Inequalities in healthcare utilisation among adults with type 2 diabetes

AIMS

To examine inequality in dentist, ophthalmologist, and podiatrist attendance among adults with type 2 diabetes in a country with varying degrees of co-payment.

RESEARCH DESIGN AND METHODS

We conducted a cross-sectional study with a population of 41,181 people with type 2 diabetes resident in the Central Denmark Region in 2019, identified through Danish registers using a prespecified diabetes algorithm. Descriptive statistics and multiple logistic regression were used to examine the attendance at dentist, ophthalmologist, and podiatrist, controlling for sociodemographic and clinical factors. Attendance at dentist, ophthalmologist, and podiatrist were examined separately.

RESULTS

The majority (59.7 %) had attended the ophthalmologist at least once in the preceding year, whereas 46.5 % and 34.2 % had visited the dentist/dental hygienist and podiatrist, respectively. Disposable household income increased attendance significantly, with a clear gradient in the OR of attending the dentist (p < 0.001), whereas age significantly magnified the OR of podiatrist and ophthalmologist attendance (p < 0.001).

CONCLUSIONS

This study provides circumstantial evidence that co-payment can increase inequality in health care attendance, especially for dental attendance, and it further shows that there is significant sociodemographic inequality in healthcare utilisation among people with type 2 diabetes.

A Call for Regular Ophthalmologist Cover for Rehabilitation Centers for the Blind

A call to the governments of developing countries that parents of visually impaired, all eyecare workers especially ophthalmologists including all schools where visually impaired people are being educated, to see the advantage of proper screening and continuous eyecare of individuals who present to these schools/rehabilitation centers by qualified eyecare personnel as well as have proper knowledge of where such rehabilitative services are available by those who should knowthe eyecare workers. The specific role of the ophthalmologist is highlighted.

Digital Survey Assessment of Individual and Occupational Factors Associated with Musculoskeletal Disorders among Indian Ophthalmologists

Purpose

To study the prevalence of musculoskeletal disorder (MSD) and the associated occupational risk factors among Indian ophthalmologists, including residents and fellows.

Methods

A cross-sectional survey was conducted among ophthalmologists in India using a semi-structured questionnaire in a web-based survey. The questionnaire was prepared in English after extensive literature research and consulting with subject experts. It was pretested on ten ophthalmologists and after confirming that there were no ambiguities, the questionnaire was circulated. After providing informed consent online and ensuring the confidentiality of information, respondents could fill out the questionnaire containing questions to assess demographic details, risk factors, and musculoskeletal symptoms.

Results

We received 551 valid responses, out of which 74.77% reported musculoskeletal symptoms since starting practice in ophthalmology. We found a statistically significant association of work-related MSD with greater hours of practice, a higher number of hours of surgery, and a larger patient load. The self-reported symptoms were maximum in lower back (56.55%), followed by neck (49.03%), upper back (38.59%), and shoulder (23.79%). As a remedial measure, 58.98% resorted to rest while only 8.98% consulted orthopedist. Only 46% were aware of good ergonomic practices. Surgery (74.5%), indirect ophthalmoscopy (51.69%), and slit-lamp examination (50.73%) were reported as the major culprits. Respondents declared an interference with personal life (39.56%), with work (33.74%) as well as having caused psychological stress (43.2%) due to work-related MSD.

Conclusion

A vast majority of our respondents reported work-related MSD. Major risk factors were hours of practice, hours of surgery, higher body mass index, sedentary lifestyle, and higher patient load. The awareness of ergonomic practices was low.

Assessment of the distribution of human and material resources for eye health in the public sector in Nampula, Mozambique

BACKGROUND

The unavailability of human and material resources can affect access to eye health services, constituting an obstacle in the fight against avoidable visual impairment. This study aimed to assess the availability and distribution of human and material resources for eye health in the public sector in Nampula province.

METHODS

A mixed method approach was used, which included document reviews (to extract information regarding the number of professionals and inhabitants in each district) and application of a questionnaire to heads of the ophthalmology department in each health facility (to obtain the list of available equipment). The ratios of eye health professionals per population in Nampula province and each of its districts were calculated and evaluated taking into account the recommendations of the World Health Organization (WHO). Based on the level of care of each health facility, the availability of equipment was evaluated.

RESULTS

Nampula Province has not reached the recommended ratio of eye health professionals per population in the different categories (ophthalmic technicians with 0.8 per 100 thousand inhabitants; optometrists and ophthalmologists with 0.4 and 0.2 per 250 thousand inhabitants, respectively). Most districts of Nampula did not reach the recommended ratio in the three categories of professionals, except Nampula City (provincial capital). However, there was a greater concentration of professionals and facilities with eye health services in the provincial capital. Primary and secondary level health facilities lacked some equipment to provide eye health services within their scope.

CONCLUSIONS

There is an unequal distribution of the workforce in Nampula and the centralization of surgical services at the Central Hospital of Nampula level. Therefore, there is a need to review resource distribution strategies and decentralization policy of eye health services in Nampula.

Knowledge about Prescribing Antibiotics as Prophylaxis in Patients with Open Globe Injury: A Survey in Iranian Ophthalmologists

Objective

This study aimed to evaluate the Iranian ophthalmologists' knowledge of prescribing prophylactic antibiotics to patients with open globe injury (OGI) in Iran.

Methods

In this cross-sectional study, we utilized a questionnaire to evaluate the ophthalmologists' knowledge about prescribing antibiotics as prophylaxis. This survey was conducted in Tehran and its suburbs. The questionnaire included demographic information as well as ophthalmologists' knowledge levels. Cronbach's alpha was used to determine its validity and reliability. The obtained data were analyzed using SPSS 24.0.

Results

Of 192 subjects, 111 (35 women, 76 men) were included. About 65 (58.6%) specialists and 45 (41.4%) subspecialists with different orientations completed the questionnaires. The total knowledge score was 13.04±2.96. The following are the results of ophthalmologists' responses to questions regarding the cornea/scleral injury (1.09±1.72), prophylactic antibiotics administration (2.79±1.11), the infectious agents in eye surgeries (3.21±1.49), diagnosis and treatment (2.84±0.944), and the effects of ocular antibiotics as well as their proper dosage (2.96±2.35). There was no significant relationship between some demographic information such as sex, working hours, workplace, and the number of studied articles (p>0.05). In addition, ophthalmologists with less work experience had significantly higher levels of knowledge than those with more work experience.

Conclusion

The findings indicated that the majority of ophthalmologists had a basic knowledge of prescribing prophylactic antibiotics in OGI.

Diagnostic Correlation between General Practitioners and the Ophthalmologist in the Management of Eye Diseases

OBJECTIVES

To determine the accuracy of diagnosis of ophthalmic disorders as well as the adequacy of referral of patients with ophthalmic disorders for specialist eye care by the general practitioners (GP).

MATERIALS AND METHODS

This was a hospital-based descriptive study. Patients selected by systematic random sampling at the General Out-Patient Department (GOPD) of a tertiary hospital were evaluated by the ophthalmologist after they had been independently assessed by the General Practitioners. Diagnoses and referral decisions of the GP were compared with those of the ophthalmologist using Kappa Statistics.

RESULTS

A total of 382 patients were studied while 22 GPs participated in the study. Ocular disorders were found by the ophthalmologist in 112 (29.3%) patients while the remaining 270 (70.7%) were normal . Only 36 (32.1%) of those with ocular disorders had a diagnosis of ocular disorders by the General Practitioners. A correct diagnosis was made by the GPs for 18 (16.1%) patients (k=0.102, p =0.001); and the highest diagnostic agreement was obtained for conjunctivitis (k=0.464, P= 0.001). No patient with posterior segment disorder was diagnosed by the GPs. Majority (81%; k = 0.616, p=0.001) of referrals were in agreement with expected referral decision. However, 28 (25.0%) under-referrals and 16 (19.0%) over-referrals were noted.

CONCLUSION

About one-third of all the patients assessed had an ocular disorder, but the general practitioners detected these disorders only one-third of the time; a correct diagnosis of ocular disorders was made in only 16.1%, while no posterior segment disease was diagnosed. Wrong referral decisions were made in up to one-third of patients. Regular update courses for general practitioners on ophthalmic evaluation will help address these observed deficiencies.

[Patient education before ocular surgery]

Particular importance and diligence must be attached to patient information prior to ocular surgery. A surgical intervention performed without error according to the state of the art in medicine remains exempt from punishment according to § 228 German Criminal Code (StGB) only if effective consent to the treatment is given and only then is there no liability if a risk inherent to the intervention materializes. The patient's consent is only effective if the patient has been properly informed beforehand. In medical malpractice proceedings, a breach of the duty to inform is regularly alleged. From the outset, the physician bears the burden of proof that he has obtained consent in accordance with Section 630d of the German Civil Code (BGB) and provided information in accordance with the requirements of Section 630e of the BGB. The provisions of the Patients' Rights Act also contain formulations that regularly lead to a very detailed individual review of possible errors of disclosure in medical liability proceedings. Apart from the indispensable requirement of an oral clarification discussion by a physician qualified to do so, who informs about "all essential circumstances" of the planned eye operation, the adherence to formal requirements for the clarification discussion and a written documentation with the individual discussion contents are of decisive importance in a lawsuit in order to reduce possible liability risks from the outset. On the one hand, case law sets high requirements for information and on the other hand, every ophthalmologist should also be aware that this effectively counteracts a depersonalization of the physician-patient relationship.

Risk factors for mental health symptoms during the COVID-19 pandemic in ophthalmic personnel and students in USA (& Canada): a cross-sectional survey study

BACKGROUND

The COVID-19 pandemic poses mental health challenges to frontline healthcare workers. Eye care professionals may be especially susceptible to mental health problems due to high-risk exposures to patients. Yet, no prior research has studied mental health issues among eye care professionals during the COVID-19 pandemic.

OBJECTIVE

The purpose of this study was to identify risk factors for mental health problems during the COVID-19 pandemic among eye care professionals.

METHODS

We conducted a cross-sectional survey study among eye care professionals and students in the United States and Canada from June 23 to July 8, 2020 during the COVID-19 pandemic. A total of 8505 eye care professionals and students received email invitations to the survey and 2134 participated. We measured mental health outcomes including symptoms of depression, anxiety, and stress using validated scales, as well as potential risk factors including demographic characteristics, state-level COVID-19 case counts, participants' patient interactions, childcare responsibilities, and pre-pandemic stress levels. Linear multiple regression and logistic regression analyses were used to determine relationships between risk factors and mental health outcomes.

RESULTS

We found that 38.4% of eyecare professional participants in the survey met screening threshold as probable cases of anxiety, depression, or both during the COVID-19 pandemic. Controlling for self-reported pre-pandemic stress level and state COVID-19 case daily cases, significant risk factors for depression, anxiety, and psychological stress during the COVID-19 pandemic included: being female, younger age, and being Black or Asian. Interestingly, we found two somewhat surprising protective factors against depression symptoms: more frequent interactions with patients and having a greater proportion of childcare responsibilities at home.

CONCLUSIONS

This study showed a high prevalence of mental health problems and revealed disparities in mental health among eye care personnel and students: Female, younger, Black, and Asian populations are particularly vulnerable to mental health issues. These results indicate that it is critical to identify mental health issues more effectively and develop interventions among this population to address this significant and growing public health issue. The strategies and policies should be reflective of the demographic disparities in this vulnerable population.

Quality of referrals for glaucoma assessment: a cross-sectional survey of clinical data and outcomes

PURPOSE

This study assessed the completeness of clinical information provided by ophthalmological and optometric referrals to glaucoma specialists consulting for open-angle glaucoma (OAG).

METHODS

A retrospective, cross-sectional study of 72 internal referrals for evaluation of OAG in a multispecialty group practice was performed. The quality of the referral was assessed based on: (1) the completeness of the clinical triad of intraocular pressure measurement, visual field (VF), and cup-to-disk ratio for each eye; (2) the availability of the data necessary to calculate an ocular hypertension treatment study (OHTS) score; and (3) the presence of retinal nerve fiber layer (RNFL) imaging by mean of optical coherence tomography.

RESULTS

The clinical triad was available in 57% of referrals, whereas an OHTS score was calculable in 24% of referrals (p < 0.001); RNLF imaging was available in 51% of referrals (p = 0.859). The completeness of clinical information was similar for ophthalmological and optometric referrals. From the date of referral to the time of the consultation, there was a significant increase in the availability of the clinical triad (57-65%; p = 0.013) and the OHTS score (24-5%; p = 0.004) but not for RNFL imaging (51-56%; p = 0.618). The most common missing clinical information was VF testing, which was absent in 42% of referrals.

CONCLUSIONS

Key clinical data necessary for effective diagnosis and staging of OAG was lacking for many patients referred to glaucoma specialists.

The evolution of the changes in the clinical course: a multicenter survey-related impression of the ophthalmologists at the peak of the COVID-19 pandemic in Turkey

PURPOSE

The coronavirus disease-2019 (COVID-19) has become a difficult pandemic to control worldwide. The high transmission risk and mortality rates of COVID-19 cause serious concerns in ophthalmologists and may cause disruptions in clinical functioning. This study aims to identify changes in the clinical approaches of ophthalmologists, understand their anxiety levels, and exhibit how patients' follow-up processes progress during the pandemic.

METHODS

A questionnaire that including demographic information, ophthalmology clinical activity scale, and Beck anxiety scale was sent to ophthalmologists in Turkey. Google Forms was used as a survey platform in this study.

RESULTS

A total of 121 ophthalmologists participated in the study. The participants stated that they could not continue routine interventional diagnosis and treatment practices during the outbreak. It was clearly stated that there were changes in their clinical approach and decreased patient examination quality. For this reason, 14.9% of physicians said to missed the diagnosis in this process. Physicians who encounter infected patients state that it is more difficult to provide ophthalmological services and their clinical approaches are affected more negatively. Anxiety levels of physicians who could access personal protective equipment (PPE) and show positive solidarity with their colleagues in the process were found to be lower.

CONCLUSION

Our study revealed that ophthalmologists, like other healthcare professionals, were severely affected by the COVID-19 outbreak. Accordingly, healthcare managers should provide adequate PPE for ophthalmologists, organize the clinical operation, and support the mental health of ophthalmologists.

"Depression, Anxiety and Stress" in a Cohort of Registered Practicing Ophthalmic Surgeons, Post Lockdown during COVID-19 Pandemic in India

Purpose: To assess the magnitude of mental health problems among ophthalmologists in India post lockdown during COVID pandemic.Method: Cross-sectional survey conducted online on registered practising ophthalmologists of India, post lockdown at the start of elective surgeries (20^th to 25^th May, 2020). The degree of symptoms of depression, anxiety and stress was assessed by DASS -21 questionnaire. DASS -Subscales: DASS- D (depression), DASS- A (anxiety) and DASS-S (stress) and grading of severity (mild, moderate, severe) were analysed.Results: A total of 144 ophthalmologists aged 29-72 years responded to online survey. Of all participants, 94 (64.2%) of ophthalmologists suffered from mental health problems. Seventy six (52.7%) ophthalmologists had depression and anxiety whereas 20 (14%) reported stress. Women ophthalmologists scored highest total DASS mean score and DASS-stress mean score (p = .04 and p = .03). Results of DASS-D and DASS-A showed female preponderance (men vs women 42.5% vs 61.5%, p = .02; 42.5% vs 60%, p = .04). Severity of symptoms revealed that ophthalmologists above 40 years of age with more than 10 years' experienced severe stress (p = .005). Comprehensive ophthalmologists presented with severe stress and ophthalmologists practicing speciality with severe anxiety. Pearson's correlation analysis showed positive correlation between total DASS-21 score with each of the three subscales scores (DASS D, r-0.88: p < .001; DASS-A, r = 0.96: p = <0.001; DASS-S, r = 0.95: p < .001).Conclusion: Screening by Dass-21 scale has brought noticeable transient mental health issue among ophthalmologist to the fore. Few with high risk may require professional mental care to alleviate it.

[Ocular involvement in rheumatoid arthritis, connective tissue diseases and vasculitis]

There are many interfaces between ophthalmologists and rheumatologists. On the one hand ophthalmologists face the question if an inflammation of the eye is caused by systemic inflammatory rheumatic diseases and on the other hand rheumatologists have to consider that ocular manifestations are relatively common in some inflammatory rheumatic diseases. Furthermore, these ocular manifestations may influence therapeutic decisions of the rheumatologist. This article summarizes which ocular inflammations can be associated with rheumatoid arthritis, connective tissue diseases and vasculitides. The description of acute anterior uveitis in spondyloarthritis and in juvenile idiopathic arthritis is omitted in this article but will be dealt with elsewhere in this issue.

Management of traumatic corneal abrasion by a sample of practicing ophthalmologists in Saudi Arabia

Purpose

Corneal epithelial defect (CED) is a common medical emergency condition involving loss of surface epithelial layer of the cornea. The aim of the study is to explore the practice patterns of ophthalmologists in management of traumatic CED in Saudi Arabia and to assess the variance in clinical practice from the established clinical practice guidelines.

Methods

A Survey based study at King Abdulaziz University Hospital between March 2015 and January 2016. A survey of 16 relevant closed ended questions was distributed to 300 practicing ophthalmologists including Saudi Ophthalmology Society (SOS) members and non-members. The survey questionnaire focused on the known aspects of traumatic CED management.

Results

188 practicing ophthalmologists responded to the distributed questionnaire. That represents a 63% response rate for the present survey study. The age group most commonly affected by traumatic CED is 6-18 years old (61.2%). Fingernail trauma (n = 129, 68.6%) was the major cause of CED reported by respondents. In large CED (>5 mm) most common modality of treatment is pressure patching with topical antibiotics with or without cycloplegics (40.4%) whereas in small CED (<2 mm) topical antibiotics and cycloplegics is the preferred way (40.4%). The most commonly used prophylactic antibiotic was second-generation fluroquinolons (58.5%).

Conclusions

Present study demonstrates that practicing ophthalmologists are reporting that traumatic CED mostly affects young people and fingernail trauma is the major cause. There is lack of clear institutional guidelines and consensus on the management of traumatic corneal abrasions.

The Knowledge of Eye Physicians on Local Anesthetic Toxicity and Intravenous Lipid Treatment: Questionnaire Study

Objectives

To evaluate the knowledge of ophthalmologists regarding local anesthesia toxicity syndrome (LATS) and intravenous lipid emulsion used in treatment, and to raise awareness of this issue.

Materials and Methods

A questionnaire comprising 14 questions about demographics, local anesthesia (LA) use, toxicity, and treatment methods was administered to ophthalmologists at different hospitals.

Results

The study included 104 ophthalmologists (25% residents, 67.3% specialists, 7.7% faculty members) with a mean age of 35.71±6.53 years. The highest number of participants was from state hospitals (65.4%), and 34.6% of the physicians had been working in ophthalmology for more than 10 years. Seventy-six percent of the participants reported using LA every day or more than twice a week, but 56.7% had received no specific training on this subject. No statistically significant difference was observed between different education levels and the rates of training (p=0.419). Bupivacaine was the most preferred LA and the majority of respondents (97.1%) did not use a test dose. Allergy (76%) and hypotension (68.3%) were the most common responses for early findings of LATS, while cardiac arrest (57.4%) and hepatotoxicity (56.4%) were given for late findings. The most common responses concerning the prevention of LATS included monitorization (72.4%) and use of appropriate doses (58.2%). Symptomatic treatment was selected by 72.4% of respondents and cardiopulmonary resuscitation and antihistamine treatment by 58.8%. Of the ophthalmologists in the study, 62.5% had never encountered LATS. The use of 20% intravenous lipid emulsion therapy for toxicity was known by 65% of the physicians, but only 1 participant stated having used it previously.

Conclusion

The importance of using 20% lipid emulsion in LATS treatment and having it available where LA is administered must be emphasized, and there should be compulsory training programs for ophthalmologists on this subject.

[Who visits an ophthalmologist and how often? Results of the German nationwide adult health survey (DEGS1)]

BACKGROUND

The prevalence of eye diseases increases in the second half of life, especially cataract, glaucoma and age-related macular degeneration. In this study we examined the influencing factors for visiting an ophthalmologist in the last 12 months.

METHODS

Visits to an ophthalmologist's practice in the last 12 months and the frequency were surveyed in the German nationwide adult health survey wave 1 (DEGS1) study (baseline examination from 2008 to 2011, N = 7987, 52.6% women, age 18-79 years). Data on utilization were processed by taking the complex study design into consideration. Multivariable logistic regression analysis was used to determine associated factors including age, sex, socioeconomic status, place of residence, type of health insurance (e.g. statutory or private) and diabetes.

RESULTS

Between the ages of 18 and 79 years, 29.3% of survey participants in Germany visited an ophthalmologist in the last year, while after the age of 60 years this was only 50.4%. Multivariable logistic regression analysis showed an association with female sex (odds ratio OR = 1.51, p < 0.001), older age, type of health insurance (private vs. statutory: OR = 0.77, p = 0.006) and diabetes (OR = 3.84, p < 0.001), but no association with socioeconomic status (p = 0.29) or place of residence (p = 0.06).

CONCLUSION

Approximately one third of the German population visit an ophthalmologist at least once a year. Especially diabetics showed a high utilization of ophthalmological consultations, which could be based on the interdisciplinary guidelines for early detection of diabetic eye complications.

Excimer laser refractive surgery rate in Iran: 2010-2014

Purpose

To determine the rate of excimer laser refractive surgery in Iran and its trend during 2010–2014, and the number of surgeries per ophthalmologist.

Methods

Twelve provinces were considered for the study; 4 major referral provinces of Tehran, Fars, Isfahan, and Khorasan, and 8 others which were selected randomly. Then a number of excimer laser centers were chosen from each province. In the timeframe between 2010 and 2014, one week per season was randomly selected for each center, and the number of surgeries conducted in these 20 weeks was determined by trained personnel.

Results

In the 12 surveyed provinces, 28 of the 57 active surgical centers were selected. The rate of excimer laser refractive surgery in 2010 in Iran was 2764 per million population which reached 3744 per million by 2012 and took a slightly decreasing trend to 3582 until 2014. Based on the number of ophthalmologists and the number of surgeries in 2014, the average number of surgeries per ophthalmologist was 103 surgeries.

Conclusion

This is the first study to report the rate of excimer laser refractive surgery in Iran.

High Prevalence of Undiagnosed Axial Spondyloarthritis in Patients with Chronic Low Back Pain Consulting Non-Rheumatologist Specialists in Belgium: SUSPECT Study

INTRODUCTION

Diagnosis of axial spondyloarthritis (SpA) can be delayed for several years mainly because of low awareness of axial SpA among non-rheumatologists who are the first interlocutors of potential SpA patients. One strategy to decrease the delay between appearance of first symptoms and diagnosis of axial SpA and to allow early management of the disease is to provide the non-rheumatologists with tools to identify patients requiring prompt referral to rheumatologists. This study was designed to evaluate in a real-world setting whether screening patients with chronic low back pain who consult physical medicine and rehabilitation (PMR) physicians, orthopedists, and ophthalmologists is useful in detecting axial SpA.

METHODS

During this non-interventional cross-sectional study, data from 161 patients with chronic back pain, consulting an orthopedist, PMR physician, or ophthalmologist were collected during a single visit. Any patient who presented with at least four out of five symptoms of inflammatory back pain (IBP) and at least one additional SpA feature were to be referred to a rheumatologist. Analysis was purely descriptive.

RESULTS

IBP was diagnosed in approximately half of the patients (89 patients) and 72 of them met the referral criteria. A total of 117 patients were finally referred to a rheumatologist and axial SpA was diagnosed for 37 of them.

CONCLUSIONS

The high prevalence of undiagnosed axial SpA in patients with chronic back pain visiting PMR physicians, orthopedists, and ophthalmologists suggests that these healthcare professionals may play a key role in the strategy developed to shorten the delay observed in the formal diagnosis of SpA.

FUNDING

Abbvie.

Intra- and inter-rater agreement between an ophthalmologist and mid-level ophthalmic personnel to diagnose retinal diseases based on fundus photographs at a primary eye center in Nepal: the Bhaktapur Retina Study

BACKGROUND

Early detection can reduce irreversible blindness from retinal diseases. This study aims to assess the intra- and inter-rater agreement of retinal pathologies observed on fundus photographs between an ophthalmologist and two-mid level ophthalmic personnel (MLOPs).

METHOD

A population-based, cross-sectional study was conducted among subjects 60 years and above in the Bhaktapur district of Nepal. Fundus photographs of 500 eyes of 500 subjects were assessed. The macula-centered 45-degree photographs were graded twice by one ophthalmologist and two MLOPs. Intra-rater and inter-rater agreements were assessed for the ophthalmologist and the MLOPs.

RESULT

Mean age was 70.22 years ± 6.94 (SD). Retinal pathologies were observed in 55.6 % of photographs (age-related macular degeneration: 34.2 %; diabetic retinopathy: 4.2 %; retinal vein occlusion: 3.8 %). Twelve (2.4 %) fundus pictures were non-gradable. The intra-rater agreement for overall retinal pathologies, retinal hemorrhage, and maculopathy were substantial both for the ophthalmologist as well as for the MLOPs. There was moderate inter-rater agreement between the ophthalmologist and the first MLOP on second rating for overall retinal pathologies, [kappa (k); 95 % CI = 0.59 (0.51-0.66)], retinal hemorrhage [k; 95 % CI = 0.60 (0.41-0.78)], and maculopathy [k; 95 % CI = 0.52 (0.43-0.60)]. Inter-rater agreement between the ophthalmologist and the second MLOP for second rating was moderate for overall retinal pathologies [k; 95 % CI = 0.52 (0.44-0.60)], substantial agreement for retinal hemorrhage [k; 95 % CI = 0. 68 (0.52-0.84)], moderate agreement for maculopathy [k; 95 % CI = 0.59 (0.50-0.67)].

CONCLUSION

There is moderate agreement between the MLOPs and the ophthalmologist in grading fundus photographs for retinal hemorrhages and maculopathy.

Setting targets for human resources for eye health in sub-Saharan Africa: what evidence should be used?

With a global target set at reducing vision loss by 25% by the year 2019, sub-Saharan Africa with an estimated 4.8 million blind persons will require human resources for eye health (HReH) that need to be available, appropriately skilled, supported, and productive. Targets for HReH are useful for planning, monitoring, and resource mobilization, but they need to be updated and informed by evidence of effectiveness and efficiency. Supporting evidence should take into consideration (1) ever-changing disease-specific issues including the epidemiology, the complexity of diagnosis and treatment, and the technology needed for diagnosis and treatment of each condition; (2) the changing demands for vision-related services of an increasingly urbanized population; and (3) interconnected health system issues that affect productivity and quality. The existing targets for HReH and some of the existing strategies such as task shifting of cataract surgery and trichiasis surgery, as well as the scope of eye care interventions for primary eye care workers, will need to be re-evaluated and re-defined against such evidence or supported by new evidence.

[Sinus thrombosis and idiopathic intracerebral hypertension: Thrombophilia and hormonal influence as potentially relevant causal connections]

BACKGROUND

Cerebral venous sinus thrombosis and idiopathic intracerebral hypertension (IIH) can lead to impaired vision, which is why the suspected diagnosis is often initially made by an ophthalmologist.

PROBLEM AND AIMS

This study aimed at discovering common features between the two underlying conditions and provide ophthalmologists with concrete measures for differential diagnosis and for the management of affected patients based on these similarities.

MATERIAL AND METHODS

This article presents detailed profiles of the underlying conditions and compares the two, focusing on similarities with respect to risk factors.

RESULTS

The following common risk factor profiles of the two underlying conditions could be determined: (1) women before menopause, (2) administration of female hormones and (3) thrombophilia.

DISCUSSION

Based on these findings at least a partial overlap of both pathophysiologies is suspected. In particular, undiagnosed cerebral thrombosis or microthrombosis can cause IIH. This mechanism could explain the typical thrombophilic risk profile of IIH, which is analogous to that of cerebral venous sinus thrombosis, including the well-established interaction of estrogens and thrombophilic risk factors.

Resources for eye care at secondary and tertiary level government institutions in Saudi Arabia

Purpose:

To evaluate the number of healthcare personnel and equipment resources for eye care at government institutions in different administrative zones of the Kingdom of Saudi Arabia (KSA) and to recommend measures for increasing resources to address deficiencies.

Materials and Methods:

Data on resources (personnel and equipment) for eye care were collected from all governmental eye units in 2012. The data was regrouped by zones and administrative areas. The mid-2012 population projections were used to calculate the ophthalmologist to population ratio and optometrist to population ratio. The equipment available for eye care was reviewed.

Results:

All 60 institutions in 13 administrative areas and five zones of KSA participated in this study. There were 407 ophthalmologists and 147 optometrists. The ophthalmologist to population ratio was 1:43,000 (1:12,900 in the northern zone to 1:80,300 in the western zone). By 2015, 700 ophthalmologists will be required, and by 2020, 1,100 ophthalmologists will be required. The optometrist to population ratio was 1:95,000 (1:34,100 in the northern zone to 1:146,700 in the western zone). Nearly 2,800 and 4,400 allied eye care personnel will be needed by 2015 and 2020. Diagnostic and treatment equipment such as lasers, electrophysiologic and ultrasound equipment, and fundus cameras were not available at all institutions.

Conclusions:

Data from the private sector need to be included to draw conclusions on the human resource index for eye care in the Kingdom. An unequal distribution of resources in different zones and administrative areas requires attention. Better utilization of available resources is recommended before fulfilling the demand for additional resources.