A survey of the use of grading scales for contact lens complications in optometric practice

Purpose:  The aim of this study was to investigate the extent and pattern of use of grading scales for contact lens complications (‘grading scales’) in optometric practice. Methods:  An anonymous postal survey was sent to all 756 members of the Queensland Division of Optometrists Association Australia. Information was elicited relating to level of experience, practice type and location, and mode of usage of grading scales. Results:  Survey forms were returned by 237 optometrists, representing a 31 per cent response rate. The majority of respondents (61 per cent) reported using grading scales frequently in practice, while 65 per cent of these preferred to use the Efron Grading Scales for Contact Lens Complications. Seventy-six per cent of optometrists use a method of incremental grading rather than simply grading with whole numbers. Grading scales are more likely to be used by optometrists who have recently graduated (p < 0.001), have a postgraduate certificate in ocular therapeutics (p = 0.018), see more contact lens patients (p = 0.027) and use other forms of grading scales (p < 0.001). The most frequently graded ocular conditions were corneal staining, papillary conjunctivitis and conjunctival redness. The main reasons for not using grading scales included a preference for sketches, photographs or descriptions (87 per cent) and unavailability of scales (29 per cent). Conclusion:  Grading scales for contact lens complications are used extensively in optometric practice for a variety of purposes. This tool can now be considered as an expected norm in contact lens practice. We advocate the incorporation of such grading scales into professional guidelines and standards for good optometric clinical practice.

Governor's sunset report on the Illinois Optometric Practice Act /

"March 1986."

Prevalence and impact of ocular allergy in the population attending UK optometric practice

To determine the prevalence of ocular allergy in patients attending optometric practices in the UK West Midlands and the impact this has on patients' daily lives.

Clinical characteristics of unilateral myopic anisometropia in a juvenile optometric practice population

Purpose: A retrospective study of longitudinal case histories, undertaken to establish the clinical and statistical characteristics of unilateral myopic anisometropia (UMA) amongst the juvenile and adolescent population at an optometric practice, is reported. UMA was defined as that specific refractive state where an unequivocally myopic eye is paired with a 'piano' [spherical equivalent refraction, (SER) = ±0.25 Dioptres (D)] companion eye. Methods: The clinical records of all patients aged <19 years on file at an established independent optometric practice were categorised as 'myopic' (SER ≤-0.50 D), 'hypermetropie' (≥+0.75 D) or 'emmetropic' (≥-0.37≤+0.62 D). Subsequently all juvenile patients matching the UMA criterion, together with a case-matched group of bilaterally myopic individuals, were selected as the comparative study populations. Results: A total of 14.4% (n = 21 of 146) of the juvenile myopic case histories were identified as cases of UMA. More than half of these UMA cases emerged between the ages of 11.5 and 13.5 years. There was a marked female gender bias. The linear gradient of the age-related mean refractive trend in the myopic eye of the UMA population was not statistically significantly different (p > 0.1) to that fitted to the ametropic progression recorded in either eye of the case-matched population of young bilateral myopes; uniquely the slope associated with the companion eye of UMA cases was statistically significantly (p < 0.025) less steep. Compared with bilateral myopes fewer cases of UMA required a refractive correction to relieve visual or asthenopic symptoms, and this initial correction was dispensed on average 1 year later (at age 12.7 years) in UMA patients. Conclusions: Individuals identified as demonstrating clinically-defined UMA can be considered as distinct but functionally normal cases on the continuum of human refractive error. However, any unilaterally-acting determining factor(s) underlying the genesis of the condition remain obscure. © 2004 The College of Optometrists.

The clinical assessment of systemic hypertension in optometric practice

This thesis sets out to examine in detail the condition of systemic hypertension (high Blood Pressure) in relation to optometric practice in the United Kingdom. Systemic hypertension, which is asymptomatic in the early stages, is diagnosed from the Blood Pressure (BP) measurement recorded by a sphygmomanometer and/or from the complications that have developed in target organs. Optometric practice based surveys revealed that diagnosed systemic hypertension was the most prevalent cardiovascular medical condition (20.5%). Measurement of BP of patients in this sample revealed that if an optometrist included sphygmomanometry into the sight examination then at least one patient each day would be referred for suspect systemic hypertension. Optometric opinion felt that the measurement of BP in optometric practice would advance the profession, being appreciated by both patients and General Practitioners (GPs), but was felt to be an unnecessary routine procedure. The present sight examination for the systemic hypertensive is similar to that of the normotensive patient, but may involve an altered fundus examination and a visual field test. The GPs were in favour of optometric BP measurement and a future role in the share care management of the systemic hypertensive. The application of a new pictorial grading scale for the grading of vascular changes associated with pre-malignant systemic hypertension was found to be both accurate and reliable. Clinical trial of the grading scale in optometric practice found positive correlations between BP and increasing severity of the retinal vascular features. The subtle pre-malignant vascular changes require reliable accurate detection and analysis to assist in the management of the systemic hypertensive patient. Vessel width was shown to decrease with increasing age. Image analysis of the A/V ratio, arteriolar tortuosity and focal calibre changes revealed a positive correlation to the patient's BP (p<0.001). The retinal vasculature is relatively stable longitudinally with only minor changes in response to early disease states. Age and elevated BP increased a patient's risk of developing systemic medical conditions over a two-year period. The application of the pictorial grading scale to optometric practice and training the optometrist in the use of sphygmomanometry would improve the management of the systemic hypertensive patient in optometric practice. Future advances in image analysis hold substantial benefits for the detection and monitoring of subtle vascular changes associated with systemic hypertension.

The management of systemic hypertension in optometric practice

Aim: Systemic hypertension is a silent killer that may have very few warning signs. This study examines detection and management of patients with cardiovascular disease (CVD) by optometrists in the UK. Method: A survey was sent out to 1402 optometrists who practice in the UK to investigate the nature and knowledge of detection of systemic hypertension. Results: The survey response rate was 37%. Optometrists were neutral to slightly positive towards the use of blood pressure (BP) monitors, but not on a routine basis. The most frequently asked question during history and symptoms concerned the patient's prescribed medication for systemic hypertension, and the least was that of specifying the last BP measurement. The additional test most widely used in the examination of the systemic hypertensive patient was direct ophthalmoscopy with red-free filter. Over one-tenth of optometric practices had a BP monitor, with automated devices being the most popular. Patients most likely to have their BP measured were suspect systemic hypertensives. Retinal haemorrhages are the most important finding in influencing an optometrist's referral criteria for suspected systemic hypertension. Conclusion: Although optometrists monitor the retina for signs of damage from systemic hypertension, further education in this important condition is warranted. © 2005 The College of Optometrists.

Exploring business models to provide a foundation for enhanced eye care services in high street optometric practice

High street optometric practices are for-profit businesses. They mostly provide sight testing and eye examination services and sell optical products, such as spectacles and contact lenses. The sight testing services are often sold at a vastly reduced price and profits are generated primarily through high margin spectacle sales, in a loss leading strategy. Published literature highlights weaknesses in this strategy as it forms a barrier to widening the scope of services provided within optometric practices. This includes specialist non-refraction based services, such as shared care. In addition this business strategy discourages investment in advanced diagnostic equipment and higher professional qualifications. The aim of this thesis was to develop a greater understanding of the traditional loss-leading strategy. The thesis also aimed to assess the plausibility of alternative business models to support the development of specialist non-refraction services within high street optometric practice. This research was based on a single independent optometric practice that specialises in advanced retinal imaging and offers a broad range of shared care services. Specialist non-refraction based services were found to be poor generators of spectacle sales likely due to patient needs and presenting concerns. Alternative business strategies to support these services included charging more realistic professional fees via cost-based pricing and monthly payment plans. These strategies enabled specialist services to be more self-sustainable with less reliance on cross-subsidy from spectacle sales. Furthermore, improving operational efficiency can increase stand-alone profits for specialist services.Practice managers may be reluctant to increase professional fees due to market pressures and confidence. However, this thesis found that patients were accepting of increased professional fees. Practice managers can implement alternative business models to enhance eye care provision in high street optometric practices. These alternative business models also improve revenues and profits generated via clinical services and improve patient loyalty.

Influence of practice setting on contact lens prescribing in the United Kingdom

We sought to determine the impact of optometric practice setting on contact lens prescribing by analysing annual survey data of lens fits collected between 2009 and 2013 from independent and national group practices throughout the United Kingdom. Compared to national group practices, independent practices fit contact lenses to older patients and more females. Independent practices also undertake a lower proportion of soft lens fits overall (and thus a higher proportion of rigid lens fits), soft toric lens fits and daily disposable lens fits. There is a higher proportion of soft extended wear and multifocal lens fits in independent practices. We conclude that contact lens fitting behaviour is influenced by optometric practice setting.

Delivering optometric care in the UK

Optometrists play an important part in delivering eye care in the United Kingdom; however opportunities for practitioners to extend their role through co-management of patients with ophthalmologists vary across the country. Devolution in Scotland and Wales has led to greater emphasis on community based care in these regions. This thesis reviews the current situation and, by examining ophthalmic outpatient clinic data, discusses further opportunities to reduce demands on secondary care and the cost savings that can be made. To assess whether the profession is currently in a position to adopt an extended clinical role, changes in the availability of optometric instrumentation are assessed over a two year period. An increased prevalence of fundus cameras and contact tonometers places optometrists in a good position to take on further responsibilities in glaucoma management, however future investment could be impacted by the current economic climate as value for money became increasingly important to practitioners looking to purchase equipment. Methods of training optometrists in the necessary skills to utilise new technology to extend their role are evaluated in terms of both learning and cost effectiveness. Interactive distance learning is proposed as a convenient and effective method to deliver continuing professional development. Any changes to optometric practice must take account of the need for a sustainable business and the importance of attracting and retaining patients. The views of patients are assessed through a validated service quality questionnaire, SERVQUAL. The questionnaire is found to be valid for use in an optometry setting. Patients have a generally positive view of the service quality they receive from their optical practice and consider the intangible aspects, in particular responsiveness and empathy, most important. Optometrists are well placed to increase their role in patient management; however a viable business model must exist to enable investment in instrumentation and training.

A review of non-pharmacological and pharmacological management of seasonal and perennial allergic conjunctivitis

Allergic eye disease encompasses a group of hypersensitivity disorders which primarily affect the conjunctiva and its prevalence is increasing. It is estimated to affect 8% of patients attending optometric practice but is poorly managed and rarely involves ophthalmic assessment. Seasonal allergic conjunctivitis (SAC) is the most common form of allergic eye disease (90%), followed by perennial allergic conjunctivitis (PAC; 5%). Both are type 1 IgE mediated hypersensitivity reactions where mast cells play an important role in pathophysiology. The signs and symptoms are similar but SAC occurs periodically whereas PAC occurs year round. Despite being a relatively mild condition, the effects on the quality of life can be profound and therefore they demand attention. Primary management of SAC and PAC involves avoidance strategies depending on the responsible allergen(s) to prevent the hypersensitivity reaction. Cooled tear supplements and cold compresses may help bring relief. Pharmacological agents may become necessary as it is not possible to completely avoid the allergen(s). There are a wide range of anti-allergic medications available, such as mast cell stabilisers, antihistamines and dual-action agents. Severe cases refractory to conventional treatment require anti-inflammatories, immunomodulators or immunotherapy. Additional qualifications are required to gain access to these medications, but entry-level optometrists must offer advice and supportive therapy. Based on current evidence, the efficacy of anti-allergic medications appears equivocal so prescribing should relate to patient preference, dosing and cost. More studies with standardised methodologies are necessary elicit the most effective anti-allergic medications but those with dual-actions are likely to be first line agents.

Essential fatty acids for dry eye:a review

Purpose Dry eye is a common complaint often encountered in optometric practice. However, it is a difficult condition to treat as clinical signs do not always correlate with patient symptoms. Essential fatty acids (EFA), particularly omega-3 EFA, may be effective in dealing with the underlying causes. Methods A literature review was carried out on the PubMed, ScienceDirect and Ovid databases. Searches included keywords such as ‘dry eye’, ‘essential fatty acids’ and ‘nutrition’ to find articles relating to the treatment of dry eye syndrome (DES) with omega-3 EFAs. Results Omega-3 and -6 EFAs need to be consumed together within a reasonable ratio to be effective. Currently, typical diets in developed countries lack omega-3 EFA and this results in an overexposure to omega-6. Omega-3 supplementation has an anti-inflammatory effect, inhibiting creation of omega-6 prostaglandin precursors. Omega-3 EFAs also demonstrate anti-inflammatory action in the lacrimal gland preventing apoptosis of the secretory epithelial cells. Supplementation clears meibomitis, allowing a thinner, more elastic lipid layer to protect the tear film and cornea. Conclusion Dietary supplementation of omega-3 EFA has already proven to be effective in coronary heart disease and arthritis. Safety is not a concern as it works synergistically with omega-6 in the body. Evidence suggests that supplementation with omega-3 EFA may be beneficial in the treatment and prevention of DES.

Clinical evaluation of the Grand Seiko Auto Ref/Keratometer WAM-5500

Purpose: A clinical evaluation of the Grand Seiko Auto Ref/Keratometer WAM-5500 (Japan) was performed to evaluate validity and repeatability compared with non-cycloplegic subjective refraction and Javal–Schiotz keratometry. An investigation into the dynamic recording capabilities of the instrument was also conducted. Methods: Refractive error measurements were obtained from 150 eyes of 75 subjects (aged 25.12 ± 9.03 years), subjectively by a masked optometrist, and objectively with the WAM-5500 at a second session. Keratometry measurements from the WAM-5500 were compared to Javal–Schiotz readings. Intratest variability was examined on all subjects, whilst intertest variability was assessed on a subgroup of 44 eyes 7–14 days after the initial objective measures. The accuracy of the dynamic recording mode of the instrument and its tolerance to longitudinal movement was evaluated using a model eye. An additional evaluation of the dynamic mode was performed using a human eye in relaxed and accommodated states. Results: Refractive error determined by the WAM-5500 was found to be very similar (p = 0.77) to subjective refraction (difference, -0.01 ± 0.38 D). The instrument was accurate and reliable over a wide range of refractive errors (-6.38 to +4.88 D). WAM-5500 keratometry values were steeper by approximately 0.05 mm in both the vertical and horizontal meridians. High intertest repeatability was demonstrated for all parameters measured: for sphere, cylinder power and MSE, over 90% of retest values fell within ±0.50 D of initial testing. In dynamic (high-speed) mode, the root-mean-square of the fluctuations was 0.005 ± 0.0005 D and a high level of recording accuracy was maintained when the measurement ring was significantly blurred by longitudinal movement of the instrument head. Conclusion: The WAM-5500 Auto Ref/Keratometer represents a reliable and valid objective refraction tool for general optometric practice, with important additional features allowing pupil size determination and easy conversion into high-speed mode, increasing its usefulness post-surgically following accommodating intra-ocular lens implantation, and as a research tool in the study of accommodation.

Optometry:science, techniques and clinical management

An introduction to the theory and practice of optometry in one succinct volume. From the fundamental science of vision to clinical techniques and the management of common ocular conditions, this book encompasses the essence of contemporary optometric practice. Now in full colour and featuring over 400 new illustrations, this popular text which will appeal to both students and practitioners wishing to keep up to date has been revised significantly. The new edition incorporates recent advances in technology and a complete overview of clinical procedures to improve and update everyday patient care. Contributions from well-known international experts deliver a broad perspective and understanding of current optometric practice. A useful aid for students and the newly qualified practitioner, while providing a rapid reference guide for the more experienced clinician.