Ophthalmic Services Research Articles

Lowering the limit: reducing the CD4 T-cell threshold for ophthalmic screening in patients with HIV in an ethnically diverse UK population.

BackgroundBefore highly active antiretroviral therapy, cytomegalovirus (CMV) retinitis was a major threat to vision in individuals with HIV. We investigate whether ophthalmic screening of asymptomatic HIV patients still has value in the highly active antiretroviral therapy era and consider CD4 thresholds in line with the world literature and UK experience.MethodsA retrospective chart review was conducted of all patients seen by the HIV Ophthalmic Service of a UK university hospital both before (2007–2008) and after (2011–2012) introduction of a threshold of CD4 lower than 100 cells/mm3. Data collected included CMV and HIV RNA load, CD4 cell counts and CD4 percentage, CMV-immunoglobulin G status, ocular symptoms, and evidence of HIV-related ocular disease.ResultsIn total, 54 patients were referred to the HIV ophthalmic service. Three patients failed to attend, resulting in complete data for 51 patients (n=24 for 2007–2008; n=27 for 2011–2012). Seven patients had ophthalmic manifestations of their HIV; these cases had lower CD4 counts than those with normal examinations (median [interquartile range], 9 [7–80] versus 175 [44–394]; P=0.0039; Mann–Whitney test). Six cases had HIV retinopathy without sight loss; one case had sight-threatening CMV retinitis associated with a CD4 count of 6 cells/mm3.ConclusionBefore 2008, our practice was to screen all asymptomatic patients with CD4 counts lower than 200 cells/mm3. Screening asymptomatic patients with CD4 counts below 100 cells/mm3 was not associated with any missed or late-presenting cases of CMV retinitis in our HIV population.

Ophthalmic digital image transfer: benefits to triage, patient care and resource.

Hospital capacity in the UK is currently significantly challenged due to new treatments, targets and resource limitations. There have been significant improvements in training, equipment and shared care services in community primary care optometry services. Despite this the challenges to ophthalmic service delivery are considerable. One area of potential benefit is the effect on outcome when a clinical image is attached to a referral. We aimed to quantify the effect of attaching digital images to ophthalmic referrals. Retrospective analysis of 358 consecutive optometry referrals to the Hospital Eye Service in Dunfermline, Scotland using electronic referral with digital images. All images were screened by consultant ophthalmologists. The patients were aged between 9 and 100 years (mean age 63.6 years). Sixty four (18%) referrals were deemed urgent (requiring appointment within 24-60 h), with the majority, 28 (8%) being wet macular degeneration. One hundred and seventy (48%) were deemed routine (appointment within 2-6 weeks), with categories including macular disease, glaucoma, cataract, optic disc and retinal abnormalities. Twenty seven (8%) patients were already attending the hospital eye service, or had been referred previously for the same condition. Categories were mainly glaucoma, diabetic retinopathy and cataract. Ninety-five (25%) were 'e-diagnosed' based on image and referral information (i.e. with no secondary eye care appointment). Diagnosis included glaucoma suspect (22, 6%), macular pathology (12, 3%), abnormal looking discs (9, 2.5%) and cataract (9, 2.5%). The overall 'did not attend' rate for those patients seen in the hospital eye service (254) was <1% (two patients). The attachment of digital images improved the quality of referral triaging from optometry to secondary eye care in the hospital eye service. It allowed detection of sight threatening disease early and more appropriate allocation of patients to specific specialist clinics at first visit. They allowed safe and speedy 'e-diagnosis' of a subgroup, saving hospital capacity and minimising patient inconvenience. Indirectly the service also reduced the 'did not attend' rate. With recent improvements in camera and internet technology digital images will have an ever increasing role in secondary eye care as it continues to adapt to meet modern demands.

A survey of current and anticipated use of standard and specialist equipment by UK optometrists.

To investigate current and anticipated use of equipment and information technology (IT) in community optometric practice in the UK, and to elicit optometrists' views on adoption of specialist equipment and IT. An anonymous online questionnaire was developed, covering use of standard and specialist diagnostic equipment, and IT. The survey was distributed to a random sample of 1300 UK College of Optometrists members. Four hundred and thirty-two responses were received (response rate=35%). Enhanced (locally commissioned) or additional/separately contracted services were provided by 73% of respondents. Services included glaucoma repeat measures (30% of respondents), glaucoma referral refinement (22%), fast-track referral for wet age-related macular degeneration (48%), and direct cataract referral (40%). Most respondents (88%) reported using non-contact/pneumo tonometry for intra-ocular pressure measurement, with 81% using Goldmann or Perkins tonometry. The most widely used item of specialist equipment was the fundus camera (74% of respondents). Optical Coherence Tomography (OCT) was used by 15% of respondents, up from 2% in 2007. Notably, 43% of those anticipating purchasing specialist equipment in the next 12months planned to buy an OCT. 'Paperless' records were used by 39% of respondents, and almost 80% of practices used an electronic patient record/practice management system. Variations in responses between parts of the UK reflect differences in the provision of the General Ophthalmic Services contract or community enhanced services. There was general agreement that specialised equipment enhances clinical care, permits increased involvement in enhanced services, promotes the practice and can be used as a defence in clinico-legal cases, but initial costs and ongoing maintenance can be a financial burden. Respondents generally agreed that IT facilitates administrative flow and secure exchange of health information, and promotes a state-of-the-art practice image. However, use of IT may not save examination time; its dynamic nature necessitates frequent updates and technical support; the need for adequate training is an issue; and security of data is also a concern. UK optometrists increasingly employ modern equipment and IT services to enhance patient care and for practice management. While the clinical benefits of specialist equipment and IT are appreciated, questions remain as to whether the investment is cost-effective, and how specialist equipment and IT may be used to best advantage in community optometric practice.

Geographical inequalities in uptake of NHS-funded eye examinations: small area analysis of Leeds, UK.

Preventable sight loss is an indicator within the Public Health Outcome Framework 2013-2018 for England. Routinely available optometric data do not permit small area analysis of access inequalities. Data were extracted from 17 680 General Ophthalmic Services (GOS1) claim forms for eye examinations conducted in Leeds during February and March 2011. The expected number of GOS1 uptake for each lower super output area was based on the GOS1 national annual uptake. A Poisson regression model was used to explore associations in the GOS1 uptake ratio with deprivation and gender. People aged 60 or over or under 16 living in the least deprived quintile are 71 and 23%, respectively, more likely to have an NHS-funded eye examination than someone in that age group in the most deprived quintile, although all are equally entitled. Uptake is higher in the more deprived quintiles among 16-59 year olds, as means tested social benefits are the main eligibility criteria in this age group. There were no statistically significant gender differences in uptake. Interventions are needed to address eye examination uptake inequalities. However, in order to better inform commissioning and planning eye care services more complete data with additional detail are required. GOS1 forms ought to be submitted electronically linked to additional demographic and clinical data to allow public health analysis. Ideally, private eye examination data should also be captured.

Telemedicine for retinal care in developing nations: the ORBIS Cyber-Sight programme, 2003–2011

ORBIS International has provided a web-based ophthalmic disease consultation service, Cyber-Sight, for developing nations since 2003. The system connects partner physicians with mentor physicians. We have reviewed consultations concerning retinal cases submitted from June 2003 to December 2011. Of 943 retinal consultations reviewed, 117 were excluded, mainly for reasons of technical limitations at the partner sites. Of the 826 included cases, 504 patients were male and 322 were female. The average age of the patients was 43 years (range 2 months to 86 years). Cases were submitted from partner physicians in 30 countries, with five countries accounting for 82% of the cases (India, Vietnam, Indonesia, China, Jordan). There was a rise in the case submission rate to a peak of 251 cases in 2010. The mean consultant response time was 5 days (SD 9). The mean time to case closure was 19 days (SD 92). The most common diagnoses were diabetic retinopathy (n = 101), retinal vascular occlusion (n = 75) and retinal detachment (n = 61). The working diagnosis submitted by the partner did not match the mentor's diagnosis in 153 cases (19%). The number of incorrect initial partner diagnoses demonstrates that the teleretinal programme serves a useful diagnostic role for partner physicians. The Cyber-Sight programme is a viable method of delivering advanced retinal expertise to partner institutions and increasing capacity for partner doctors in the developing world.

G320 Transfer of Ophthalmic services from a Hospital based Eye clinic to Special School Eye clinic for children with special needs

IntroductionChildren with moderate to severe learning difficulties find attending Hospital based Eye (HBE) clinics a difficult experience. Long waiting times in a strange, often extremely busy location, coupled with the...

Effect of sleep related breathing disorders on ocular function

IntroductionSleep disorders are common and obstructive sleep apnea hypopnea syndrome (OSAHS) is the commonest. OSAHS is not commonly diagnosed by the ophthalmologist, but it has many systemic and ocular complications. Aim of the workThe aim of this study was to detect the effect of sleep related breathing disorders on ocular function. Patients and methodsThirty patients with OSAHS were enrolled after obtaining informed consents. Patients were subjected to full history taking, Epworth sleepiness scale, anthropometric data, Mallampati score, clinical apnea score, sleep study and complete ocular examination. Results4 patients had mild OSAHS (13.33%), 12 patients had moderate OSAHS (40%) and 14 patients had severe OSAHS (46.67%) two of them had sleep hypoventilation. 4 patients were free from any ocular manifestations. In 26 patients one or more of the following ocular findings were found: floppy eyelid syndrome (FES) was detected in 3 (10%) patients, glaucoma was diagnosed in 5 (16.67%) patients, senile cataract was found in 3 (10%) patients, nonarteritic anterior ischemic optic neuropathy (NAION) was detected in 4 (13.33%) patients, papilledema was diagnosed in 3 (10%) patients and 18 (60%) patients had dry eye manifestations. In conclusionThe increased prevalence of ocular symptoms and signs in patients with OSAHS indicates a need to increase awareness and establish close collaboration with the sleep physicians with clear pathways for review of OSAHS patients by the ophthalmic services. We should study the effect of treatment of OSAHS on the ocular manifestations.

Cataract research in India: A scientometric study of publications output, 2002-2011

Analyses the 1293 Indian publications in cataract research during 2002-2011, with a focus on contribution and citation impact of 15 most productive countries, India's overall contribution, its growth, citation impact, the share of international collaborative papers, identification of significant countries in India's international collaboration, different types of cataract research, analyses of research by sub-fields and different population age groups, productivity, and impact of leading Indian institutions and authors and pattern of communication of Indian output in most productive journals. The Scopus Citation Database has been used to retrieve the data for 10 years (2002-2011). Indian publications increased from 87 papers in 2002 to 195 papers in 2011, witnessing an annual average growth rate of 10.03%, registering an average citation impact per paper of 3.26 and international collaborative share of 21.58% during 2002-2011. Suggest that the government should encourage the decision makers and ophthalmologists and allied persons involved in ophthalmic services to make serious efforts in reducing the burden of cataract disease by increasing the R&D, strengthening of national and international collaboration and improve the existing training programs for ophthalmologic professionals.

Introducing specialist services into routine practice

The demand for eye care is ever on the increase with an aging population and a reduction of funding for public services. Often local fund holders are looking for more efficient methods of delivering good quality eye care. As a result it is not uncommon for local Trusts to enter into agreements with local ophthalmic service providers and formulate shared care schemes. Are these schemes necessary and are they financially viable? Independent prescribing of therapeutic drugs in primary eye care practice is one specialised service that has come about to try and reduce the burden on the hospital eye service.

Reflections on a slit-lamp teacher-training workshop for ophthalmic nurses in Korle Bu, Ghana

Korle Bu Eye Unit based in Accra, Ghana is linked with Moorfields Eye Hospital in a VISION 2020 partnership. Its primary aim is to support and strengthen ophthalmic services within the eye unit at Korle Bu. This article outlines a recent initiative whereby ten ophthalmic Korle Bu nurses undertook a three-day training course with a final day of assessment to become trainers of slit lamp skills.

Providing comprehensive genetic-based ophthalmic care

The diagnosis of an inherited retinal dystrophy can have a significant impact on both the physical and emotional lives of patients and their families. In order to optimize the health and quality of life for these individuals, a comprehensive approach to clinical care starting at the time of diagnosis and continuing throughout their lifespan is critical. A multidisciplinary team approach integrating ophthalmic and genetic counseling services can optimize the diagnostic process and long-term management of these patients. When vision loss is first appreciated, the diagnostic specificity of an ophthalmic evaluation can be enhanced by a detailed genetic work-up. This evaluation can help confirm the diagnosis and allow for accurate risk counseling of the patient and their family. Genetic counseling is critical at the time of diagnosis and is an opportunity to provide education about the diagnosis, discuss low-vision rehabilitation, and explore impacts on academics and employment. In addition, counseling can help patients deal with the current psychological aspects of their vision loss, prepare for the lifelong impact of their diagnosis and over time adjust to the impact of progressive vision loss.

The Richest Monetary Prize in Vision

T HOSE SEEKING BREAKTHROUGH DISCOVER- iesinophthalmologyandvision,likethose working to bring the benefits of such dis- coveries and modern ophthalmic care to poor people around the globe, are not do- ing it for the recognition or the money. Still, recogni- tion and monetary awards, particularly those that advance their work, do not hurt. The Antonio Cham- palimaud Vision Award, which is given annually, brings both recognition and funding to research and practice. At €1 million ($1.32 million at recent exchange rates), it is also among the richest prizes in all of medicine and,byfar,thelargestprizeforvisionresearchandblind- ness prevention. The Vision Award was established by the Champali- maud Foundation of Lisbon, Portugal, to recognize the Foundation'sfounder,AntonioChampalimaud,wholeft a significant portion of his fortune to be used for medi- cal advancement in the fields of neuroscience and on- cology. Because Antonio de Sommer Champalimaud, a Portugueseindustrialistandentrepreneur,sufferedfrom severe visual loss near the end of his life, the Founda- tion's President, Dr Leonor Beleza, and its Board of Di- rectors established the Vision Award in his honor. TheVisionAwardisgiven,onalternateyears,toapro- gram that has contributed significantly to blindness pre- vention among poor and underserved populations and, on the subsequent year, for significant research discov- eries. The formal award presentation occurs in Septem- ber at a grand affair in Lisbon presided over by the presi- dent of Portugal. The first, third, and fifth awards, respectively, went to the Aravind Eye Care System in India, for its having played a critical role in vastly expanding access to cata- ract and other ophthalmic services by pioneering high- quality, sustainable, and efficient delivery mechanisms; to Helen Keller International, a US-based nongovern- mental organization, for its leadershipin developing and promoting global programs for the control of blinding (and fatal) vitamin A deficiency in children; and to the African Program for Onchocerciasis Control, for devel- opingaunique,community-based,bottom-upsystemfor delivering annual doses of ivermectin that are protect- ing millions of people from river blindness in 17 coun- tries across sub-Saharan Africa. The second, fourth, and sixth awards went to leading vision researchers. In 2008, it recognized the contribu- tions of Jeremy Nathans and King-Wai Yau, for their dis- coveries related to the way light rays are detected by reti-

Time trends over five decades, and recent geographical variation, in rates of childhood squint surgery in England

AimsTo study trends in rates of childhood squint surgery in England over five decades, and to study recent geographical variation in England.MethodsUse of routine hospital statistics to analyse trends in...

Blindness and severe visual impairment in pupils at schools for the blind in Burundi

Purpose:To determine the causes of childhood blindness and severe visual impairment in pupils attending schools for the blind in Burundi in order to assist planning for services in the country.Materials and Methods:All pupils attending three schools for the blind in Burundi were examined. A modified WHO/PBL eye examination record form for children with blindness and low vision was used to record the findings. Data was analyzed for those who became blind or severely visually impaired before the age of 16 years.Results:Overall, 117 pupils who became visually impaired before 16 years of age were examined. Of these, 109 (93.2%) were blind or severely visually impaired. The major anatomical cause of blindness or severe visual impairment was cornea pathology/phthisis (23.9%), followed by lens pathology (18.3%), uveal lesions (14.7%) and optic nerve lesions (11.9%). In the majority of pupils with blindness or severe visual impairment, the underlying etiology of visual loss was unknown (74.3%). More than half of the pupils with lens related blindness had not had surgery; among those who had surgery, outcomes were generally poor.Conclusion:The causes identified indicate the importance of continuing preventive public health strategies, as well as the development of specialist pediatric ophthalmic services in the management of childhood blindness in Burundi. The geographic distribution of pupils at the schools for the blind indicates a need for community-based programs to identify and refer children in need of services.

Using electronic referral with digital imaging between primary and secondary ophthalmic services: a long term prospective analysis of regional service redesign

Demands on publicly funded ophthalmic services worldwide continue to increase with new treatments, waiting time targets, working time limits, and restricted budgets. These highlight the necessity to develop innovative ways of utilising existing capacity more effectively. A new regional, fully electronic ophthalmic-referral service with digital imaging was trialled using existing information-technology (IT) infrastructure. Following successful pilot study, the service was rolled out regionally. Service delivery data was prospectively collated for all the attendances in the year prior to (2006) and the year following (2008) introduction. Comparing 2006 against 2008, median waiting times reduced (14 vs 4 weeks), and fewer new patients were observed (8714 vs 7462 P<0.0001), with 1359 referrals receiving electronic diagnosis (e-diagnosis). New patient did not arrive (635 vs 503 P<0.0001) and emergencies also reduced (2671 v 1984 P<0.0001). Novel use of existing IT infrastructure improves communication between primary and secondary care. This promotes more effective use of limited outpatient capacity by retaining patients with non-progressive, asymptomatic pathology in the community, whilst fast-tracking patients with sight-threatening disease. Resultant significant, sustained improvements in regional service delivery point to a simple model that could easily be adopted by other providers of universal healthcare globally.

Investigation of ophthalmic resources in Xinjiang Uyghur Autonomous Region in China

To explore ophthalmic resources and existing problems in Xinjiang Uyghur Autonomous Region, and to provide reasonable developing configuration for the future. It was a population-based cross-section study. By using questionnaire to collect data from all eye units (national and private) which were registered in Xinjiang area. Investigation included: (1) ophthalmic medical unit of name, structure type, departments constitute; (2) the ophthalmic medical work; (3) the number of ophthalmology health technicians and distribution; (4) ophthalmic devices usage; (5) carry out the problems and difficulties encountered in ophthalmic work. Descriptive statistic method was used to analyze the structure of ophthalmic material, the availability of resource, the medical institution of different regions and types. One hundred and thirty questionnaire were filled out and 110 questionnaire were recovery. There were 107 eye units, 1709 beds for ophthalmic, 1672 employees, including 525 doctors, the ratio of doctors and nurses was 1.0:1.3. And the ophthalmic resources mainly distributed in northern Tianshan, very few in the eastern area in Xinjiang; ophthalmic units were denser in general hospitals which were above the county level. There were 43 580 ophthalmic surgeries in all, the main eye operation carried out was cataract surgery, including 20 303 (counted 46.59%) cataract operation. The ophthalmic units distribution is unbalanced, which is short of ophthalmologists. It provides base for government to arrange ophthalmic resources reasonably, to enhance the research motivation and to cultivate more professors, and to increase the number of ophthalmic specialists in the general hospitals, and eventually to maximize the benefit of ophthalmic service in Xinjiang.

Projected prevalence of age‐related macular degeneration in Scandinavia 2012–2040

To project the number of persons with late age-related macular degeneration (AMD) in Scandinavia through 2040. Age- and sex-specific prevalence rates of late AMD (choroidal neovascularization and geographic atrophy) from the European Eye Study and the Eye Diseases Prevalence Research Group were applied to the projected Danish, Norwegian and Swedish population from 2012 to 2040. A total of 187 000 persons aged ≥65 years in Scandinavia are currently affected by late AMD: 47 000 in Denmark, 43 000 in Norway and 97 000 in Sweden. Owing to an ageing population, the number of persons affected by late AMD will increase 75% to 328 000 in 2040. The number of patients with late AMD in Scandinavia is expected to increase substantially over the next three decades, resulting in increased demand for ophthalmic health services.

Analysis of factors associated with patient satisfaction in ophthalmology: the influence of demographic data, visit characteristics and perceptions of received care

To identify factors associated with satisfaction among patients receiving ophthalmic services and to indicate the intensity of this relationship. The data used was obtained through a self-administered, post-visit questionnaire from randomly selected 507 patients treated in seven eye clinics in Germany. The instrument assessed satisfaction with several aspects of care and patient baseline and visit characteristics. Bivariate and multivariate techniques were used to reveal relations between indicators and overall satisfaction. Factor analysis yielded two factors, 'medical aspects of care' and 'performance of service', explaining 55% of total variance. Cronbach's α coefficient for both scales indicates acceptable internal consistency. Bivariate analysis showed strong relations between overall satisfaction and perceived care with weaker findings pertaining to visit characteristics. Not any of the demographic variables was associated with overall satisfaction. Perceived length of stay, intention to return to the clinic, and occurrence of complications were influential attributes on satisfaction ratings. The multivariate analysis identified seven factors associated with overall satisfaction including the treatment outcome (OR: 4.57), kindness of the nurses (OR: 5.27) and medical practitioners (OR: 2.23), room amenities (OR: 2.72), organization of procedures and operations (OR: 2.71), information about anaesthesia (OR: 1.95), and cleanliness (OR: 1.93). Factors associated with patient satisfaction in ophthalmology concern medical aspects like the organization of procedures and operations but also aspects that are not directly related to technical care, such as kindness of the nurses and cleanliness. Results show that patients' subjective experiences of received care and services relate more strongly and consistently to overall satisfaction than patient demographic data or visit characteristics. Revealed factors predicting patient satisfaction are alterable by health care managers. Therefore, focusing on these attributes represents an effective manner to enhance patient satisfaction in ophthalmology.

Challenges Faced by British Military Ophthalmic Services During the First World War

The First World War was a time of great change for many areas of military medicine. This article reviews some of the particular challenges faced by British Ophthalmic Services during...

Magnitude and causes of childhood blindness and severe visual impairment in Sekoru District, Southwest Ethiopia: a survey using the key informant method

There are very few population-based data on childhood blindness in the Horn of Africa. In Sekoru district, Ethiopia, we performed a whole-of-population cross-sectional survey using the key informant method to determine the magnitude and causes of childhood blindness (presenting visual acuity <3/60 in the better eye) and severe visual impairment (SVI; presenting visual acuity <6/60 but ≥3/60 in the better eye). Forty-two key informants were trained to identify blind/SVI children aged <16 years. Identified children were examined by an ophthalmologist. Causes of blindness/SVI were established by clinical examination. Key informants visited 94% of 22 666 households, identifying 112 children, of whom 36 (32%) were confirmed to be blind/SVI by the ophthalmologist. Twenty (56%) of the 36 were male. The mean age was 10.7 years. The district prevalence of childhood blindness/SVI was 0.062% (95% CI 0.042–0.082%). Lens-related abnormalities (mainly congenital cataract) were the commonest causes. Avoidable causes of blindness accounted for 89% of cases. Paediatric ophthalmic services are required here, as elsewhere in rural Ethiopia. Assessment by key informants has an acceptable positive predictive value in this setting. This method warrants further evaluation as a tool for measuring the prevalence of other rare conditions in rural and remote populations.