Ophthalmic Health Care Research Articles

Evaluation of Nuclear Cataract with Smartphone-Attachable Slit-Lamp Device.

Background: Visual impairments and age-related eye diseases need to be detected and treated in a timely manner. However, this is often hampered by lack of appropriate medical equipment. We have invented a portable, recordable, and smartphone-attachable slit-lamp device, called the Smart Eye Camera (SEC). The aim of this study was to compare evaluating nuclear cataract (NUC) between the SEC and the conventional, non-portable slit-lamp microscope. Methods: A total of 128 eyes of 64 Japanese patients (mean age: 73.95 ± 9.28 years; range: 51‒92 years; female: 34) were enrolled. The NUC was classified into four grades (grade 0 to 3) based on three standard photographs of nuclear opacities according to the WHO classification by ophthalmologists. An ophthalmic healthcare assistant (non-ophthalmologist) filmed the eyes in video mode by the SEC and an ophthalmologist graded the NUC. Grade correlation and inter-rater reproducibility were determined. Results: NUC grading by the two approaches correlated significantly (both eyes: r = 0.871 [95%CI: 0.821 to 0.907; p < 0.001]). Inter-rater agreement was high (weighted κ = 0.807 [95%CI: 0.798 to 0.816; p < 0.001]). Conclusions: This study suggests that the SEC is as reliable as the conventional non-portable slit-lamp microscope for evaluating NUC.

Cataract induced by eyelid cosmetic treatment with intense focused ultrasound

A 45-year-old woman, immediately after receiving a cosmetic treatment with intense focused ultrasound (IFUS) over the eyelids, developed an acute, progressive, severe cataract with a unique shape as an adverse effect of the IFUS esthetic treatment. At examination of the lens in the right eye, 4 drop-like dense lens opacities aligned consecutively in a horizontal line together with a posterior capsular opacity in a stellate-shaped fashion. It rapidly progressed into a dense posterior cataract, leaving the patient with an uncorrected distance visual acuity (UDVA), from 20/20 prior to the event, to 20/160 4 days later. Phacoemulsification and intraocular lens implantation were performed, restoring her UDVA to 20/25. Cosmetic and ophthalmic healthcare providers should be aware of the potentially damaging effect of IFUS.

COVID-19: Limiting the Risks for Eye Care Professionals

ABSTRACT After the outbreak of the disease COVID-19, it has reached pandemic proportions within a very short time. It is mainly transmitted human-to-human through direct contact with secretions from an infected person or through inhalation of droplets containing SARS-CoV-2. It is controversial whether the virus may be transmitted via tears. Exposed ocular surface can serve as a gateway in transmission and acquiring respiratory diseases. Considering the reported cases on healthcare workers indicating nosocomial transmission and the anatomical and physiological aspects it is perceived that ophthalmic healthcare professionals are at higher risk of contracting the virus by virtue of their job. In this narrative review we discuss current evidence around detection of SARS-CoV-2 in human tears and forms of transmissions reported to date. We also provide a comprehensive approach that may be implemented in an ophthalmic care facility to protect healthcare personnel, as well as patients, from contracting the virus.

Commentary: COVID-19-How it has impacted ophthalmic care and where do we go from here?

The COVID-19 pandemic has sent the world in a turmoil. A prominent strategy for minimizing the COVID-19 transmission has been social isolation and lockdown measures. An important yet little understood aspect of the pandemic has been the impact it has had on patients suffering from non-COVID-19 illnesses. Initial evidence suggests that patients are being deprived of access to surgical treatments in UK and poorer adolescent sexual and reproductive health in low and middle income countries, and disrupted healthcare services in rural India.[123] Government of India has circulated guidelines on essential services during the pandemic as has the World Health Organization.[45] There is no doubt that the health systems need to adapt to the pandemic, and the first step in remediation is an assessment of where we stand. The present article is one of the initial studies quantifying the impact 000 pandemic on ophthalmic services. Through analysis of data from a multi-tier ophthalmology network, the authors have quantified COVID-19 associated lockdown's impact on patients with ocular disorders.[6] As expected, there was a drastic decrease in footfall, and patients living further away were more affected. The results suggest that the requirement of ophthalmic sub-specialties also is altered during lockdown. Lockdown was also associated with in-equity. Nearly two-thirds of patients were emergency and one-fourth were routine, when classified as per the AIOS-IJO guidelines. It was interesting to observe that among patients who were triaged as routine, nearly one-fourth had conjunctivitis and another 6% had allergic conjunctivitis. There should be no reason for patients to travel to a tertiary eye care institutes for minor ocular conditions. As the pandemic associated lockdown is lifted, there is an anticipation that patients will be able to access ophthalmic healthcare services. That said, because of the community awareness about social distancing and quarantining, patients requiring routine ophthalmic services may hesitate leading to delays in their care seeking. While there were initial expectations that the pandemic may quickly attain a peak and then fall off, recent estimates indicate that the pandemic is here to stay. As a corollary, the effects of endemic on ophthalmic care seeking will continue being felt for months. We may be looking at a situation where cataracts are left to get mature, and follow-ups of chronic ophthalmic conditions such as diabetic retinopathy or glaucoma get delayed. In the current situation, the poor and marginalized communities are likely to get further marginalized in terms of access to ophthalmic services. Reasons may be manifold: prioritization of livelihood over health seeking, lack of transportation, fear of getting infected, travel back to hometown where ophthalmic care services are not easily available, etc., A key question is how to mitigate the setbacks that COVID-19 is posing. The ophthalmic health systems must rapidly evolve. We will need to explore mechanisms to facilitate routine ophthalmic care in a manner that minimizes COVID-19 transmission risk to the patient as well as to the healthcare workers. There is a need to rapidly ensure an effective tiered system of ophthalmic care seeking, with the well-rounded referral mechanisms. Teleophthalmology could play a major role, and with the notification of the telemedicine guidelines in India, the legal landscape is also becoming clearer.[78] Also, there is plenty of room for innovation and we would quite possibly need to adopt a horses-for-course approach. What works in one setting may not work in another. As we implement more and more models, we will become richer in our experiences and be able fine-tune ophthalmic care systems that are best suited to the “New Normal” that is the COVID-19 world.

Direct Ophthalmic Healthcare Resource Use among Patients with Geographic Atrophy in a Large Cohort from the United Kingdom

To estimate the direct ophthalmic healthcare resource use in patients with geographic atrophy (GA) secondary to age-related macular degeneration (AMD). Retrospective analysis of anonymized data derived from electronic medical records (EMRs) acquired at 10 clinical sites in the United Kingdom. Patients aged ≥50 years with ≥1 eye with a clinical record of GA or, for comparison, bilateral early/intermediate AMD. Four subgroups were identified: GA in both eyes (GA:GA); GA in 1 eye, choroidal neovascularization (CNV) in the fellow eye (GA:CNV); GA in 1 eye with early or intermediate AMD in the fellow eye (GA:E); and early/intermediate AMD in both eyes (E:E). The EMRs were analyzed to derive the median number of visits over the first 2 years after diagnosis of GA or early/intermediate AMD. Clinical tests recorded at visits were used to calculate estimated costs (payer perspective) of monitoring. Analyses were restricted to patients with an initial diagnosis on or after January 1, 2011, to represent present day monitoring and costs associated with AMD. Median number of visits and estimated monitoring costs per patient (in £) over the first 2 years among patients with ≥2 years of follow-up and in the individual subgroups. Intravitreal treatment costs in the GA:CNV group were excluded. For all 3 GA subgroups (n= 1080), the median number of visits over the first 2 years was 5, and monitoring costs were £460.80 per patient. The GA:CNV subgroup (n= 355) had the highest number of visits (median, 15), with a cost of £1581, compared with the GA:E subgroup (n= 283; median 4 visits; cost ∼£369) and the GA:GA subgroup (n = 442; median 3 visits; cost ∼£277). Ophthalmic tests were conducted most frequently in the GA:CNV subgroup. Visits and costs in the E:E subgroup (n= 6079) were lower. Resource use in patients with GA varies considerably and is strongly influenced by the concomitant presence of CNV and lack of monitoring strategies for GA.

Recommendation for ophthalmic care in German preschool health examination and its adherence: Results of the prospective cohort study ikidS.

BackgroundEach child in Germany undergoes a preschool health examination including vision screening and recommendations for further ophthalmic care. This study investigated the frequency of and adherence to these recommendations.MethodsA population-based prospective cohort study was performed in the area of Mainz-Bingen (Rhineland-Palatinate, Germany). All preschoolers were examined at the statutory preschool health examination, which includes vision testing (Rodenstock vision screener) with available correction in the last preschool year. Based on the results, recommendations for further ophthalmic care were given to the parents. Six weeks prior to school entry, parents were surveyed concerning ophthalmic health care visits, diagnoses, and treatments. Ophthalmic care recommendation frequency and its adherence were investigated using logistic regression analysis adjusted for potential confounders.Results1226 children were included in this study, and 109 children received a recommendation for ophthalmic care based on the preschool health examination. At the follow-up, 84% of children who had received a recommendation had visited an ophthalmologist within the preceding year compared to 47% of children who had not received a recommendation. The recommendation for ophthalmic care was clearly associated with a higher number of ophthalmological visits (odds ratio = 7.63; 95% confidence interval: 3.96–14.7). In a subgroup analysis, adherence to a recommendation was lower in children with migrant background (OR = 2.26; 95%-CI: 0.64–7.90, compared to: OR = 11.6; 95%-CI: 4.95–27.4) and in those with low socio-economic status.ConclusionsAdherence to preschool recommendations for ophthalmic care is high in German preschoolers. However, a migrant background and low socio-economic status may reduce this adherence.

Visual impairment and blindness in institutionalized elderly in Germany.

To determine the prevalence of and identify factors associated with visual impairment and blindness in institutionalized elderly in Germany. In this prospective multicenter cross-sectional study, ophthalmic health care need and provision were investigated in institutionalized elderly in 32 nursing homes in Germany. All participants underwent a standardized examination including medical and ocular history, refraction, visual acuity testing, tonometry, biomicroscopy, and dilated funduscopy. A standardized questionnaire was used to identify factors associated with eye healthcare utilization, visual impairment and/or blindness. Visual acuity of 566 (94.3%; 413 women and 153 men) of a total of 600 institutionalized elderly was determined. Mean age of the included patients was 82.9years (± 9.8). Of all participants, 30 (5.3%; 95% CI 3.4-7.2%) were blind and 106 (18.7%; 95% CI 15.5-21.9%) were moderately or severely visually impaired according to the World Health Organization definition. The 136 blind and moderately or severely visually impaired participants were older (OR, Odds Ratio = 1.1, 95% CI 1.0-1.1; p < 0.001), and more likely to have reduced mobility (OR = 12.6, 95% CI 2.8-57.6; p = 0.001). A high proportion of blindness and visual impairment was found amongst nursing home residents. Age and reduced mobility were factors associated with an increased likelihood of blindness and visual impairment. Any surveys of blindness and visual impairment excluding nursing homes may considerably underestimate the prevalence of visual impairment and blindness.

Usage of glaucoma-specific patient-reported outcome measures (PROMs) in the Singapore context: a qualitative scoping exercise

BackgroundDespite the increasing emphasis on the role of glaucoma-specific patient-reported outcome measures (PROMs) as relevant outcome measures for the impact of glaucoma and its intervention on patients' daily lives, the feasibility of implementing PROMs in the routine clinical setting in Singapore remains undefined. We aim to evaluate the comprehensibility, acceptability, and relevance of four glaucoma-specific PROMs at healthcare professionals' and patients' level in a Singapore context.MethodsSixteen ophthalmic healthcare professionals and 24 glaucoma patients, with average age 60 years (SD = 15), were invited from a tertiary hospital in Singapore. Semi-structured interviews were conducted to explore participants’ perceptions on the content and administration of four glaucoma-specific PROMs - the Glaucoma Quality of Life-15, Glaucoma Symptom Identifier, Independent Mobility Questionnaire and Treatment Satisfaction Survey of Intra-ocular Pressure. Semi-structured interviews were hand transcribed, and analysed thematically. Each participant filled out a feasibility survey at the end of interview.Results79% of glaucoma patients and 94% of glaucoma healthcare professionals felt selected PROMs relevant to patients. 63% of glaucoma patients and 50% of healthcare professionals felt that selected PROMs were sufficiently comprehensive for clinical use. 46% of glaucoma patients and 56% of healthcare professionals felt selected PROMs were user-friendly.ConclusionsUsing PROMs in the Singapore clinical setting receives promising support from both healthcare professionals and patients. The identified potential barriers tailored to Singapore clinical setting will help successful implementation of PROMs into routine clinical care.

Specvis: Free and open-source software for visual field examination.

Visual field impairment affects more than 100 million people globally. However, due to the lack of the access to appropriate ophthalmic healthcare in undeveloped regions as a result of associated costs and expertise this number may be an underestimate. Improved access to affordable diagnostic software designed for visual field examination could slow the progression of diseases, such as glaucoma, allowing for early diagnosis and intervention. We have developed Specvis, a free and open-source application written in Java programming language that can run on any personal computer to meet this requirement (http://www.specvis.pl/). Specvis was tested on glaucomatous, retinitis pigmentosa and stroke patients and the results were compared to results using the Medmont M700 Automated Static Perimeter. The application was also tested for inter-test intrapersonal variability. The results from both validation studies indicated low inter-test intrapersonal variability, and suitable reliability for a fast and simple assessment of visual field impairment. Specvis easily identifies visual field areas of zero sensitivity and allows for evaluation of its levels throughout the visual field. Thus, Specvis is a new, reliable application that can be successfully used for visual field examination and can fill the gap between confrontation and perimetry tests. The main advantages of Specvis over existing methods are its availability (free), affordability (runs on any personal computer), and reliability (comparable to high-cost solutions).

Accessibility of ophthalmic healthcare for residents of an offshore island-an example of integrated delivery system.

BackgroundTo assess the utilization of and satisfaction with ophthalmic healthcare provided by integrated delivery system (IDS) since 2000 and vision-related quality of life (VRQoL) for residents of an offshore island of Taiwan.MethodsFacilitators interviewed residents (age ≥ 50 years) with the 25-item National Eye Institute Visual Function Questionnaire (NEI-VFQ-25) for VRQoL and a questionnaire on clinical information, ophthalmic care utilization and satisfaction.ResultsA total of 841 participants (response rate 93.4 %, 841/900) completed the questionnaire survey. Mean age was 63.7 (±10. 7) years. The common eye diseases were cataract (44.7 %), dry eye (15.5 %), and glaucoma (8.7 %). Among the participants, 61.0 % sought ophthalmic care under the IDS in the past year and 17.6 % experienced unmet ophthalmic needs in the past 6 months. Satisfaction with ophthalmic care under the IDS was 88.1 %. Determinants of dissatisfaction under the IDS were distance to healthcare facility and VRQoL. Predictors of VRQoL included age, residential area, marital status, occupation, comorbid condition, commercial insurance, household income, cataracts and glaucoma.ConclusionsThe implementation of IDS improves accessibility of ophthalmic care for residents of an offshore island. Geographic proximity to avail healthcare facility and VRQoL affect satisfaction with the IDS.

Acceptability, Usability, and Views on Deployment of Peek, a Mobile Phone mHealth Intervention for Eye Care in Kenya: Qualitative Study.

BackgroundThe Portable Eye Examination Kit (Peek) is a mobile phone–based ophthalmic testing system that has been developed to perform comprehensive eye examinations. Shortages in ophthalmic personnel, the high cost, and the difficulty in transporting equipment have made it challenging to offer services, particularly in rural areas. Peek offers a solution for overcoming barriers of limited access to traditional ophthalmic testing methods and has been pilot tested on adults in Nakuru, Kenya, and compared with traditional eye examination tools.ObjectiveThis qualitative study evaluated the acceptability and usability of Peek in addition to perceptions regarding its adoption and nationwide deployment.MethodsSemistructured interviews were conducted with patients and analyzed using a framework approach. This included analysis of interviews from 20 patients, 8 health care providers (HCPs), and 4 key decision makers in ophthalmic health care provision in Kenya. The participants were purposefully sampled. The coding structure involved predefined themes for assessing the following: (1) the context, that is, environment, user, task, and technology; (2) patient acceptability, that is, patients' perceived benefits, patient preference, and patient satisfaction; (3) usability, that is, efficiency, effectiveness, learnability, and flexibility and operability of Peek; and (4) the benefits of Peek in strengthening eye care provision, that is, capabilities enhancer, opportunity creator, social enabler, and knowledge generator. Emerging themes relating to the objectives were explored from the data using thematic analysis.ResultsPatients found Peek to be acceptable because of its benefits in overcoming the barriers to accessing ophthalmic services. Most thought it to be fast, convenient, and able to reach a large population. All patients expressed being satisfied with Peek. The HCPs perceived it to satisfy the criteria for usability and found Peek to be acceptable based on the technology acceptance model. Peek was also found to have features required for strengthening ophthalmic delivery by aiding detection and diagnosis, provision of decision support, improving communication between provider and patient and among providers, linking patients to services, monitoring, and assisting in education and training. Some of the deployment-related issues included the need for government and community involvement, communication and awareness creation, data protection, infrastructure development including capacity creation, and training and maintenance support.ConclusionsAccording to all parties interviewed, Peek is an acceptable solution, as it provides a beneficial service, supports patients' needs, and fulfills HCPs' roles, overall contributing to strengthening eye health.

Анализ удовлетворенности населения качеством оказания офтальмологической помощи государственными и частными учреждениями здравоохранения (на примере города Ставрополя)

Анализ удовлетворенности населения качеством оказания офтальмологической помощи государственными и частными учреждениями здравоохранения (на примере города Ставрополя)

Singapore National Eye Centre: an ophthalmic nursing journey

The growing demand for eye care services and a lack of training opportunities for ophthalmic healthcare professionals have prompted the launch of new educational programmes in Singapore. This article outlines the development of ophthalmic nursing in Singapore and provides an introduction to the Singapore National Eye Centre (SNEC). The new Ophthalmic Academic Clinical Programme at the SNEC focuses on developing a comprehensive framework of research and training capabilities to ensure effectiveness in promoting clinical competence and performance. It is hoped that the pilot project to form a Dedicated Education Unit will act as an innovative model of transforming clinical nursing education into an environment of support. This will enable nurses to continue to provide high-quality care to ophthalmic patients. SNEC aims to provide continuing education, in partnership with other educational institutions, for nurses across the continuum of care as they navigate the rapidly changing ophthalmic nursing environment. This education and training has introduced a diversity of career paths, which provide nurses and allied healthcare professionals with innovative opportunities to advance their opthalmic nursing practice.

Long-term ophthalmic health care in Usher Syndrome type I from an ICF perspective

Purpose. The aim was to explore ophthalmic health care in female patients with Usher Syndrome type I (USH I) over 20 years and to evaluate the relationship between the ophthalmic health care and the health state of the patients from a health perspective.Methods. A retrospective study of records from ophthalmology departments (OD) and low vision clinics (LVC) from 1985 to 2004. Assessment of the reports was performed based on the International Classification of Functioning, Disability and Health (ICF). Findings were analysed by manifest content analysis with ICF as a framework and using four themes: health care system, procedure examinations, patient's functioning and disability and procedure actions.Results. The records of nine female patients (aged 25–39 years, 1985) with USH I were selected from the national database of USH. A great number of notes were collected (OD 344 and LVC 566). Procedure examinations were exclusively oriented towards body structure and function. All patients showed aggravated visual impairment over and above the hearing and vestibular impairment. Procedure actions were oriented towards environmental factors. No correlation was found between procedures performed and patient's experience of disability.Conclusions. The high degree of resource allocation was not correlated to the patients' impairment. The study indicates that the ophthalmic health care was characterised by inefficiency. This conclusion is very serious because patients very likely face severe disability and emotional difficulties. ICF is ought to be incorporated in ophthalmic health care strategy to improve the health care.

EyeDiagnostics – a collaboration tool in eye care

Abstract Purpose An Internet‐based system for inter‐professional collaboration between opticians/optometrists and ophthalmologists was developed and tested during 2007‐2008. The purpose of the current study was to describe the main screening findings and the actions taken, based on the test results. Methods State‐of‐the‐art non‐mydriatic fundus cameras and visual field testing equipment were installed and the opticians were offered targeted training in the use of these instruments. The examination results were uploaded to EyeDiagnostics server and evaluated by ophthalmologists. 2301 subjects,63% women and 37% men, age 24 to 91 years (median 63, IQ 53‐73), have been examined by one of 55 different opticians and the findings evaluated by one of two experienced ophthalmologist. Results 63% (1 335) of the examined subjects showed no abnormalities. In 30% (675) a follow‐up examination was judged to be indicated, which could be performed by the optician. 7% (159) of the tested subjects were referred to ophthalmic health care for treatment or further examinations. Conclusion Modern technology in communication, fundus imaging and visual field examination have made it possible to reach a large number of people with advanced ophthalmic testing. This increase in diagnostic facilities can be expected to reduce workload in medical ophthalmic care, since many subjects, e.g. with family history of glaucoma, can be screened and followed using the EyeDiagnostics system. Commercial interest

This Issue of Acta

The guest editorial in this issue, by Leila Laatikainen, deals with litigation in ophthalmology. This has been a big issue particularly in the United States. Laatikainen describes how a society-financed insurance system can decrease the problem, ensuring that patients can be compensated for damage occurring in the health care system without the need of retrieving compensation from or putting unnecessary blame on individuals working in health care. The editorial refers to the very interesting article by Mavroforou and Michalodimitrakis, on the liability of ophthalmologists. These authors discuss reasons for medical litigation. They emphasise the important role of clear communication and proper documentation, and discuss the value of signed informed consent forms. The occurrence of secondary cataract after IOL implantation with various lens types are subjects for ever continuing discussions among ophthalmologists. Stordahl and Drolsum, compared two modern lenses in a large material of cataract surgeries finding distinct differences between the lenses. One of the lenses was associated with a capsolotmy rate of only 2.7% after a mean follow-up of 23 months. Laser interferometry is used frequently instead of ultrasound A-scan to measure axial length prior to cataract surgery and IOL implantation. Goyal et al. report interesting results after a study of 100 patients; the two techniques gave different estimates, but laser interferometry was the more reproducible, and therefore may improve the accuracy of axial length measurements in clinical settings. Suominen and coworker discuss a different tool of analysis of importance for visual outcomes after surgery. They have devised a new index estimating the accuracy of refractive surgery. There are three glaucoma papers in the current issue. Wishart et al. report two very large series of patients operated by viscocanalostomy or deep sclerectomy. The results were encouraging with final mean IOP in the range of 15–17 mmHg, and few complications. Stewart and coworkers report a comparison between two fixed combinations of timolol and dorzolamide versus timolol and pilocarpine. The results indicate that the latter combination, which has been very popular in the Nordic countries can provide a reduction of IOP similar to that of the former, which has appeared on the market more recently. Kotikoski and coworkers studied the effect of a single dose of isosorbide-5-mononitrate on aqueous flow in healthy volunteers, and observed no change. Teär-Fahnehjelm and coworkers studied a group of children with reduced visual acuities caused by serious posterior ocular malformations (optic nerve hypoplasia and optic nerve colobomas). They found that neonatal hypoglycaemia was common in patients with optic nerve hypoplasia and was associated with severe visual impairment. Screening for diabetic retinopathy is an important, high-volume task for the ophthalmic health care system today. In the Nordic countries screening is most often photo-based, but in many countries nonophthalmologists perform such screening with ophthalmoscopy. Verma and coworkers studied the performance of general physicians and optometrists. There was good agreement among the diagnoses of these categories of personnel, and those of opthalmologists. This method of diabetic screening may be of particularly great value in countries with a shortage of ophthalmologists. Olopatadine is a drug that has become available for treatment of allergic conjunctivitis in recent years. Yalali et al. compare the results achieved with this drug to those of ketorolac or placebo. Both drugs were effective, and symptoms of itching were lower in the olopatadine group. Three articles deal with ocular tumours. Cohen and coworkers compared metastasis free survival after enucleation and stereotactic radiotherapy of choroidal melanomas. There was no statistically significant difference between the two study groups. As expected large tumour size and ciliary body location were associated with poor survival. Kodjikian et al. report two families and provide a literature review on unusual familial uveal melanomas. Palazzi and coworkers report oncogenic human papillomavirus types 16 and 35 in 28% of 43 tumour specimens from children with unilateral retinoblastoma. Intravitreal triamcinolone has been increasingly used for a variety of ocular disorders. The group of Jonas has been very active in research in this area. In the Diagnosis and Therapy in Ophthalmology Section they report morphological and functional changes after such intravitreal triamcinolone injections in patients with retinal vein occlusion with persisting cystoid macular edema. Visual acuity improved, and OCT and fluoresceing angiography showed normalization of retinal thickening and CME. There are two case reports in this issue: one describing permanent cortical blindness after hepatic encephalopathy, the other describing bilateral, combined retinal and choroidal detachments in a patient c-ANCA-positive scleritis. And there are many interesting letters to the editor in the current issue.

The dry eye: an introduction.

Understanding the dry eye would be a great deal easier if we thoroughly understood normal tear function. To date, many aspects of tear function remain poorly understood. Only when normal tear characteristics and function are fully illuminated will the treatment of tear abnormalities and ocular surface disease be remedied. This instructional article aims to provide the reader with basic information regarding tear production, abnormalities, and current therapies in order to permit ophthalmic health care providers to intervene and teach patients who suffer from the frustrating and often chronic maladies associated with a dry eye.

Dry eye: an introduction for ophthalmic health care personnel.

Dry eye: an introduction for ophthalmic health care personnel.

Ophthalmic health care in diabetes mellitus: a cross-sectional study in northern Sweden

The purpose of this study was to estimate the prevalence of diabetic retinopathy, visual impairment/blindness and previous surgical eye treatments in patients with older-onset vs. younger-onset diabetes mellitus. A cross-sectional study of patients with diabetes mellitus in the area of Umeå, Sweden (135,000 inhabitants) was performed during 1994-1995, comprising 1,805 diabetic patients. Diabetic patients of younger ages were referred more frequently than older for fundus examination. With age at diagnosis <30 years retinopathy was seen in 68% of the patients; with age at diagnosis 30 years or older retinopathy was seen in 66% of the insulin-treated, 30% of the oral agent-treated and 7% of the diet-treated patients. Retinopathy that had previously been treated or needed treatment was seen in about one-third of the patients in both the younger-onset and the insulin-treated older-onset groups. The corresponding values for the oral agent-treated and diet-treated older-onset diabetic patients were 9.4% and 0.6%, respectively. No older-onset diabetic patient with acceptable glycemic control and with only dietary treatment had received or needed ophthalmic treatment. In the Umeå area, patients with a relatively short duration of diabetes had a lower prevalence of diabetic retinopathy than that found in Wisconsin in 1979-1980. We conclude that demand for ophthalmic care in general is much higher for older-onset diabetic patients because of the greater number of patients with older-onset than younger-onset diabetes. In addition, older-onset patients should be examined regularly for treatable retinopathy. Diet-treated older-onset diabetic patients with acceptable glycemic control need little ophthalmic screening.

Measuring the outcomes of ophthalmic healthcare: low vision rehabilitation

The measurement of health status and medical outcomes is becoming a major requirement for all providers of healthcare services. There is a need to measure the outcomes of healthcare, not only to demonstrate the effectiveness of care, but also to assess the relative (and possibly competing) worth of different forms of care. At the same time, there is a growing awareness of the limitations of clinical outcomes in contrast to those measured by patients themselves. There is, therefore, considerable interest in the use of generic and disease specific ‘Quality of Life’ (Qol) instruments.Within ophthalmic healthcare, clinical outcomes include, for example, measures of visual function or the gradings of images of ocular structure. Other outcome measures used may include specific disease scales or indices, including questionnaire measures of visual disability (e.g. the VF14, ‘Activities of Daily Vision Scale’ and TyPE scales, designed to assess the impact of cataract and cataract surgery on self‐rated visual disability). In contrast to disease specific measures, generic measures are designed to provide an overall measure of an individuals health status. These measures are classified into profile measures (e.g. the SF36) or indices (e.g. the Rosser index or the EuroQol).There have been a number of studies which have evaluated the effectiveness of low vision rehabilitation, although these have mainly been small cross sectional surveys which have used a single definition of ‘success’, including for example, the visual acuity/visual performance achieved with the LVA or the usage of the LVA. More recently questionnaire approaches have been used to measure ‘success’, but as with clinical outcomes, the validity and reliability of the outcomes used has not been established. Given the considerable scale of the low vision population and the current debate about optimal models of low vision care, there is a pressing need to (1) define an appropriate set of outcome measures and (2) carry out randomised controlled trials comparing the effectiveness and cost‐effectiveness of different forms of care.If we as clinicians fail to inform the debate about appropriate outcomes in ophthalmic healthcare, this may result in such care being incorrectly valued by others.