after-tourniquet-release group, and the 80 patients in the ε-ACA-before-tourniquet-release group were compared regarding blood loss, treatment costs, and thromboembolic complications. The mean±SD calculated blood loss was 1478.8±367.1 mL for the control group, 1424.0±249.3 mL for the ε-ACA-after-tourniquet-release group, and 1052.3±419.1 mL for the ε-ACA-before-tourniquet-release group (P<.05). Using ε-ACA before tourniquet release reduced the length of hospital stay by 0.7 days (P<.05) compared with not using ε-ACA, leading to cost savings of $1547.37 per patient. One patient in the ε-ACA-before-tourniquet-release group and 1 patient in the control group developed a venous thromboembolism in the postoperative period. Epsilon-aminocaproic acid significantly reduces blood loss after TKA when topically applied before tourniquet release. Its application reduced costs by decreasing the length of hospital stay and did not increase thromboembolic events. [Orthopedics. 2017; 40(6):e1044-e1049.].

Retrospective economic analysis of the transfer of services from hospitals to the community: an application to an enhanced eye care service

OBJECTIVE

This research aims to evaluate the wider health system effects of the introduction of an intermediate-tier service for eye care.

SETTING

This research employs the Minor Eye Conditions Scheme (MECS), an intermediate-tier eye care service introduced in two London boroughs, Lewisham and Lambeth, in April 2013.

DESIGN

Retrospective difference-in-differences analysis comparing changes over time in service use and costs between April 2011 and October 2014 in two commissioning areas that introduced an intermediate-tier service programme with changes in a neighbouring area that did not introduce the programme.

DATA SOURCES

MECS audit data; unit costs for MECS visits; volumes of first and follow-up outpatient attendances to hospital ophthalmology; the national schedule of reference costs.

MAIN OUTCOME MEASURES

Volumes and costs of patients treated.

RESULTS

In one intervention area (Lewisham), general practitioner (GP) referrals to hospital ophthalmology decreased differentially by 75.2% (95% CI -0.918% to -0.587%) for first attendances, and by 40.3% for follow-ups (95% CI -0.489% to -0.316%). GP referrals to hospital ophthalmology decreased differentially by 30.2% (95% CI -0.468% to -0.137%) for first attendances in the other intervention area (Lambeth). Costs increased by 3.1% in the comparison area between 2011/2012 and 2013/2014. Over the same period, costs increased by less (2.5%) in one intervention area and fell by 13.8% in the other intervention area.

CONCLUSIONS

Intermediate-tier services based in the community could potentially reduce volumes of patients referred to hospitals by GPs and provide replacement services at lower unit costs.

Effectiveness of UK optometric enhanced eye care services: a realist review of the literature

PURPOSE

UK demographic and legislative changes combined with increasing burdens on National Health Service manpower and budgets have led to extended roles for community optometrists providing locally-commissioned enhanced optometric services (EOS). This realist review's objectives were to develop programme theories that implicitly or explicitly explain quality outcomes for eye care provided by optometrists via EOS and to test these theories by investigating the effectiveness of services for cataract, glaucoma, and primary eye care.

METHODS

The review protocol was published on PROSPERO, and RAMESES publication standards were followed. Programme theories were formulated via scoping literature searches and expert consultation. The searching process involved all relevant electronic databases and grey literature, without restrictions on study design. Data synthesis focussed on questioning the integrity of each theory by considering supportive and refuting evidence from the source literature.

RESULTS

Good evidence exists for cataract, glaucoma and primary eye care EOS that: with appropriate training, accredited optometrists manage patients commensurate with usual care standards; genuine partnerships can exist between community and hospital providers for cataract and glaucoma EOS; patient satisfaction with all three types of service is high; cost-effectiveness of services is unproven for cataract and primary eye care, while glaucoma EOS cost-effectiveness depends on service type; contextual factors may influence service success.

CONCLUSIONS

The EOS reviewed are clinically effective and provide patient satisfaction but limited data is available on cost-effectiveness.

Effectiveness of portable electronic and optical magnifiers for near vision activities in low vision: a randomised crossover trial

PURPOSE

To compare the performance of near vision activities using additional portable electronic vision enhancement systems (p-EVES), to using optical magnifiers alone, by individuals with visual impairment.

METHODS

A total of 100 experienced optical aid users were recruited from low vision clinics at Manchester Royal Eye Hospital, Manchester, UK, to a prospective two-arm cross-over randomised controlled trial. Reading, performance of near vision activities, and device usage were evaluated at baseline; and at the end of each study arm (Intervention A: existing optical aids plus p-EVES; Intervention B: optical aids only) which was after 2 and 4 months.

RESULTS

A total of 82 participants completed the study. Overall, maximum reading speed for high contrast sentences was not statistically significantly different for optical aids and p-EVES, although the critical print size and threshold print size which could be accessed with p-EVES were statistically significantly smaller (p < 0.001 in both cases). The optical aids were used for a larger number of tasks (p < 0.001), and used more frequently (p < 0.001). However p-EVES were preferred for leisure reading by 70% of participants, and allowed longer duration of reading (p < 0.001). During the study arm when they had a p-EVES device, participants were able to carry out more tasks independently (p < 0.001), and reported less difficulty with a range of near vision activities (p < 0.001).

CONCLUSIONS

The study provides evidence that p-EVES devices can play a useful role in supplementing the range of low vision aids used to reduce activity limitation for near vision tasks.

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.

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.

Evaluating the Effectiveness of an Established Community-Based Eccentric Viewing Rehabilitation Training Model-the EValuation Study

PURPOSE

This study evaluated the community-based eccentric viewing (EV) training offered across the United Kingdom by the Macular Society. Volunteer trainers deliver free one-to-one training, usually in learners' homes. They also share information about lighting, magnification, social support, and low-vision technology.

METHODS

The audio-recorded reading performance of learners was compared before and after training. Telephone questionnaires were used to assess life satisfaction, amount of reading performed, and health- and vision-related quality of life. Learners were also interviewed to obtain their subjective opinions.

RESULTS

A total of 121 learners completed all stages of the study. There was no significant change in maximum reading speed. A statistically significant (P < 0.001) but small improvement in both critical print size and threshold print size was found, but frequency and duration of reading did not increase. There was a borderline significant (P = 0.022) increase in "life satisfaction" for the learners, but a highly significant (P < 0.001) decrease in their "positive affect." There was no change in health- or vision-related quality of life, or in the difficulty experienced in performing everyday tasks. However, according to learner interviews, 72% felt they had achieved a positive outcome from the training, and 75% felt they had received helpful advice in addition to the EV training.

CONCLUSIONS

The lack of improvement of reading speed and modest improvement in threshold print size should be interpreted in the context of the unique features of this EV program, since many learners who would seem to have limited scope for improvement still undertake the training.

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.

Cytotoxicity screening of surfactant-based shampoos using a multiwell fluorescence scanner: Correlation with Draize eye scores

The irritancy potential of seven shampoos was evaluated by a rapid cytotoxicity assay in cultured human keratinocytes and rat hepatocytes. Loss of cell viability was estimated from increases in propidium iodide fluorescence measured using a multiwell fluorescence scanner. The concentration of shampoo causing a 50% loss of cell viability after 15 min of incubation (V(50)) was determined by probit analysis. Log V(50) measured in human keratinocytes showed a strong negative correlation (r = -0.95; P <0.001) with Draize eye scores in rabbits. Log V(50) measured in rat hepatocytes did not show a statistically significant correlation with Draize eye scores. The results indicate that cytotoxicity screening of human keratinocytes using propidium iodide and a multiwell fluorescence scanner is highly predictive of Draize eye scores for surfactant-containing shampoos.

Agreement between specially trained and accredited optometrists and glaucoma specialist consultant ophthalmologists in their management of glaucoma patients

AIMS

Optometrists are becoming increasingly involved in the co-management of glaucoma patients as the burden on the Hospital Eye Service continues to escalate. The aim of this study was to assess the agreement between specially trained optometrists and glaucoma-specialist consultant ophthalmologists in their management of glaucoma patients.

METHODS

Four optometrists examined 23-25 patients each and the clinical findings, up to the point of dilation, were documented in the hospital records. The optometrist, and one of two consultant ophthalmologists, then independently examined and documented the optic-disc appearance before recording their decisions regarding the stability and management of the patient on a specially designed proforma. Percentage agreement was calculated together with kappa or weighted kappa statistics, where appropriate.

RESULTS

Agreement between consultants and optometrists in evaluating glaucoma stability was 68.5% (kappa (κ)=0.42-0.50) for visual fields, 64.5% (weighted κ=0.17-0.31) for optic discs, and 84.5% (weighted κ=0.55-0.60) for intraocular pressures. Agreement regarding medical management was 96.5% (κ=0.73-0.81) and for other glaucoma management decisions, including timing of follow-up, referral to a consultant ophthalmologist, and discharge, was 72% (weighted κ=0.65). This agreement increased to 90% following a retrospective independent then consensus review between the two consultants and when qualified agreements were included. Of the 47 glaucoma and non-glaucoma queries generated during the study, 42 resulted in a change of management.

CONCLUSION

Confirming the ability of optometrists to make appropriate decisions regarding the stability and management of glaucoma patients is essential if their involvement is to continue to develop to meet the demand of an aging population.

Psychosocial adjustment in age related macular degeneration

This article describes longitudinally the psychosocial adjustment to visual impairment of patients with age related macular degeneration (AMD). As part of a larger randomized controlled trial (RCT), the present study design consisted of the use of prospective qualitative diaries completed over 12 months by patients with AMD who were newly referred to a low vision clinic. Out of the patients recruited (n = 226), the completion rate of a full set of four diaries (n = 37) and one three-month diary (n = 194) was very good. Vision related to daily life in patients with AMD appears to decline over 12 months with limited psychosocial adjustment to visual loss. Seven themes were generated from the patients' accounts of their experiences, as recorded in the diaries: safety, loss of independence, isolation, support mechanisms, mood, effects of the media and psychosocial adjustment. There was little evidence in the diaries of psychosocial adjustment to visual loss. The relevance of the theory of grieving and cognitive and rational-emotional theory in the context of AMD is explored in detail.

The effectiveness of the Heidelberg Retina Tomograph and laser diagnostic glaucoma scanning system (GDx) in detecting and monitoring glaucoma

OBJECTIVES

To determine the potential of optic nerve head tomography [Heidelberg Retina Tomograph (HRT)] and scanning laser polarimetry (GDx) for identifying patients with glaucomatous visual field loss.

DESIGN

Examinations were performed with the HRT, GDx and Humphrey Field Analyzer (HFA). Glaucoma was defined by the presence of a field defect. Patients within the cross-sectional groups underwent a single examination, whereas patients in the longitudinal groups were examined 6 monthly, for an average of 3.5 years.

SETTING

Manchester Royal Eye Hospital, UK.

PARTICIPANTS

Patients with primary open angle glaucoma (POAG) or who were at risk of developing glaucoma.

INTERVENTIONS

The diagnostic accuracies of the HRT and GDx were compared; specificity was set at 95%. The rate of change was determined by linear regression. To estimate the clinical application of the instruments, the proportion of an unselected group of patients on whom the examinations could be performed was calculated. Additionally, the time taken to perform and process each examination was measured.

MAIN OUTCOME MEASURES

The ability of the techniques to identify cases showing deterioration. The level of agreement and applicability of the techniques. Time taken to perform and process each examination.

RESULTS

From the cross-sectional group, the maximum sensitivities of the HRT and GDx were 59% and 45%, respectively (at 95% specificity). From the two longitudinal cohorts, the level of agreement between the three instruments for identification of the development and deterioration of POAG was low. The applicability of the techniques was 80% (HRT), 88% (GDx) and 98% (HFA). The length of time to perform a full examination with each instrument was 12.3, 11.8 and 28.3 minutes, respectively. Agreement of HRT and GDx parameters between and within observers was largely good.

CONCLUSIONS

There is poor agreement for detection of glaucoma between the HFA, HRT and GDx. The techniques are amenable to use in the clinical environment, but no single examination has sufficient diagnostic precision to be used in isolation; also, the imaging techniques were not universally applicable. Neither the HRT nor GDx should be viewed as a replacement for visual field examination. Further research is needed into why most patients within the longitudinal arms of the study showed very little deterioration and into determining aspects of the structure versus function relationship in glaucoma that may explain why any one technique fails to detect a proportion of cases.

Technical Note: grading the vertical cup:disc ratio and the effect of scaling

PURPOSE

To evaluate the effect of scaling on sensitivity to change for grading the vertical cup:disc ratio (CDR).

METHODS

Vertical CDR was assessed by six observers (three ophthalmologists and three optometrists) on 43 stereo disc photographs. Repeated observations were made for both 0.1 and 0.05 interval scales. Paired differences were calculated for all observers and each observer separately. Mean and standard deviation of differences and agreement statistics were used to compare scales.

RESULTS

Five observers demonstrated a reduction in the spread of differences (mean difference 0.19 to 0.15) and all observers demonstrated a reduction in concordance using the finer scale (mean concordance 54% to 39%).

CONCLUSION

The use of a finer scale reduces test-retest variability and increases sensitivity to change when estimating the vertical CDR. Use of this scale does not require any additional resource and it may be easily implemented in routine clinical practice.

Visual Acuity and Fixation Characteristics in Age-Related Macular Degeneration

PURPOSE

To compare "single letter" (SL) acuity, "crowded letter" (CL) acuity, and "repeated letter" (RL) acuity for patients with age-related macular degeneration (AMD) and investigate if differences between these visual acuities are associated with fixation characteristics.

METHODS

A total of 243 patients with AMD had their best-corrected visual acuity measured on an ETDRS chart. SL, CL, and RL acuities were measured using Landolt C targets on a monitor. Fifty-degree-field red-free fundus photographs were taken and a static target was used to calculate the Preferred Retinal Locus (PRL) distance and direction from the fovea. Quality of fixation (consistency and oculomotor response) was also assessed using a fundus camera and a dynamic target.

RESULTS

RL acuity was almost always better than CL acuity and SL acuity was almost always better than CL acuity. The mean (+/-SD) RL-CL and SL-CL acuity differences were -0.13 (+/-0.15) logMAR and -0.11 (+/-0.13) logMAR respectively. The median PRL distance was 3.73 degrees and the preferred retinal areas for the location of the PRL were the left (left quadrant of visual field; 39.5% of cases) and superior (inferior quadrant of visual field; 25.4%). Visual acuity was significantly associated with PRL distance but PRL distance only explained 10% of the variation in visual acuity. PRL distance was found to be a significant but weak predictor of the SL-CL acuity difference but fixation quality was not a good predictor of the RL-CL acuity difference.

CONCLUSIONS

Although the acuity measured under different stimulus conditions varies, the absolute differences are small. This suggests that these techniques would not be helpful in determining fixation characteristics, or predicting the outcome of rehabilitation in individual patients with AMD.

A randomized controlled trial to determine the effectiveness of prism spectacles for patients with age-related macular degeneration

OBJECTIVE

To determine the effectiveness of prism spectacles in people with age-related macular degeneration by relocating the retinal image.

METHODS

We implemented a randomized, placebo-controlled, double-masked trial. Participants with age-related macular degeneration received a standard low-vision assessment and the prescription of conventional low-vision aids 6 weeks before the study intervention. Participants were randomized to receive 1 of the following, including the optimal refractive correction: (1) custom, incorporating bilateral prisms to match participants' preferred power and base direction; (2) standard, incorporating standard bilateral prisms (6 prism diopters [Delta] base up for logMAR [logarithm of the minimum angle of resolution] visual acuity (VA) of 0.48-1.00 and 10Delta base up for logMAR VA of 1.02-1.68); or (3) placebo, consisting of spectacles matched in weight and thickness to prism spectacles but without prism.

MAIN OUTCOME MEASURES

Outcomes measured binocularly at baseline and 3-month follow-up included distance logMAR VA, reading speed, critical print size, visual functioning questionnaires, and observed visual task performance. Scores on the 25-item National Eye Institute Visual Functioning Questionnaire and the Melbourne Low-Vision ADL (Activities of Daily Living) Index were converted to linear estimates using Rasch analysis. The Manchester Low Vision Questionnaire was used to collect descriptive data.

RESULTS

A total of 225 participants completed the trial (median age, 81 years). We found no significant effect of treatment group on any of the outcome measures, including VA, the primary outcome (adjusted for baseline) (P = .63). Participants' responses to the Manchester Low Vision Questionnaire suggested that the prism spectacles added to their problems.

CONCLUSIONS

Prism spectacles are no more effective than conventional spectacles for people with age-related macular degeneration.

Using gloves coated with a dermal therapy formula to improve skin condition

Thirty-one health care workers, of whom 24 (77%) were perioperative nurses, evaluated a new nonlatex surgical glove with a coating consisting of ingredients clinically proven to have beneficial effects on skin health. In this one-day, clinical self-assessment study, nurses and other health care workers compared the condition of the skin on their hands before and after wearing these surgical gloves. Eighty-one percent of the perioperative nurses and health care workers rated the skin on the hand that had worn the glove as less dry than it had been at baseline. Sixty-five percent rated their skin as more hydrated, and 58% rated their skin as smoother and more supple after wearing a surgical glove coated with a dermal therapy formulation.

Enhanced low vision rehabilitation for people with age related macular degeneration: a randomised controlled trial

AIM

To compare the effectiveness of three models of low vision rehabilitation for people with age related macular degeneration (AMD) referred for low vision rehabilitation (LVR): (a) an enhanced low vision rehabilitation model (ELVR) including supplementary home based low vision rehabilitation; (b) conventional low vision rehabilitation (CLVR) based in a hospital clinic; (c) CLVR with home visits that did not include rehabilitation (CELVR), intended to act as a control for the additional contact time with ELVR.

METHOD

A single centre parallel group randomised controlled trial in participants' homes and the low vision clinic, Manchester Royal Eye Hospital. People referred for LVR with a primary diagnosis of AMD and visual acuity worse than 6/18 in both eyes and equal to or better than 1/60 in the better eye. The main outcome measures were vision specific quality of life (QoL) (primary outcome, VCM1) and generic health related QoL (SF-36); psychological adjustment to vision loss; measured task performance; restriction in everyday activities; use of low vision aids (LVAs).

RESULTS

226 participants were recruited (median age 82 years); 194 completed the trial (86%). Except for SF-36 physical and mental component summary scores, arms did not differ significantly for any of the outcomes. Differences for the VCM1 were ELVR v CLVR, 0.06 (95% CI to 0.17 to 0.30, p = 0.60); ELVR v CELVR, 0.12 (95% CI to 0.11 to 0.34, p = 0.31); CELVR v CLVR, -0.05 (95% CI -0.29 to 0.18, p = 0.64). Differences for the SF-36 favoured CLVR compared to ELVR (ELVR v CLVR: physical = -6.05, 95% CI -10.2 to -1.91, p = 0.004; mental = -4.04, 95% CI -7.44 to -0.65, p = 0.02). At 12 months, 94% of participants reported using at least one LVA.

CONCLUSION

ELVR was no more effective than CLVR. Researchers should be wary of proposing new LVR interventions without preliminary evidence of effectiveness, given the manifest lack of effectiveness of the model of enhanced LVR evaluated in the trial.

Face recognition in age related macular degeneration: perceived disability, measured disability, and performance with a bioptic device

AIMS

(1) To explore the relation between performance on tasks of familiar face recognition (FFR) and face expression difference discrimination (FED) with both perceived disability in face recognition and clinical measures of visual function in subjects with age related macular degeneration (AMD). (2) To quantify the gain in performance for face recognition tasks when subjects use a bioptic telescopic low vision device.

METHODS

30 subjects with AMD (age range 66-90 years; visual acuity 0.4-1.4 logMAR) were recruited for the study. Perceived (self rated) disability in face recognition was assessed by an eight item questionnaire covering a range of issues relating to face recognition. Visual functions measured were distance visual acuity (ETDRS logMAR charts), continuous text reading acuity (MNRead charts), contrast sensitivity (Pelli-Robson chart), and colour vision (large panel D-15). In the FFR task, images of famous people had to be identified. FED was assessed by a forced choice test where subjects had to decide which one of four images showed a different facial expression. These tasks were repeated with subjects using a bioptic device.

RESULTS

Overall perceived disability in face recognition did not correlate with performance on either task, although a specific item on difficulty recognising familiar faces did correlate with FFR (r = 0.49, p<0.05). FFR performance was most closely related to distance acuity (r = -0.69, p<0.001), while FED performance was most closely related to continuous text reading acuity (r = -0.79, p<0.001). In multiple regression, neither contrast sensitivity nor colour vision significantly increased the explained variance. When using a bioptic telescope, FFR performance improved in 86% of subjects (median gain = 49%; p<0.001), while FED performance increased in 79% of subjects (median gain = 50%; p<0.01).

CONCLUSION

Distance and reading visual acuity are closely associated with measured task performance in FFR and FED. A bioptic low vision device can offer a significant improvement in performance for face recognition tasks, and may be useful in reducing the handicap associated with this disability. There is, however, little evidence for a correlation between self rated difficulty in face recognition and measured performance for either task. Further work is needed to explore the complex relation between the perception of disability and measured performance.

Neurologic and psychiatric manifestations in a family with a mutation in exon 2 of the guanosine triphosphate-cyclohydrolase gene

OBJECTIVE

To investigate the range of clinical features to correlate genotypic and phenotypic manifestations in hereditary progressive and/or levodopa-responsive dystonia due to a defect in the guanosine triphosphate-cyclohydrolase (GCH1) gene.

DESIGN AND SETTING

A large family from Texas was studied in an ambulatory setting by clinicians in genetics, neurology, and psychiatry using structured interviews and examinations.

PATIENTS

The family was selected after neurometabolic investigations of a young boy (proband) with foot dystonia and fatigue and his father, who had a long history of anxiety and depression. Results of metabolic studies showed decreased levels of metabolites of biopterin and biogenic amines in cerebrospinal fluid. Subsequently, a novel mutation (37-base pair deletion) in exon 2 of the GCH1 gene was demonstrated in 11 family members. There was no observed female sex bias, but there was a wide variability of motor dysfunctions in family members. Approximately 50% had clinical deafness and a similar number had significant psychiatric dysfunction, including depression and anxiety.

CONCLUSION

Study of additional families with hereditary progressive and/or levodopa-responsive dystonia using modern molecular methods will be necessary to confirm the neuropsychiatric spectrum of this disorder, in which important clinical features may be unrecognized and thus inappropriately managed.