UK Eye Care Services Project Phase One: Systematic Review of the Organisation of UK Eye Care Services

University of Warwick

September 2010 (Revised February 2011)

Dr Carol Hawley Helen Albrow Dr Jackie Sturt Lynda Mason UK Eye Care Services Project Contents Phase One: Systematic Review of the Organisation of UK Eye Care Services

Study team i Acknowledgements i Glossary of abbreviations ii Executive Summary 1

1. Background to current organisation of UK eye care services 4 Devolution in Scotland and Wales 6 Global thinking surrounding eye care services and the UK response 8 Other ophthalmic roles 9 Generalisability of care pathways 11 Report Aim 11

2. Methods 12 2.1 Data searches 12 2.2 Data Extraction 14

3. Results 15 3.1 Report organisation 15 3.2 Summary of ‘black’ literature 17 Optometrists in primary care 18 Optometrists within the HES 19 Combined eye examination and referral initiatives for all eye conditions 22 Referral initiatives for all eye conditions 23 Referral quality and frequencies for all eye conditions 25 Glaucoma 28 Ocular Hypertension (OHT) 40 Cataract 41 Posterior Capsular Opacification 47 Diabetic Retinopathy (DR) 49 Blood Glucose screening 60 Optometric Prescribing 61 Low Vision Services 64 Paediatric eye care services 67 Melanoma 71 Flashes and floaters 72 Critique of the COSI concept (Community Optometrists with a Special Interest) 74 Optometric technological comparison studies 75

4. Conclusions from the literature 76

5. References 78 UK Eye Care Services Project Appendices Phase One: Systematic Review of the Organisation of UK Eye Care Services

Appendices 88 Appendix 1 – Search terms 89 Appendix 2 – Data extraction sheet 91 Appendix 3 – Hau 95 Appendix 4 – Scully 96 Appendix 5 – Shah 97 Appendix 6 – All ‘Black’ literature 98 Appendix 7 – CCI eye care pathways 121 Appendix 8 – Recommended eye care pathways 126 Appendix 9 – Grey literature 128 Appendix 10 – Published and unpublished care pathway schemes 131 Applications produced for new eye care schemes 131 GP and PEARS Schemes 131 Paediatric Schemes 137 Low Vision Schemes 137 Glaucoma referral refinement and/or co-management schemes 139 Cataract referral schemes 146 Diabetic Retinopathy Screening Schemes 154 Age-Related Macular Degeneration 155 UK Eye Care Services Project List of Tables & Figures Phase One: Systematic Review of the Organisation of UK Eye Care Services

List of Tables Table 1 : Summary of papers by database 14 Table 2 : Evaluations of specific eye care schemes 17 Table 3 : Optometrists in primary care 18 Table 4 : Optometrists within the HES 21 Table 5 : Optometrists in combined examination and referral initiatives for all conditions (Wales) 22 Table 6 : Optometrist involved in referral initiatives (all eye conditions) 24 Table 7 : Optometrist referral quality and frequency of referral (all eye conditions) 26 Table 8 : Optometrists involved in glaucoma schemes 34 Table 9 : OHT co-management scheme in Edinburgh 40 Table 10 : Optometrists involved in cataract one-stop surgery schemes 44 Table 11 : Optometrists involved in PCO referrals 47 Table 12 : Optometrists involved in DR co-management schemes 55 Table 13 : Optometrists involved in blood glucose screening 60 Table 14 : Optometrists involved in prescribing 62 Table 15 : Optometrists involved in Low Vision schemes 66 Table 16 : Optometrists involved in paediatric eye care schemes 69 Table 17 : Optometrists involved in melanoma detection 71 Table 18 : Optometrists work with flashes and floaters 73 Table 19 : Critique of the COSI role 74 Table 20 : Optometrists involved in schemes with electronic referral 75

List of Figures Figure 1 : QUORUM Chart 14 Figure 2 : Paper distribution according to eye condition or initiative 16 Figure 3 : Study design used in papers 16

Study Team

Dr Carol Hawley Principal Investigator Dr Jackie Sturt Co-Investigator Helen Albrow Research Associate Irena Wowk Research Fellow Diane Clay Information Scientist Lynda Mason Project secretary

Acknowledgements

The study team wish to acknowledge the expert knowledge and input from the Project Steering Group. Members of the group were:

Michael Bowen - Head of Research, College of Optometrists Dr Kamlesh Chauhan Dr Robert Lindfield Sali Davies Dr Ross Henderson Tony Trowsdale Martin Cordiner

Glossary of abbreviations A&E Accident and Emergency ABDO Association of British Dispensing Opticians AGO Accredited Glaucoma Optometrist AO Accredited Optometrist AOP Association of Optometrists ARMD Age-related Macular Degeneration CCI Centre for Change and Innovation (Scotland) CET Continuing Education and Training COAG Chronic Open Angle Glaucoma CoO College of Optometrists COSI Community Optometrist with Special Interest CVista Children’s Visual Impairment Scheme- Tayside Agencies DES Data extraction sheet DoH Department of Health DR Diabetic Retinopathy FODO Federation of Dispensing Opticians GOC General Optical Council GOS General Ophthalmic Services GP General Practitioner HES Hospital Eye Service IAPB International Agency for the Prevention of Blindness ISIP Integrated Services Improvement Partnership IOP Intra-ocular pressure LOC Local Optometry Committee LV Low Vision NHS National Health Service NICE National Institute for Clinical Excellence NSC National Screening Committee OA Optometric Advisor OH Ocular Hypertension OHT Ocular Hypertension OPSI Optometrist with Special Interest PEARS Primary Eyecare Acute Referral Scheme PCO Posterior Capsular Opacification PCT Primary Care Trust POAG Primary Open Angle Glaucoma QUORUM Quality of Reporting of Meta-analyses RCT Randomised Controlled Trial RNIB Royal National Institute for the Blind SHA Strategic Health Authority STDR Sight Threatening Diabetic Retinopathy STED Sight Threatening Eye Disease SVFA Suprathreshold Visual Field Analysis UHW University Hospital Wales UKECSSP UK Eye Care Services Survey Project VA Visual Acuity VF Visual Field WECI Welsh Eye Care Initiative WEHE Welsh Eye Health Examination WHO World Health Organisation WMSHA West Midlands Strategic Health Authority

Executive Summary

Aim of the report and the overall project The joint paper ‘Primary Care and Community Services: Improving eye health services’, produced by the UK Vision Strategy, Department of Health and World Class Commissioning, dedicates an entire section to mapping baseline services, and therefore suggests the importance of mapping ‘baselines’ in order to make improvements to eye health services (DoH, 2009: 26-34). Mapping exercises can be supported by academic research, audits of optometric practices and mapping patient journeys. This report is directly tied to this, with the overall project aim being to map UK eye care services. The aim of this report is to present the current literature relating to optometrists within UK Eye Care Services in a variety of capacities. By mapping services, any organisations outside of the College, including PCTs, can be supported in identifying service gaps, as well as understand the ways in which current services operate to facilitate the development of new schemes. The schemes described in this report will also provide exemplars for other regions not currently involved in enhanced eye care services.

Methods A systematic review was carried out of all UK-based research papers regarding UK Eye Care Services published since 1997 which incorporate the role of optometrists in a variety of ways. All relevant databases were searched, including Medline, Embase, Cochrane, Science Citation Index, Applied Social Science Index of Abstracts (ASSIA), Health Management Information Consortium (HMIC), Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PsychINFO.

This report makes recommendations for future research based upon the findings. Where relevant, grey literature material was also identified during the literature search, this is included to provide background to the research evidence. Grey literature was identified from a variety of sources, including the National Institute for Clinical Excellence (NICE), the Association of Optometrists (AOP), the Federation of Dispensing Opticians (FODO), the Association of British Dispensing Opticians (ABDO), and the College of Optometrists. All AOP-listed optometric schemes are also included, as well as those schemes identified from the grey literature.

Results 5287 abstracts were screened, of these 5062 were excluded as not relevant to the organisation of eye care services. Two hundred and twenty-five full text papers were read and their bibliographies scrutinised to identify further potentially relevant articles. This revealed a further fourteen papers. Eighty-eight papers were included in a meta analysis which was carried out using detailed data extraction forms (Appendix 2).

Summary of findings  The findings suggest that many optometrists are working within structured, co- managed schemes in order to provide enhanced services to patients. These schemes commonly occur in pockets within primary care trust (PCT) or local health board areas. The schemes are listed within the final section of the report.

 As the population ages, such schemes will be increasingly necessary in order to stem the flow of referrals to a heavily loaded hospital eye service (HES), (Royal College of Ophthalmologists, May 2004).

 Communication between all those involved is a crucial element in making such schemes function effectively. Communication between all parties involved in eye care services will require some enhancement in order to provide the best practice services to patients in need. Some evidence suggests communication between optometrists and ophthalmologists, in terms of feedback, could be improved (Whittaker et al., 1999).

 Where optometric eye care schemes are identified in this report, the research evidence suggests optometrists provide a safe and high quality service, which is already incorporated within the core skills of their initial degree training.

 Referral guidance is a major aspect to consider within referral refinement and co- management schemes. This is particularly the case for glaucoma referral refinement and/or co-management schemes. NICE guidance (2009) defines the approach to the referral and management of OHT and Glaucoma. The section of the guidance relating to inter-ocular pressure (IOP) created a difficulty in primary care settings as the repeated IOP measurements for patients with pressures over 21mmHg indicated by the NICE guidance, did not fit within the current funding structure. Schemes which encompass new ways of working in terms of referrals must consider the impact of such guidance upon referral patterns. AOP guidance in 2007 also strongly encouraged optometrists to follow the NICE guidance carefully for reasons of personal legal protection. Joint College of Optometrists and Royal College of Ophthalmologists clarification on this point was aimed at addressing some of the reported confusion relating to when community optometrists working within ‘standard’ primary care settings should refer. The NICE guidance helped to clarify the need for community eye care services and secondary (Hospital Eye Services – HES) to be organised in a manner that took account of key clinical and professional guidance in ensuring schemes provided safe and effective care that does not conflict with the standards and expectations of the bodies that govern and guide clinical and professional practice.

 The financial restraints placed on local PCTs and their successors, GP-led Consortia, must be considered. Where referral refinements and/or co- management schemes exist, the very nature of these means referrals are made only when the optometrist is satisfied that the patient requires additional care from the HES. This presents a competing challenge between streamlining glaucoma services via referral refinement and co-management, and adhering to professional guidance from key bodies including NICE.

Conclusion In summary, this report suggests that the co-management schemes identified are particularly effective, however there will be continued debate regarding the generalisability of such schemes across wider areas.

Scotland and Wales have devolved powers for healthcare, here eye care services operate on higher fees to optometrists for each patient seen (Scotland) or are directly funded by the Government (Wales Eye Care Initiative (WECI) scheme).

The UK is divided in terms of its eye care provision to patients. Where schemes initially implemented in Wales have been taken up within England, these have been arranged between the PCT and optometrists within the particular area. There is evidence of success, in terms of improved access to diagnostic eye care services, improving the quality of referrals and reducing demands in Primary care (Sheen et al 2009). These include referral refinement and primary eye care acute referral schemes (PEARS). It remains to be seen how these pockets of best practice could be transferred across larger areas, where patient need may differ, and PCT budgets may have correspondingly different priorities. Furthermore, the recent announcements regarding the abolition of PCTs and strategic health authorities (SHAs) by 2012 made during the write-up of this report, and the emphasis this places on GP-based commissioning and community health services, could present a particular opportunity for community-based optometric care.

Finally, the report also advises on future research priorities, and identifies methods of data collection and presentation for this future research within eye care services.

1. Background to current organisation of UK eye care services

The quality and management of UK Eye Services has been the subject of much scrutiny over a number of years. Changes in English governmental jurisdictions over Wales and Scotland, has meant the evolution of new practice as a result of governmental devolution. Many sectors of the Scottish and Welsh public, including those in at-risk groups, can now receive free eye examinations under new guidelines and eye care schemes in both countries (e.g. PEARS and the new GOS contract in Scotland). In contrast, England continues to have a significant proportion of eye examinations requiring private funding from patients. Only certain groups, including full- time students aged 19 or under, under 16 year-olds, over 60 year-olds, those receiving state-benefits, people with diabetes, and those with a family history of certain conditions, can receive free eye examinations by a qualified eye-care professional, typically a community optometrist. Optometrists provide the largest eye care service in the UK, and are responsible for the largest number of referrals across the eye care services sector. For example, 90% or more of primary open angle glaucoma referrals in the UK originate from optometric practice (Gilchrist, 2000). Follow-up on such cases accounts for one quarter of the Hospital Eye Service (HES) workload (Gilchrist, 2000).

The leading causes of certifications for blindness and partial sight are macular degeneration and posterior pole degeneration, closely followed by glaucoma and diabetic retinopathy (Bunce and Wormald (2006). Since their study, an ageing population may have led to an increased incidence of these conditions as a result of a greater number of people in the age groups at most risk. Projections from commissioning sources suggest that the demand for NHS sight tests will rise by some 20% over the next twenty years as a result of the increase in the over 60 population. Furthermore, the cases of eye conditions such as glaucoma are set to increase by a third by 2021, and will continue to rise at a similar pace until 2031 (Commissioning toolkit for community based eye care services, January 2007). Therefore the future impact of the aging population upon referrals to HES will be particularly significant. In order to minimise excessive hospital workload, in which appointment slots are increasingly in short supply, referrals from the community require high levels of accuracy in order to ensure that only those conditions which truly require HES examination are passed on.

The General Optical Council (GOC), is currently considering the implementation of revalidation, in which all optometrists would be required to re-validate their license to practice by demonstrating quality of service and the scope of services provided by optometrists (GOC bulletin, Winter 2009). This is likely to involve development of the existing system for continuing education and training (CET) points, gained on training courses, conferences and similar professional activities.

In parallel to this, various other guidelines involving optometrists and health care professionals have been introduced, for example the NICE guidelines for the ‘diagnosis and management of chronic open angle glaucoma and ocular hypertension’, 2009, and the Department of Health’s ‘Action on Cataracts’, 2000. The latter suggested the need for increases in surgical throughput for cataracts, recommending changes to cataract care pathways. Correspondingly, direct cataract referral schemes and one-stop cataract surgery pathways have evolved considerably, and are included in this report. However, the impact of new governmental plans for restricting common operations including cataract surgery remains to be seen. Optometrists feature in key places within these schemes as the direct referrers from their community practice to the HES. Other

schemes involving optometrists include diabetic retinopathy screening, glaucoma monitoring, prescribing and schemes for acute eye conditions.

Within the diverse context of new guidance and a rapidly evolving environment for eye care provision, the long-standing debate continues regarding the role of eye-care professionals, particularly optometrists. As the population continues to age, the role of optometrists will become even more important in meeting the increasing demand for eye care services whilst taking account of the challenging budgetary decisions facing the NHS. The new GP-led Consortia, along with the rest of the NHS will be working within a tight regime of restricted funding and demands for cost saving measures across the board. The full impact of the 2010 spending review on the NHS has yet to become clear, but its impact is already influencing commissioning decisions. 80% of the NHS budget will be handed to GP-led Consortia, making them a key function in the system. Expanding roles for community optometrists has the potential to reduce the burden on the HES, particularly ophthalmologists, who are expensive in time and money to train and increasingly short on physical space within their working environments.

Guidance produced by the Integrated Services Improvement Partnership (ISIP), outlines the steps in a ‘benefits realisation’ approach to eye care services (Step-by-Step Guide to Commissioning Community Eye Care Services, 2007). This approach allows further engagement from stakeholder groups, and part of the process means stakeholders agree on the priority areas for change, based on the gap between current provision and where future provision should be. Therefore, by identifying this gap, the key factors for change can be identified. Many of the activities outlined by the ISIP pertain to community-based and co-managed eye care. In terms of service re-design for example, desired outcomes include patients being treated closer to home and being seen more quickly, increasing the range of services available to patients, community training programmes, and the increased use of community workforces.

The ISIP Guide (2007) also outlines recommended eye care pathways for cataract, glaucoma and low vision (Appendix 8). Many established and new eye care schemes described in the research papers included in this report largely mirror these model eye care pathways. Under the NHS Modernisation Agency, a chronic eye care services programme was established in order to pilot new patient pathways for low vision, age- related macular degeneration and glaucoma. The schemes detailed within the programme’s literature review are also included in the final section of this report (McLeod et al., 2006).

Some authors have called for the entire restructuring of eye care services, including one paper suggesting the implementation of a community ophthalmologist system in order to reduce ophthalmic referrals from general practice (Chopdar, 1999). However, the vast majority of new shared-care schemes in the UK include the training of community optometrists to detect, initially diagnose and later to manage specific eye conditions within a community setting.

Devolution of Scotland, Wales and Northern Ireland

Scottish Community Eye Care Services In October 2005, Sense Scotland delivered a response to the Scottish Executive interim report on the review of eye care services in Scotland. The recommendations and comments mirror the full review article by providing an initial commentary regarding a ‘patient-centred approach to the design of eye care services.’ Similarly, the interim report also suggests the use of ‘the optometry network’ to deliver ‘an extended eye examination’, as well as the possible consideration of supermarket based ophthalmic services. Additionally, the recommendations suggested the need for further work to address the specific eye care needs of children (Sense Scotland, 2005: 3).

The follow-up report from the Scottish Executive, the ‘Review of Community Eye Care Services in Scotland’ in 2006 marked a significant development of eye care services for optometrists. As a result of this review, optometrists became able to use their clinical judgement to determine the content of a sight test, rather than to follow a rigidly prescribed format which could include carrying out procedures which did not benefit the patient. This increased flexibility has advantages for both optometrists and for patients. The fee structure was also reviewed, and the sight test fee paid to optometrists was increased from £18.50 to £36 (2007-2008 fees). Consequently, optometrists in Scotland are reimbursed for carrying out extended examinations, which is still a source of debate in England in terms of reimbursement methods and remuneration figures (Scottish Executive, 2006).

The final report of the review of community eye care services in Scotland set out a number of key recommendations including some of the following pertaining to service design and integration:

- Taking an integrated, patient-centred approach to designing eye care services for adults and children. - The extended role of the optometrist should be used in order to strengthen clinical management of patients as well as strengthen links to support in the community. - The CVISTA scheme (Children’s Visual Impairment Scheme - Tayside Agencies) should be undertaken across Scotland. CVISTA is an integrated team of health and social care agencies in Tayside who provide services for children and their families with visual impairment. The agencies include NHS Tayside, Angus Council, Forfarshire Society for the Blind, RNIB Scotland, Parent to Parent, Sense Scotland, Guide Dogs and Pamis. The agencies can recommend tests for low vision aids or an orientation and mobility assessment, as well as equipment and strategies for school, the home and in the community. This information is available from the CVISTA information sheet.

The other recommendations also directly relate to the optometrist role, and how this should be utilised in order to strengthen eye care services to patients. Similarly, where the guideline recommends a patient-centred approach, co-managed schemes will help to achieve this, placing the patient in charge of appointment times, deciding whether they wish to have surgery for conditions which are treated with surgery, and which particular optometrist to access within the community.

The current Scottish system is summarised by Optometry Scotland as follows (http://www.optometryscotland.org.uk):

1. Universal access to free NHS routine eye examination by community optometrists 2. Universal access to free NHS eye care by community optometrists between scheduled recall periods if a visual or eye problem develops 3. Funding for retinal cameras in all Scottish community practices in 2008/2009 4. Funding for automated visual field analysers with threshold capability in 2006/2007 5. Recurrent annual education funding of £1 million delivered by NHS Education Scotland (NES).

The Centre for Change and Innovation in Scotland also produced patient pathways for an entire range of eye conditions, including strabismus, glaucoma, flashes and floaters, external eye disease, diplopia, cataract and ARMD. These pathways provided the recommended outlines for creating new pathways in individual areas of Scotland. Many of the resulting pathways share similarities with the co-management schemes in England and Wales, utilising optometrists’ skills. Some of the resulting local schemes in Glasgow, Lothian and Grampian (Aberdeen), are listed in the scheme section later. All CCI pathways are documented in Appendix 7.

Welsh Community Eye Care Services The governmental independence of the Welsh Assembly has permitted the development of eye care services within Wales. As a result, the Welsh system has developed quite differently to other UK countries, although it is similar to Scotland in terms of growth in eye-care services. The Welsh Eye Care Initiative (WECI), incorporates both the Welsh Eye Health Examination scheme (WEHE), which is an extended sight test, and the Primary Eye Care Acute Referral Scheme (PEARS), as well as Low Vision, Diabetic Retinopathy Screening, Glaucoma Co-management, a Primary Care Cataract Post-Operative Service and Children’s Screening (information available from Welsh Assembly Government website).

There are 532 optometric practices in Wales, with at least one in every conurbation, and many rural practices. This permits widespread access to eye-care services for patients throughout Wales. A catalogue of local optometric care pathways has recently been published by Optometry Wales (2010). This provides a reference guide to local optometric schemes across Wales. Consequently, Wales has a suite of eye care services, and detailed protocols for some of these eye-care initiatives are available from the Eye Care Wales website (www.wales.nhs.uk). Schemes have been piloted prior to general implementation, and reports are available which evaluate the schemes and any cost-savings (Optometry Wales, 2010).

The Welsh Assembly funds the WECI. All optometrists are trained on Cardiff University approved courses in order to provide the services under the WECI, and practitioners display signage within their practices in order to show their involvement in the schemes. The WEHE is applicable to particular patients, including those in at-risk groups for particular eye conditions including glaucoma. The PEARS scheme allows community optometrists to refer patients directly to the HES when patients present with acute eye conditions requiring urgent HES appointments. If the patient first presents to a GP, the GP can refer the patient to the nearest accredited PEARS optometrist for subsequent HES referral.

The Low Vision Scheme involves over one hundred optometrists and dispensing opticians who can provide low vision assessments. Any necessary low vision aid is prescribed free of charge (RNIB, 2007). The optometrists and dispensing opticians who provide the low vision service take an Association of British Dispensing Opticians (ABDO) Low Vision qualification and referrals can be sent from ophthalmologists, GPs, optometrists, social workers, rehabilitation workers, relatives and the patient (self- referral) (Welsh Low Vision Scheme Service Manual, October 2005).

Condition-specific schemes include diabetic retinopathy screening, glaucoma co- management and cataract care. The diabetic retinopathy scheme exists across all Local Health Groups in Gwent, as well as Anglesey (Welsh Assembly Government, 2002). This was followed by a proposal made in 2005 for improving glaucoma services, by implementing service re-design to allow optometrists to co-manage care (Optometry Wales, 2005). A primary care cataract post-operative service is operating in Gwent, whereby trained and accredited optometrists carry out sight tests on patients after their cataract surgery which frees capacity in secondary care thus reducing HES waiting times (Optometry Wales, 2010). As with the WECI and PEARS examinations, a fee is paid to optometrists over and above the GOS sight test fee.

Schemes for children include the Cycloplegic Refraction Scheme which is operating in Camarthenshire (Optometry Wales, 2010). Optometrists receive referrals from HES orthoptists or ophthalmologists. As with the cataract scheme, trained and accredited optometrists carry out the full GOS sight test plus cycloplegic refraction. Again a fee is paid to optometrists over and above the GOS sight test fee.

Global Thinking Surrounding Preventable Blindness and the UK Response

The Vision 2020 Initiative and the UK Vision Strategy Vision 2020 is a global initiative co-ordinated by the World Health Organisation (WHO) and the International Agency for the Prevention of Blindness (IAPB). The aim is to eliminate preventable blindness on a global level by 2020. This represents a massive undertaking and therefore a substantial commitment to improvements in eye care delivery and management.

The UK Vision Strategy, which is outlined in the document ‘Evidence Base for the UK Vision Strategy’, ‘aims to promote the elimination of avoidable sight loss, and improve the care, quality of life and opportunities of individuals and families affected by sight problems’ (Bosanquet and Mehta, 2008). The report estimates some two million people have significant sight loss in the UK. Most are older people aged 65 or over, though 80,000 are working age, and 25,000 are children living with sight problems. In addition to this, the most common causes of certification for blindness and partial sight are glaucoma, age-related macular degeneration (ARMD) and cataract. Figures are increasing with an ageing population. Diabetic retinopathy (DR) has seen a doubling of figures in the over 65s according to the report findings. Other reports from Northern Ireland suggest diabetic retinopathy increased by 120% between 1996 and 2003 and by 113% for ARMD in the same period (Kelliher, Kenny and O’Brien, 2006).

Other Ophthalmic Roles

Orthoptist Roles and Paediatric Eye Care in the Community In 2003, Hall and Elliman produced policy recommendations on child eye care in the ‘Health for All Children’ document, which suggested the alteration of the screening age for children. Screening had previously been recommended to take place when the child was aged six weeks, 3 and a half, 5, 7 and 11 years. Hall and Elliman suggested results from eye screening examinations prior to the age of 5 were not reliable, and recommended an end to screening below this age. Screening at age 3 and a half had been carried out by a health visitor. Hall and Elliman further argued that if an effective orthoptist-led service was in place for age 4-5 year olds, then subsequent screening could also be discontinued. These recommendations were approved by the National Screening Committee and introduced by the Government, thereby introducing the orthoptist into school vision screening.

The Children’s Eye Health report in 2007 however suggested that the current orthoptist service does not have a sufficiently large workforce to screen all children (de Zoete, 2007). In addition, take up of free eye tests by optometrists for under 16s is particularly low. Between April 2006 and March 2007, only 22% of under-16 year olds in England and Wales took advantage of a free eye test. Other figures from this paper suggest some 663,000 four-year-olds in the UK are being screened by just 1,283 orthoptists. The final report of the Review of Community Eye Care Services in Scotland outlined the shortage of orthoptists in Scotland (Scottish Executive, 2006: 6). This is stated in the context of delivering integrated health and social care services for adults and children, and therefore suggests an immediate need to either increase the workforce or utilise current skills in a new way.

To add to the workload issues, orthoptist work not only involves school-vision screening but also includes the provision of services within hospital ophthalmology clinics. In light of this, the overall provision of child eye care services is being questioned, and ‘a nationwide review of the availability and effectiveness of vision screening for children’ has been recommended (de Zoete, 2007). deZoete also recommends that ‘children should visit an optometrist for a free NHS sight test before entering school’, which would represent a U-turn in thinking with regard to the age that children should be initially screened.

The Extension of the Role of the Nurse Practitioner - the HES Context Within the hospital context, the role of the nurse has extended substantially to include ophthalmic care within the remit of some nurse practitioners. Research suggests that a high percentage of patients can be seen exclusively by the nurse practitioner within emergency eye care (Buchan et al., 2009). In their study, 311 out of 1831 patients were seen exclusively by the specialist nurse in 2006 (comparisons between 2001 and 2006 were made throughout the study). Eighty-one of the 311 did however return to the department. When 51 records were examined, 18 were scheduled returns, leaving a remainder of patients who returned for reasons which were not clear. Other work by Ezra et al. (2005) suggests emergency nurse practitioners are more accurate than A&E senior house officers in relation to history taking, recording visual acuity (VA), making a provisional diagnosis and describing ocular anatomy. Findings in the non-A&E context also suggest that agreement between nurse practitioners and other ophthalmic health professionals, in this case consultants, is particularly high (Banerjee et al., 1998). This research suggested all diagnoses made by nurse practitioners were agreed by the consultant, and where management was proposed by the nurse, 96% of cases were

also agreed by the consultant.

Other schemes have also utilised nurse and ophthalmologist workforce skill mix for tele- consultations in post-operative cataract patients with glaucoma (Rendell, Burns and Murdoch, 2000). Some 90% of the patient cohort were satisfied with the tele- consultation, and 76% felt the tele-consultation was either as personal (62%) or more personal (14%) than the traditional face-to-face consultation. Some patients felt less embarrassed about seeing the ophthalmologist via the tele-consultation method. Tele- consultation involved the nurse setting up examination equipment and examining using slit lamp (anterior segment) and taking IOP measurements. The nurse then presented the patients for tele-consultation. The ophthalmologist could then be involved in the examination from the HES via live feed (Moorfield’s Eye Hospital in Central London). The actual examination took place one and a half hours away in Ealing.

Rose et al. (1999) conducted action research involving nurses working within a peripheral hospital clinic and a specialist eye hospital. The peripheral clinic included one staff nurse and another enrolled for the study, both from the general hospital. Other personnel included a surgeon contracted from the specialist eye hospital, a clinical assistant (a GP from a local practice), and two optometrists. Patients were either randomised into the control group, where the established day-care surgery model was used, or the experimental group where care was organised to reduce the number of visits to the HES and with greater input from the optometrists and ophthalmic nurse. Once the study was implemented, the peripheral clinic team added an ophthalmic nurse into the team. Preoperative assessment contained the same elements at both sites. The control group however were seen on four separate assessment periods: by a doctor, auxiliary nurse, and two trained nurses.

The experimental group however were seen just once by the trained ophthalmic nurse, representing a ‘less fragmented model of care’ (Rose et al, 1999). As the study progressed however, the optometrists’ workload meant they could not successfully rotate preoperative assessment care with the nurses, and instead the care pathway evolved. With the support of the consultant ophthalmologist, the nurse continued to learn slit-lamp and applanation tonometry skills, which optometrists’ are already well- versed in, whilst the optometrist role developed to advising patients on eye drop instillation. The post-operative care of patients was compromised when the ophthalmic nurse was away from the hospital. Although cover was provided, the stand-in nurses did not have sufficient expertise to operate without medical supervision.

Evidence of Contact with Optometric and Ophthalmic Services Cox et al. (2005) reported on the contact that elderly people had with optometric and ophthalmic services. The study population included elderly patients with and without visual impairment who had fallen and sustained a fractured neck of femur (Cox et al., 2005). Those patients with severe dementia and/or could not answer or take part in the study were excluded.

The study included 537 patients who had undergone hip fracture surgery within Glasgow, Ayr, Dundee and Fife. The results suggested that 393 patients (79%) had optometric contact within the last 3 years preceding surgery. Of 21% who had not had recent optometric contact, 64 had visual impairment due to uncorrected refractive error and cataract. Overall, visual impairment was identified in 239 patients (46%). However, just 16% (39 patients) of those with visual impairment were under ophthalmic care at the time of taking part in the study. Those in the more socially deprived group were also

less likely than any other group to have seen an optometrist. Furthermore, this group had a higher number of falls during the 5 years prior to the study. Overall, this suggests that poor contact with both optometric and ophthalmic services is having an effect upon incidence of falls in the elderly. In terms of patient safety in the home and the community, this represents a large, un-met need within this vulnerable population, and methods for increasing involvement within elderly groups are required to enhance their safety, and also to reduce the potential for additional hospital stays as the result of falls, which might otherwise have been prevented. The authors recommended that domiciliary visits made by optometrists could improve outcomes.

Generalisability of Care Pathways

The action research by Rose et al. (1999) meant the eye-care pathway was adapted to suit the very particular need within the hospital. This would be a different approach to implementing a care pathway which has been originally designed outside a proposed implementation area. When considering current care pathway schemes as exemplars for future implementation in other areas, it is important to recognise that schemes may have evolved since implementation. Understanding the reasons for such changes will be important in establishing generalisable results and information about the likely key factors in the application of a scheme developed in one area as opposed to another area. This is particularly pertinent when comparing Scottish and Welsh schemes and workforce structures to English systems, due to the fact the devolved countries have set-up eye care services differently in terms of fee structures and budgets for paying fees to optometrists. Furthermore, PCTs have different financial demands, requiring careful planning when considering transplanting a scheme into other Trusts.

Report Aim

The aim of this report is to present the current literature involving optometrists within UK Eye Care Services, in a variety of capacities. The report also aims to advise on future research priorities, and to identify methods of data collection and presentation for this future research within eye care services. To achieve these aims, this report necessarily focuses upon research conducted since 1997, when a change of UK government took place. The findings will provide a guide for future research avenues and associated methods of data collection and presentation.

2. Methods

2.1 Data Searches All literature relating to UK eye-care schemes was included in the review. Searches were restricted to literature published from 1997 onwards. 1997 was chosen as this was when the New Labour Government came to power and embarked on considerable re- organisation of the UK National Health Service. This decision was taken for two reasons, firstly to include the most recent and current eye-care management schemes; and secondly reduce the number of ‘hits’ to a manageable size.

2.1.1. ‘Black’ Literature Search terms were identified with input from the project steering group, and are reproduced in Appendix 1. The searches were carried out by the principal investigator and information scientist. The following databases were searched for relevant literature:  Medline  Health Management Information Consortium (HMIC)  Cochrane Collection  EmBase  Applied Social Science Index of Abstracts (ASSIA)  Cumulative Index to Nursing and Allied Health Literature (CINAHL)  ESRC Evidence Based Policy and Practice Network  DHSS-DATA (forms part of HMIC)  British Nursing Index  Science Citation Index  PsychINFO.

The abstracts of all papers were screened by a team of three researchers. Each abstract was screened by two independent researchers. The inclusion criteria used were:

A) Definitely relevant if: 1. Study carried out in UK AND 2. Study describes eye care services and management of these in some way. OR 3. Study describes eye care screening or co-ordination of services. OR 4. Study describes pathways of care and/or referral patterns. OR 5. Study describes an evaluation of eye care services, a pilot or experiment in new ways of service delivery OR 6. Study describes communication and/or referral pathways between different health professional groups with regard to eye care services (e.g. optometrists and nurses, ophthalmologists, GPs, etc.)

B) Possibly relevant if: 1. Study carried out in UK, AND 2. Study describes eye care services, perhaps as a secondary focus of the article.

C) Relevant review papers were also included which described: 1. Eye care services and management of these in some way. OR 2. Eye care screening or co-ordination of services. OR 3. Pathways of care and/or referral patterns. OR 4. Evaluation of eye care services, a pilot or experiment in new ways of service delivery OR 5. Communication and/or referral pathways between different health professional groups with regard to eye care services (e.g. optometrists and nurses, ophthalmologists, GPs, etc.).

2.1.2. Grey Literature The same search criteria were applied to grey literature sources. Information was collected using existing databases and through contacting relevant bodies and organizations, and also by personal communication with experts in the field. The grey literature sources were as follows:  NHS PRODIGY – practical, reliable evidence-based guidance  Aggressive Research Information Facility (ARIF – Birmingham University – provides critical appraisals on specific topics)  Health Technology Assessment Programme  Current Controlled Trials  BMJ clinical evidence  BMJ best treatments  NHS Evidence (Website – www.evidence.nhs.uk)  Primary Care Contracting website (www.primarycarecontracting.nhs.uk )  Eyes and Vision Research Collaboration  Local Optometry Committees and networks  LOCCSU (Local Optometry Committees Central Support Unit)  UK University Departments of Optometry  Queen’s University  University of Liverpool – research and teaching centre for control / treatment of ocular disorders  Bristol Eye Hospital  Hospital Optometry Committees  British Contact Lens Association (BCLA)  Association of Optometrists (AOP)  RNIB (Royal National Institute for the Blind)  Fight for Sight  Thomas Pocklington Trust  General Optical Council (GOC)  Royal College of Ophthalmology  Institute of Ophthalmology  The Eye Care Trust  National Eye Research Centre.

2.2 Data Extraction A comprehensive data extraction sheet was developed, piloted and refined with input from the project steering group. A copy of the data extraction sheet (DES) is presented in Appendix 2. The DES gathered information on study design, methods, participants, results, data quality and reviewer comments. Data were extracted from all relevant papers by two researchers.

The search results from each major database are shown in table 1 below.

Table 1: Summary of papers by database Database Abstracts screened Full text paper read and data extracted Embase 5167 67 Medline 2380 51 British Nursing Index (BNI) 157 41 Social Citation Index (SCI) 130 29 Applied Social Science Index of 105 11 Abstracts (ASSIA) PsychInfo 46 5 Health Management Information 26 21 Consortium (HMIC)

The QUORUM chart (figure 1 below) shows the total number of papers found initially, and the reasons for exclusions which resulted in the final 88 papers.

Figure 1: QUORUM Chart : initial search to final papers

Potentially relevant studies identified and screened for retrieval: 8069 Studies excluded: 2782 Duplicates Studies retrieved for more detailed evaluation: 5287 abstracts screened Studies excluded Reasons for exclusion: Not relevant to the organisation of eye care services, many pertaining to medical ocular care: 5062 Potentially appropriate studies to be included in the meta-analysis: 225 full text papers read. A further 14 papers added from references found in full text papers. (239 papers read) 151 papers discarded as not meeting study criteria 88 papers meeting study criteria entered into the review database and data extracted

3. Results

3.1 Report organisation

The report contains 88 of the most relevant research articles incorporating optometrist practice within the wider context of UK eye care services (See Appendix 6 for table). The report is segmented according to type of eye disorder and corresponding schemes, many of which include refinements of optometric referral processes and other new initiatives for increasing eye health of the local population utilising the skills of accredited optometrists within the community. Each sub-section is headed by the number of research papers within the particular area, therefore suggesting the coverage of research overall and within specific eye condition care pathways. The final statement within each sub-section contains ideas for future research identified by the study authors and the report authors. Figure 2 shows the focus of the 88 papers included in the report. Figure 3 shows the type of study design used by authors of the 88 papers.

This report also contains findings from 57 grey literature sources. These include telephone conversation transcripts and follow-up documents from optometric advisors (personal communication), AOP-listed enhanced service schemes, all of which are contained in the final section of this report. Other background documents include NICE guidelines, AOP guidance, Welsh and Scottish eye care and Government documents, as well as Primary Care Commissioning documents, some literature review documents, local Government sources and also evidence from charitable organisations, particularly the RNIB. All of these documents are referenced throughout, and are therefore identifiable as grey literature. Appendix 9 contains the comprehensive list of grey literature included throughout this report. The references section also includes the grey literature (in grey font). AOP listed schemes do not appear in the references section.

Figure 2: Representation of paper distribution according to eye condition or initiative

Glaucoma Diabetic Retinopathy Cataract HES Optom Referral quality, frequency, all conditions Flashes and floaters Prescribing Low Vision Referral initiative for all eye conditions Paediatric General commentary Optometric technological comparison … COSI critique Posterior Capsular Opacification Melanoma Blood Glucose screening Ocular Hypertension Combined referral and eye exam initiative

0 2 4 6 8 10 12 14 16 18 20 Number of papers

NB: Glaucoma papers incorporated screening and referral quality (9), new initiatives (4), economic evaluation (2) and referral refinement (1). Cataract papers incorporated referral schemes (6) and quality of referrals from community optometrists to the HES (4). DR papers incorporated a mixture of referral initiatives and competency within these to manage DR.

Figure 3: Study Type

Cohort Other Questionnaire Randomised Controlled … Unmatched control Observational Before and after

0 1020304050

3.2 Summary of ‘black’ literature

This report includes 88 UK-based research papers regarding UK Eye Care Services since 1997 which incorporate the role of the optometrists in a variety of ways, and makes recommendation for future research based upon the findings. 21 papers are specific evaluations of eye care schemes involving optometrists (table 2 below), and many of these schemes re-appear in the final schemes section of this report.

Table 2: Evaluations of specific eye care schemes

Authors Year Scheme the paper evaluates Sheen et al. 2008 Welsh PEARS and WEHE Austen 2003 Loughborough GP referral scheme Dahlmann-Noor et al. 2008 West Suffolk referral scheme Gray et al. , Spry et al. (1999), 1997 Bristol Gray et al. (2000), Coast et al. (1997) Azuaro- Blanco 2007 Glaucoma schemes in Scotland Henson 2003 Manchester Glaucoma co-management scheme Fielding and Watt 1998 Edinburgh Ocular Hypertension referral scheme Gaskell 2001 Ayrshire Cataract scheme Sharp et al. 2003 Stockport Cataract scheme Muthcumarana and Rimmer 2000 Peterborough cataract scheme Newsom 2005 Huntingdon cataract referral scheme Pointer et al. 1998 Kettering Diabetic Retinopathy scheme Ryder et al. 1998 Birmingham diabetic retinopathy scheme Burnett et al. 1998 London diabetic retinopathy schemes Prasad 2001 Wirral diabetic retinopathy scheme Tu et al. 2004 Warrington Diabetic Retinopathy scheme Hulme 2002 Preston diabetic retinopathy scheme Warburton 2004 Stockport diabetic retinopathy scheme James et al. 2000 Liverpool diabetic retinopathy scheme Total: 21

NB: Table 2 does not include those papers which review optometrist referral quality within a particular area. This table lists those papers specifically related to the evaluation of a particular scheme.

Optometrists in primary care (Red)

In 1997, Ewbank discussed the concept of optometrists within the primary care context. Various areas of practice, including suitability for assessing certain eye diseases, have been the subject of controversy. According to this, 49% of ophthalmologists were against the concept of optometrists or opticians assessing anterior segment disease when surveyed. GPs on the other hand welcomed the idea of optometrists treating external eye conditions, including conjunctivitis. Ewbank also observed that professions now overlap due to the plethora of roles, including optical assistants, dispensing opticians, optometrists, pharmacists, orthoptists, school nurses, and HES nurse practitioners.

Table 3: Optometrists in primary care

Authors Date Location Description Design New Participants/ Outcome initiative number of case notes Ewbank 1997 Not Discussed the concept of Not No. Not applicable Not applicable optometrists within the applicable applicable primary care context. Various areas of practice, including suitability for assessing certain eye diseases.

Optometrists within the Hospital Eye Service (HES) (Orange)

Five papers specifically reported studies on HES optometrists.

Oster, Culham and Daniel (1999) evaluated the referral appraisal skills of the hospital optometrist in Moorfields Eye Hospital, London. Referrals sent into the hospital would be seen by the hospital optometrist, thus representing an extension of their role. It is unclear whether one of the authors of the paper is the optometrist evaluated. The study took place over a 6 month period spanning December 1996 - May 1997, and therefore presents relatively old data in a limited time period. Referrals received were generally involving individuals over the age of 60 (56% of patients, n=86). 25% were aged 61-70, and thus involving an older study population. A provisional diagnosis was made in 152 cases out of the 157 patients included in the study. Some 79.6% and 17.1% were deemed correct or partially correct appraisals. Correct appraisal meant an accurate recording of both a primary and secondary diagnosis, whereas a partially correct diagnosis meant either the primary or secondary diagnosis was omitted or inaccurate. The results therefore suggest that hospital optometrists can accurately appraise a high number of referrals into the HES, and therefore sheds light on evidence for the validity of hospital-based optometrist care which could significantly save ophthalmologist resource. Similar results were produced by Banes et al. (2000 and 2006) within the same eye hospital, in terms of agreement with the consultant ophthalmologist on glaucoma management decisions. This suggests the short-term study in 1999 represented long-term efficiency of the hospital optometrist.

Hau et al. (2007) reviewed the ability of two senior optometrists based within the A&E department of Moorfield’s Eye Hospital to identify and manage eye disease. The two optometrists had a minimum of three years extended role experience, and as hospital- based optometrists represent a relatively small sector of the optometrist labour force. 150 patients were seen during the 6 month study period between January - June 2005. Those being seen by a nurse practitioner, or had pre-existing diagnoses from a previous visit/visits, were excluded. A wide variety of conditions were seen by the optometrists including the most prevalent conditions of glaucoma and cataracts, and other conditions related to contact-lens usage, blepharitis, dry eye and strabismus. Some 22 specific eye conditions are listed within the study article (see Appendix 3). Agreement was reached in 134, or 89.3% of cases of primary diagnosis, and there were 136 cases of management outcome agreement. As a result, this suggests hospital- based optometrists with experience of the role are well-placed to identify and manage the full range of eye conditions. The authors suggest that further research should assess whether trained optometrists are suitable to prescribe safely and competently in an A&E department.

This may be useful for those community optometrists who do spend some proportion of their work time within the HES, and also for extending the role of hospital optometrists on a larger scale.

In terms of other research based within the HES, Hau et al. (2008) suggested that a high number of ophthalmic A&E cases could in fact be managed in the community as a result of patients attending with conditions which may not represent genuine emergencies. Furthermore, the authors suggest that educating patients, specialist ophthalmic training for GPs and optometrists, and expanding outpatient services are required in order to ensure emergency services remain genuine emergency service

providers (Hau et al.: 740). In the context of the work by Oster, Culham and Daniel (1999), the work conducted by the hospital optometrist may therefore be directed, perhaps at least in part towards emergency cases, or at least cases with a long-term need for optometric or ophthalmic management.

Suggestions for future research: 1. Research regarding the utility and safety of optometric therapeutic practice within HES contexts. 2. Research regarding the scope of optometrists to treat emergency cases, bearing in mind the role of other practitioners, namely nurses. 3. Research on community optometrists as independent prescribers.

Types of work recommended for data collection and presentation: 1. Cohort studies utilising pilots for community optometrists and optometrists in the HES to use therapeutic agents. 2. Questionnaire studies of eye care providers, including ophthalmologists, optometrists and others to ascertain views on initial treatment of emergency cases by optometrists with later referral to the ophthalmologist.

Table 4: Optometrists within the HES

Authors Date Location Description Design New initiative Participants/ number Outcome of case notes

Banes et al. 2000 Moorfield’s Eye Comparison of HES Retrospective case No. Established 54 (108 eyes) Glaucoma management decisions Hospital, London optometrist and note analysis system of HES- were of high quality/ similar to ophthalmologist based ophthalmologist management management optometrist care Banes et al. 2006 Moorfield’s Eye Analysis of agreement Case note analysis No. 350 patients. 4 Overall agreement was 55% for VF Hospital, London between optometrists and (specially designed optometrists (HES status, 79% for management (medical ophthalmologists on forms for the purpose based) and 3 medical aspects), other aspects of glaucoma management of recording clinical clinicians, with 50 managements- 72-98% and 78% for decisions management patients each scheduling the next appointment. decisions)

Hau et al. 2007 London Evaluation of the ability of Case note analysis No. 150 within the 6 Agreement was reached in 134, or two senior optometrists months 89.3% of cases of primary diagnosis, based within the A&E and there were 136 cases of department of Moorfield’s management outcome agreement. Eye Hospital to identify and manage eye disease Hau et al. 2008 London Review of A&E cases to an Questionnaire No. 560 questionnaires High numbers of patients A&E department in an eye prospective study were evaluated hospital Oster et al. 1999 Moorfield’s Eye Evaluated the referral Case note analysis of No. 157 examined by the 79.1% and 17.1% were deemed Hospital, London appraisal skills of the discussion, optometrist, correct or partially correct according to hospital optometrist measurement and provisional diagnosis the study criteria, based on optometrist recording history, in 152. 56% were over re-examination and history-taking in measures of vision, the age of 60 (86 HES. slit-lamp examination, patients) and 25% Goldmann tonometry were aged 61-70.

Combined eye examination and referral initiatives for all eye conditions (yellow)

One paper emerged referring to eye examination initiatives for all eye conditions. The largest initiative which covers a number of eye conditions is the Welsh Eye Care Initiative covering vast areas of Wales since 2003. The scheme is an umbrella for the Primary Eye Care Acute Referral Scheme (PEARS) and WEHE (Welsh Eye Health Examination). The former allows primary care interventions for acute ocular conditions by optometrists, whereas the WEHE scheme is a ‘case-finding service for ocular disease in patients considered at risk’ (Sheen et al., 2008). The authors concluded that the management of eye conditions within the two schemes was ‘acceptable’ and the cost per patient was relatively low. The conclusions also suggested that protocols for referral into the HES (hospital eye service) ‘would enhance the systems’ (Sheen: 435). According to personal communication with an OA within WMSHA, a similar PEARS scheme is being trialled locally, within the PCT. As the WMSHA scheme is particularly new, initial findings have yet to be published.

Table 5: Optometrists in combined examination and referral initiatives for all conditions (Wales)

Authors Date Location Description Design New initiative Participants/ Outcome number of case notes Sheen 2009 Wales Evaluation Donabedian Yes. Community 6432 participants The management et al. of the WECI model using optometrists going through of eye conditions structure, accredited to diagnose scheme, of which within the two process and and managed eye 4243 (66%) were schemes was outcome conditions including managed by ‘acceptable’ and the applied to glaucoma optometrists. cost per patient was participants relatively low.

Future working: 1. Enhancing protocols within the WECI/ similar schemes for HES referrals.

Types of work recommended for data collection and presentation: 1. Design and dissemination of protocols between SHAs, PCTs, LOCs and the College and Association.

Referral initiatives for all eye conditions (Blue)

Two papers specifically refer to referral initiatives for all eye conditions

Austen (2003) set up a GP referral scheme within the North Charnwood PCG (Loughborough) prior to the PCG becoming part of the local PCT, whereby GPs referred patients to their local accredited optometrist. 113 patients were seen via this service within the first year, and recent personal communication with the author suggests a very high patient satisfaction rate in terms of service quality and convenience. Similarly, the author also suggested patients are happier to attend the optometric practice due to the fact the nearest eye hospital is some distance away in Leicester, and not always available at convenient times (personal communication, Austen, March 2010). Furthermore, when the Leicester HES service is closed, the patient would be referred to a hospital even further away in Nottingham.

More recently, Dahlmann-Noor et al. (2008) reported the findings of an evaluation of the West Suffolk referral scheme, which the authors claim to be the first of its kind to include referral options to ophthalmic sub-specialties i.e. the optometrist can chose to refer to a particular branch of ophthalmology within the HES. Diagnostic competence was deemed very high (87%), and referrals were appropriate in 99% of cases. The optometrists’ choice of sub-specialty referral was less accurate, as was referral urgency (74% and 75% respectively), though overall it was concluded that the West Suffolk Direct Referral Scheme provided ‘an efficient service of high quality’ (Dahlmann- Noor et al., 2008: 185).

Both schemes represent overall referral schemes which refer the range of conditions. Other schemes involve either national schemes (WECI), a focus upon referrals for specific conditions, include optometrists in novel contexts, for example the HES, or measure referral quality in community optometrists referring to the HES. As these schemes are relatively new, it may be premature to suggest further working until the current schemes are refined. Table 6 below summarises these studies.

Table 6: Optometrist involved in referral initiatives (all eye conditions)

Authors Date Location Description Design New initiative Participants/ Outcome Comments/ notes where number of case applicable notes Austen et al. 2003 Loughborough Commentary paper on Not applicable Yes. GP referral 113 patients were High levels of patient Personal communication a new GP referral scheme to seen in the first satisfaction with the author also scheme (GPs referring accredited year suggests patients perceive to the local accredited optometrists in the greater convenience in the optometrist) community optometrist practice- based

Dahlmann- 2007 Suffolk Evaluation of the West Audit of existing Yes. Direct referral 185 seen during Diagnostic competence Noor et al. Suffolk direct referral practice, including scheme between the observation was deemed very high scheme (all eye three interventions HES and community period (referred by (87%), and referrals were conditions) during 2003: direct accredited accredited appropriate in 99% of referral clinics for optometrists optometrists) cases. The optometrists’ urgent cases. choice of sub-specialty referral was less accurate, as was referral urgency (74% and 75% respectively)

Referral quality and frequencies for all eye conditions (Purple)

Four papers reviewed referral quality and frequencies for all eye conditions.

Pooley et al. (1999) reviewed the feasibility of optometrist and ophthalmic medical practitioner direct referrals to the HES within Merton, Sutton and Wandsworth Health Authority (also contained in the grey literature section). 433 patients were referred during the dates when the data was collected: 28/7/97-22/8/97 in one hospital (St George’s Hospital and 11/8/97-22/8/97 in Sutton Eye Unit). Sutton represented the most affluent area. 172 patients were referred by the optometrist, 28 by the ophthalmic medical practitioner. 51% of optometrist referrals contained a diagnosis, and were significantly more likely to contain a diagnosis than a GP initiated referral. 90% of glaucoma referrals originated from the optometrist, and showed varying levels of screening utilisation as found in other studies in this report (100%, 80% and 45% for intra-ocular pressure (IOP), optic disc measurement and visual field (VF) measurements respectively). Cataract was however the most frequently stated diagnosis by the optometrists (in 27% of referral cases). The results suggested a number of aspects, including the wide variation in the tests utilised to screen for glaucoma and a low level of accuracy of glaucoma referral. It is also possible that the significantly higher proportion of specific initial diagnoses deriving from optometrist examination is due to their concentration upon eye care specifically, and the amount of experience, and an associated level of confidence in examining eye conditions in comparison to GPs.

In terms of GP referral quality, Sheth et al. (2008) recently audited letters brought by patients into Moorfields Eye Hospital between November 2006- February 2007. Most patients had first presented to their GP, with fewer presenting to their optometrist initially (22.6%). Most letters were typed (GP referrals), and most that were handwritten were deemed legible. However, a number contained medical history and medication omissions. It is unclear whether the GPs believed that these details were not necessary due to the severity level of the particular eye condition. This is not discussed by the authors. This is particularly relevant considering 12 cases were finally recorded by the ophthalmologist as ‘no abnormality detected’ and the next most common eye condition was conjunctivitis, a relatively common condition (n=9 cases). On the other hand, 8 cases were finally recorded as posterior vitreous detachment, being the next most common condition, and this condition can often require urgent follow-up. In addition, it could be argued that including medical history and medication lists represents good practice in all cases.

Pierscionek, Moore and Pierscionek (2009) later compared optometric and GP referrals to ophthalmology, also based upon the traditional referral pathway. This Belfast-based study compared the two groups of professionals in terms of the conditions referred, and the reasons for referral (if the two professional groups concurred). Data were analysed from 566 patient referrals produced during the study period of 3 months between January 2007 and March 2007. Most were made by optometrists (323, where the optometrist initiated the referral, and 243 were initiated by the GP. Other reports have also suggested that optometrists initiate referrals the most for other eye conditions (Weed and McGhee, 1998, keratoconus). Table 7 below summarises these studies.

Table 7: Optometrist referral quality and frequency of referral (all eye conditions)

Authors Date Location Description Design New Participants/ number Outcome Comments/ notes where initiative of case notes applicable Pierscionek 2009 Belfast Compared optometric Data were No. 566 patient referrals Most referrals were made by et al. and GP referrals to analysed from Traditional optometrists (323, where the ophthalmology, also 566 patient referral optometrist initiated the referral, and based upon the referrals pathway (via 243 were initiated by the GP. traditional referral produced during GP) pathway the study period of 3 months between January 2007 and March 2007 Pooley et 1999 Merton, Sutton Feasibility of 433 patients were 90% of glaucoma referrals originated The results suggested a al. and optometrist and referred during the from the optometrist, and showed number of aspects, including Wandsworth ophthalmic medical dates when the data varying levels of screening utilisation the wide variation in the tests Health practitioner direct was collected: as found in other studies in this report utilised to screen for Authority. referrals to the HES 28/7/97-22/8/97 in one (100%, 80% and 45% for IOP, optic glaucoma and a low level of hospital (St George’s disc measurement and VF accuracy of glaucoma Hospital and 11/8/97- measurements respectively). Cataract referral. 22/8/97 in Sutton Eye was however the most frequently Unit). stated diagnosis by the optometrists (in 27% of referral cases) Sheth et al. 2008 Moorfield’s Eye Letters brought No. Most letters were typed (GP referrals), It is unclear whether the GPs Hospital, by patients into and most that were handwritten were believed that these details London Moorfields Eye deemed legible. However, a number were not necessary due to Hospital between contained medical history and the severity level of the November 2006- medication omissions. particular eye condition. This February 2007. is not discussed by the authors.

Suggested future research: 1. A study could explore the utility of medical history and medication lists on optometric referrals sent via GPs, and ascertain the additional value of these to the overall referral. An up-to-date study would be useful in the context of shared-care and the associated proliferation of optometric and ophthalmic job roles within eye care services. 2. Study of ophthalmologists to determine their perceptions regarding GP referrals containing medication lists and medical history.

Types of work recommended for data collection and presentation: 1. Case note, cohort studies of notes sent by GPs comparing those sent with and those without medical history and medication lists, then compared with ophthalmologist follow-up, length of time for follow-up to happen at HES and the reasons for this i.e. whether this relates to the referral details. 2. Question ophthalmologists utilising a questionnaire to ascertain how relevant they find GP medication lists and medical history on referrals, in context of certain types of conditions.

Glaucoma (Green)

Glaucoma in the older population Sinclair, Hinds and Sanders (2004), conducted a case note analysis study in order to identify the characteristics of patients in Fife who were registered as blind with the main diagnosis of glaucoma. Patients were registered between 1990 and 1999, and 87 sets of notes were studied (for 87 patients). The average age for registration was 78 years. The results suggested that compliance with treatment was poor in over a quarter of the study population (26%), and by the time the patient had been referred to hospital initially, more than half of these patients were aware of visual loss. This suggests that older patients’ glaucoma is not being identified effectively, leading to potential sight loss later. This is particularly relevant in light of the fact that 23% of the patients could be registered blind at their first hospital low vision clinic assessment.

It should be noted, however, that because the cohort was registered between 1990 and 1999, they may not have been screened extensively for glaucoma given they attended optometrists in the 1970s and 1980s when optometrists did fewer visual field checks. The characteristics of the patients may also indicate the need for enhancing services to older people who have particular mental health needs and hearing impairment. A third of the patients had hearing impairment, and dementia was identified in 24%. The findings may be confined to this study due to the relatively small sample size and the location of the study within one area in Scotland, although further research across a larger UK area may indicate similar results, or provide evidence for patient management in those older patients with a diagnosis of glaucoma.

Glaucoma in children Whilst glaucoma in children (primary congenital glaucoma, or PCG) represents a small proportion of visual impairment overall (1/18,500 in the UK), Papadopoulos et al. (2007) published research to identify the ‘incidence, detection patterns…management and IOP control’ in children. The report concluded that the incidence of PCG was ‘comparable’ to other populations reporting PCG incidence. The incidence of PCG was nine times higher in children of Pakistani origin than Caucasians. There were also comparable levels of IOP control post surgery, with 94% achieving 21mmHg and below with medication, and 86% in cases of secondary glaucoma with medications. This drops to 28% in cases of secondary glaucoma with medications.

The optometry landscape for glaucoma In 2009, NICE produced glaucoma guidance in relation to the ‘diagnosis and management of chronic open angle glaucoma and ocular hypertension, and this is applicable to England and Wales (NICE guidelines, 2009). With regard to the tenth chapter on ‘Service Provision’ some authors have produced summaries for healthcare professionals (HCPs), in order to present the most relevant details (Spry, 2009). This document was produced as an annual evidence update on glaucoma, and is available from NHS Evidence- eyes and vision (http://www.library.nhs.uk/eyes).

The NICE guidelines refer to ‘healthcare professionals’ throughout, whereby HCPs must be trained in case detection and referral refinement if they are involved in the diagnosis of ocular hypertension and chronic open angle glaucoma (suspect cases) and those involved in ‘preliminary identification of COAG.’ As a result, where schemes exist involving HCPs, including optometrists, then training must be provided. Perhaps the key aspects of the guideline are that OHT must be formally diagnosed using gonioscopy

before continued monitoring, and also that ocular hypertension (OHT) must be referred to the HES where IOP, or intraocular pressure is over 21mmHG. This guideline means those with a high IOP measure in isolation should be referred, whether other risk factors or signs of glaucoma are or are not present.

Similarly, the Association of British Dispensing Opticians, the Association of Optometrists and the Federation of Ophthalmic and Dispensing Opticians also provided joint guidance regarding the NICE glaucoma guidelines (‘Advice on NICE glaucoma guidelines’, 2009). The paper warns that ‘optometrists and optical businesses put themselves at risk unless they recognise the implications of the guideline and follow the [this] advice.’ The paper represents the response of these professional bodies to the NICE guidelines, and may be indicative of some of the challenges facing the eye-care system as a whole.

Hatt, Wormald and Burr (2009) also recently reviewed randomised controlled trials involving screening for chronic open angle glaucoma (COAG), which typically involve older people. The results suggested that screening for COAG lacks an evidence base, and therefore opportunistic case finding should be retained. Evidence from Smeeth and Iliffe (1998) also suggests that population screening for impaired vision among older people ‘is not justified’, where the authors suggest that visual impairment can be treated, and therefore reduced. The screening tools and outcome measures were based upon self- reported measures of visual impairment. Smeeth and Iliffe conclude that the accuracy and referral quality of opportunistic case-finding remains a high priority for eye care service personnel.

Research Literature 16 research papers were found which involve optometrists in glaucoma care and referral schemes, referral quality or detection of glaucoma. A number of studies involve audits of referral reliability, as well as referral refinement and co-management schemes. Table 8 below summarises the papers on glaucoma care.

Glaucoma Shared- Care Schemes: A suite of papers One of the largest glaucoma shared-care schemes is the Bristol Glaucoma Shared- Care scheme (Gray et al., 1997, Spry et al., 1999, Gray et al., 2000) (also in grey literature section 1). The initiative involved community optometrists monitoring primary open-angle glaucoma (POAG) and glaucoma suspect patients, and utilising direct referrals between the community and the HES. Initially the study group researched the validity of visual parameter measurements taken by community optometrists (Gray et al.,1997). The results suggested that community optometrists could make measurements ‘of comparable accuracy to those made in the Hospital Eye Service’ (Gray: 431). In addition, patients were particularly satisfied with the community scheme in terms of waiting time.

Spry et al. (1999) utilised an RCT study to assess the optometrists’ monitoring compared to the ‘research gold standard’ ophthalmologist assessment. The findings again suggested that community optometrists could provide equivalent services to that of the HES, in terms of using the key glaucoma case-finding methods of visual- field taking, cup to disc ratio and IOP. Follow-up two years into the scheme suggested no significant differences overall in outcome between patients in HES follow-up and community optometrist follow-up (Gray et al., 2000). The economic outcomes were also

similar between community optometrists and the HES if the follow-up interval by community optometrists is similar to the HES (£46.31 and £14.50-£59.95 respectively).

In a similar, more recent study, Azuara-Blanco et al. (2007) reviewed the performance of accredited glaucoma optometrists in Scotland, where healthcare service management in Scotland has been devolved, and is now largely provided free of charge with the exception of AOs (accredited optometrists), including AGOs (accredited glaucoma optometrists). The study compared ‘the diagnostic performance’ of AGOs with a consultant ophthalmologist. Whilst the authors acknowledged that some cases were missed, the study concluded that with glaucoma training, the optometrists could provide as reliable a service as junior ophthalmologists. As the members of the latter group are likely perform much ophthalmic work within the HES, it is a particularly encouraging finding for the optometric world that community based practitioners can operate at similar competency levels to trainee medical personnel at least in terms of diagnosis assessment.

Glaucoma screening and referral reliability within traditional frameworks In terms of glaucoma detection, Shah et al. (2009) recently published a study based upon the findings of a community based study. The London- based study utilised an actor presenting as a 44 year old of African racial origin who was having recent near- sight difficulties, and was requesting new spectacles. The ‘patient’ had no family history of glaucoma and was thus examined in private practice. The findings suggested that 95% of optometrists visited by the actor carried out at least the minimum standard two tests for glaucoma, including optic disc assessment and tonometry. 35% utilised all three standard tests, including optic disc assessment, tonometry and visual field testing. This suggests both a relatively high standard of eye testing, but also variability in the number of tests and types of tests utilised in glaucoma optometric screening services. The authors suggested ‘a need for CPD in glaucoma screening’ particularly in light of the additional finding that 6% of the sample advised the ‘patient’ of the increased risk of POAG in individuals of African racial descent.

Various studies of optometrists’ referral reliability within traditional frameworks emerged (Bell and O’Brien, 1997, Newman et al. 1998, Theodossiades and Murdoch, 1999, Vernon, 1998). Vernon (1998) researched referral patterns in order to identify any changes over a five year period for suspect glaucoma. The retrospective analysis of referrals in 1988 and in 1993 revealed a reduction in the rate of true positive referrals from 48% to 34% at the two time points. However, measures were not taken between the time points and also represent relatively old data. Furthermore, the conclusions suggest that increases in the use of visual field measures were partly the reason for the decrease in true positive referrals. As false positives result in longer waiting times within the HES, this research suggests the possible need to ensure referral accuracy.

Newman et al. (1998) also concluded that all methods of screening have poor validity when used in isolation, including ophthalmoscopy, tonometry, and visual field testing. According to this study, optimal validity is achieved using all three, and therefore the number of screening tests used per examination may need to be increased by some practitioners.

Leong et al. (2003, Moorfield’s) suggested that two forms of glaucoma case-finding strategies (POAG), including intraocular pressure measurement and suprathreshold visual field analysis (SVFA) evoked similar sensitivity and specificity levels (71% and

69% sensitivity respectively and identical 94% specificity in both forms of screening). This suggests that certain forms of examination equipment do not necessarily lead to differing levels of sensitivity and specificity, and that all types of equipment in isolation are likely to lead to false positives. However, Ieong et al. (2003) also revealed some evidence which suggested optometrists can miss earlier changes in the optic disc including haemorrhage, nerve fibre layer defects and subtle forms of neuroretinal thinning.

To add to the evidence regarding optometric glaucoma referral, Theodossiades and Murdoch (1999) utilised positive predictive values to measure referrals for suspected glaucoma at Moorfield’s Eye Hospital. In support of Newman et al. (1998), and Ieong et al. (2003) in later years, this study also suggested that referrals which reported the use of all three types of glaucoma testing showed the highest positive predictive value (place in figure here). In addition, it was found that referral accuracy improved as the number of suspicious findings increases, suggesting the effect of previous experience and practice in revealing suspect glaucoma. A study of newly qualified optometrists and optometrists with more practice experience could strengthen this concept.

Bell and O’Brien (1997) researched the referral accuracy of optometrists in the traditional Scottish referral system, prior to devolution and the emergence of more recent eye care pathways. Akin to the current English system in most areas, the optometrist would send the referral to the GP prior to the GP’s referral to the HES, which generally includes the optometrists report. This study retrospectively reviewed 271 referral case notes from both the community optometrist and the GP over a 6 month period. Cases of previous history of ocular hypertension or glaucoma were excluded. The study revealed a high false positive rate (36%). Furthermore, it was suggested that combined approaches to screening for glaucoma gained the highest detection rate, and optometrists should combine methods in order to improve referral efficiency.

Willis et al. (2000) conducted a questionnaire study of 171 optometrists across Northern Ireland, many of whom were senior, sole practitioners. The results suggested that glaucoma detection within optometric practice is highly variable in terms of the equipment employed, and therefore the tests conducted with patients could be equally variable. The authors concluded that most optometrists are well-equipped for glaucoma screening as many utilised direct ophthalmoscopy (114 who responded to the question all used this), tonometry (116 had tonometers) and all but one optometrist had VF screening equipment. 89% said they would refer at any level of IOP ‘if visual field defect or disc cupping were present.’ However, 12 of the optometrists suggested guidelines regarding referral would be useful to them, suggesting that referral guidelines at the time of the study in 2000 were unclear. 9% said they would be interested in taking part in a shared-care scheme. These are interesting findings in the context of the current UK Eye Care Services Survey Project, and will likely form questionnaire items in phase 2 regarding interest in future shared-care schemes and refinement of referral protocols.

In a more recent, longitudinal study Bowling et al. (2005) reviewed the outcomes of glaucoma referrals made by community optometrists to the Oxford Eye Hospital between July 1994 and June 2004. The optometrists made 2505 referrals during this period. 510 patients had glaucoma, with 160 of these having normal intraocular

pressure (IOP). 1123 ‘were judged to have no evidence of glaucoma or OHT’, representing some 44.8% of the total sample (99% CI 42.2% to 47.4%). This study suggests referral inaccuracy is high. This could be viewed with concern, but may also suggest that optometrists are referring cases to be on the safe side, particularly in light of their duty to refer when any abnormality is revealed. As a result, many studies of referral accuracy should be treated with some caution due to the optometrists’ duty of care. Moreover, following GOC rules (1999) on referral, optometrists are not required to refer any abnormality and may choose not to refer in some circumstances.

Scully et al. (2009) have also recently reviewed the content of optometrists’ letters to Moorfield’s Eye Hospital. Criteria included ‘Ideal’, ‘Acceptable’ and ‘Fail’ (Scully et al.: 26) (see Appendix 4). The majority of the referral letters were considered ‘acceptable’ according to the study criteria of ‘acceptable’ with 7% only being ‘ideal’ and the rest ‘failing.’ Reasons for failure included the lack of information for non-clinical elements including patient details and practice details. In terms of clinical details, 26% lacked information regarding optic disc evaluation and 6% lacked IOP information. In light of the research which suggests a combination of 2/3 glaucoma tests is the most conducive for referral quality, this suggests that optometrists could be in a position improve the efficiency of eye care by providing thorough information on referral letters or GOS 18 forms.

Critique of glaucoma referral effectiveness measures Gilchrist (2000) presented a critique of the conventional use of specificity and sensitivity as measurements for the effectiveness of screening. As Gilchrist explains, sensitivity and specificity measure ‘the association between screening test results and final diagnosis of all the patients screened (Gilchrist, 2000: 452). Gilchrist argues that diagnoses are gained only on those patients who are referred, and therefore the disease status of those not referred remains unknown. Instead, measures of detection rate should be utilised instead i.e. the proportion of those who are screened who are correctly referred/ detected as having glaucoma, and ‘referral accuracy’ i.e. the proportion of those who are correctly referred. As this report includes a number of papers involving specificity and sensitivity, such arguments could provide a healthy consideration of alternative methods for measuring referral effectiveness, particularly where sensitivity and specificity may not be the best method for such important evaluations of optometric practice.

Glaucoma referral refinement schemes As a result of high false positive rates over the past decade, some research has involved the implementation of refinement schemes in the Manchester community (Henson et al., 2003). According to this study the number of suspect glaucoma cases was reduced by 40% as a result of the scheme. The refinement involved the removal of the traditional GP to optometrist pathway prior to HES involvement. Instead referrals were made directly to the HES by the accredited optometrists. It is of course possible that the training of the optometrist to become an accredited optometrist also reduced the number of false positives, though this is not reported. This may be an additional area of future research i.e. the effect of accredited optometrist training itself upon levels of false positives within shared-care schemes. Measuring this in isolation however may be problematic.

A further glaucoma referral refinement scheme is also soon to be piloted within WMSHA (personal communication with optometric advisor) which could act as an update to previous referral refinement schemes, and provide the UK Eye Care Services Survey Project with a tangible, local study based upon local needs and financial provision.

Economic evaluation of glaucoma services In terms of economic evaluations, Hernandez et al. (2008) conducted a study of screening for open angle glaucoma in Aberdeen. Various findings suggested that technician screening was more effective than a traditional case-finding, opportunistic approach, though more costly, and screening by an accredited optometrist was more costly than technician screening. Furthermore, general population screening was deemed to be less cost-effective than screening at-risk groups, as many in the general population are too young to see the benefits of long-term screening. At-risk groups were those aged 40-50 with a risk factor, for example family history, and that screening should occur at 10 year intervals.

Previous evaluations by Coast et al. (1997) in Bristol also suggested that management of glaucoma in the community is not necessarily more cost-effective than HES management (Bristol Shared-care study). A more current UK evaluation comparing shared-care referral and patient management schemes for glaucoma, and traditional HES schemes could be useful. As the optometrists in the earlier shared-care schemes are now likely to have additional experience, it may be possible that this learning has impacted upon their practice quality, and therefore would mean fewer false positives to the HES and associated lower costs to the HES. Other research might also look at the impact of false positives and how much each false positive costs the HES.

Table 8: Optometrists involved in glaucoma schemes

Authors Date Location Description Design New initiative Participants/ Outcome Comments/ notes where no. of case applicable notes Azuaro- Blanco 2007 Scotland Comparison of the Case note cohort No. The paper is 100 Optometrists provided as et al. diagnostic study however based reliable a service as junior performance of upon the AGO ophthalmologists in the HES. AGOs versus Glaucoma consultant service ophthalmologists Bell et al. 1997 Edinburgh Glaucoma referral Retrospective No. The case 295 (case High false positive rate (36%). accuracy by case-note analysis notes were notes) Recommendation that optometrists based on optometrists combine tonometry traditional joint and ophthalmoscopy in order to GP/optometrist improve referral quality. referral to the HES Bowling et al. 2005 Oxford Eye Community Case note No 2505 referrals 510 (20.4%) were diagnosed Hospital optometrist referral analysis from subsequently with glaucoma, of (Radcliffe) outcomes optometry which 160 were normal tension glaucoma. 44.8% were deemed to show no evidence of glaucoma or OHT. Coast et al. 1997 Bristol Economic Cost analysis No, however the Not applicable. Management of glaucoma in the A more current UK evaluation evaluation of alongside an RCT. analysis was community was deemed not comparing shared-care referral and glaucoma based upon the necessarily more cost-effective patient management schemes for community new Bristol than HES management (Bristol glaucoma, and traditional HES initiatives and HES Share-Care Shared-care study) schemes could be useful. As the care Glaucoma optometrists in the earlier shared- scheme. care schemes are now likely to have additional experience, it may be possible that this learning has impacted upon their practice quality, and therefore would mean fewer false positives to the HES and associated lower costs to the HES.

Authors Date Location Description Design New Participants/ no. Outcome Comments/ notes where initiative of case notes applicable Gilchrist 2000 Not Critique of the Critique article No Not applicable Gilchrist argues that diagnoses applicable conventional use are gained only on those of specificity and patients who are referred, and sensitivity as therefore the disease status of measurements for those not referred remains the effectiveness unknown. Instead, measures of of screening detection rate should be utilised instead i.e. the proportion of those who are screened who are correctly referred/ detected as having glaucoma, and ‘referral accuracy’ i.e. the proportion of those who are correctly referred. Gray et al. 1997 Bristol Researched the ‘Randomised Yes. The 12 optometrists The results suggested that validity of visual study’(Gray et Bristol included, 403 community optometrists could parameter al.:431) Shared- patients (203 to make measurements ‘of measurements Care community, 200 to comparable accuracy to those taken by Glaucoma HES) made in the Hospital Eye community scheme, Service’ optometrists whereby community optometrists manage glaucoma conditions Gray et al. 2000 Bristol Follow-up study Randomised study Follow-up of 2780 (752 The scheme suggested no Economic outcomes were also two years after the with patient an initiative identified with significant differences overall in similar between community commencement of allocation to either established established or outcome between patients in optometrists and the HES if the the Bristol Shared- HES or community in 1998. suspected HES follow-up and community follow-up interval by community Care Glaucoma optometrist care glaucoma. The optometrist follow-up optometrists is similar to the HES study rest were (£46.31 and £14.50-£59.95 excluded) respectively).

Hatt et al. 2009 Not RCT studies Review article No. Not applicable The results suggested that applicable involving screening for COAG lacks an screening for evidence base, and therefore chronic open opportunistic case finding should angle glaucoma be retained. (COAG) Henson et al. 2003 Manchester Glaucoma referral Case note Yes 18 optometrists, According to this study some refinement analysis 194 patients, with 40% of the number of suspect scheme 112 referred to the glaucoma cases were reduced HES, 93 with by 40% as a result of the suspected scheme glaucoma

Authors Date Location Description Design New Participants/ no. Outcome Comments/ notes where initiative of case notes applicable Hernandez et 2008 Aberdeen Study of screening Markov model was No. None as such Suggested that technician At-risk groups were those aged 40-50 al. for open angle utilised ‘to screening was more effective with a risk factor, for example family glaucoma estimate lifetime than a traditional case-finding, history, and that screening should costs and benefits opportunistic approach, though occur at 10 year intervals. of a cohort of more costly, and screening by patients facing, an accredited optometrist was alternatively, more costly than technician screening or screening. Furthermore, general opportunistic case population screening was finding strategies’, deemed to be less cost-effective the latter being than screening at-risk groups, as current practice many in the general population (Hernandez et al., are too young to see the benefits 2008: 203) of long-term screening. Leong et al. 2003 Moorfield’s To compare the 8 optometrists Yes. 8 optometrists with Results suggested that two use of usual best were asked to a minimum of 4 forms of glaucoma case-finding practice (history classify each of years experience strategies (POAG), including taking, IOP the 66 in private practice. intraocular pressure measurement, participants. 66 patients (37 measurement and disc examination Subjects with normals, 29 with suprathreshold visual field and SVFA) with a POAG were POAG- 15 of analysis (SVFA) evoked similar technique which recruited through which were normal sensitivity and specificity levels replaces SVFA glaucoma clinics tension glaucoma) (71% and 69% sensitivity with computerised within the HES. respectively and identical 94% quantitative disc Doctors at specificity in both forms of assessment glaucoma clinic screening approached those with simple POAG, spouses and partners were also recruited into normal group if no history of glaucoma. Other ‘normals’ came from a practice in Ealing. Newman et al. 1998 Suffolk Assessing the Retrospective No 86 out of initial 586 Results suggested all methods PPV of VF testing case note study were for of screening have poor validity by optometrists’ suspected when used in isolation, including glaucoma (original ophthalmoscopy, tonometry, and cohort was 595, visual field testing though 9 records could not be found.)

Authors Date Location Description Design New Participants/ Outcome Comments/ notes where initiative no. of case applicable notes Papadopoulos 2007 Not This research Survey study sent No. 99 children were The report concluded that the et al. applicable aimed to identify to the reporting eligible for incidence of PCG was (nationwide the ‘incidence, ophthalmologist to inclusion in the ‘comparable’ to other populations survey) detection report study. 47 had reporting PCG incidence. The patterns…manage demographic and primary open incidence of PCG was nine times ment and IOP socioeconomic angle glaucoma higher in children of Pakistani control’ in children data and and 52 origin than Caucasians. information on secondary clinical glaucoma. presentation and management. Scully et al. 2009 Moorfield’s Reviewed the Retrospective No. 466 referrals The majority of the referral letters In light of the research which Eye content of case note/ letter initially. 326 were considered ‘acceptable’ suggests a combination of 2/3 Hospital, optometrists’ analysis satisfied according to the study criteria of glaucoma tests is the most conducive London letters inclusion criteria ‘acceptable’ with 7% only being for referral quality, this suggests that for GP referrals, ‘ideal’ and the rest ‘failing.’ In optometrists could be in a position with 121 terms of clinical details, 26% improve the efficiency of eye care by containing lacked information regarding optic providing thorough information on optometric letter. disc evaluation and 6% lacked IOP referral letters or GOS 18 forms. information Shah et al. 2009 London To evaluate the Study actor No. 100 optometrists The findings suggested that 95% The authors suggested ‘a need for content of of optometrists visited by the actor CPD in glaucoma screening’ optometric carried out at least the minimum particularly in light of the additional examinations. standard two tests for glaucoma, finding that 6% of the sample advised Utilised an actor including optic disc assessment the ‘patient’ of the increased risk of presenting as a 44 and tonometry. 35% utilised all POAG in individuals of African racial year old of African three standard tests, including descent. racial origin who optic disc assessment, tonometry was having recent and visual field testing. near-sight difficulties, and was requesting new spectacles Sinclair, Hinds 2004 Case note Retrospective No. 78 sets of case Results suggested that and Sanders analysis study in case note analysis notes compliance with treatment was order to identify poor in over ¼ of the study the characteristics population (26%), and by the time of patients in Fife the patient had been referred to who were hospital initially, more than half of registered as blind these patients were aware of with the main visual loss. This suggests that diagnosis of older patients’ glaucoma is not glaucoma. being identified effectively, leading to potential sight loss later.

Authors Date Location Description Design New Participants/ Outcome Comments/ notes where initiative no. of case applicable notes Smeeth and 1998 Authors A review of the Systematic No. 3494 individuals The results and conclusions This could have important Iliffe address is effectiveness of literature review who were suggested that screening of ramifications for planning eye care Royal Free screening older involved in five asymptomatic older people was services for older people. Hospital, people for trials of ‘not justified.’ London impaired vision in ‘multiphasic (though this a community assessment.’ is a review setting. article) Spry et al. 1999 Bristol Assessed RCT study Yes. 405 (2,780 The findings again suggested that optometrists’ though 674 were community optometrists could glaucoma eligible, then provide equivalent services to that monitoring 405/674 were of the HES, in terms of using the compared to the willing to key glaucoma case-finding ‘research gold partake.) methods of visual- field taking, cup standard’ to disc ratio and IOP. ophthalmologist assessment Theodossiades 1999 Moorfield’s A study to Referral notes No. 87, most aged Referrals which reported the use It was found that referral accuracy et al. Eye Hospital measure referrals reviewed from 50s-60s (22/87 of all three types of glaucoma improved as the number of for suspected optometrists from and 24/87 testing showed the highest suspicious findings increases, glaucoma September 1996- respectively). positive predictive value suggesting the effect of previous February 1997. 54% female. experience and practice in revealing Median age at suspect glaucoma glaucoma diagnosis/ glaucoma suspects- 63. Vernon et al. 1998 Nottingham A study to review Retrospective No. 75 in 1988, 71 in The results revealed a reduction in Vernon suggested that increases in referral patterns in analysis of 1993. 146 in the rate of true positive referrals the use of visual field measures were order to identify referrals in 1988 total. Mean age from 48% to 34% at the two time partly the reason for the increase, any changes over and in 1993 in 1988- 61.2. points and concluded that increased false a 5 year period for Mean age in positives result in waiting time suspect glaucoma 1993- 59.4. increases for the HES. The measures were not taken between the time points and also represent relatively old data. Willis et al. 2000 Northern Questionnaire Questionnaire No. 171 results suggested that glaucoma Ireland study of study optometrists, detection within optometric optometric many of whom practice is highly variable in terms practice were senior of the equipment employed, and practitioners therefore the tests conducted with within their patients could be equally variable practice.

Future working: 1. Encouraging optometrist use of various screening methods for enhanced referral efficiency. 2. Research to compare entire shared care glaucoma schemes with HES services for economic purposes. 3. Research into the economic impact of false positives/ cost of each false positive on HES. 4. More current research regarding levels of false positives by COs/AOs 5. Research study to ascertain the effect of experience/ practice on identifying glaucoma suspects for referral to the HES. 6. Adding referral protocol refinement and interest in shared-care schemes to the questionnaire in phase 2.

Types of work recommended for data collection and presentation: 1. College campaign to raise awareness and CPD/CET events 2. Hospital financial records of shared-care schemes and HES services and compare the two across our SHA. 3. Identify cases of false positives, the number of steps within each, cost each step, and compare with a usual case where a true positive is identified and followed-up accordingly (potential ethical issues noted). 4. Case note analysis utilising the gold standard ophthalmologist comparison, or perhaps peer review by other optometrists, which would be a particularly novel approach to data collection and finding results. 5. Identify newly qualified optometrists and experienced optometrists from CoO lists and compare quality of referrals over a longitudinal study to see the effect of time/ experience over a long period.

Ocular Hypertension (OHT) (lilac)

One paper emerged regarding ocular hypertension specifically.

Fielding and Watt (1998) described the initial process of the OH shared-care scheme in Edinburgh, based at the Princess Alexandra Eye Pavilion. During two periods between June 1996 and September 1997, 200 patients were seen within the service.

The scheme was borne out of the need for change due to an over-stretched eye care clinic, where numbers of new patients with OH continued to increase. This scheme meant 40 participating optometrists and GPs could see patients within the community if the patient was willing to enter the scheme. Patients were those who had initially been seen within the HES. It was estimated that approximately 40% of patients could be re- referred to the community scheme, and there would be some 1000 patients seen within the scheme within 4 years. As this paper described the early stages of a new scheme, it remains to be seen how the scheme progressed.

Table 9: OHT co-management scheme in Edinburgh

Author Date Location Description Design New Participants Outcome Comments/ notes s initiative / number of where applicable case notes Fielding 1998 Princess Describes the Not Yes. 200 patients As this It was estimated that et al. Alexandra initial process applicable were seen paper approximately 40% of Eye of the OHT within the described patients could be re- Pavilion, shared-care service the early referred to the Edinburgh scheme in during two stages of community scheme, Edinburgh time periods a new and there would be between scheme, some 1000 patients June 1996 therefore seen within the and overall scheme within 4 September results of years. 1997. 40 the participating scheme optometrists were not and GPs. produced.

Cataract (Pink)

Background to the current research As the result of the Department of Health’s ‘Action on Cataracts’ in 2000, the UK has seen an increase in cataract direct referral schemes for surgery. One of the key objectives of this paper was to highlight the need for an increase in surgical throughput and decrease waiting times for patients, resulting in such schemes. Action on Cataracts has provided one of the key drivers for change in cataract care. Ten papers on cataract management are included in this review. These are summarised in table 10 below.

Cataract Referral Schemes Six papers specifically refer to new cataract referral schemes involving optometrists, or cataract referral quality. Table 10 summarises these papers.

The earliest paper in 2001 reported the feasibility of direct referral from optometrists to a one-stop cataract surgery pilot scheme in Ayrshire (Gaskell et al., 2001). The study involved 40 community optometrists and 160 patients who were referred to the one-stop clinic via telephone call to the HES from the referring optometrist. The one-stop concept included pre-operative assessment (blood pressure, IOP and biometry testing by a cataract nurse). The ophthalmologist then assessed the patient and if deemed appropriate, the ophthalmologist gained the consent of the patient if they wished to proceed with surgery on the same day. Surgery was then performed. A post-operative assessment was then conducted one hour later by the cataract nurse. A review appointment was also booked for 3-4 weeks after the cataract surgery either within the hospital clinic or with the referring optometrist.

This model and other very similar ones (Sharp et al., 2003, described below) form the basis of one-stop cataract referral schemes. The authors concluded that all patients achieved a good level of VA post-operatively, and just 3.7% of patient referrals were deemed inappropriate. The authors attribute this to development of direct optometric referral guidelines, training and screening of referral letters. GPs only supplemented 1.8% of referrals with further information also suggesting the content of the optometric direct referral was adequate in the vast majority of cases. Similar work by Muthcumarana and Rimmer (2000) in Peterborough supports the post-operative discharge of patients to their optometrist, as discussed by Gaskell et al. (2001).

Evans, Saunders and Haslett (2004) however refer to the findings of Gaskell et al. within a critique article regarding one-stop cataract clinics. The authors point to the fact that the ‘impressive listing rate’ was due to additional ‘optometric training and telephone pre-assessment both requiring additional resources (Evans et al., 2004: 227)’. Therefore, any time or resource saved within the one-stop cataract clinic would be required to train and pay staff during the times they conduct telephone pre-assessment. Similarly, Evans et al. (2004) suggest one-stop clinics do not necessarily lead to a more effective use of resources as the same staff time is necessary just for different purposes.

Another scheme in Stockport was described by Sharp et al. (2003), whereby a similar scheme to Ayrshire was piloted. Patients in the Stockport scheme completed a self- assessment questionnaire to aid the optometrist decision i.e. the questionnaire included the patients decision whether they felt surgery was appropriate for them. (The author of this report has not found any other schemes which include the patient questionnaire.)

The optometrist in the Stockport scheme also provided counselling. The results suggested waiting times were short, with an average of just ten days between their initial assessment and cataract assessment. 86% of the patients assessed during the pilot were also deemed to be appropriate candidates for direct referral as opposed to a two-stage plan, and 98% of these were listed for surgery. GPs and optometrists were ‘very supportive of the scheme.’

Newsom et al. (2005) also described a direct referral scheme in Huntingdon, Cambridgeshire, whereby AOs referred patients directly to the HES. Waiting times dropped from 15 months to 3 for the entire cataract pathway, being the national target derived from the Department of Health (Action on Cataracts, 2000, DoH). The small audit of referrals (100 direct referrals compared with 100 non-direct referrals) showed similar levels of post-operative visual acuity and post-operative refraction levels in both routes. The authors’ closing statements suggested other neighbouring PCTs to theirs (Hitchingbrooke Health Care NHS Trust, Huntingdon) were developing similar schemes, though this is outside phase 2 parameters of the WMSHA, or the West Midlands Strategic Health Authority, which is the target location for initial pilots of the questionnaire within the UKECSSP (UK Eye Care Services Survey Project).

Research by Tey et al. (2007) also suggests that in line with the Government ‘Action on Cataracts’ paper in 2000, one-stop cataract clinics were having a massive impact upon surgical throughput with a 71% increase in cataract operations (863 in 1997, 1473 in 2004). This presented findings from a district hospital within South-East Scotland, and surgery audit data from 1997 in Fife was used to provide the national comparison. The increase in surgery is marked, though the critique by Evans et al. (2004) may suggest a need to review the use of optometric time within new cataract care pathways.

Quality of optometric referrals to cataract services Lash et al. (2006, Bournemouth) presented research regarding optometric referrals within the context of the ‘Action for Cataracts’ guidelines in order to determine whether optometrists were following them and ‘whether they are effective.’ (Lash: 464). 412 referrals were analysed, 50% being conventional via GP, 11% via optometrists letter, 35% via direct referral and 15% were GP referrals with no optometric information. Listing rates were 83% and 74% for direct and conventional routes respectively, meaning more listing in direct routes. Full information however was provided in just 17% of letter referrals and 10% of GOS 18 referrals.

Previous research by Lash et al. (2003, Southampton) reviewed 444 referral forms sent to a hospital ophthalmology department over a ten week period (cataract, n=163, glaucoma, n=82). The authors concluded that information on cataract referral forms could be more in-depth. Furthermore, 47% of referrals for cataract later resulted in these patients being listed for cataract surgery, representing a somewhat lower proportion than the later study in 2006. As a result, the studies represent somewhat differing findings, and further research could seek to address this.

Park et al. (2009) suggested that optometric direct referral for cataract surgery provided better information regarding measured vision and ‘better delivery of pre-operative counselling.’ GP referrals however contained better medical history, drug information, and details of personal circumstances.

This suggests that the two parties, being optometrists and GPs, provide better information within the cataract referral pathway just merely on different aspects, and the types of aspects one would expect according to the practitioners scope of practice, and the different records available to them for each patient. This suggests that direct cataract referral schemes must allow sufficient opportunity for the GP to respond to information sent from the optometrist regarding a particular patient’s referral to cataract surgery, as this will allow for sufficient care delivery in the HES and crucially patient safety, for example in cases where patients take other medications which can interfere with cataract surgery.

Goyal, Shankar and Sullivan (2004: 773) presented research regarding the ‘variations in cataract presentation within three eye units across a SHA,’ – the units being: Cardiff Eye Unit, University Hospital Wales (UHW), Royal Glamorgan Hospital and Princes Charles Hospital in Merthyr Tydfil. The three areas represent diverse levels of social deprivation. The authors also aimed to ascertain associations between the cataract at presentation and indices of social deprivation. 112 patients were involved, and results suggested that VA (visual acuity) was poorer than the national average across all three sites, though the lowest levels were in Merthyr Tydfil in both the listed eye and other eye. Patient waiting times, both for surgery and outpatient appointments were also longer. Social deprivation indices also correlated with the variation in cataract presentation and the use of optometric services, whereby higher levels of social deprivation correlated with poorer use of optometric services. These social factors need to be addressed and considered in any future research regarding the extension of optometric services to ensure the patients requiring the most help are those who are seen.

Table 10: Optometrists involved in cataract one-stop surgery schemes

Authors Date Location Description Design New initiative Participants/ no. of Outcome Comments/ notes where case notes applicable Evans et 2004 Not applicable Commentary Not applicable Not applicable, Not applicable The authors point to the fact that al. paper regarding though the ‘impressive listing rate’ was one-stop cataract comments on due to additional ‘optometric surgery the new advent training and telephone pre- of one-stop assessment both requiring cataract surgery additional resources (Evans et al., schemes 2004: 227)’ Gaskell 2001 Ayrshire Reported the Case note referral Yes The study involved The authors concluded that all The authors attribute this to et al. feasibility of direct analysis 40 community patients achieved a good level of development of direct referral from optometrists and VA post-operatively (151 achieved optometric referral guidelines, optometrists to a 160 patients who VA of 6/12 or better at an average training and screening of one-stop cataract were referred to the of 31 days post-operatively), and referral letters. surgery pilot one-stop clinic via just 3.7% of patients’ referral were scheme telephone call to the deemed inappropriate. GPs only HES from the supplemented 1.8% of referrals referring optometrist. with further information also suggesting the content of the optometric direct referral was sufficiently adequate in the vast majority of cases. Goyal et 2004 Cardiff Eye Unit, Social deprivation Prospective No 112 Results suggested that VA (visual Social deprivation indices did al. University indices for cataract questionnaire study. acuity) was poorer than the also correlate with the variation Hospital Wales care/ surgery and Participants filled in national average across all three in cataract presentation and the (UHW), Royal identifying the Berth-Peterson sites, though the lowest levels use of optometric services, Glamorgan variations in VF Index were in Merthyr Tydfil in both the whereby higher levels of social Hospital and cataract listed eye and other eye. Patient deprivation correlate with Princes Charles presentation. waiting times, both for surgery and poorer use of optometric Hospital in outpatient appointments were also services. Merthyr Tydfil longer. Lash et 2003 Southampton Referral quality 444 referral forms Yes, whereby 444 referral forms The authors concluded that al. analysis for sent to a hospital referral forms for information on cataract referral cataract ophthalmology new cataract forms could be more in-depth. department over a schemes were Furthermore, 47% of referrals for ten week period analysed. cataract later resulted in these patients being listed for cataract surgery, representing a somewhat lower proportion than the later study in 2006.

Authors Date Location Description Design New initiative Participants/ no. of Outcome Comments/ notes where case notes applicable Newsom 2005 Huntingdon, Direct cataract Small audit of 100 Yes 200 referrals. Waiting times dropped from 15 to et al. Cambridgeshire referral scheme referrals (direct 3 months for the entire cataract referrals) compared pathway, being the national target with another 100, derived from the Department of non-direct referrals Health (Action on Cataracts, 2000, DoH). The small audit of referrals (100 direct referrals compared with 100 non-direct referrals) showed similar levels of post-operative visual acuity and post-operative refraction levels in both routes. Park et 2009 Bristol Comparison of Quality of referral Yes 124 patients referred Suggested that optometric direct This suggests that the two al. referrals and was checked for cataract surgery, referral for cataract surgery parties, being optometrists and listing rates for against CoO referral 62 via optometrist provided better information GPs, provide better information direct referrals framework. direct referral, and regarding measured vision and within the cataract referral from optometry 62 via traditional ‘better delivery of pre-operative pathway just merely on and traditional GP pathway . counselling.’ GP referrals however different aspects, and the types referrals for contained better medical history, of aspects one would expect cataract surgery drug information, and details of according to the practitioners (Park et. al: 309) personal circumstances.’ scope of practice. Sharp et 2003 Stockport Description of the Not applicable Yes Not applicable The results suggested waiting GPs and optometrists were al. new one-stop times were short, with an average ‘very supportive of the cataract referral of just ten days between their scheme.’ scheme initial assessment and cataract assessment. 86% of the patients assessed during the pilot were also deemed to be appropriate candidates for direct referral as opposed to a two-stage plan, and 98% of these were listed for surgery. Tey et 2007 Findings from a Audit of cataract Findings from a Yes Not applicable. Results suggest that in line with The increase in surgery is al. district hospital one-stop clinics in district hospital the Government ‘Action on marked, though the critique by within South-East SE Scotland within South-East Cataracts’ paper in 2000, one-stop Evans et al. (2004) may Scotland Scotland. Surgery cataract clinics were having a suggest a need to review the audit data from 1997 massive impact upon surgical use of optometric time with new in Fife was used to throughput with a 71% increase in cataract care pathways. provide the national cataract operations comparison.

Suggested future research: 1. Cataract referral accuracy. 2. Better understanding of social deprivation indices relevant to the use of optometric services and schemes to enhance this.

Types of work recommended for data collection and presentation: 1. Case note analysis of more recent cases to update findings and ascertain the reasons for the differing research findings. 2. Pilot projects to enhance optometric service use in lower socio-economic areas.

Posterior Capsular Opacification (Mint green) One paper specifically referred to posterior capsular opacification (a complication associated with cataract surgery) in terms of direct referral, with a second paper supporting findings with regard to seeking patient consent.

Menon, Faridi and Gray (2004) studied referrals for laser capsulotomy by optometrists and compared this referral method with the traditional referral route (via the GP). A total of 222 referrals were reviewed, 156 being direct and 66 via the GP. The assessment of quality included nine sub-sections:  referral form usage  legibility  whether the letter was dated  diagnosis clearly stated or not  patient details  discussion of visual problems  visual acuity  refraction and  patient consent for the ophthalmologist to write back to the optometrist making the referral.

Each carried a potential mark, therefore each referral could be graded between 0-9 (8- 9- Good, 6-7- Average and 5 marks or less- Poor). The majority of letters were graded average (63.5%, n=141), 45 were good and 36 were poor. The diagnosis agreement between the ophthalmologist standard and the referral letters was 99%. Laser capsulotomy rate was 98.2% or 215/219 referrals which were initially deemed by the optometrist to require such surgery. Overall, direct referral was effective, and reduced the workload of GPs. As the number of practitioners gaining patient consent was low, it was concluded that this should be sought by optometrists referring on to the HES. Whittaker et al. (1997) similarly noted previously that some 21 out of 79 optometrists surveyed did not gain consent from their patients, with a further 23 gaining consent ‘sometimes.’ In addition, ophthalmologists replied to the optometrists in 2 out of 17 cases where patient consent had been recorded on a revised GOS 18 form. This lack of communication would be worthy of future research.

Table 11: Optometrists involved in PCO referrals

Authors Date Location Description Design New Participants/ Outcome initiative number of case notes Menon 2004 Taunton Studied All referral Not as 222 referrals The majority of letters were graded et al. and referrals for letters such. were average (63.5%, n=141), 45 were Somerset laser sent to the reviewed, good and 36 were poor. The NHS capsulotomy HES from 156 being diagnosis agreement between the Trust by July 2002- direct and ophthalmologist standard and the optometrists January 66 via the referral letters was 99%. Laser and 2003 were GP. capsulotomy rate was 98.2% or compared utilised to 215/219 referrals which were initially this referral compare deemed by the optometrist to require method with the such surgery. the traditional pathways. referral route (via the GP)

Suggested future research: 1. A study to ascertain the reasons underlying the lack of patient consent sought by eye care providers, including GPs and optometrists.

Types of work recommended for data collection and presentation: 1. The author of this report recognises the potential bias involved in asking practitioners why they do not gain consent in all cases from patients.

Diabetic Retinopathy (DR) (White) The National Screening Committee (NSC) in England produces guidance for all screening programmes within the UK including diabetic retinopathy screening. The corresponding National Screening Programme for Diabetic Retinopathy produced commissioning guidelines in 2007 to support those commissioning such programmes within SHAs and PCTs. Key recommendations include programme size and the corresponding ratio of optometrists who should be employed under individual programmes, being 12,000 patients to 4 optometrists respectively. The report also suggested that referral and treatment, with good feedback processes to the programme were essential for ‘closing the gap’ in the referral, treatment and feedback process. Furthermore, the report also states that costing documents produced for optometrist-led programmes do not include the cost of installation of software or maintenance costs. It is also assumed that the optometrist will provide their own camera.

Amongst a plethora of guidelines, NICE, in partnership with the Royal College of Physicians also produced the ‘clinical management of type 2 diabetes in primary and secondary care’ report. This document contains guidance for the array of issues associated with diabetes including diabetic retinopathy. One of the first key recommendations within the section covering ‘eye damage’ is the screening of all newly diagnosed diabetes patients (recommendation R104). Repeat screening is recommended annually, which is in line with the recommendation from the National Diabetic Retinopathy Screening programme from the NSC. As a result, eye care services need to be in a position to ensure this level of service to prevent avoidable eye disease as a consequence of diabetes.

One of the key providers of guidance to optometrists is the AOP. In 2007, the AOP produced guidance for optometrists regarding Diabetic Retinopathy schemes. The paper suggests that a number of PCT areas have utilised a non-optometric screening service in order to screen patients, and these schemes have subsequently been found to be under-resourced and therefore unable to screen patients regularly i.e. once per year as guidelines from the National Screening Committee suggest. Instead, screening periods can be two or more years, and as a result mean more potential cases of more severe diabetic retinopathy at subsequent screening presentation.

Other schemes involving the optometrist can take various forms, including: ‐ screening that takes place ‘in parallel with a sight test, with or without grading’ at the time of the testing ‐ screening which is a stand-alone service provision i.e. with no sight test at the time, and grading is performed at the same time ‐ screening again as a stand-alone service i.e. with no sight test at this time as in scenario 2, but grading is not performed at the same time and photography is carried out by the optometrist or carried out by a clinical assistant ‐ grading which is carried out by the optometrist independent of photography i.e. performed elsewhere.

As a result, the optometrist involvement differs across the four scenarios, and therefore professional liability changes according to the level of involvement. The following research presents evidence for safe optometric work within such schemes

Research papers Fourteen papers relating to diabetic retinopathy co-management schemes were found. These are summarised in table 12 below.

Wilson et al. (2004) surveyed twenty five health authorities across England and Wales in order to ascertain diabetic retinopathy screening provision. 9,200 records were reviewed during the process, and 63.2% or 5,812 had a record of one or more retinal examinations in the year before the survey. These examinations were from any source i.e. either from an ‘expert’ (ophthalmologist, optometrist or diabetologist) or a camera screening service. The overall results suggested that all types of schemes were associated with a doubling of the odds of individual patients with diabetes having had a retinal examination. There was also more doubling of testing within optometry schemes, though such schemes also recommend early referral for uncertain cases. Furthermore, double testing is a built-in mechanism for fail-safe, and is useful for quality assurance or intra-practitioner reliability. There was also a small difference in coverage according to the type of schemes, whereby camera schemes were favoured over optometry schemes. These results suggest that a variety of schemes, including optometry schemes will increase the odds of patients with diabetes having retinopathy screening. It also suggests that fail-safe mechanisms are in place within optometry schemes which mean doubling of testing procedures, and therefore testing duplication. This would have an effect upon time for optometrists to screen patients if they are re-screening certain proportions of patients.

Evidence from Philip, Cowie and Olson (2005) reviewed the effect of the newly implemented grading model for referrals to ophthalmology services in Scotland. Three new levels of referral are now utilised in Scotland, and triage occurs within primary care, whereby graders took images at levels 1 and 2, and these were passed to the level 3 grader for inspection. The level 2 graders had experience in retinal screening. The level 3 grader was a consultant in medical ophthalmology. Levels of retinopathy ranged from R0 (None)- R4 (proliferative retinopathy), R5 (enucleated eye) and R6 (not visualised adequately due to technical failure). R1 was mild, R2 was moderate retinopathy and R3 is classified as severe. These are the classifications derived from the Health Technology Board for Scotland grading model. The results suggested that only 302, or 5.4% of patient images required referral to the level 3 grader, and of those just 3.4% or 190 were referred into the HES. The authors also point to the fact that the difference between England and Scotland in this approach is that the Scottish approach allows those patients with ungradeable images requiring slit-lamp examination to remain in the screening programme. In England, ungradeable images result in ophthalmic referral. In this study, 11.9% or 661 patients required examination by slit-lamp. The authors also pointed to figures from other studies which suggest technical failure rates of 3.7%- 19.7%, which would mean a significant workload in the English HES due to technical failures, not accounting for other work. This paper therefore represents evidence for diabetic retinopathy services in England which involve triage within the primary care screening service i.e. across different levels of screeners and retinopathy.

This paper now presents research which involves an optometrist within various screening scenarios depending, and ten papers emerged regarding such schemes.

The earliest papers to emerge from the literature search in terms of diabetic retinopathy schemes included work conducted in Kettering (Pointer et al., 1998), Birmingham (Ryder et al., 1998) and London (Burnett et al., 1998).

Ryder et al. (1998) concluded that the hospital- based scheme in Birmingham was ‘fail- safe’, utilising retinal photography examined by a specialist optometrist within the HES Diabetes unit, ophthalmoscopy with selective dilation, and diabetologist back-up in cases of ‘uncertainty’. The first audit review included patients seen using ophthalmoscopy, and all patients’ in this initial cycle experienced pupillary dilation. Cases were however being missed, and this inspired the change.

Pointer et al. (1998) report on a collaborative shared-care scheme evaluated after the first 12 months, between April 1995 and March 1996. Patients in this study instead visited accredited optometric practices (44 optometrists participated from 26 practices with 1781 patients screened), ‘with 92% of the optometrists in the locality recording 34% of the projected diabetic population of the Kettering Health area’ therefore providing significant coverage within the first year of the scheme. The authors suggest that publicising the scheme and introducing training regarding false positives in order to lead to a reduction, would be necessary in later stages. Furthermore, it was concluded that a review of a cohort of patients to check optometric sensitivity and specificity by ophthalmologists was necessary for future working.

Prasad et al. (2001) researched the effectiveness of optometric examination using slit- lamp biomicroscopy through dilated pupils for DR screening. 4904 patients were screened in 18 months within the Wirral- based study. Disagreement in grading was found in 13 cases, 5 of which were sight threatening cases. 371 were considered borderline or ‘threshold’ cases, in which 30.18% or 112 were false positives. The most common cause of these false positives was ‘drusen in patients with background DR.’ Overall, test sensitivity for STDR (sight threatening diabetic retinopathy) was 76% and specificity 95% utilising this one method of screening for DR. The authors concluded that the optometrists performed well, and that this performance was ‘facilitated by the use of simple grading and referral criteria.’ This may be an important consideration for further research, in terms of ensuring grading and referral systems are communicated to optometric staff, and are readily comprehended. Similarly, a review of guidelines and referral criteria across referral schemes and strategic health authorities could guide this.

Olsen et al. (2003, Aberdeen) reported similar levels of sensitivity and specificity when optometrists used slit-lamp examination in referable cases (73% and 90% sensitivity and specificity respectively). Olsen et al. (2003) compared digital retinal imaging, fundus photography (both utilising retinal photographers), and slit-lamp biomicroscopy (specially trained optometrists). The highest sensitivities and specificities were achieved within the retinal photography cohorts.

Okoli and Mackay (2002, Barnet Health Authority) evaluated three models of DR screening ahead of setting up a screening programme. The models included a GP-led scheme (single-lens reflex retinal camera and indirect ophthalmoscopy or slit lamp), and two optometrist led models (one using the same scheme as the GP-led scheme, the other utilising indirect ophthalmoscopy only). Both of the optometrist-led schemes had been operational for 18 months prior to the study, and were organised differently. The GP-led scheme had started a year before the optometrist models, therefore around 30 months before the study. The authors suggested that comparisons were therefore difficult across the schemes. All three schemes were deemed to provide an effective service however. The authors also suggested that the eventual screening programme should set-up a system of call and recall in order to facilitate uptake, and to place diabetes registers in GP practices.

Hasting and Shephard (1998) suggested the use of a dedicated diabetic eye care co- operation card improved the number of patients receiving an examination in the preceding two years. All eye examinations made by GP practice staff, community optometrists and hospital clinics were recorded on the patient’s card. The project took place in South Leicestershire across five GP practices. This suggests the importance of recording diabetic eye care information, and adds to the literature regarding recording information in order to recall patients efficiently.

Tu et al. (2004) also compared forms of DR screening including optometric screening and digital photography screening in the Warrington NHS Health Trust (Warrington and Halton areas). Optometric screening included slit-lamp biomicroscopy and the digital photography initiative was located within the HES and conducted by a medical photographer. A call-recall service was utilised under the Cheshire Health Agency and based upon the diabetes register. Those already attending the hospital eye clinic were excluded from this recall facility. Uptake for both systems was poor from a total of 1643 patients screened in the two schemes. As a result, cost effectiveness was also deemed to be poor. This also highlights the potential for poor uptake despite a call-recall service.

Hulme et al. (2002) evaluated a district wide DR screening service which utilised optometrists using slit-lamp and Volk lenses. The Preston-based audit was set against the national targets of 80% and 95% for sensitivity and specificity respectively, and was based upon screenings between April 1997 and November 1999. 439 patients (872 eyes) were examined, of which 64% were normal. Sensitivity for any retinopathy was 72%, specificity 77%. For the detection of sight threatening eye disease, sensitivity and specificity were 87% and 91% respectively. 26% of people with diabetes were screened over a 4-year period thus suggesting a reasonable level of service provision within a geographical location.

Warburton, Hale and Dewhurst (2004) researched the sensitivity and specificity rates for sight-threatening eye disease in the diabetic retinopathy screening service in Stockport, between April 2000 and March 2001. The data are therefore a decade old. Screening was performed using slit-lamp binocular indirect ophthalmoscopy and a hand-held fundus- imaging lens through dilated pupils. A number of patients were selected at random from the screen- negatives group to determine specificity. 3510 patients were screened during the study period. The results suggested that sensitivity fell somewhat short of the UK National Screening Committee target of 80%, recording instead 75.8%. Specificity was surpassed by 4% (target- 95%, actual- 99%). Geographical coverage was 1.2% with a target of 1.8% for new screening schemes. The authors did however suggest a 57% increase in overall numbers of individual screens and therefore in the context of this geographical area the scheme could be viewed as a vast improvement and a success. The authors also concluded that a computerised register was required in order to facilitate call-recall of patients and therefore avoid missed appointments.

Burnett et al. (1998) conducted research with the aim of recalling patients via a computerised system for DR screening by 63 accredited optometrists. The number of optometrists trained and subsequently recruited suggests a large-scale scheme. 666 patients were also recruited into the new scheme, of which 645 were scheduled for screening. 536 of these patients attended, representing an 83% uptake.

Scanlon et al. (2005) conducted an audit of ophthalmology department workload changes after the introduction of a diabetic retinopathy programme in Gloucestershire Health Authority. The study included 3877 patients over the first four years, between 1997 and 2001, including those already registered at the eye clinic who attended as emergencies booked between appointments. The results suggested that workload in fact increased on the first round of screening, and in further rounds the workload did not decrease below pre-screening levels, with the exception of laser surgery which did show a decrease. As a result, screening programmes could represent ‘a significant workload’ to the NHS. The authors suggested the failure to find a drop in workload was possibly due to the increasing numbers of individuals with diabetes.

Overall, sensitivity rates for any retinopathy were similar across the studies, though somewhat lower in terms of specificity. Screening methods were similar across the studies, though sample sizes were significantly different and represented different geographical locations. The reason for the difference in specificity is unclear. Further research could compare sensitivity and specificity rates across different diabetic retinopathy schemes and ascertain reasons for these. Other work could update the study by Burnett et al. and suggest the current utility of a computerised call-recall system for DR screening, and therefore be more reflective of the recent context integration plans for ICT within the NHS. In addition, further analysis of the workload issues surrounding new diabetic retinopathy screening programmes may prove useful for PCTs considering community based care.

Cost effectiveness of screening James et al. (2000) utilised previous studies from Liverpool to ascertain the cost- effectiveness of screening for sight-threatening diabetic eye disease. Two papers were used from the Liverpool Diabetic eye study (early-mid 1990s), and another study outside of Liverpool. The results suggested that systematic screening is more cost- effective than opportunistic. The number of true cases found on an opportunistic basis totalled 346, and 502 in the systematic screening programmes. The cost-effectiveness measure was based upon the total cost divided by these true case figures. The report was however based on a relatively limited number of diabetic eye disease screening schemes. Similarly, sensitivity analysis was not conducted on cost data.

Davies et al. (2004) also compared two alternative policies for screening for diabetic retinopathy. Policy one involved screening the patient using a chosen screening method until background or more advanced retinopathy was discovered. The patient would then be assessed by an ophthalmologist in an outpatient clinic using mydriatic seven-field photography. If retinopathy was then confirmed, the screening would stop. If it was not confirmed then it would be resumed. Those patient who were found to have background DR were seen at more regular intervals in the clinic until they needed photocoagulation.

Three different types of screening were considered under policy 1:

‐ GP Ophthalmoscopy every 12 months, with reduced intervals of 6 months between visits once DR had been detected ‐ Ophthalmoscopy conducted by a diabetologist every 12 months, again with a reduced interval of 6 months between visits once DR had been detected. ‐ Fundoscopy conducted by an optometrist with the same screening intervals as the two schemes above.

Under policy 2, patients were screened using a mobile camera, which generated a single photo which was reviewed by the diabetologist. The patients were screened every 12 months, with the same 6 monthly visits once background DR was detected. Those patients under policy 1 who had been treated for either type of treatable DR continued to be seen in the ophthalmology outpatient clinic. Under policy 2, patients would continue to be screened until they had severe or central vision loss, required treatment for another type of DR (other than treatable), or died.

The final results of the study suggested policy 1 was more cost-effective, on the condition that the screening ‘sensitivity and compliance were relatively high (Davies, 2004).

Both of these papers were conducted some time prior to this literature review, and as many more schemes have been established across other areas of the UK, it may be worth considering a fresh look at the cost-effectiveness of DR screening, by comparing available schemes.

Table 12: Optometrists involved in DR co-management schemes

Authors Date Location Description Design New initiative Participants/ no. of case Outcome Comments/ notes where notes applicable Burnett et 1998 Catchment Retinal screening Service audit Yes. 666 invited overall, 191 83% uptake. al. area programme seen by accredited surrounding optometrists. 536 of these Whittington patients attended, Hospital, representing an 83% London uptake. Davies et 2004 Not applicable Compared two Not applicable No. Not applicable Policy one was the preferred al. alternative policies for (review article) system for screening for DR. screening for diabetic retinopathy Hasting 1998 Leicestershire Researched use of a Audit Yes. 450 patients in the first The use of the card improved and dedicated diabetic eye review and 370 in the the number of patients Shephard care co-operation card second. An additional 133 receiving an examination in were found for the second the preceding two years. review from case notes, totalling 503 for the second review of records. Hulme et 2002 Preston Evaluated a district Audit of optometrist Yes. 439 patients (872 eyes). Sensitivity for any retinopathy al. wide DR screening screening by 64% were normal. was 72%, specificity 77%. For service which utilised ophthalmologist. STED sensitivity and optometrists using slit- specificity were 87% and 91% lamp and Volk lenses respectively. 26% of people with diabetes were screened over a 4-year period thus suggesting a reasonable level of service provision within a geographical location. James et 2000 Not applicable Utilised previous To assess the cost- No. The effectiveness data was The results suggested that Data of this kind suggests al. studies from Liverpool effectiveness of derived from two Liverpool systematic screening is more only systematic screening to ascertain the cost- systematic studies, the first with 320 cost-effective than should be implemented for effectiveness of photographic patients and the second opportunistic. case finding purposes. screening for sight- screening versus with 1,363, totalling 1,683 threatening diabetic opportunistic patients with diabetes. eye disease screening for STDR within primary care services

Authors Date Location Description Design New initiative Participants/ no. of case Outcome Comments/ notes where notes applicable Okoli et al. 2002 Barnet Health Evaluated three Case-note review Not as such, 2230 patients with All three schemes were The authors also Authority models of DR and database though the study diabetes were March deemed to provide an effective suggested that the screening ahead of analysis for uptake compared three 1998- August 2000. service. GP-led model (single- eventual screening setting up a screening and coverage of different lens reflex retinal camera and programme should set-up a programme service, follow-up for methods of DR indirect ophthalmoscopy, system of call and recall in abnormal findings, screening prior results interpreted by order to facilitate uptake, postal questionnaire to setting up a orthoptist), optometrist and to place diabetes for service users, new DR scheme- same as GP led but registers in GP practice. interviews with screening with camera rotating between service providers, scheme. optometrists, second PPV evaluations optometrist scheme- indirect ophthalmoscopy only operated from own practice and they interpreted the results. Olson et 2002 Aberdeen Compared digital No. A number of 6 optometrists (high-street 73% and 90% sensitivity and al. retinal imaging, fundus DR screening based) specificity respectively photography (both methods were utilising retinal compared to photographers), and ascertain the slit-lamp best for a new biomicroscopy screening (specially trained scheme. optometrists) Pointer et 1998 Kettering Collaborative shared- Audit of first 12 Yes. 44 optometrists 92% of the optometrists in the The authors suggest that al. care scheme months of participated from 26 locality recording 34% of the publicising the scheme and evaluated after the collaborative practices with 1781 projected diabetic population of training regarding false first 12 months, scheme. patients screened. the Kettering Health area. positives in order to lead to between April 1995 a reduction, would be and March 1996 necessary in later stages. Furthermore, it was concluded that a review of a cohort of patients to check optometric sensitivity and specificity by ophthalmologists was necessary for future working.

Authors Date Location Description Design New initiative Participants/ no. of case Outcome Comments/ notes where notes applicable Prasad et 2001 Wirral Researched the Prospective study. No. Those not under HES- 4904 patients were screened in The authors concluded that al. effectiveness of Diabetes register invited for eye test by AO. 18 months. 371 were the optometrists performed optometric utilised to collect 27 AOs.* 4904 patients considered borderline or well, and was ‘facilitated by examination using slit- patient demographic screened in first 18 ‘threshold’ cases, in which the use of simple grading lamp biomicroscopy data, including 64 months. 90.5% were 30.18% or 112 were false and referral criteria.’ This through dilated pupils GP practices, negative screens, 429 positives. The most common may be an important for DR screening hospital sites with (9.67%) were re- cause of these false positives consideration for further diabetic clinics, screened. was ‘drusen in patients with research, in terms of laboratory reports. background DR.’ Overall, test ensuring grading and Positive referrals sensitivity for STDR (sight referral systems are and 10% of threatening diabetic communicated to negatives were re- retinopathy) was 76% and optometric staff, and are examined by an specificity 95% utilising this comprehensible. ophthalmologist. one method of screening for DR.

Ryder et 1998 Birmingham Utilised retinal Implemented as part Yes. 289 hospital clinic Concluded that the hospital- al. photography of an on-going audit patients not attending an based scheme was ‘fail-safe’ examined by a of DR screening ophthalmologist already. specialist optometrist service. 144 for first audit, 145 for within the HES second. Diabetes unit, ophthalmoscopy with selected dilation, and diabetologist back-up in cases of ‘uncertainty’. Scanlon et 2005 Gloucestershir Audit of Medical records of Yes. 3877 patients with The results suggested that As a result, screening al. e Health ophthalmology patients attending diabetes over the first four workload in fact increased on programmes could Authority department workload eye clinics over the years between 1997-2001 the first round of screening, represent ‘a significant changes after the four years. First year including those already and in further rounds the workload’ to the NHS. The introduction of a was prior to registered at the eye clinic workload did not decrease authors suggested the diabetic retinopathy screening, two years who attended as below pre-screening levels, failure to find a drop in programme was first round, final emergencies booked with the exception of laser workload was possibly due year was the second between appointments. surgery which did show a to the increasing numbers round. decrease. of individuals with diabetes.

Tu et al. 2004 Warrington Compared forms of Comparative study Yes. 1643 patients screened in Uptake for both systems was NHS Health DR screening the two schemes poor. Trust including optometric (Warrington screening and digital and Halton photography areas) screening

Authors Date Location Description Design New initiative Participants/ no. of case Outcome Comments/ notes where notes applicable Warburton 2003 Stockport Researched the Screening was Yes. A number of patients Specificity was surpassed by The authors did however et al. sensitivity and performed using slit- were selected at random 4% (target- 95%, actual- 99%). suggest a 57% increase in specificity rates for lamp binocular from the screen- Geographical coverage was overall numbers of sight-threatening eye indirect negatives group to 1.2% with a target of 1.8% for individual screens and disease in the diabetic ophthalmoscopy and determine specificity. new screening schemes. therefore in the context of retinopathy screening a hand-held fundus- 3510 patients were Sensitivity fell somewhat short this geographical area the service imaging lens screened during the study of the UK National Screening scheme could be viewed through dilated period. Committee target of 80%, as a vast improvement. pupils. recording instead 75.8%. Wilson et 2004 Nationwide Surveyed twenty five Case notes analysis. No. 9,200 records were The overall results suggested al. health authorities reviewed during the that all types of schemes were across England and process associated with a doubling of Wales in order to the odds of individual patients ascertain diabetic with diabetes having had a retinopathy screening retinal examination. There was provision. also more doubling of testing within optometry schemes, though such schemes also recommend early referral for uncertain cases.

Future working: 1. Compare sensitivity and specificity rates across different diabetic retinopathy schemes and ascertain reasons for these. 2. Training optometrists in order to reduce false positives within DR schemes. 3. Ensuring good schemes for referral and grading for DR. 4. The use/ effect of call-recall diabetes registers for DR screening schemes. 5. Analysis of workload implications in new community-based diabetic retinopathy screening schemes. 6. An up-to-date cost effectiveness analysis of the various kinds of DR screening.

Types of work recommended for data collection and presentation: 1. Create a collaborative study of neighbouring PCTs to compare sensitivity and specificity rates. A WMSHA optometric advisor has already mentioned some 100 DR schemes. 2. CET events to reduce DR false positives within DR schemes. 3. Research listed in 1 above. 4. Pilot studies across the WMSHA to trial call-recall registers based upon the previous research. 5. Compare records pre and post- community based DR schemes. 6. Cost effectiveness study.

Blood Glucose screening (Brown)

One paper investigated blood glucose screening by optometrists, it is relevant within the context of the diabetic retinopathy schemes. Table 13 summarises the paper.

Lask (1997) produced a report on the commencement of a collaborative study funded by Brixton Professionals in Partnership (BPIP) in order to test blood glucose levels. The author highlights the fact the pilot was a screening project only, and that diagnoses remained the responsibility of the patient’s GP, and those under the treatment of the GP or hospital were not measured. Instead, this pilot aimed ‘to find previously undiagnosed cases of high blood glucose levels’ (Lask: 29). 23 optometrists out of 120 invited agreed to take part, and attended an evening course discussing the background of diabetes, prevalence among the targeted ethnic groups and the issues surrounding blood glucose measurement. The report does not present any results however, and it is unclear whether this initiative continued.

The author of this report considers such a scheme, if successful, a useful link for diabetic case finding, which may prevent associated eye conditions later along the line.

Table 13: Optometrists involved in blood glucose screening

Authors Date Location Description Design New Participants/ number Outcome initiative of case notes Lask 1997 London Report on the Optometrists were Yes. Those under the The report commencement of recruited treatment of the GP does not a collaborative according to the or hospital were not present any study funded by Health Authority measured.23 results Brixton list. 23/120 applied optometrists out of however, and Professionals in for a place on the 120 invited agreed it is unclear Partnership (BPIP) study, including to take part. whether this in order to test evening course initiative blood glucose attendance. continued. levels

Optometric Prescribing (turquoise)

3 papers studied optometric prescribing, and are summarised in table 14 below.

Mason and Mason (2002) conducted research to ascertain the use of therapeutic agents by optometrists and whether optometrists would like to train to become accredited optometrists for this purpose, both to prescribe dependently and independently. Other questionnaire items included whether the respondent felt optometrists should be allowed to prescribe both dependently and independently. A 10% random sample of optometrists was taken from a list of 7,500 GOC registered practitioners. The first survey was sent out in September 2000. The results suggested 67% of optometrists would like to prescribe either independently or dependently (69%). The vast majority felt optometrists should be able to do this for infection and inflammation (87%, independently). 90% were also willing to undergo further training for this, which may be an interesting question for phase 2 questionnaire purposes.

Bateman et al. (2002) reviewed the effect of new treatments for the management of glaucoma in Scotland. That data represented operation and prescribing rates between 1994 and 1999 across four geographical locations within Scotland. Overall prescribing rates per 1000 increased by nearly 25% (24.9%), though the increase across the regions varied between 14.3% and 31.9%. There was an increase in newer agents and a drop in miotic use. Furthermore, increases were reported, in: cataract operations, eye tests, numbers of optometrists and ophthalmic surgeons. The latter two are particularly encouraging in light of the ageing population and the associated increase in glaucoma over the forthcoming years and the corresponding need for more eye-care professionals.

An update of the study by Mason and Mason was conducted by Needle et al. (2008) in order to ascertain the current practice of optometrists, and to discover their views regarding the extension of their role in terms of prescribing. Between the Mason and Mason study and Needle et al., medicinal legislation change since 2005 now means optometrists can use and supply additional types of therapeutic drugs. Prior to this, in 2000 the GOC had allowed optometrists to manage a patient’s condition by virtue of the removal of the requirement to refer patients on. Some 1288 optometrists were therefore surveyed from the College of Optometrists list of registered practitioners. Participants were recruited via email. The optometrists managed an array of conditions, some including dry eye, blepharitis/ lid problems, simple corneal abrasions, allergic conjunctivitis, with management rates of 87-96% across these conditions. Optometrists in hospital were also more likely to manage acute sight-threatening diseases. Nearly 80% felt they could manage PAOG with further training, and also felt that most main classes of drugs should be available to them. This somewhat contradicts the initial commentary presented by Ewbank (1997) regarding ophthalmologists views on optometric prescribing.

Table 14: Optometrists involved in prescribing

Authors Date Location Description Design New initiative Participants/ Outcome Comments/ notes where number of case applicable notes Bateman 2002 Scotland (four Examination of the impact Retrospective No Not listed Increases in topical prostaglandins, et al. geographical of new drug treatments on analysis of carbonic anhydrase inhibitors. Increases in areas-) glaucoma management national health cataract surgery, eye tests, numbers of statistics optometrists. Fall in myotic usage. Mason 2002 UK-wide Research to ascertain the Questionnaire Not as such, A 10% random The results suggested 67% of optometrists Useful for Phase 2 and use of therapeutic agents study though sample of would like to prescribe either independently questionnaire Mason by optometrists and measures optometrists was or dependently (69%). The vast majority whether optometrists interest in the taken from a list of felt optometrists should be able to do this would like to train to newer 7,500 GOC for infection and inflammation (87%, become accredited optometric area registered independently). 90% were also willing to optometrists for this of prescribing. practitioners. undergo further training for this. purpose, both to prescribe dependently and independently Needle et 2008 UK-wide To ascertain the current Questionnaire Not as such 1288 optometrists The optometrists managed an array of This somewhat al. practice of optometrists, study were therefore conditions, some including dry eye, contradicts the initial and to discover their views surveyed from the blepharitis/ lid problems, simple corneal commentary presented regarding the extension of College of abrasions, allergic conjunctivitis, with by Ewbank (1997) their role in terms of Optometrists list of management rates of 87-96% across these regarding prescribing. registered conditions. Optometrists in hospital were ophthalmologists views practitioners also more likely to manage acute sight- on optometric threatening diseases. Nearly 80% felt they prescribing. could manage PAOG with further training, and also felt that most main classes of drugs should be available to them.

Future research: 1. Add questions regarding therapeutic prescribing to the questionnaire for phase 2. This has been completed. 2. Further research regarding the use of therapeutic agents in general to ascertain view points.

Types of work recommended for data collection and presentation: 1. This has been completed. 2. Questionnaire and/or interviews with various eye care providers regarding therapeutic agent usage by optometrists.

Low Vision Services (lime green)

Background A systematic review of low vision service outcomes was produced in a collaborative project for the RNIB (Binns et al., 2009). This project team evaluated low vision service outcomes. The outcome measures included quality of life and vision related quality of life. One paper suggested that ‘enhanced’ low vision services were not significantly better than ‘good hospital services’ in terms of improving vision related quality of life. The report does not define ‘good hospital services.’ In addition to this, the report evidence suggests that multidisciplinary services are no better than optometric services for vision related quality of life. This is a particularly important finding for optometry. The report also concluded that the evidence remained contradictory in terms of rehabilitation programmes improving ‘vision related quality of life.’

Another paper produced by the research team provided the partner paper which profiles UK low vision services, though is primarily based upon English services. The report includes the range of low vision services, from ‘one stop shops’ to more traditional HES and corresponding referral pathways. The report suggested that there was not one service which ‘ticked all boxes.’ Furthermore, where all services showed some weakness, the authors also emphasised the fact that weakness was a ‘matter of opinion’ due to the paucity of ‘objective assessments of effectiveness.’ (Dickinson et al., 2009: 32). The second chapter of the report also outlines the economic study involving finance directors in Low vision services within the NHS, local authorities and voluntary sector. All directors received email or telephone calls and requests were made by the research team for cost data based on 2007-08 tax year. The key drivers were staffing and the provision of aids and equipment for service users. Overall, the respondents were concerned about financial sustainability of certain aspects of the service, including rehabilitation and eye clinic liaison officers, who are often based in the HES.

Both papers suggest that low version services operate across large areas, and are particularly varied in terms of service personnel and funding. Correspondingly, service pathways are also varied, which could lead to different patient outcomes, in this case in terms of quality of life. Furthermore, as there paucity of research regarding measurements of effectiveness, it is important to eye care services as a whole to gain a handle on low vision service evaluation in order to reach clearer decisions regarding the best form of low vision service provision.

Research papers Two research papers specifically referred to Low Vision services (summarised in table 15 below).

In 2002, Culham et al. reported the ‘type and location of LV services within the UK’ (Culham et al., 2002: 743) due to a lack of knowledge regarding delivery of LV services. The postal questionnaire was distributed to all LV service providers and telephone interviews were utilised in cases where service providers failed to return the initial questionnaire. The service providers included ‘hospital eye departments (HED), Social services/ social work departments (SSD), opticians/ optometry practices (OP), local societies/ voluntary organisations for people with visual impairment (VO), specialist teachers (ST) and universities and colleges with optometry/ optical dispensing courses (UC) (Culham et al., 2002: 743)’.

The study period was October 1997 to June 1998, prior to devolution and over a decade before the current research. The findings suggested the majority of low vision services were provided by the HES. As the HES is already stretched and the number of older people will continue to rise over the coming years, this finding is concerning for providing adequate eye care services. The authors also suggested that there were ‘inadequacies’ in terms of distribution, magnitude and coordination overall when compared to the ‘probable number of people with a visual impairment.’

Russell et al. (2001) utilised a RCT to compare a traditional hospital based eye care service with an integrated service and a non-integrated service, each including a community-based rehabilitation officer and a ‘generic community’ service which was not ‘vision specific.’ Outcome measures were used at time of recruitment and at 12 months post-intervention, including vision and quality of life measures, ‘patterns of low vision use and task performance’ (Russell et al., 2001: 36). Whilst this paper described the design and methodology, it does not present data regarding the efficacy of each study arm in terms of eye care services and input of eye care professionals. Therefore, further research is required regarding the outcomes of LV shared-care services.

Table 15: Optometrists involved in Low Vision schemes

Authors Date Location Description Design New Participants/ no. of case notes Outcome Comments/ initiativ notes where e applicable Binns et. 2009 Nationwide Systematic review of low Not applicable Yes. Not stated. The findings suggested the al. vision service outcomes majority of low vision services were provided by the HES. The authors also suggested that there were ‘inadequacies’ in terms of distribution, magnitude and coordination overall when compared to the ‘probable number of people with a visual impairment.’

Culham et 2002 UK - wide Reported the ‘type and Questionnaire No. 2539 service providers Suggested the majority of low al. location of LV services survey of UK vision services were provided by within the UK’ LV service the HES. providers Dickinson 2009 Authors based Profile of UK low vision Systematic No. Not applicable. The report suggested that there et al. in Cardiff. services, though is literature was not one service which ‘ticked Nationwide primarily based upon review all boxes.’ The financial manager review English services questionnaire respondents were concerned about financial sustainability of certain aspects of the service, including rehabilitation and eye clinic liaison officers, who are often based in the HES. Russell et 2001 Manchester Comparing a traditional RCT study Yes. 226 patients. Randomised to study This paper described the design Further al. hospital based eye care arm- conventional, hospital based care and methodology, and does not research is service with an integrated with integrated home-based present data regarding the efficacy required service and a non- intervention by LV rehabilitation officer of each study arm in terms of eye regarding the integrated service, each (still receiving same optometric care care services and input of eye outcome of LV including a community- as study arm 1 participants), arm 3- care professionals shared-care based rehabilitation officer HES and generic intervention at home services. and a ‘generic community’ (not vision based) by community care service which was not worker

‘vision specific.’

Paediatric eye care services (pale pink)

Five papers covered child eye care services, they are summarised in table 16 below.

Wickham et al. (2002) conducted a national audit of paediatric services with regard to the assessment and management of strabismus (squint) and amblyopia. The research team received responses from 75% of orthoptic departments where paediatric work is largely conducted (288 orthoptic departments were asked in total). The results suggested that a variety of systems are in place, and this is dependent upon the referral route. 66% involved ‘orthoptic assessment without refraction’ (Wickham et al., 2002: 522), ‘66% combined orthoptist and ophthalmologist assessment’ and ‘22% had an entirely orthoptist or optometric system.’ As a result, services appear to be particularly varied, and therefore children are receiving different services across different parts of the UK.

On a more local level, Karas et al. (1999) conducted a study to ascertain whether a community based hospital optometrist and community orthoptist model could provide a vision screening service for children. Between April 1994- March 1996, a total of 483 new patients were seen by the service representing an uptake of 65% (748 were offered the service). Children aged over 8 were not initially included in the scheme, though this criterion was waived in a small number of cases due to individual circumstances. Agreement regarding referrals to the HES strabismus centre was then sought from the hospital ophthalmologist. The authors commented that the low referral rate could reduce the use of the HES and subsequent cost by retaining the children within the community scheme. The scheme was deemed successful overall, with a referral rate of 14% and the ophthalmologist agreeing with 78% of these.

A follow-up study by Donaldson et al. (2002) re-visited the scheme above, utilising referrals made between 1994- 1998 being the first 4 years. 43% of the children (1300/1755 invited) were subsequently found to have ‘normal’ vision, and in 41% of these, the children required only spectacles. 17% had an orthoptic abnormality, generally refractive error and 98% were seen by the orthoptist, suggesting the high utility of orthoptist care instead of HES referral. The authors also suggested that only 16% of the children failing the primary vision screening in school needed HES referral due to the skill-mix of the combined orthoptist- optometrist practice within the clinic. Therefore, at initial stages and at follow-up the scheme appeared to reduce referrals and represent a scheme which could manage child-eye needs sufficiently within the community. This has particular benefits to the patient and parent in terms of convenience. Interesting further work could focus on the reasons for non-attendance in those who did not attend when invited.

Within the Huntingdonshire PCT, Alexander, Rahi and Hingorani (2009) described and costed paediatric eye care services. The total cost within the PCT was over £360,000. The study population involved over 33,000 children during the year of study, and 1970 (5.9%) had required outpatient appointments. 1870 (5.6%) underwent screening by an orthoptist. It is unclear from the paper the number of children who were referred from community to hospital care services. 1.3% of the children had been prescribed spectacles, which would happen in the community, however the figure requiring hospital appointments suggests a number of children are suspected of having conditions which cannot be treated simply with spectacle prescriptions.

The authors concluded that the resources required for comprehensive chid eye care services is considerable to in order to screen and manage conditions, as well as supporting those with ‘serious eye conditions or visual impairment. The latter accounted for 69, or 0.2% of the study sample. This financial output is an important consideration for any similar paediatric eye care services, particularly in the current economic climate and the knock-on effect on healthcare services in general.

Thomson and Evans (1999) also reviewed the use of a new type of screening in schools. The system utilised a computer program. Prior to using the program, parents completed a questionnaire regarding the child’s symptoms, history and family history. 48 children later failed the test, with 32 unaware of there being any problem with their eyes. The program also gave a specificity of 93.8% and a specificity of 96.1%. Both aspects suggest efficiency of the program for detecting eye sight problems in children.

Table 16: Optometrists involved in paediatric eye care schemes

Authors Date Location Description Design New initiative Participants/ number of Outcome Comments/ case notes notes where applicable Alexander 2009 Huntingdonshire Describes and costs Cost-effectiveness No. The study population The authors concluded that the et al. paediatric eye care paper utilising care involved over 33,000 resources required for comprehensive services records. children during the year chid eye care services is considerable of study to in order to screen and manage conditions, as well as supporting those with ‘serious eye conditions or visual impairment. The latter accounted for 69, or 0.2% of the study sample. Donaldson 2002 John Scott Health Follow-up to Karas et Case note analysis No. The initiative 1300/1755 (74%) 43% of the children (1300/1755 et al. Centre, Hackney, al. (1999). Referrals was implemented 4 attended the clinic invited) were subsequently found to London made between 1994- years prior to the have ‘normal’ vision, and in 41% of 1998 being the first 4 study, and this these, the children required only years. paper represents a spectacles. 17% had an orthoptic 64-month review. abnormality, generally refractive error and 98% were seen by the orthoptist, suggesting the high utility of orthoptist care instead of HES referral. Karas et al. 1999 London To ascertain whether a Case note analysis Yes. Between the study The authors commented that the low community based (agreement between period of April 1994- referral rate could reduce the use of hospital optometrist consultant’s diagnosis March 1996 a total of the HES and subsequent cost by and community and the clinic team 483 new patients were retaining the children within the orthoptist model could referees) seen by the service community scheme. The scheme was provide a service of representing an uptake deemed successful overall, with a vision screening for of 65% (748 were referral rate of 14% and the children offered the service). ophthalmologist agreeing with 78% of these. Thomson 1999 London This study researched The system utilised a Yes. 48 children later failed the test, with and Evans the use of a new type computer program. 32 unaware of there being any of screening in schools Parents completed a problem with their eyes. The program questionnaire also gave a specificity of 93.8% and a regarding the child’s specificity of 96.1%. symptoms, history and family history Wickham 2002 National audit Conducted a national Survey- based No. 288 orthoptic The results suggested that a variety et al. audit of paediatric departments were of systems are in place, and this is services with regard to asked in total. The dependent upon the referral route. the assessment and research team received 66% involved ‘orthoptic assessment management of responses from 75% of without refraction’ (Wickham et al., strabismus (squint) orthoptic departments 2002: 522), ‘66% combined orthoptist and amblyopia. where much of the and ophthalmologist assessment’ and paediatric work is ‘22% had an entirely orthoptist or undertaken. optometric system.’

Future research: 1. A research study focus on the reasons for non-attendance in those who did not attend when invited.

Data collection and presentation: 1. Questionnaire or interview study of non-attenders identified from previous research.

Melanoma (Pale blue)

One paper described the detection of uveal melanoma by UK optometrists.

Damato (2001) conducted a study regarding the detection of uveal melanoma by community optometrists. The research was based upon retrospective data analysis of 223 patients with a mean age of 59.7. Larger melanomas were associated with male gender (p=0.003). According to the findings, ‘79% of symptomatic patients reported that their tumour was detected at their first visit’ (Damato, 2001: 268) and 45% of those with patients with melanomas were asymptomatic. Where there was a failure to detect the tumour, this was associated with an absence of ‘tumour extension posterior to equator’ and this finding was significant (p<0.0001). This suggested the importance of a full examination of the fundus area and ‘the importance of pupil dilation’ when a patient presents with symptoms.

Table 17: Optometrists involved in melanoma detection

Authors Date Location Description Design New Participant Outcome initiative s/ number of case notes Damato 2001 Liverpool The Retrospective No. 223 ‘79% of symptomatic patients University detection of data analysis patients reported that their tumour was Hospital uveal with a detected at their first visit’ melanoma mean age (Damato, 2001: 268) and 45% of by of 59.7 those with patients with community melanomas were asymptomatic. optometrists Where there was a failure to detect the tumour, this was associated with an absence of ‘tumour extension posterior to equator’ and this finding was significant (p<0.0001).

Flashes and floaters (Peach)

Three papers specifically related to either: flashes and floaters at patient presentation; or a ‘presbyopic’ actor with recent photopsia. These papers are summarised in table 18.

Alwitry, Chen and Wigfall (2002) conducted a postal survey study to ascertain the management practices undertaken by optometrists in patients presenting with flashes and floaters. Flashes and floaters can be indicative of retinal tear and/or retinal detachment. The optometrists estimated that they saw an average of 14 patients with flashes and floaters, though relied on recall accuracy. This figure represented 8% of patients within a given month. The results suggested a wide variation in management and referral patterns. 30% of optometrists utilised slit-lamp biomicroscopy to examine the patient, with dilation performed in just some of these cases. The authors concluded that there is a need for further undergraduate and postgraduate level education in vitreous pigment.

Later research by Shah et al. (2008) presented a study with a 20-year old ‘patient’ (an actor) presenting to community optometrists complaining of headaches. 98% of optometrists identified the case of headache, with 82% ascertaining from questioning the reason for the visit. 48% found the patients symptoms of flashing lights.

Shah et al.’s 2009 study also involved an actor presenting to 102 community optometrists with recent onset flashing lights. Photopsia, or flashing lights, was detected in 87% without provocation from the actor. None of the optometrists asked all 7 questions regarding the flashing lights (see Appendix 5). 35% asked 4 out of 7 questions, and 85% asked if the patient had noticed any floaters in his vision, and therefore showing linkage between flashes and floaters as symptoms which together can indicate a condition of the retina, including tear or detachment. 66% also recommended fundoscopy screening with dilation, to be carried out themselves or by another eye care professional, and those who referred 70% suggested the patient be seen either on the same day or within a week. The results therefore suggested large variations in optometric care for photopsia.

Table 18: Optometrists working with flashes and floaters

Authors Date Location Description Design New initiative Participants/ number Outcome Comments/ notes where of case notes applicable Alwitry et al. 2002 Derbyshire Royal To ascertain the Postal survey No. 74/130 optometrists The results suggested a The authors concluded Infirmary, Derby management practices responded (56.9%) wide variation in that there is a need for undertaken by management and referral further undergraduate optometrists in patients patterns. 30% of and postgraduate level presenting with flashes optometrists utilised slit- education in vitreous and floaters. lamp biomicroscopy to pigment. examine the patient, with dilation performed in just some of these cases. Shah et al. 2009 London Involved an actor Standardised patient No. 102 community None of the optometrists The results suggested presenting to 102 (study actor) presenting optometrists asked all 7 questions large variations in community to community regarding the flashing lights optometric care for optometrists with optometrists then (see Appendix 5). 35% photopsia. recent onset flashing recording the details of asked 4 out of 7 questions. lights the examination 85% asked if the patient had afterwards. This design noticed any floaters in his is used throughout all vision, 66% also Shah et al. studies. recommended fundoscopy screening with dilation, to be carried out themselves or by another eye care professional, and of those who referred the patient, 70% suggested the patient be seen either on the same day or within a week. Shah et al. 2008 London 20-year old ‘patient’ Standardised patient/ 98% of optometrists (an actor) presenting to study actor identified the case of community headache, with 82% optometrists ascertaining from complaining of questioning the reason for headaches to ascertain the visit. 48% found the the content of patients symptoms of optometric flashing lights examinations for headaches.

Critique of the COSI concept (Community Optometrists with a Special Interest) (pale purple)

One paper contained a critique of the concept of COSIs.

Ellis et al. (2006) comment on the concept of COSIs with some criticism using the example of macular degeneration. They note that the role of the COSI is to triage patients suspected of having exudative age related macular degeneration (AMD). They argue that by adding another tier onto a macular disease pathway will not detect more patients with disease. It could save money but this is by no means guaranteed, for example if the patient still needs referral on to a medical retina specialist. In fact, all patients referred to the HES by the community expert will incur the cost of the retinal specialist as well as the additional cost of the community expert (COSI). Ellis et al go on to suggest that once training costs of COSIs are taken into account, any cost savings may be negated.

Table 19: Critique of the COSI role

Authors Date Location Description Design New Participants/ Outcome Comments/ notes where initiative number of applicable case notes Ellis et 2006 Not Comment Not No Not Not Suggests that the costs al. applicable on the applicable applicable applicable incurred by the patient concept of referred to the HES by the COSIs COSI would incur both the COSI consultation cost and costs associated with the HES visit. Furthermore, the COSI cost would be incurred by the patient whether they were referred to the HES or not, whereas current systems do not lead to this additional cost.

Suggested future research: 1. Research patient views regarding the utility of COSIs and the cost associated with visiting a COSI. 2. Comparison of the benefits of special interest optometrists with entry level optometrists.

Data Collection and Presentation: 1. Questionnaire based studies akin to recent GP patient surveys, sent via postal services or provided within GP and optometric practice.

Optometric technological comparison studies (Terracota red)

One paper referred to comparisons between electronic referrals.

Cameron et al. (2009) studied the ‘feasibility, safety and clinical effectiveness’ (Cameron et al: 1134) of utilising electronic referral of patients between community practice and the HES. Study arms included referrals with images sent via email and without images sent via email. Over the 18 month study period, 346 electronic referrals were received into the HES with 218 (63%) requiring a HES appointment, in comparison to 85% referred through the traditional GP referral route. This suggests that referrals, with or without images sent electronically, reduce the number of subsequent HES appointments, perhaps due to the level of detail contained within the referrals. This could have a particularly significant impact upon HES resources. Future research could explore the use of digital imaging referrals on ophthalmic services.

Table 20: Optometrists involved in schemes with electronic referral

Authors Date Location Description Design New Participants/ Outcome Comments/ initiative number of notes where case notes applicable Cameron 2009 Queen Study Comparative Yes. 346 e- 346 electronic E-referrals et al. Margaret reviewing the analysis of e- referrals in referrals were appeared to Hospital, ‘feasibility, referrals from the study received into save an Dunfermline, safety and 3 optometric group. All the HES with additional Fife clinical practices, referrals 218 (63%) 22% of effectiveness’ paper from the 3 requiring a hospital (Cameron et. referrals from optometric HES referral al: 1134) of the same 3 practices appointment, appointments. utilising optometry and the in comparison electronic practices prior remainder of to 85% referral of to study Fife (control referred patients period groups A through the between (Control A), and B) traditional GP community and paper referral route. practice and referrals from the HES optometrists in the remainder of Fife.

Suggested future research: 1. The utility of digital imaging referrals on ophthalmic services.

Data Collection and Presentation: 1. A RCT of traditional systems versus electronic referral with or without images, therefore three study arms would be.

4. Conclusions from the literature

In line with the overall rationale for the UK Eye Care Services Survey Project, this report aimed to synthesise the literature involving optometrists and other healthcare professionals involved in the primary and secondary sectors of the optometric and ophthalmic care pathway. As a result, a number of research avenues have been presented, which could lead to a wealth of future research projects within a field which is already establishing extended roles for optometrists within geographical pockets. Where schemes exist, these often include glaucoma co-management, diabetic retinopathy co-management schemes, and cataract one-stop schemes. In addition, a small number of papers pertained to the therapeutic aspect of optometrists’ roles, and this has been extending to involve new types of therapeutic agents. Claydon, Efron and Woods (1998) suggested that the issue of non-compliance in optometric practice would ‘become more poignant’ in this context, and is an important consideration for prescribing optometrists, in terms of patient outcomes and resource usage.

England, Scotland and Wales have differing approaches to eye care services. It is not clear from the literature whether the Scottish system of universal free access to eye care is beneficial versus a more targeted approach such as the Welsh system. This is an important topic for future research.

In light of the evidence presented, the next logical step may be to develop a joined-up approach across PCTs nationwide, in order to offer schemes on a national scale but taking into account local needs and budgets. This may prove to be one of the biggest overall challenges for eye care services i.e. gaining the efficient balance between the needs of particular locations and providing eye care schemes which can be accessed across the country, and offering the same level of service. What is quite clearly necessary is the acknowledgement that optometrists overall provide high quality, sometimes extended services within the GOS (General Optical Services) contract which already allows much of the extended practice to happen due to the initial degree training undertaken by optometrists working under the contract. The larger scale schemes, including the WECI in Wales, as well as the various research studies based upon smaller scale projects, highlight the evidence for this. In addition, with current optometric CET point systems to ensure continual development of optometric practice, the future could be particularly bright for optometrists where gaps in service provision can be filled by their existing skills. This is particularly pertinent at a time when the population continues to age, and ophthalmologist time becomes correspondingly tight when dealing with conditions associated with older age, including cataract, glaucoma, and diabetic retinopathy. Careful negotiation over time is required to ascertain how extension of the optometrist’s role could fit in with other ophthalmic roles, and therefore allow all healthcare professionals to work together without fear of marginalisation.

A number of roles, including nurse practitioner, orthoptist, ophthalmologist, ophthalmic medical practitioner and dispensing optician, exist within the community and HES settings. Therefore the integration of all parties is a particularly important aspect to consider should co-management schemes become more prevalent. A number of papers were identified regarding nurse-led clinics for diabetic retinopathy and glaucoma, which did not include the role of optometrists. Whilst these do not inform the UK Eye Care Services Survey Project regarding optometrists’ roles, and were therefore excluded from this report, this perhaps reiterates the point regarding the delicate nature of extending one health-care professional’s role within the context of the similar patterns

in the role of others.

This report has also informed the second phase of the project in terms of questionnaire items, and focus group questions, which will also provide insight into local priorities for eye care, and also current research projects. Items will include referral refinement and the extent to which optometrists are involved in a local referral refinement or co- management scheme. This questionnaire will also ask about future training needs, and the extent to which optometrists are currently involved in training for new schemes or therapeutic practice.

Uncertainty also lies with the recent change of UK government and how exactly Government funding will be utilised for healthcare. Widespread spending cuts are predicted. A coalition government of Conservative and Liberal Democrats means that compromises will need to be made in terms of pre-election party manifesto pledges. The Conservatives showed some support for shared-care within other healthcare professions (regarding patients being permitted to utilise local pharmacists for screening and the treatment ‘of minor ailments’, Draft Health Manifesto, 2010, Conservatives: 7). Whether this could mark the beginning of a similar push for co- managed optometric services is uncertain. The recent announcement of the future abolition of SHAs and PCTs will also affect the way in which community based healthcare is delivered in England. Radical changes for the commissioning and funding of UK healthcare are proposed. In future, budgets are to be managed by GP consortia, it remains to be seen how this will affect the delivery of optometric care.

5. References (black type : black literature, grey type : grey literature)

Alexander, P., Rahi, J.S. and Hingorani, M. (2009). Provision and cost of children’s and young people’s eye services in the UK: findings from the single primary care trust. British Journal of Ophthalmology, 93, 645-649.

Alwitry, A, Chen, H and Wigfall, S. (2002). Optometrists’ examination and referral practices for patients presenting with flashes and floaters. Ophthalmic and Physiological Optics, 22, 183-188.

Association of British Dispensing Opticians, Association of Optometrists and Federation of Ophthalmic and Dispensing Opticians (2010). Advice on NICE Glaucoma guidelines. Online [accessed 15/2/10]: http://www.assocoptometrists.org/uploaded_files/glaucoma_advice_and_faqs_01.06.09 .pdf]

Association of Optometrists (2007). Guidance for Optometrists in relation to Diabetic Retinopathy Screening Schemes. Online [accessed 15/2/10: http://www.aop.org.uk/uploaded_files/drs_and_nsf_blakeney_broadbent_12jan07.pdf]

Austen, D. (2003). Primary eyecare in the community: GP ophthalmic referrals to optometrists. Quality in Primary Care, 11, 293-304.

Azuara- Blanco, A., Burr, J., Thomas, R., Maclennan, G. and McPherson, S. (2007). The accuracy of accredited glaucoma optometrists in the diagnosis and treatment recommendation for glaucoma. British Journal of Ophthalmology, 91, 1639-1643.

Banerjee, S., Beatty, S., Tyagi, A. and Kirkby, G.R. (1998). The role of ophthalmic triage and the nurse practitioner in an eye-dedicated casualty department. Eye, 12, 880-882.

Banes, M.J., Culham, L.E., Crowston, J.G., Bunce, C. and Khaw, P.T. (2000). An optometrist’s role of co-management in a hospital glaucoma clinic. Ophthalmic and Physiological Optics, 20, 5, 351-359.

Banes, M.J., Culham, L.E., Bunce, C., Xing, W., Viswanathan, A. and Garway-Heath, D. (2006). Agreement between optometrists and ophthalmologists on clinical management decisions for patients with glaucoma. British Journal of Ophthalmology, 90, 579-585.

Bateman, D.N., Clark, R., Azuaro-Blanco, A., Bain, M. and Forrest, J. (2002). The effects of new topical treatments on management of glaucoma in Scotland: an examination of ophthalmological health care. British Journal of Ophthalmology, 86, 551- 554.

Bell, R.W.D. and O’Brien, C. (1997). Accuracy of referral to a glaucoma clinic. Ophthalmic and Physiological Optics, 17, 1, 7-11.

Binns, A., Bunce, C., Dickinson, C., Harper, R., Tudor- Edwards, R., Woodhouse, M., Linck, P., Suttie, A., Jackson, J., Lindsay, J., Wolffsohn, J., Hughes, L. and Margrain, T. (2009). Low vision service outcomes: a systematic review. RNIB. London.

Bosanquet, N. and Mehta, P. (2008). Evidence base to support the UK Vision Strategy. RNIB. London.

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APPENDICES

Appendix 1: Search Terms

Example: Ovid Medline

Ovid MEDLINE(R) 1950 to October Week 3 2009 # Searches Results 1 low vision.ab,ti. 1346 2 exp Vision Disorders/ or Vision disorder*.mp. 49508 3 exp Eye Diseases/ or Eye disease*.mp. 368446 4 eyecare.mp. 67 5 exp Glaucoma/ or Glaucoma.mp. 41555 6 Diabetic retinopathy.mp. [mp=title, original title, abstract, name of substance word, subject heading word, unique identifier] 17693 7 diabetic retinopathy.ab,ti. 10161 8 exp Cataract/ or cataract*.mp. 44516 9 macular degeneration.mp. or exp Macular Degeneration/ 12892 10 or/1-9 384947 11 exp "Delivery of Health Care"/ 614154 12 Health Care Costs/ 18940 13 exp Health Services Accessibility/ 64876 14 Health Services Research/mt [Methods] 3852 15 Optometry.mp. or exp Optometry/ 4789 16 Primary health care.mp. or exp Primary Health Care/ 62760 17 (referral and consultation).mp. [mp=title, original title, abstract, name of substance word, subject heading word, unique identifier] 43237 18 Ambulatory Care/og [Organization & Administration] 1923 19 exp Community Health Services/ 405913 20 Physician's Practice Patterns/sn [Statistics & Numerical Data] 6967 21 community.ab,ti. 191225 22 exp Physicians, Family/ 13425 23 multi-agency.ab,ti. 220 24 shared care.ab,ti. 583 25 patient care management.mp. or exp Patient Care Management/ 399596 26 patient care pathway*.ab,ti. 20 27 exp Patient Care Team/ or multi-disciplinary.mp. 45789 28 Primary care physician*.ab,ti. 10484 29 professional role*.ab,ti. 917 30 exp Vision Screening/ or vision screen*.mp. 1714 31 (diab* and screen* and retinopathy).ab,ti. 1092 32 Diabetic Retinopathy/pc [Prevention & Control] 1121 33 Optometry.mp. or exp Optometry/ 4789 34 exp Optometry/ or Optometrist*.mp. 4969 35 Ophthalmology.mp. or exp Ophthalmology/ 23106 36 Ophthalmologist*.ab,ti. 6752 37 (general practitioner* or GP*).ab,ti. 81288 38 orthoptist*.ab,ti. 164 39 hospital*.ab,ti. 599275 40 or/11-39 1758571 41 Evaluat*.mp. 1736132 42 audit*.mp. or exp Clinical Audit/ 112655 43 exp Models, Organizational/ 11424

44 (model* and care).ab,ti. 49901 45 (organisation and (care or services*)).ab,ti. 3055 46 (task* and redesign*).ab,ti. 203 47 or/41-46 1876986 48 40 and 10 and 47 7484 49 limit 48 to yr="1997 -Current" 5637 50 limit 49 to (english language and humans) 4710

Appendix 2 Data Extraction Sheet

DATA EXTRACTION SHEET – OPTOMETRY EYE CARE SERVICES 8 FEBRUARY 2010 A. General Information Study number First 6 words of title Authors

Occupation/role of Optometrist  Researcher/Academic  main authors Ophthalmologist  Other ……………………………………………………………..…. Publication date (year) Journal

Institution of authors If in a hospital, which dept/ clinic (if listed)? City/County study took place Geographical (e.g. how many practices, hospitals, PCTs?) coverage of study

Multi-site? YES  NO  Country Screening colour PINK  YELLOW  ORANGE  GREEN  Reviewer name Reviewer comments Is this a key paper? YES  NO  Make contact with authors? YES  NO  Date contact made: ………………

Add this paper to the written report? YES  NO  NOT SURE  Type of paper Review  Editorial  (tick all that apply) Original research  Audit  Descriptive  Evaluative  Observational  Other …………………………………………………………………. B. Professional groups studied and numbers if given Eye specialists (list) Optometrists  Number surveyed …..… Ophthalmologists (consultant)  Number surveyed …..… Orthoptists  Number surveyed …..… Other ………….………………….  Number surveyed …..… Nurses (list) Specialist nurses  Number surveyed …..… Nurse practitioners  Number surveyed …..… Other ………….………………..  Number surveyed …..… Medical (list) GP  Number surveyed …..…

Hospital doctor  Number surveyed …..… Therapists (list) Psychologists  Number surveyed …..… Occupational therapists  Number surveyed …..… Social workers  Number surveyed …..… Physiotherapists  Number surveyed …..… Other …………..…………….…  Number surveyed …..… Other professional Pharmacists  Number surveyed …..… groups Other …………..………….……  Number surveyed …..… Number of professionals studied (if applicable) C. Methodological Details : study details Focus of study Organisation of services  Shared care  Other (describe)…………………………………………………….. Aim of study

Location of study Community  Hospital  (tick all that apply) Independent Practice  Multiple/franchise Practice  GP surgery  Other …………………………………………………………………. Eye condition Glaucoma  Cataracts  studied Low Vision  Diabetic retinopathy  Vision pathway  Childhood eye problems  Range of eye conditions  Other …………………………………………………………………. Key words given on paper Dates data collected Duration of study Method and place of recruitment (if any) Patient population e.g. adults, children, older people, diabetics only, etc. etc. Number of patients (if applicable) Inclusion criteria

Exclusion criteria

D. Methodological Details : study quality Study type RCT  Matched control  Unmatched control  Historic control 

Qualitative  Observational  Cohort  Before and After  Other (specify)………………………………………………………….

Type of Evaluation Economic  Process  Other …………………………………………………………………….. E. Novel Interventions Intervention site (e.g. primary care / outpatients)

Novel interventions Shared Care  Care pathway  (tick all that apply) Optometrist prescribing  Referral pathway  Nurse prescribing  Screening  Nurse triage  Other (describe) ………………………………………………….….. Summarise the intervention/initiative

What was the trigger for this initiative? e.g. policy change Did it work? Yes  Partly  Unsure  No  Not applicable  Authors’ positives: What worked well?

Authors’ negatives: What did not work or could be improved? Evidence that the YES  NO  novel intervention/ Not applicable practice continued after end of project? Possible to Yes  Partly  Unsure  No  implement the initiative in another area (from the data presented)? Study limitations

F. Outcomes Principal and Principal:………………………………………………………………… secondary Secondary:……………………………………………………………… outcome measures Referral YES  NO  implications? If yes what? ……………………………………………………………..

Any implications YES  NO  for training? If yes what? …………………………………………………………….. Evidence of cost- YES  NO  effectiveness? If yes what? …………………………………………………………….. Cost of YES  NO  intervention given? If yes what? …………………………………………………………….. Potential for YES  NO  national roll-out by Comments ………………………………………..…………………….. the College G. Statistical analysis Methods used

H. Reviewer Notes Summarise main results:

Key recommendations for future working:

References to check?

Contacts for more information?

Please complete Reviewer Comments section on page 1.

Appendix 3: Hau (2997): Eye conditions seen by optometrists

Primary diagnoses agreement, diagnoses classification and agreement in those conditions suitable to be seen by the optometrists only (n =134)

Conditions suitable to be seen by Primary diagnoses agreement Frequency (%) Diagnosis classification optometrists only

Posterior vitreous detachment 15 (11.2) Acute Yes (exclude high myope) Contact lens-related problems* 13 (9.7) Acute CLARE, deposits problem, keratopathy, abrasion Other conjunctival disorders† 11(8.2) Acute Allergic eye disease, trauma, SCH, inflamed pinguecula and pterygium Vitreoretinal‡ 10 (7.5) Acute No Blepharitis 9 (6.7) Non-acute Yes Cornea problems§ 9 (6.7) Acute FB, abrasion, RCE Medical retina¶ 9(6.7) Acute Dry AMD Nothing abnormal detected 9 (6.7) Non-acute Yes Conjunctivitis 7(5.2) Acute Yes Neuro-ophthalmic** 7(5.2) Acute Migraine Episcleritis/scleritis†† 6 (4.5) Acute Episcleritis Anterior uveitis 5 (3.7) Acute No Chalazion 4 (3) Non-acute Yes Dry eye 4(3) Non-acute Yes Other uveitis‡‡ 4 (3) Acute No Eczema 3 (2.2) Non-acute Yes Orbital§§ 3 (2.2) Acute Lagophthalmos secondary to Bells HSV infections¶¶ 2 (1.5) Acute No Cataracts 1 (0.7) Non-acute Yes Glaucoma 1 (0.7) Acute No Herpes zoster ophthalmicus 1 (0.7) Acute No Strabismus*** 1 (0.7) Acute Yes

AMD, age-related macular degeneration; CLARE, contact lens-associated red eye; FB, foreign body; HSV, Herpes Simplex virus; RCE, recurrent corneal erosion; SCH, subconjunctival haemorrhage. *Nine keratitis, one deposits problem, one CLARE, one abrasion, one keratopathy. †One allergic eye disease, one conjunctival trauma, two inflamed pinguecula, one inflamed pterygium, one conjunctival phlycten, four SCH, one stitch granuloma. ‡One macular hole, five retinal detachment, three retinal tear, one retinoschisis. §Four corneal foreign body, one corneal abrasion, one non-contact lens-related corneal ulcer, one endothelitis, one filamentary keratitis, one RCE. ¶One central retinal vein occlusion, three central serous retinopathy, one commotio, one valsava retinopathy, one dry AMD, two wet AMD. **One inferior quadrantanopia, four migraine, one sixth nerve palsy, one Amaurosis fugax with no embolus detected. ††Three episcleritis, three scleritis. ‡‡One Fuchs heterochromic cyclitis, one hypertensive uveitis, two postoperative uveitis. §§One orbital fracture, one preseptal cellulitis, one lagophthalmos secondary to Bells. ¶¶One Herpes simplex keratitis (HSV), one primary HSV blepharoconjunctivitis. ***One decompensating esophoria.

Appendix 4: Scully et al. (2009)- list of ‘ideal’, ‘acceptable’ and ‘fail’ criteria for study referral forms

Standard Criteria required Acceptable Date of referral Referring practice details Patient details (name, address, DOB) VA and refraction Optic disc assessment Intra-ocular pressure measurement Ideal All criteria in ‘acceptable’ standard, plus: Mention of risk factors for development of disease, e.g. presence of family history, ethnicity (for POAG), or presence of ocular co-morbidity (for secondary disease) VF assessment with accompanying plot Optometrist impression or tentative diagnosis Referral urgency (‘routine’/ ‘soon’/ ‘urgent’) Fail Letters not satisfying all criteria in ‘acceptable’ standard

Appendix 5: Items asked of the study ‘patient’ (Shah et al. (2009: 112))

Questions appropriate to identifying the nature of % of optometrists asking the the flashing lights question

Where is your vision do you see the flashing lights? 53

Are the flashing lights in one eye or both eyes? 72 Describe the flashes 26 Is there a pattern to the occurrence of the flashes? 83 Is there a change in pattern of occurrence? 39 How long ago did you first notice them? 94 How long do they last? 34

(n=102)

Appendix 6: All black literature

Authors Date Location Description Design New initiative Participants/ Outcome Comments/ notes number of case where applicable notes Alexander et 2009 Huntingdonshire Describes and costs Cost-effectiveness No. The study population The authors concluded al. paediatric eye care paper utilising care involved over 33,000 that the resources services records. children during the required for year of study comprehensive chid eye care services is considerable to in order to screen and manage conditions, as well as supporting those with ‘serious eye conditions or visual impairment. The latter accounted for 69, or 0.2% of the study sample. Alwitry et al. 2002 Derbyshire Royal To ascertain the Postal survey No. 74/130 optometrists The results suggested a The authors concluded Infirmary, Derby management responded (56.9%) wide variation in that there is a need for practices undertaken management and referral further undergraduate by optometrists in patterns. 30% of and postgraduate level patients presenting optometrists utilised slit- education in vitreous with flashes and lamp biomicroscopy to pigment. floaters. examine the patient, with dilation performed in just some of these cases. Austen et al. 2003 Loughborough Commentary paper Not applicable Yes. GP referral 113 patients were High levels of patient Personal communication on a new GP referral scheme to seen in the first year satisfaction with the author also scheme (GPs accredited suggests patients referring to the local optometrists in perceive greater accredited the community convenience in the optometrist) optometrist practice- based

Azuaro- 2007 Scotland Comparison of the Case note cohort No. The paper is 100 Optometrists provided as Blanco et al. diagnostic study however based reliable a service as performance of upon the AGO junior ophthalmologists in AGOs versus Glaucoma the HES. consultant service ophthalmologists

Authors Date Location Description Design New initiative Participants/ Outcome Comments/ notes number of case where applicable notes Banes et al. 2000 Moorfield’s Eye Comparison of HES Retrospective case No. Established 54 (108 eyes) Glaucoma management Hospital, London optometrist and note analysis system of HES- decisions were of high ophthalmologist based quality/ similar to

management optometrist care ophthalmologist management

Banes et al. 2006 Moorfield’s Eye Analysis of Case note analysis No. 350 patients. 4 Overall agreement was Hospital, London agreement between (specially designed optometrists (HES 55% for VF status, 79% optometrists and forms for the purpose based) and 3 for management (medical ophthalmologists on of recording clinical medical clinicians, aspects), other aspects glaucoma management with 50 patients of managements- 72- management decisions) each 98% and 78% for decisions scheduling the next appointment. Bateman et al. 2002 Scotland (four Examination of the Retrospective analysis No Not listed Increases in topical geographical impact of new drug of national health prostaglandins, carbonic areas-) treatments on statistics anhydrase inhibitors. glaucoma Increases in cataract management surgery, eye tests, numbers of optometrists. Fall in myotic usage.

Bell et al. 1997 Edinburgh Glaucoma referral Retrospective case- No. The case 295 (case notes) High false positive rate accuracy by note analysis notes were (36%). Recommendation optometrists based on that optometrists traditional joint combine tonometry and GP/optometrist ophthalmoscopy in order referral to the to improve referral HES quality. Bowling et al. 2005 Oxford Eye Community Case note analysis No 2505 referrals from 510 (20.4%) were Hospital optometrist referral optometry diagnosed subsequently (Radcliffe) outcomes with glaucoma, of which

160 were normal tension glaucoma. 44.8% were deemed to show no evidence of glaucoma or OHT.

Authors Date Location Description Design New initiative Participants/ Outcome Comments/ notes number of case where applicable notes Burnett et al. 1998 Catchment area Retinal screening Service audit Yes. 666 invited overall, 83% uptake. surrounding programme 191 seen by Whittington accredited Hospital, London optometrists. 536 of these patients attended, representing an 83% uptake. Coast et al. 1997 Bristol Economic evaluation Cost analysis No, however the Not applicable. Management of A more current UK of glaucoma alongside an RCT. analysis was glaucoma in the evaluation comparing community initiatives based upon the community was deemed shared-care referral and and HES care new Bristol not necessarily more patient management Share-Care cost-effective than HES schemes for glaucoma, Glaucoma management (Bristol and traditional HES scheme. Shared-care study) schemes could be useful. As the optometrists in the

earlier shared-care schemes are now likely to have additional experience, it may be possible that this learning has impacted upon their practice quality, and therefore would mean fewer false positives to the HES and associated lower costs to the HES. Cameron et al. 2009 Queen Margaret Study reviewing the Comparative analysis Yes. 346 e-referrals in the 346 electronic referrals E-referrals appeared to Hospital, ‘feasibility, safety and of e-referrals from 3 study group. All were received into the save an additional 22% Dunfermline, Fife clinical effectiveness’ optometric practices, referrals from the 3 HES with 218 (63%) of hospital referral (Cameron et. al: paper referrals from optometric practices requiring a HES appointments. 1134) of utilising the same 3 optometry and the remainder of appointment, in electronic referral of practices prior to Fife (control groups comparison to 85% patients between study period (Control A and B) referred through the community practice A), and paper referrals traditional GP referral and the HES from optometrists in route. the remainder of Fife. Culham et al. 2002 UK - wide Reported the ‘type Questionnaire survey No. 2539 service Suggested the majority of and location of LV of UK LV service providers low vision services were services within the providers provided by the HES. UK’

100

Authors Date Location Description Design New initiative Participants/ Outcome Comments/ notes number of case where applicable notes Dahlmann- 2007 Suffolk Evaluation of the Audit of existing Yes. Direct 185 seen during the Diagnostic competence Noor et al. West Suffolk direct practice, including referral scheme observation period was deemed very high referral scheme (all three interventions between HES (referred by (87%), and referrals were eye conditions) during 2003: direct and community accredited appropriate in 99% of referral clinics for accredited optometrists) cases. The optometrists’ urgent cases. optometrists choice of sub-specialty referral was less accurate, as was referral urgency (74% and 75% respectively) Damato 2001 Liverpool The detection of Retrospective data No. 223 patients with a ‘79% of symptomatic University uveal melanoma by analysis mean age of 59.7 patients reported that Hospital community their tumour was optometrists detected at their first visit’ (Damato, 2001: 268) and 45% of those with patients with melanomas were asymptomatic. Where there was a failure to detect the tumour, this was associated with an absence of ‘tumour extension posterior to equator’ and this finding was significant (p<0.0001). Donaldson et 2002 John Scott Health Follow-up to Karas et Case note analysis No. The initiative 1300/1755 (74%) 43% of the children al. Centre, Hackney, al. (1999). Referrals was attended the clinic (1300/1755 invited) were London made between 1994- implemented 4 subsequently found to 1998 being the first 4 years prior to the have ‘normal’ vision, and

years. study, and this in 41% of these, the paper represents children required only a 64-month spectacles. 17% had an review. orthoptic abnormality, generally refractive error and 98% were seen by the orthoptist, suggesting the high utility of orthoptist care instead of HES referral.

101

Authors Date Location Description Design New initiative Participants/ Outcome Comments/ notes number of case where applicable notes Davies et al. 2004 Not applicable Compared two Not applicable (review No. Not applicable Policy one was the alternative policies article) preferred system for for screening for screening for DR. diabetic retinopathy Ellis et al. 2006 Not applicable Comment on the Not applicable No Not applicable Not applicable Suggests that the costs concept of COSIs incurred by the patient referred to the HES by the COSI would incur both the COSI consultation cost and costs associated with the HES visit. Furthermore, the COSI cost would be incurred by the patient whether they were referred to the HES or not, whereas current systems do not lead to this additional cost. Evans et al. 2004 Not applicable Commentary paper Not applicable Not applicable, Not applicable The authors point to the regarding one-stop though fact that the ‘impressive cataract surgery comments on listing rate’ was due to the new advent additional ‘optometric of one-stop training and telephone cataract surgery pre-assessment both schemes requiring additional resources (Evans et al., 2004: 227)’ Ewbank 1997 Not applicable Discussed the Not applicable No. Not applicable Not applicable concept of optometrists within the primary care context. Various areas of practice, including suitability for assessing certain eye diseases.

102

Authors Date Location Description Design New initiative Participants/ Outcome Comments/ notes number of case where applicable notes Fielding et al. 1998 Princess Describes the initial Not applicable Yes. 200 patients were As this paper described It was estimated that Alexandra Eye process of the OHT seen within the the early stages of a new approximately 40% of Pavilion, shared-care scheme service during two scheme, therefore overall patients could be re- Edinburgh in Edinburgh time periods results of the scheme referred to the between June 1996 were not produced. community scheme, and and September there would be some 1997. 40 1000 patients seen participating within the scheme within optometrists and 4 years. GPs.

Gilchrist 2000 Not applicable Critique of the Critique article No. Not applicable Gilchrist argues that conventional use of diagnoses are gained specificity and only on those patients sensitivity as who are referred, and measurements for therefore the disease the effectiveness of status of those not screening referred remains unknown. Instead, measures of detection rate should be utilised instead i.e. the proportion of those who are screened who are correctly referred/ detected as having glaucoma, and ‘referral accuracy’ i.e. the proportion of those who are correctly referred. Goyal et al. 2004 Cardiff Eye Unit, Social deprivation Prospective No. 112 Results suggested that Social deprivation University indices for cataract questionnaire study. VA (visual acuity) was indices did also Hospital Wales care/ surgery and Participants filled in poorer than the national correlate with the (UHW), Royal identifying variations the Berth-Peterson VF average across all three variation in cataract Glamorgan in cataract Index sites, though the lowest presentation and the Hospital and presentation. levels were in Merthyr use of optometric Princes Charles Tydfil in both the listed services, whereby Hospital in eye and other eye. higher levels of social Merthyr Tydfil Patient waiting times, deprivation correlate both for surgery and with poorer use of outpatient appointments optometric services. were also longer.

103

Authors Date Location Description Design New initiative Participants/ Outcome Comments/ notes number of case where applicable notes Gray et al. 1997 Bristol Researched the ‘Randomised Yes. The Bristol 12 optometrists The results suggested validity of visual study’(Gray et al.:431) Shared- Care included, 403 that community parameter Glaucoma patients (203 to optometrists could make measurements taken scheme, community, 200 to measurements ‘of by community whereby HES) comparable accuracy to optometrists community those made in the optometrists Hospital Eye Service’ manage glaucoma conditions Gray et al. 2000 Bristol Follow-up study two Randomised study Follow-up of an 2780 (752 identified The scheme suggested Economic outcomes years after the with patient allocation initiative with established or no significant differences were also similar commencement of to either HES or established in suspected overall in outcome between community

the Bristol Shared- community 1998. glaucoma. The rest between patients in HES optometrists and the Care Glaucoma optometrist care were excluded) follow-up and community HES if the follow-up study optometrist follow-up interval by community optometrists is similar to the HES (£46.31 and £14.50-£59.95 respectively).

Hasting and 1998 Leicestershire Researched use of a Audit Yes. 450 patients in the The use of the card Shephard dedicated diabetic first review and 370 improved the number of eye care co- in the second. An patients receiving an operation card additional 133 were examination in the found for the second preceding two years. review from case notes, totalling 503 for the second review of records. Hatt et al. 2009 Not applicable RCT studies Review article No. Not applicable The results suggested involving screening that screening for COAG for chronic open lacks an evidence base, angle glaucoma and therefore (COAG) opportunistic case finding should be retained.

104

Authors Date Location Description Design New initiative Participants/ Outcome Comments/ notes number of case where applicable notes Hau et al. 2007 London Evaluation of the Case note analysis No. 150 within the 6 Agreement was reached ability of two senior months in 134, or 89.3% of cases optometrists based of primary diagnosis, and within the A&E there were 136 cases of department of management outcome Moorfield’s Eye agreement. Hospital to identify and manage eye disease Hau et al. 2008 London Review of A&E cases Questionnaire No 560 questionnaires High numbers of patients to an A&E prospective study were evaluated department in an eye hospital Henson et al. 2003 Manchester Glaucoma referral Case note analysis Yes 18 optometrists, 194 According to this study refinement scheme patients, with 112 some 40% of the number referred to the HES, of suspect glaucoma

93 with suspected cases were reduced by glaucoma 40% as a result of the scheme. Hernandez et 2008 Aberdeen Study of screening Markov model was No. None as such Suggested that At-risk groups were al. for open angle utilised ‘to estimate technician screening was those aged 40-50 with a glaucoma lifetime costs and more effective than a risk factor, for example benefits of a cohort of traditional case-finding, family history, and that patients facing, opportunistic approach, screening should occur alternatively, though more costly, and at 10 year intervals. screening or screening by an opportunistic case accredited optometrist finding strategies’, the was more costly than latter being current technician screening. practice (Hernandez Furthermore, general et al., 2008: 203) population screening was deemed to be less cost- effective than screening at-risk groups, as many in the general population are too young to see the benefits of long-term screening.

105

Authors Date Location Description Design New initiative Participants/ Outcome Comments/ notes number of case where applicable notes Hulme et al. 2002 Preston Evaluated a district Audit of optometrist Yes. 439 patients (872 Sensitivity for any wide DR screening screening by eyes). 64% were retinopathy was 72%, service which utilised ophthalmologist. normal. specificity 77%. For

optometrists using STED sensitivity and slit-lamp and Volk specificity were 87% and lenses 91% respectively. 26% of people with diabetes were screened over a 4- year period thus suggesting a reasonable level of service provision within a geographical location. Ieong et al. 2003 Moorfield’s To compare the use 8 optometrists were Yes. 8 optometrists with a Results suggested that of usual best practice asked to classify each minimum of 4 years two forms of glaucoma (history taking, IOP of the 66 participants. experience in private case-finding strategies

measurement, disc Subjects with POAG practice. 66 patients (POAG), including examination and were recruited through (37 normals, 29 with intraocular pressure SVFA) with a glaucoma clinics POAG- 15 of which measurement and technique which within the HES. were normal tension suprathreshold visual replaces SVFA with Doctors at glaucoma glaucoma) field analysis (SVFA) computerised clinic approached evoked similar sensitivity

quantitative disc those with simple and specificity levels assessment POAG, spouses and (71% and 69% sensitivity partners were also respectively and identical recruited into normal 94% specificity in both group if no history of forms of screening glaucoma. Other ‘normals’ came from a practice in Ealing. James et al. 2000 Not applicable Utilised previous To assess the cost- No. The effectiveness The results suggested Data of this kind studies from effectiveness of data was derived that systematic screening suggests only Liverpool to ascertain systematic from two Liverpool is more cost-effective systematic screening the cost- photographic studies, the first with than opportunistic. should be implemented effectiveness of screening versus 320 patients and the for case finding screening for sight- opportunistic second with 1,363, purposes. threatening diabetic screening for STDR totalling 1,683 eye disease within primary care patients with services diabetes.

106

Authors Date Location Description Design New initiative Participants/ Outcome Comments/ notes number of case where applicable notes Karas et al. 1999 London To ascertain whether Case note analysis Yes. Between the study The authors commented a community based (agreement between period of April 1994- that the low referral rate hospital optometrist consultant’s diagnosis March 1996 a total could reduce the use of and community and the clinic team of 483 new patients the HES and subsequent orthoptist model referees) were seen by the cost by retaining the could provide a service representing children within the service of vision an uptake of 65% community scheme. The screening for children (748 were offered scheme was deemed the service). successful overall, with a referral rate of 14% and the ophthalmologist agreeing with 78% of these. Lash et al. 2003 Southampton Referral quality 444 referral forms Yes, whereby 444 referral forms The authors concluded analysis for cataract sent to a hospital referral forms for that information on ophthalmology new cataract cataract referral forms

department over a ten schemes were could be more in-depth. week period analysed. Furthermore, 47% of referrals for cataract later resulted in these patients being listed for cataract surgery, representing a somewhat lower proportion than the later study in 2006. Lash et al. 2006 Bournemouth Research regarding 412 referrals were Yes. 412 referrals Listing rates were 83% optometric referrals analysed, 50% being and 74% for direct and within the context of conventional via GP, conventional routes the ‘Action for 11% via optometrists respectively, meaning Cataracts’ guidelines letter, 35% via direct more listing in direct in order to determine referral and 15% were routes. Full information whether optometrists GP referrals with no however was provided in were following them optometric just 17% of letter and ‘whether they information. referrals and 10% of are effective.’ GOS 18 referrals. Lask 1997 London Report on the Optometrists were Yes. Those under the The report does not commencement of a recruited according to treatment of the GP present any results collaborative study the Health Authority or hospital were not however, and it is unclear

funded by Brixton list. 23/120 applied for measured.23 whether this initiative Professionals in a place on the study, optometrists out of continued. Partnership (BPIP) in including evening 120 invited agreed to order to test blood course attendance. take part. glucose levels.

107

Authors Date Location Description Design New initiative Participants/ Outcome Comments/ notes number of case where applicable notes Mason and 2002 UK-wide Research to Questionnaire study Not as such, A 10% random The results suggested Useful for Phase 2 Mason ascertain the use of though sample of 67% of optometrists questionnaire therapeutic agents by measures optometrists was would like to prescribe optometrists and interest in the taken from a list of either independently or whether optometrists newer 7,500 GOC dependently (69%). The would like to train to optometric area registered vast majority felt become accredited of prescribing. practitioners. optometrists should be optometrists for this able to do this for purpose, both to infection and prescribe inflammation (87%, dependently and independently). 90% independently were also willing to undergo further training for this Menon et al. 2004 Taunton and Studied referrals for All referral letters sent Not as such. 222 referrals were The majority of letters Somerset NHS laser capsulotomy by to the HES from July reviewed, 156 being were graded average Trust optometrists and 2002- January 2003 direct and 66 via the (63.5%, n=141), 45 were compared this were utilised to GP. good and 36 were poor. referral method with compare the The diagnosis agreement the traditional referral pathways. between the route (via the GP) ophthalmologist standard and the referral letters was 99%. Laser

capsulotomy rate was 98.2% or 215/219 referrals which were initially deemed by the optometrist to require such surgery. Muthucumaran 2000 Peterborough ‘To ascertain the Case note analysis for No. 288 patients (318 Results support the post- a et al. outcome of discharge referrals dated eyes underwent operative discharge of on the first day post- between 1 April 1997- surgery) patients to their surgery for cataract 30 June 1998. optometrist and feedback from the patients’ optometrists.’

108

Authors Date Location Description Design New initiative Participants/ Outcome Comments/ notes number of case where applicable notes Needle et al. 2008 UK-wide To ascertain the Questionnaire study Not as such 1288 optometrists The optometrists This somewhat current practice of were therefore managed an array of contradicts the initial optometrists, and to surveyed from the conditions, some commentary presented

discover their views College of including dry eye, by Ewbank (1997) regarding the Optometrists list of blepharitis/ lid problems, regarding extension of their role registered simple corneal abrasions, ophthalmologists views in terms of practitioners allergic conjunctivitis, on optometric prescribing. with management rates prescribing. of 87-96% across these

conditions. Optometrists in hospital were also more likely to manage acute sight-threatening diseases. Nearly 80% felt they could manage PAOG with further training, and also felt that most main classes of drugs should be available to them. Newman et al. 1998 Suffolk Assessing the PPV Retrospective case No 86 out of initial 586 Results suggested all of VF testing by note study were for suspected methods of screening optometrists glaucoma (original have poor validity when cohort was 595, used in isolation, though 9 records including could not be found.) ophthalmoscopy, tonometry, and visual field testing Newsom et al. 2005 Huntingdon, Direct cataract Small audit of 100 Yes. 200 referrals. Waiting times dropped Cambridgeshire referral scheme referrals (direct from 15 to 3 months for referrals) compared the entire cataract

with another 100, non- pathway, being the direct referrals national target derived from the Department of Health (Action on Cataracts, 2000, DoH). The small audit of

referrals (100 direct referrals compared with 100 non-direct referrals) showed similar levels of post-operative visual acuity and post-operative refraction levels in both routes. 109

Authors Date Location Description Design New initiative Participants/ Outcome Comments/ notes number of case where applicable notes Okoli et al. 2002 Barnet Health Evaluated three Case-note review and Not as such, 2230 patients with All three schemes were The authors also Authority models of DR database analysis for though the study diabetes were March deemed to provide an suggested that the screening ahead of uptake and coverage compared three 1998- August 2000. effective service. GP-led eventual screening setting up a of service, follow-up different model (single-lens reflex programme should set- screening for abnormal findings, methods of DR retinal camera and up a system of call and programme postal questionnaire screening prior indirect ophthalmoscopy, recall in order to for service users, to setting up a results interpreted by facilitate uptake, and to interviews with service new DR orthoptist), optometrist place diabetes registers providers, PPV screening scheme- same as GP led in GP practice. evaluations scheme. but with camera rotating between optometrists, second optometrist scheme- indirect ophthalmoscopy only operated from own practice and they interpreted the results. Olson et al. 2002 Aberdeen Compared digital No. A number of 6 optometrists (high- 73% and 90% sensitivity retinal imaging, DR screening street based) and specificity respectively fundus photography methods were (both utilising retinal compared to photographers), and ascertain the slit-lamp best for a new biomicroscopy screening (specially trained scheme. optometrists) Oster et al. 1999 Moorfield’s Eye Evaluated the referral Case note analysis of No. 157 examined by the 79.1% and 17.1% were Hospital, London appraisal skills of the discussion, optometrist, deemed correct or hospital optometrist measurement and provisional diagnosis partially correct recording history, in 152. 56% were according to the study measures of vision, over the age of 60 criteria, based on slit-lamp examination, (86 patients) and optometrist re- Goldmann tonometry 25% were aged 61- examination and history- 70. taking in HES.

110

Authors Date Location Description Design New initiative Participants/ Outcome Comments/ notes number of case where applicable notes Park et al. 2009 Bristol Comparison of Quality of referral was Yes. 124 patients referred Suggested that This suggests that the referrals and listing checked against CoO for cataract surgery, optometric direct referral two parties, being rates for direct referral framework. 62 via optometrist for cataract surgery optometrists and GPs, referrals from direct referral, and provided better provide better optometry and 62 via traditional information regarding information within the traditional GP pathway . measured vision and cataract referral referrals for cataract ‘better delivery of pre- pathway just merely on surgery (Park et. al: operative counselling.’ different aspects, and 309) GP referrals however the types of aspects one contained better medical would expect according history, drug information, to the practitioners and details of personal scope of practice. circumstances.’ Papadopoulos 2007 Not applicable This research aimed Survey study No. 99 children were The report concluded et al. (nationwide to identify the eligible for inclusion that the incidence of survey) ‘incidence, detection in the study. 47 had PCG was ‘comparable’ to patterns…managem primary open angle other populations ent and IOP control’ glaucoma and 52 reporting PCG incidence. in children secondary The incidence of PCG glaucoma. was nine times higher in children of Pakistani origin than Caucasians.

Pierscionek et 2009 Belfast Compared Data were analysed No. Traditional 566 patient referrals Most referrals were made al. optometric and GP from 566 patient referral pathway by optometrists (323, referrals to referrals produced (via GP) where the optometrist ophthalmology, also during the study initiated the referral, and

based upon the period of 3 months 243 were initiated by the traditional referral between January GP. pathway 2007 and March 2007

111

Authors Date Location Description Design New initiative Participants/ Outcome Comments/ notes number of case where applicable notes Pointer et al. 1998 Kettering Collaborative shared- Audit of first 12 Yes. 44 optometrists 92% of the optometrists The authors suggest care scheme months of participated from 26 in the locality recording that publicising the evaluated after the collaborative scheme. practices with 1781 34% of the projected scheme and training first 12 months, patients screened. diabetic population of the regarding false positives between April 1995 Kettering Health area. in order to lead to a and March 1996 reduction, would be necessary in later stages. Furthermore, it was concluded that a review of a cohort of patients to check optometric sensitivity and specificity by ophthalmologists was necessary for future working. Pooley et al. 1999 Merton, Sutton Feasibility of All referrals made No. 433 patients were 90% of glaucoma The results suggested a and Wandsworth optometrist and between stated dates referred during the referrals originated from number of aspects, Health Authority. ophthalmic medical to HES from dates when the data the optometrist, and including the wide

practitioner direct optometrists and was collected: showed varying levels of variation in the tests referrals to the HES medical practitioners. 28/7/97-22/8/97 in screening utilisation as utilised to screen for one hospital (St found in other studies in glaucoma and a low George’s Hospital this report (100%, 80% level of accuracy of and 11/8/97-22/8/97 and 45% for IOP, optic glaucoma referral. in Sutton Eye Unit). disc measurement and

VF measurements respectively). Cataract was however the most frequently stated diagnosis by the optometrists (in 27% of referral cases)

112

Authors Date Location Description Design New initiative Participants/ Outcome Comments/ notes number of case where applicable notes Prasad et al. 2001 Wirral Researched the Prospective study. No. Those not under 4904 patients were The authors concluded effectiveness of Diabetes register HES- invited for eye screened in 18 months. that the optometrists optometric utilised to collect test by AO. 27 AOs.* 371 were considered performed well, and was

examination using patient demographic 4904 patients borderline or ‘threshold’ ‘facilitated by the use of slit-lamp data, including 64 GP screened in first 18 cases, in which 30.18% simple grading and biomicroscopy practices, hospital months. 90.5% were or 112 were false referral criteria.’ This through dilated pupils sites with diabetic negative screens, positives. The most may be an important for DR screening clinics, laboratory 429 (9.67%) were common cause of these consideration for further reports. Positive re-screened. false positives was research, in terms of

referrals and 10% of ‘drusen in patients with ensuring grading and negatives were re- background DR.’ Overall, referral systems are examined by an test sensitivity for STDR communicated to ophthalmologist. (sight threatening optometric staff, and are diabetic retinopathy) was comprehensible. 76% and specificity 95% utilising this one method of screening for DR. Russell et al. 2001 Manchester Comparing a RCT study Yes. 226 patients. This paper described the further research is traditional hospital Randomised to design and methodology, required regarding the based eye care study arm- and does not present outcome of LV shared- service with an conventional, data regarding the care services. integrated service hospital based care efficacy of each study and a non-integrated with integrated arm in terms of eye care service, each home-based services and input of eye including a intervention by LV care professionals. community-based rehabilitation officer rehabilitation officer (still receiving same and a ‘generic optometric care as community’ service study arm 1 which was not ‘vision participants), arm 3- specific.’ HES and generic intervention at home (not vision based) by community care worker

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Authors Date Location Description Design New initiative Participants/ Outcome Comments/ notes number of case where applicable notes Ryder et al. 1998 Birmingham Utilised retinal Implemented as part Yes. 289 hospital clinic Concluded that the photography of an on-going audit of patients not hospital- based scheme examined by a DR screening service. attending an was ‘fail-safe’ specialist optometrist ophthalmologist within the HES already. 144 for first Diabetes unit, audit, 145 for ophthalmoscopy with second. selected dilation, and diabetologist back-up in cases of ‘uncertainty’. Scanlon et al. 2005 Gloucestershire Audit of Medical records of Yes. 3877 patients with The results suggested As a result, screening Health Authority ophthalmology patients attending eye diabetes over the that workload in fact programmes could department workload clinics over the four first four years increased on the first represent ‘a significant changes after the years. First year was between 1997-2001 round of screening, and workload’ to the NHS. introduction of a prior to screening, two including those in further rounds the The authors suggested diabetic retinopathy years was first round, already registered at workload did not the failure to find a drop programme final year was the the eye clinic who decrease below pre- in workload was second round. attended as screening levels, with the possibly due to the emergencies booked exception of laser increasing numbers of between surgery which did show a individuals with appointments. decrease. diabetes.

Scully et al. 2009 Moorfield’s Eye Reviewed the Retrospective case No. 466 referrals initially. The majority of the In light of the research Hospital, London content of note/ letter analysis 326 satisfied referral letters were which suggests a optometrists’ letters inclusion criteria for considered ‘acceptable’ combination of 2/3 GP referrals, with according to the study glaucoma tests is the 121 containing criteria of ‘acceptable’ most conducive for optometric letter. with 7% only being ‘ideal’ referral quality, this and the rest ‘failing.’ In suggests that terms of clinical details, optometrists could be in 26% lacked information a position improve the regarding optic disc efficiency of eye care by evaluation and 6% providing thorough lacked IOP information. information on referral letters or GOS 18 forms.

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Authors Date Location Description Design New initiative Participants/ Outcome Comments/ notes number of case where applicable notes Shah et al. 2009 London Involved an actor Standardised patient No. 102 community None of the optometrists The results suggested presenting to 102 (study actor) optometrists asked all 7 questions large variations in community presenting to regarding the flashing optometric care for optometrists with community lights (see Appendix 5). photopsia. recent onset flashing optometrists then 35% asked 4 out of 7 lights recording the details questions. 85% asked if of the examination the patient had noticed afterwards. This any floaters in his vision, design is used 66% also recommended throughout all Shah et fundoscopy screening al. studies. with dilation, to be carried out themselves or by another eye care professional, and of those who referred the patient, 70% suggested the patient be seen either on the same day or within a week. Shah et al. 2008 London 20-year old ‘patient’ Standardised patient/ No. 100 optometrists. 98% of optometrists (an actor) presenting study actor identified the case of to community headache, with 82%

optometrists ascertaining from complaining of questioning the reason headaches to for the visit. 48% found ascertain the content the patients symptoms of of optometric flashing lights examinations for headaches. Shah et al. 2009 London To evaluate the Study actor No. 100 optometrists The findings suggested The authors suggested content of optometric that 95% of optometrists ‘a need for CPD in examinations. visited by the actor glaucoma screening’ Utilised an actor carried out at least the particularly in light of the presenting as a 44 minimum standard two additional finding that year old of African tests for glaucoma, 6% of the sample racial origin who was including optic disc advised the ‘patient’ of having recent near- assessment and the increased risk of sight difficulties, and tonometry. 35% utilised POAG in individuals of was requesting new all three standard tests, African racial descent. spectacles including optic disc assessment, tonometry and visual field testing.

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Authors Date Location Description Design New initiative Participants/ Outcome Comments/ notes number of case where applicable notes Sharp et al. 2003 Stockport Description of the Not applicable Yes. Not applicable The results suggested GPs and optometrists new one-stop waiting times were short, were ‘very supportive of cataract referral with an average of just the scheme.’

scheme ten days between their initial assessment and cataract assessment. 86% of the patients assessed during the pilot were also deemed to be

appropriate candidates for direct referral as opposed to a two-stage plan, and 98% of these were listed for surgery. Sheen et al. 2009 Wales Evaluation of the Donabedian model Yes. Community 6432 participants The management of eye WECI using structure, optometrists going through conditions within the two process and outcome accredited to scheme, of which schemes was applied to participants diagnose and 4243 (66%) were ‘acceptable’ and the cost managed eye managed by per patient was relatively conditions optometrists. low. including glaucoma Sheth et al. 2008 Moorfield’s Eye Audit of the quality of Letters brought by No. 88 referrals between Most letters were typed It is unclear whether the Hospital, London referral letters and patients into November 2006- (GP referrals), and most GPs believed that these diagnostic Moorfields Eye February 2007. that were handwritten details were not concordance Hospital between were deemed legible. necessary due to the between GPs and November 2006- However, a number severity level of the eye casualty February 2007. contained medical history particular eye condition. ophthalmologists. and medication This is not discussed by omissions. the authors.

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Authors Date Location Description Design New initiative Participants/ Outcome Comments/ notes number of case where applicable notes Sinclair, Hinds 2004 Case note analysis Retrospective case No 78 sets of case Results suggested that and Sanders study in order to note analysis notes compliance with identify the treatment was poor in characteristics of over ¼ of the study patients in Fife who population (26%), and by were registered as the time the patient had blind with the main been referred to hospital diagnosis of initially, more than half of glaucoma. these patients were aware of visual loss. This suggests that older patients’ glaucoma is not being identified effectively, leading to potential sight loss later. Smeeth and 1998 Authors address A review of the Systematic literature No. 3494 individuals who The results and This could have Iliffe is Royal Free effectiveness of review were involved in five conclusions suggested important ramifications Hospital, London screening older trials of ‘multiphasic that screening of for planning eye care (though this is a people for impaired assessment.’ asymptomatic older services for older review article) vision in a community people was ‘not justified.’ people. setting. Spry et al. 1999 Bristol Assessed RCT study Yes. 405 (2,780 though The findings again optometrists’ 674 were eligible, suggested that glaucoma monitoring then 405/674 were community optometrists

compared to the willing to partake.) could provide equivalent ‘research gold services to that of the standard’ HES, in terms of using ophthalmologist the key glaucoma case- assessment finding methods of visual- field taking, cup to disc ratio and IOP. Tey et al. 2007 Findings from a Audit of cataract one- Findings from a Yes. Not applicable. Results suggest that in The increase in surgery district hospital stop clinics in SE district hospital within line with the Government is marked, though the within South-East Scotland South-East Scotland. ‘Action on Cataracts’ critique by Evans et al. Scotland Surgery audit data paper in 2000, one-stop (2004) may suggest a from 1997 in Fife was cataract clinics were need to review the use used to provide the having a massive impact of optometric time with national comparison. upon surgical throughput new cataract care with a 71% increase in pathways. cataract operations

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Authors Date Location Description Design New initiative Participants/ Outcome Comments/ notes number of case where applicable notes Theodossiades 1999 Moorfield’s Eye A study to measure Referral notes No. 87, most aged 50s- Referrals which reported It was found that referral et al. Hospital referrals for reviewed from 60s (22/87 and the use of all three types accuracy improved as suspected glaucoma optometrists from 24/87 respectively). of glaucoma testing the number of September 1996- 54% female. Median showed the highest suspicious findings February 1997. age at glaucoma positive predictive value increases, suggesting diagnosis/ glaucoma the effect of previous suspects- 63. experience and practice in revealing suspect glaucoma Thomson and 1999 London This study The system utilised a Yes. 48 children later failed Evans researched the use computer program. the test, with 32 unaware of a new type of Parents completed a of there being any screening in schools questionnaire problem with their eyes. regarding the child’s The program also gave a symptoms, history and specificity of 93.8% and a family history specificity of 96.1%. Tu et al. 2004 Warrington NHS Compared forms of Comparative study Yes. 1643 patients Uptake for both systems Health Trust DR screening screened in the two was poor. (Warrington and including optometric schemes

Halton areas) screening and digital photography screening Vernon et al. 1998 Nottingham A study to review Retrospective analysis No. 75 in 1988, 71 in The results revealed a Vernon suggested that referral patterns in of referrals in 1988 1993. 146 in total. reduction in the rate of increases in the use of order to identify any and in 1993 Mean age in 1988- true positive referrals visual field measures changes over a 5 61.2. Mean age in from 48% to 34% at the were partly the reason year period for 1993- 59.4. two time points for the increase, and suspect glaucoma concluded that increased false positives result in waiting time increases for the HES. The measures were not taken between the time points and also represent relatively old data.

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Authors Date Location Description Design New initiative Participants/ Outcome Comments/ notes number of case where applicable notes Warburton et 2003 Stockport Researched the Screening was Yes. A number of patients Specificity was The authors did al. sensitivity and performed using slit- were selected at surpassed by 4% (target- however suggest a 57% specificity rates for lamp binocular indirect random from the 95%, actual- 99%). increase in overall sight-threatening eye ophthalmoscopy and screen- negatives Geographical coverage numbers of individual disease in the a hand-held fundus- group to determine was 1.2% with a target of screens and therefore in diabetic retinopathy imaging lens through specificity. 3510 1.8% for new screening the context of this screening service dilated pupils. patients were schemes. Sensitivity fell geographical area the screened during the somewhat short of the scheme could be viewed study period. UK National Screening as a vast improvement. Committee target of 80%, recording instead 75.8%. Weed et al. 1998 Ninewells Determining the Anonymous postal No. 160 patients with Most referrals came from Hospital, Dundee patterns of referral, questionnaire keratoconus optometrists. hospital-based management and degree of visual success achieved by patients with keratoconus. Whittaker et al. 1999 Southampton Descriptive paper Questionnaires sent to No. 79 optometrists 21 out of 79 optometrists regarding optometrists. Medical (54.5% response surveyed did not gain ophthalmologist and records of all new rate) consent from their optometrist patients in outpatient patients, with a further 23 communication department and gaining consent identified the patients ‘sometimes.’ for whom the new style GOS 18 had been utilised. Wickham et al. 2002 National audit Conducted a national Survey- based No. 288 orthoptic The results suggested audit of paediatric departments were that a variety of systems services with regard asked in total. The are in place, and this is to the assessment research team dependent upon the and management of received responses referral route. 66% strabismus (squint) from 75% of involved ‘orthoptic and amblyopia. orthoptic assessment without departments where refraction’ (Wickham et much of the al., 2002: 522), ‘66% paediatric work is combined orthoptist and undertaken. ophthalmologist assessment’ and ‘22% had an entirely orthoptist or optometric system.’

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Authors Date Location Description Design New initiative Participants/ Outcome Comments/ notes number of case where applicable notes Willis et al. 2000 Northern Ireland Questionnaire study Questionnaire study No. 171 optometrists, results suggested that of optometric practice many of whom were glaucoma detection senior practitioners within optometric practice within their practice. is highly variable in terms of the equipment employed, and therefore the tests conducted with patients could be equally variable Wilson et al. 2004 Nationwide Surveyed twenty five Case notes analysis. No. 9,200 records were The overall results health authorities reviewed during the suggested that all types across England and process of schemes were Wales in order to associated with a ascertain diabetic doubling of the odds of retinopathy screening individual patients with provision. diabetes having had a retinal examination. There was also more doubling of testing within optometry schemes, though such schemes also recommend early referral for uncertain cases.

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Appendix 7: CCI listed Eye Care Pathways

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Ophthalmology – Cataract Patient Pathway July 2005

Patient Presentation GP Suspected Cataract Suspected Cataract Optometric Examination • History & Symptoms Optometrist • Refraction & Visual Acuity & Pupils Eye Examination, Co- Morbidity, Standard Referral Form, • Slit Lamp – anterior segment Patient Information Leaflet, Risks + Benefits, Desire for Surgeryy Tonometry & Visual Field • Fundus exam – dilated slit lamp biomicroscopy • Discuss risks & benefits of surgery with patient Cataract Assessment Clinic • Issue information leaflet to patient • Agree desire for surgery with patient • Refer on standardised referral form as per local protocol. Cataract Co-ordinator: Sets pre-operative assessment and collects audit from post operative best corrected visual acuity and refractive error.

• Pre-assessment done by nurse and others: Risk factors, Medical & Social History, biometry to assist intraocular lens calculation, other examination, patient education, Routine review by transport, consent form. community • Ophthalmologist assessment. optometrist Listing for second eye surgery

Optometrist or HES If cataract surgery not Hospital Eye Service (HES) Optometrist or HES Post operative follow up (as indicated: discharge or Discharge letter Day of the surgery per local protocol. refer as appropriate Critical incident reporting.

‘Posterior capsule opacification (PCO) is the commonest complication of cataract surgery. It is caused by the proliferation of lens epithelial cells left behind following cataract surgery.The cells migrate behind the intraocular lens implant (IOL) to obscure the visual axis and reduce the patient’s visual function similar to that experienced with the originalcataract. If PCO occurs vision may be restored by a laser capsulotomy. As patients are discharged soon after cataract surgery it is essential that they are warned of the potential problem of PCO and advisedto seek attention if they feel their vision deteriorates. Regular optometry review will ensure that PCO is detected and further referral to the HES may be organised as necessary’.

122 Patient Primary Care Secondary Care

Ophthalmology – Diplopia Patient Pathway June 2005

Patient Presentation Suspected Diplopia

GP / Optometrist / Hospital A&E

Diagnosis – Monocular or Binocular Diplopia

Monocular / Chronic / Longstanding Acute

Optometrist Assessment if unable to determine diagnosis or if neurogenic, myogenic or mechanical aetiology is suspected

Hospital Eye Service Optometrist Refer to Hospital Eye Service for diagnosis Appropriate management If no improvement within 3 months and appropriate orthoptic management

Useful Information for Patients

Patient Primary Care Secondary Care

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Ophthalmolo gy – External Eye Disease Patient Pathway June 2005

Patient Presentation Suspected external Optometrist / GP eye disease Suspected external eye disease

Standard optometric examination of an eye: Optometrist / GP History & Symptoms: Protocol Diagnosis External – slit lamp - anterior eye examination Diagnostic agents: pinhole Visual Acuity, Intra-Ocular Pressure, Dilation

Common conditions that are not Condition not normally Diagnosis uncertain If sight threatening Conditions that are normally normally sight threatening (can sight threatening condition is identified sight threatening (should therefore be managed in the therefore be managed in community) for example: secondary care) for example: Dry Eye Anterior Uveitis Corneal Abrasion Optometrist/GP Inclusion Foreign bodies Management URGENT REFERRAL Scleritis Blepharitis Advice Endophthalmitis Episcleritis Prescription Cellulitis Bacterial conjunctivitis Microbial Keratitis Conjunctival haemorrhage Angle Closure Glaucoma Hordeola If no response Chemical Burns Allergic, Toxic or Viral external or there is concern Marginal Keratitis eye conditions Neoplasia Hospital Eye Service Optometrist/GP Refer to Hospital Eye Service for diagnosis and Follow up & discharge appropriate management

Useful Information for Patients

124 Patient Primary Care Secondary Care

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Appendix 8: Recommended eye care pathways (NHS Primary Care Contracting, 2007)

Cataract: 1. Patient attends optometrist 2. Patient attends HES 3. Patient attends HES for surgery 4. Patient attends HES or optometrist Each stage explained 1. The optometrist conducts a sight test, diagnoses the cataract and discusses this with the patient. The risks and benefits of surgery are discussed and if the patient wishes to proceed, information regarding the surgery is provided. 2. The patient has an outpatient appointment with the ophthalmologist (the details of medication are received from the optometrist, GP or patients- this is according to the local protocol). A pre-assessment with a nurse also happens at this stage, and cataract surgery is agreed/ arranged. 3. The patient visits the HES for day surgery 4. Patient then finally attends the HES or optometrist for a final check, sight test, and are either discharged or second eye surgery is discussed and an appointment arranged.

Glaucoma: 1. Patient attends community optometrist 2. Attends OPSI or OMP 3. OPSI/OMP relays data to HES 4. OPSI/ OMP manages patient in community Each stage explained 1. The patient attends the community optometrist for a sight test, and where an IOP over 21Hhmg and/or visual field defect and/or excavated discs is detected, the patient or optometrist makes an appointment with the optometrist with special interest in glaucoma (OSI) or the ophthalmic medical practitioner (OMP). 2. The patient attends the OSI or OMP and a full history and assessment is carried out according to the local protocol. The decision is then taken whether the patient has OHT (which the OSI/OMP reviews) or can be discharged to return to the community optometrist or indeed has glaucoma (requiring either treatment or referral to the HES). The patient is advised and given information and further appointments made where necessary. 3. The OSI or OMP relays the data to the HES and the HES advises the OSI/OMP regarding management of the patient’s condition and sets up a review at the HES if necessary. 4. The OSI/OMP manages the patient is the community, ensuring regular reviews take place and the OSI or OMP continues to relay data to the HES if it is significant.

Low Vision: 1. Patient referred to LV Service 2. Patient attends LVS 3. Patient has follow-up visits when necessary 4. Service enables re-access

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Each stage explained 1. The patient is referred to the Low Vision Service (LVS) and a referral may be made from secondary care, the patients GP, social, rehabilitation officer, community nurse, occupational therapist or it may be a self-referral. The patient may have a letter of visual impairment (LVI- explained below), Referral of Vision Impairment or a Certificate of Vision Impairment (CVI). All patients are contacted by LVS within ten working days. 2. The patient attends the LVS and the service is ‘seamless across health, social care and the voluntary sector.’ A full sight test is carried out as part of the assessment and the patient is provided with information on their eye condition, as well as entitlements and local services. They are also provided with counselling and advice on employment and education if required. Spectacles, Low Vision Aids and advice with regard to lighting, contrast and size and home adaptations are discussed and made available where appropriate. A referral to other areas of health and social care are also made where necessary, including certification of partial sight. 3. The patient has follow up visits when required, and the visits can take place in the patients home or elsewhere, and the visit will be by an appropriate member of the low vision team. 4. The service enable re-access (and the patient continues in stages 3 and 4.)

Terminology LVI: this is an information leaflet for patients who are newly diagnosed as blind or partially sighted. This has been replaced by the low Vision Leaflet (LVL). The LVL is more of a standardised information leaflet rather than a referral form. LVIs and LVLs are issued by high street optometrists. They contain a tear-off form that the patient can fill in and send to their local social services to request an assessment. RVI: this is a form completed by the Hospital Eye Service to advise social services about a newly diagnosed blind or partially sighted patient, to request an assessment of support needs and to state how urgently the patient requires the support. CVI: this is completed by the hospital ophthalmologist to notify social services that a patient is eligible to be registered as blind or partially sighted.

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Appendix 9: Grey Literature table (below) Website/ organisation name Title of document Document Type Document Summary NICE (3) ‘Action on Cataracts,’ Health guidelines This document outlines measures for improving surgical throughout, as well as recommending numbers of surgical procedures to be performed across the UK per annum. The emphasis is on increasing surgery figures. ‘Glaucoma: diagnosis and Health guidelines This document outlines new policy for managing glaucoma. management of chronic open angle Optometrists must now refer to the HES on the basis on an glaucoma and ocular hypertension,’ IOP over 21 Hhmg. Type 2 diabetes: National clinical Health Guidelines Includes the treatment of eye conditions associated with guideline for management in primary diabetes. and secondary care (update)

NICE Evidence (2) ‘Childrens’ Eye Health: A report on Report This document draws on the Hall and Elliman paper ‘Health vision screening for children’, De Zoete for all Children’ and refers to this throughout. The report essentially critiques the current system for screening children, and points to a lack of orthoptic services. Annual Evidence Update on Research evidence summary This article summarises the evidence regarding glaucoma Glaucoma- Service Provision from an academic perspective. This document also (Prepared by Spry, P.) summarises the tenth chapter of the NICE Glaucoma, in order to present the most relevant details NHS Primary Care Commissioning (4) Step-by-Step Guide to Commissioning New service guidelines This guide provides an outline of current services, Community Eye Care Services commissioning cycles and the next recommended steps for commissioning services in eye care. Kent- Glaucoma referral refinement Primary care resource pack This primary care resource pack is the document submitted scheme in order to develop the Kent glaucoma scheme involving optometrist co-management of the condition. Shipley SOAPS (Shipley Optometric Primary care resource pack As above, a primary care resource pack submitted to the Acute Scheme) scheme PCT. ‘Community Eye care Services: Review This document reviews all of the aforementioned schemes Review of local schemes for Low and provides useful scheme information for the schemes Vision, Glaucoma and Acute Care’ listed at the end of this report. Many schemes run successfully throughout the UK. GOC (General Optical Council) (1) GOC Bulletin Newsletter This newsletter is for all who read the GOC updates. This Winter 2009 edition outlines the changes in CET accreditation i.e. that optometrists must prove their ability via CET points. DoH website (2) ‘Primary Care and Community New service guidelines Dedicates a section regarding the mapping baseline Services: Improving eye health services, and therefore suggests the importance of mapping services’ ‘baselines’ in order to make improvements to eye health services (DoH, 2009: 26-34). Directly links with this project. ‘Commissioning toolkit for community New service guidelines This document provides support for those who wish to based eye care services’ produce new enhanced ways of working in terms of enhanced optometric services. AOP Website (22) All primary care resource packs (20) Primary Care resource packs (final All PCT application and paperwork for the schemes listed at section of this report includes all listed the end of this report. Includes glaucoma, cataract, DR schemes and are labelled ‘AOP’ listed) screening, ARMD, PEARS and GP schemes, and paediatric schemes.

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‘Advice on NICE glaucoma guidelines’, Guideline advice letter to optometrists Created by the optometric advisor for the College of (revised 22nd December 2009) Optometrists and College colleagues. This paper advises optometrists to follow NICE glaucoma referral guidance. Guidance for Optometrists in relation Professional guidance for optometrists The paper suggests that a number of PCT areas have to Diabetic Retinopathy Screening utilised a non-optometric screening service in order to Schemes screen patients, and these schemes have subsequently been found to be under-resourced and therefore unable to screen patients regularly i.e. once per year as guidelines from the National Screening Committee suggest. Instead, screening periods can be two or more years, and as a result mean more potential cases of more severe diabetic retinopathy at subsequent screening presentation.

Centre for Change and Innovation, All CCI pathways listed in Appendix 7 Pathways designed by CCI These documents are diagrammatical representations of Scotland (4) pathways utilised in Scotland. The CCI pathways are a model for creating more localised pathways across the Scottish nation. Eye Care Wales (under the auspices Service Manual: Welsh Low Vision Guidelines This manual outlines the Welsh LV scheme. of the Welsh Assembly Government) Scheme (1) RNIB (3) ‘Profiling of UK Low Vision Services’ Literature review document This review concluded that all low vision services had both Dickinson et al. (prepared for RNIB) positive and negative points, meaning that there was no service which provided completely comprehensive care. All services could therefore be improved. Binns et al. (prepared for RNIB) ‘Low Vision Outcomes: a systematic Literature review document Some of the re view evidence suggests enhanced services review’ are not better at improving vision-related quality-of-life beyond good hospital services. ‘A guide to low vision services and the This guide is aimed at parents and guardians of children low vision aids available for children in with LV and the services in Wales for child care of LV. Wales’

Centre for Reviews and The evaluation of screening policies Economic audit of DR screening methods This paper analyses 2 different policies for DR and Dissemination (1) for diabetic retinopathy using determines the most effective in economic terms simulation (Davies et al.)

Angus Local Government Website (1) CVista leaflet Information leaflet aimed at parents This is a leaflet aimed at parents and guardians. CVISTA is the Children’s Visual Impairment Scheme- Tayside Agencies, representing an integrated approach to child eye care, involving health and social care services. Conservative Party website (1) Draft Manifesto Political party manifesto The 2010 Draft Health Manifesto from the Conservative Part which suggests more community care services, with specific mention of services in pharmacy outlets. Vision 2020 website (1) Evidence base to support the UK RNIB report The report estimates some two million people have Vision Strategy (Bosanquet and significant sight loss in the UK. Most are older people aged Mehta) 65 or over, though 80,000 are working age, and 25,000 are children living with sight problems.

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National Screening Programme for 'Essential Elements in Developing a Guidelines Guidelines in to support those commissioning such Diabetic Retinopathy website (1) Diabetic Retinopathy Screening programmes within SHAs and PCTs. Key recommendations Programme' include programme size and the corresponding ratio of optometrists who should be employed under individual programmes, being 12,000 patients to 4 optometrists respectively. The report also suggested that referral and treatment, with good feedback processes to the programme were essential for ‘closing the gap’ in the referral, treatment and feedback process.

Scottish Government website (2) Review of Community Eye care Governmental Report A continuation of the interim report stated below. Services in Scotland: Final Report Review of Eye care Services in Governmental Report Review of eye care services in Scotland. The Scotland: INTERIM REPORT recommendations and comments mirror the full review article by providing initial commentary regarding a ‘patient- centred approach to the design of eye care services.’

NHS Wales site (3) A Welsh Eye Care Initiative Guideline: Informational booklet Outline of the assessment and management of Cataract The Assessment and Management of under the scheme. Cataract A Welsh Eye Care Initiative Guideline: Informational booklet Guidance on the assessment and management of suspect The Assessment and Management of retinal tear, hole or detachment suspect Retinal Tear, Hole or Detachment A Welsh Eye care Initiative- Protocol: Informational booklet Guidance for the assessment and management of ARMD, The Assessment and Management of as per the Welsh ARMD Scheme Age-related Macular Degeneration Transcripts created by the researcher Two telephone interviews- one Personal communication, followed up These interviews provided initial information regarding eye (2) optometrist, one optometric advisor with information on new care pathways care schemes within the West Midlands Strategic Health Authority, and the associated findings are detailed in the final section of this report. NHS EyeCare Pathways (1) Evaluation of the chronic eye care Literature review of all enhanced eye The chronic eye care services programme was established services programme: final report care services under the auspices of the in order to pilot new patient pathways for low vision, age- (McLeod et al., 2006) chronic eye care services programme related macular degeneration and glaucoma. The schemes detailed within the programme’s literature review are also included within the end section of this report.

Optometry Wales (1) ‘Improving Glaucoma Services in Contains recommendations for improving glaucoma Wales’ services, by implementing service re-design to allow optometrists to co-manage care. Welsh Assembly Government (1) The Future of Optometric Services in This report details various schemes within Wales. These Primary Care In Wales: a consultation include DR services, including Anglesey and the Gwent document, 2002 areas. Total: 57

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Appendix 10: Published and unpublished care pathway schemes

Applications produced for new eye care schemes 50 published and unpublished co-management schemes involving optometrists have been identified as part of the extensive grey literature search. Some of these schemes are covered within the research literature presented above. These schemes include a number of GP referral refinement schemes (for all conditions or PEARS schemes), paediatric schemes, low vision, cataract and referral refinement schemes specifically for glaucoma care. Some of these are available from the AOP website as Primary Care Resource Packs. Other schemes currently being established are also included where personal communication with optometric advisors and optometrists has taken place. Two further schemes, including the Grampian Glaucoma Scheme, and the Lothian Cataracts Scheme, are contained in the final report of the Community Review of Eyecare Services in Scotland (Scottish Executive, 2006). The Community Eye Care Services: Review of Local Schemes for Low Vision, Glaucoma and Acute Care, also provides a list of schemes across the UK, and these schemes are also included if they have not already been sourced from the AOP site, or if the AOP site does not list these.

The source of all schemes appears in brackets beside each scheme title. Essentially, schemes exist in pockets, and differ in terms of the eye conditions treated. As a result, different patient groups are targeted and eye care service provision is correspondingly varied across PCTs and SHAs, Health Boards in Scotland and Wales.

Where costs to the patient or particular Health Authority are included in the Primary Care Resource Pack, these are listed. The costs relate to 2010.

Some sub-sections also include the flow- charts from the AOP documents to provide a visual representation of the scheme. Where subsequent schemes for the same eye condition are very similar, the diagram is not provided. Some of the information sources do not contain such diagrams.

Personal communication was made with optometric advisors within the WMSHA, and where unpublished schemes were discussed an outline has been produced in the following section alongside the AOP-listed schemes.

GP and PEARS referral schemes for all conditions

1. North Charnwood GP referral scheme (AOP site) This scheme allows GPs to refer patients with eye conditions to the accredited optometrist in the area. Criteria for referral include the following, as listed in the Primary Care Resource Pack: Loss of vision including transient loss Ocular pain Systematic disease affecting the eye Differential diagnosis of the red eye Foreign body and emergency contact lens removal Dry eye Epiphora (watery eye) Trichitic (ingrowing) eyelashes Differential diagnosis of lumps and bumps in the vicinity of the eye Ulcers

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Diplopia Flashes/ floaters Serious conditions which are still directly referred to the hospital by the optometrist include: Retinal detachments Perforating eye injuries Acute glaucoma The referral procedure involves: 1. A phone call to the optometrist practice from the GP to request the patient be seen. The level of urgency is agreed at this point. 2. If the patient presents within opening time of the optometrist practice, they are seen the same day. 3. Once the practice has agreed to see the patient, a referral form is completed- one copy to the patient in an envelope marked confidential, the other retained by the GP. Cost: £30 per consultation

2. Colchester PCT GP Ophthalmic Referral Scheme (AOP site) This scheme allows GPs to refer patients with eye conditions to the accredited optometrist in the area (very similar to the North Charnwood and all-Suffolk scheme). Criteria for referral include the following, as listed in the Primary Care Resource Pack:  Loss of vision including transient loss  Ocular pain  Systematic disease affecting the eye  Differential diagnosis of the red eye  Foreign body and emergency contact lens removal  Dry eye  Epiphora (watery eye)  Trichitic (ingrowing) eyelashes  Differential diagnosis of lumps and bumps in the vicinity of the eye  Ulcers  Diplopia  Flashes/ floaters  Refinement of non-specific or inadequate referral/ GOS18 from local optometrists  Serious conditions which are still directly referred to the hospital by the optometrist include:  Retinal detachments  Perforating eye injuries  Acute glaucoma.

The referral procedure involves: 1. A phone call to the PCT for authorisation number i.e. phone number. Call then made to the optometrist practice to request the patient be seen. The level of urgency is agreed at this point. 2. Once the practice has agreed to see the patient, a referral form is completed- one copy to the patient in an envelope marked confidential, the other retained by the GP. The GP receives a report form within 5 working days, detailing the results of the ophthalmic examination. 132

Cost: £40 per consultation

3. Macclesfield Referral Refinement scheme (AOP site) (pilot scheme, commenced in 2000) This scheme is essentially very similar as the previous two, whereby the optometrist receives a form from the GP when the patient presents to the optometrist practice. Alternatively, the optometrist receives the form directly from the GP, with the GP completing the patient and GP practice details. The GP also provides any relevant medical details, presenting signs and symptoms, and a possible diagnosis. The optometrist will then complete another section of the same form with clinical findings and will indicate clinical management advice- either to refer on, no further action, or possibly to prescribe a therapeutic agent with the dosage and use advice. The optometrist will also indicate when the patient will be reviewed. Cost: £25 for first visit, £15 for follow-up A diagram of this scheme is shown below.

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4. Primary Eye care Referral Scheme- Bro Taf (AOP site) (this is also a nationwide scheme) In a similar fashion to the two previous schemes, Cardiff LHG has a PEARS scheme allowing GPs to refer acute eye conditions/ suspected eye disease to accredited optometrists. The patient is only examined according to the referred problem, or any other obvious eye abnormality. The referral procedure involves: 1. The GP refers to one of the locally accredited optometrists (accreditation takes place at Cardiff University) using a particular referral form for the PEARS scheme. 2. The optometrist examines the patient and provides a written feedback form to the referring GP in an agreed format within a specified time-span (patients can select any optometrist according to a list available from GPs).

5. North Staffordshire Acute Eye Management Scheme (AOP site) This scheme also allows GP referral to an optometrist, and also referral by pharmacists should a patient present to a pharmacist initially. Akin to other schemes, all parties receive feedback reports, though in this case, the pharmacist will also receive an optometrist examination report if the patient initially presented to the pharmacist (the pharmacist can allow the patient to decide whether they attend the GP or optometrist). Cost: £25

6. Surrey PEARS scheme (AOP site) The following information is based upon the SLA for this scheme between Surrey PCT and AOs.

The pilot period lasted from November 2006- March 2007. This would be extended for a period of three years if the PCT accepted the scheme.

Again, the scheme involved GP- AO referral, whereby the patient would bring a copy of the written referral to the AO. Patients referred from GPs would be encouraged to phone the Optometry practice prior to arrival to ensure an AO was available.

Cost/ remuneration to the PEARS AO: £40 for first appointments and £25 for follow-up appointments.

7. Essex Integrated Eye care Scheme (AOP site) This scheme represented a pilot in the BBW (Billericay, Brentwood and Wickford) PCT area, whereby two optometrist in the area received referrals from GPs, or GP practices nurses or receptionists.

8. Bradford Consultant and Optometrist Triage and Treatment Scheme (originally sourced in the ‘Community Eye Care Services Review: Review of Local Schemes for Low Vision, Glaucoma and Acute Care, January 2007’ document) The paper does not state further details.

9. Airedale GPSI triage (GP with specialist interest) (originally sourced in the ‘Community Eye Care Services Review: Review of Local Schemes for Low Vision, Glaucoma and Acute Care, January 2007’ document)

The paper does not state further details.

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10. Nottinghamshire County Triage scheme (originally sourced in the ‘Community Eye Care Services Review: Review of Local Schemes for Low Vision, Glaucoma and Acute Care, January 2007’ document)

The paper does not state further details.

11. Shipley GP scheme (Optometrist triage) (originally sourced in the ‘Community Eye Care Services Review: Review of Local Schemes for Low Vision, Glaucoma and Acute Care, January 2007’ document) The paper does not state further details. The Commissioning toolkit for community based eye care services (2007) however mentions that this is provided through a GP and also outlines the findings from the audit. The key findings are as follows: 3. Waiting time is two weeks, and around 75% of the patients in the current scheme do not require HES referral 4. The scheme makes ‘modest’ cost savings, though these are not detailed in the toolkit document 5. An audit of the first 100 patients revealed 60 patients who were not referred to the hospital did not have any further complications later on, where follow-up amounted to 2 years. 6. There is a high satisfaction rating amongst patients and GPs.

12. Suffolk GPSI and COSI scheme (originally sourced in the ‘Community Eye Care Services Review: Review of Local Schemes for Low Vision, Glaucoma and Acute Care, January 2007’ document) The paper does not state further details.

13. W Kent and Maidstone Minor Eye Condition Scheme (originally sourced in the ‘Community Eye Care Services Review: Review of Local Schemes for Low Vision, Glaucoma and Acute Care, January 2007’ document) The paper does not state further details.

14. Worcestershire PEARS Scheme According to personal communication with the area OA, this scheme has been established in a similar fashion to the Welsh PEARS scheme, the latter providing the example for many PEARS schemes across England. This scheme allows GPs, pharmacists, optometrists and allied health professionals to refer to the accredited optometrist. The entire NHS Worcestershire area is involved in the scheme, with the exception of Redditch and Bromsgrove clusters (at the time of writing).

15. Glasgow Integrated Eye care Scheme (AOP site) The GIES, or Glasgow Integrated Eye care Scheme, means those patients who initially approach their GP with an eye condition, often a red eye condition, can be referred to an accredited GIES optometrist for care and management. The optometrist will then either continue to care for the patient as per the scheme protocol, or refer to the HES, as per the protocol. The GP and optometrist may however retain the patient’s care within the community jointly. This is somewhat different to the scheme in Shipley, which is provided through a GP clinic. An independent audit of the scheme suggested good results, and it was intended to roll the schemes across all of the south-side of Glasgow later that year, being 2003.

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According to the commissioning toolkit for community based eye care services, the scheme audit found the following: - All referrals were seen within 2 weeks, and some 90% of these within 4 days - 77% of patients are retained and safely managed in the primary care setting - All of the referrals into the HES were considered appropriate by the consultant ophthalmologist receiving the referrals - There was an 80% reduction in topical antibiotic prescribing - There has been a high patient and professional satisfaction rating* *This section was sourced from the Commissioning toolkit for community based eye care services paper, 2007: 27

Paediatric Schemes

16. Stockport Children’s Refraction Scheme (AOP site) This scheme provides referral of children from community clinics to local optometrists for cycloplegic refraction following screening by orthoptists at 3 ¼ years of age. The orthoptist provides parents with a list of participating optometrists and the parent can select which optometrist they attend. A prescription for spectacles may then be issued by the optometrist following refraction and assessment by the optometrist. Cost: £25 plus GOS sight test fee.

17. South Birmingham paediatric scheme (personal communication) According to personal communication with the area optometric advisor, an enhanced service for children means those failing the age 4 school test can visit a community based clinic with a specialist protocol (in comparison to traditional pathways). This is reducing the load of the HES where referrals would otherwise be made.

Low Vision Schemes

18. Merton, Sutton and Wandsworth Scheme (pilot) (AOP site) Five optometrists provided a LV service across Merton and Sutton. Merton and Sutton Social Services, and the Merton Association for the Blind were also involved. Referral to the service was due to be made initially by Merton or Sutton Social Services. Patients were issued with a leaflet explaining the scheme and a voucher inviting them to participate in the scheme. The target population was those experiencing difficulties due to reduced vision which cannot be adequately corrected by conventional spectacles.

19. Hereford (pilot) (AOP site) This scheme allows trained community optometrists to provide low vision aid assessments and low vision aids. This is a new, integrated service with social services and GP practices. It has meant patients can be referred either from the GP or social services to the optometrist. Cost: the service attracts a £40 fee in addition to the regular GOS STF.

20. Dorset (AOP site) This scheme involves patient referrals from the hospital service, social services, optometrists, dispensing opticians and local societies for the blind or visually handicapped. The scheme was initially introduced in 1993 on a pilot basis as the first community-based low vision aid service. In 1993, fewer optometrists were involved, though exact figures are not contained within the resource pack.

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The scheme allows optometrists to provide LVAs (low vision aids) to patients with LV following a full eye examination. A report is then sent back to the GP. Patients are then followed up two weeks later, and are issued with a different LVA is necessary, or provided further training.

21. Derbyshire (AOP site) This scheme involves a community-based LVAs service. Optometrists would be trained to undertake assessments in the community. This service would run alongside the established one-day per week clinic service provided in the hospital by the hospital optometrist. According to the primary care resource pack, patients would be referred to the eye clinic by GPs. Where it was deemed appropriate, the consultant ophthalmologist could then refer the patient to the LVAs clinic. The hospital optometrist would decide whether patients could be assessed in the community for LVAs. Eligibility includes: patients registered blind or partially sighted and registered with the local PCT (South Derbyshire) patients who had been referred to the Derbyshire Royal Infirmary and had a visual acuity of less than 6/18. patients who came into direct contact with optometrists at their practice only if they were registered blind or partially sighted Supplier: The LVAs would be supplied by the Derbyshire Association for the Blind (DAB) on behalf of the PCT. Cost: £60 (paid by the patient unless they are exempt from charges)

22. East Hull (originally sourced in the ‘Community Eye Care Services Review: Review of Local Schemes for Low Vision, Glaucoma and Acute Care, January 2007’ document) The paper does not state further details.

23. Camden and Islington (as above) The paper does not state further details.

24. Nottinghamshire County (as above) The paper does not state further details.

25. Gateshead (detailed in the ‘Evaluation of the chronic eye care programme: final report’, 2009) According to the aforementioned report, 478 low vision assessments had taken place by the time of publication. 355 domiciliary follow-up visits had also taken place. All of the Low Vision Projects described in the report operated on a one-stop combined LV assessment by an optometrist and a rehabilitation worker within community settings (see Appendix 8). The Gateshead project is deemed the ‘gold standard’ in terms of capacity for domiciliary visits, and also the duration of assessments.

26. Waltham Forest (detailed in the ‘Evaluation of the chronic eye care programme: final report’, 2009) This scheme was initially intended to be placed into 3 local clinics, though the project continued within 2 clinics. The report includes the fact that some administration issues were experienced between the two clinics. The clinics operated weekly.

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The report also suggests that the administrative issues were also part of a larger problem regarding ‘sub-optimal communication between participating managers and clinicians about roles and responsibilities, and limited empathy.’ At the time of publication, it was unclear whether this scheme would continue, in part due to PCT re- organisation.

27. Havering, Barking and Dagenham (detailed in the ‘Evaluation of the chronic eye care programme: final report’, 2009) As stated under the Gateshead scheme, this scheme provided one-stop services to patients, which links into Appendix 8. The Evaluation report aforementioned explains a high staff turnover. Furthermore, the project experienced tensions between health and social care agencies across the two PCTs and boroughs. Other areas of the UK, including Northern Ireland, integrate health and social care services within local health and social care boards. It would therefore be interesting to establish how well such LV schemes operate in areas where historically health and social care are intrinsically linked together.

Glaucoma referral refinement schemes

28. Wales (WECI Glaucoma Service Scheme) (AOP site) Wales already has the Welsh Eye Care Initiative (WECI), incorporating the welsh eye health examination (WEHE) and the primary eyecare acute referral scheme (PEARS), the latter of which has been copied in a number of locations, including those referral schemes listed above. The scheme proposal involves the set-up of a new WECI Glaucoma Service, a half-way house between the patients’ initial Welsh Eye Health Examination (WEHE) sight test, and the Hospital eye service. Borderline suspect cases would be retained within the WECI Glaucoma service (community-based/ ‘primary care optometry’), and those with stable glaucoma would also be routinely monitored in this service. Those cases where glaucoma is suspected, or there is a change in stable glaucoma, then the patient would be necessarily referred from this new WECI Glaucoma service to the HES. Likewise, selected stable glaucoma cases in the HES could be referred to the WECI Glaucoma service, representing a complete cycle whereby patients with less severe and/or stable glaucoma could be seen in the community, and those with changing glaucoma, or glaucoma suspected for the first time, would be referred to the HES. The examination carried out under the new Glaucoma Scheme would be the same those incorporated in the WEHE. Cost: Same as WEHE due to similarity of test (£36)

29. Hull Glaucoma and Ocular Hypertension Scheme (AOP site) According to the scheme protocol, this represents a partnership between the Royal Hull Hospitals NHS Trust, East Riding Health, the Local Optical Committee for Humberside and the Humberside Family Health Services Authority. The diagram for this scheme is presented below.

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30. Bristol Glaucoma and ocular hypertension scheme (AOP site) Initially designed in 1995, this represents a relatively old scheme, whereby community optometrists were trained to monitor stable glaucoma patients and glaucoma suspects. A number of papers included in the literature papers section pertain to this well- established and nationally recognised scheme. The primary care resource pack does not contain details of costs.

31. Manchester Glaucoma referral refinement scheme (AOP site) This scheme involved 18 optometrists attending an accreditation course to undertake glaucoma monitoring in the community to fulfil this scheme. All possible glaucoma referrals received by the accredited optometrists came from GPs or non-accredited optometrists. It was expected the 18 optometrists would see approximately 1200 new referrals for glaucoma each year, thus reducing pressure on the HES. Following referral to the accredited optometrist, the patient would then have a glaucoma refinement examination, and where they fulfilled criteria for further referral (to the HES), the HES, patient’s GP, the referrer (the accredited optometrist) and the audit team for the scheme received a copy of the referral form. In instances where the patient did not fulfil criteria, the GP, audit and referrer only would receive copies, and not the HES. Cost: £35 The diagram of the scheme can be viewed below.

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32. Bradford Glaucoma and ocular hypertension scheme (monitoring) (AOP site) This scheme represents a slightly different approach to the other glaucoma monitoring schemes. Stage 1 involves the HES contact, whereby a consultant, senior registrar, registrar or clinical assistant decides whether the patient’s condition is stable and therefore whether the patient is a suitable candidate for the monitoring scheme. The practitioner then describes the scheme to the patient, and if they agree to take part, they are asked to nominate a glaucoma monitoring scheme (GMS) registered optometrist, normally being their usual optometrists, unless the optometrist is not registered. The practitioner records the optometrist’s details and the time intervals the patient will visit. The patient is then given their next out-patient appointment at the hospital and told when they are to make appointments with their optometrist. The patient is also asked to obtain treatment from the GP as and when necessary. The practitioner notifies the GP of this. The Head Optometrist then registers the patient onto the schemes electronic database system. When the patient sees the optometrist the optometrist will fill in the GMS2 form. Copies are sent to the HES, GP and the third is retained for the optometrists own records.

If the optometrist is dissatisfied with a patient’s progress this is recorded under ‘Clinical Decision’ section on the GMS2 form and the patient will be recalled to the hospital. Also, where a patient appears unlikely to attend further GMS appointments, the optometrist must inform the hospital which will trigger a recall to the HES. The Head Optometrist will check with the optometrist if they do not receive a report within one month of the scheduled GMS appointment, therefore leaving ultimate responsibility for patient follow-up with the HES. If the patient has attended all appointments (at the intervals requested by the hospital practitioner), or if the patient has been re-referred to the HES, this is treated as a complete cycle and therefore it is unnecessary to arrange a further appointment with the optometrist. Following the next HES appointment, the patient may be re-registered onto the GMS for a further cycle if the practitioner feels it is necessary.

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33. Peterborough Glaucoma Pilot Study (AOP site. Also discussed in the Evaluation of the chronic eye care services programme: final report) This scheme involves SOGs (specialist optometrists in glaucoma) trained to provide an examination service in the community. The scheme incorporates three phases, whereby the clinical data and investigation information is sent to the HES for evaluation. A consultant sees the referral, completes an audit form and the outcome letters are sent to the patient, GP, the SOG and the original referral source. GPs initiate the treatment. At the time of writing (January 2008), all SOGs were in this phase. Phase two would allow SOGs more independence. The SOGs would only send information to the HES for those patients who they believed would require treatment for their glaucoma, or patients with exclusion criteria and any other case which the SOG wanted to discuss with the HES. Those patients who were found to be ‘normal’ could be discharged back to the community optometrist. SOGs would retain those patients who were either at risk of glaucoma or those with suspected early glaucoma.

As the evaluation report notes, this scheme is somewhat different to others, namely the Waltham Forest scheme, whereby the latter allows more optometrist autonomy from the consultant. As stated under the Waltham Forest description, the Peterborough scheme remained more ‘cautious’, with consultants still seeing and checking the referrals. In Waltham Forest however, this was not the case, and allowed optometrists also to prescribe. As a result, comparing schemes in terms of efficacy of optometrist work, may prove problematic, and the audits conducted locally for each may provide the best information for determining whether pilot schemes should continue.

34. Heart of Birmingham Scheme (personal communication) According to personal communication with a local Optometric advisor, a glaucoma referral refinement scheme is being established currently within the Heart of Birmingham Teaching Primary Care Trust via primary care commissioning. It is planned that this will eventually involve a co-management scheme with optometrists included. Optometrists have already completed stage one training. This year the hospital will move to the outskirts of Sandwell, therefore moving the initial stages of the scheme.

35. Grampian Glaucoma Scheme (Scottish Executive, 2006 report) The paper does not state further details.

36. Bedfordshire (originally sourced in the ‘Community Eye Care Services Review: Review of Local Schemes for Low Vision, Glaucoma and Acute Care, January 2007’ document) The paper does not state further details.

37. Bexley (as above) The paper does not state further details.

38. Gateshead and South Tyneside (as above) The paper does not state further details.

39. Huntingdonshire (as above) The paper does not state further details.

40. Nottingham (as above) The paper does not state further details. 145

41. SW Kent and Maidstone (as above) The paper does not state further details.

42. Worcestershire Level 2 Glaucoma Monitoring Scheme Following personal communication with the OA involved, a business case was submitted in September 2009 for a level two stable glaucoma monitoring scheme. In a similar vein to other glaucoma schemes, all optometrists involved in the scheme are trained to monitor glaucoma in their community practice. This scheme is being utilised with patients who have a diagnosis of ocular hypertension (OHT) or suspected chronic open angle glaucoma as confirmed by a consultant, and do not require treatment. Patients are referred into the pathway from secondary care i.e. from the consultant ophthalmologist who has confirmed the diagnosis.

43. Waltham Forest (Evaluation of the chronic eye care services programme: final report) This scheme involves the screening of new referrals, as detailed in the report (McLeod et al., 2006). The scheme involves ‘shared-care follow-up’, with community optometrists with a special interest in glaucoma working in community centres in order to undertake the follow-up work. The COSIs, via a GP letter, can initiate medication without notes being reviewed by a consultant. According to the report, a clinical audit indicated strong evidence for the COSIs skills. The report does not provide any further details about this scheme.

Cataract referral schemes

44. South Gloucestershire Scheme (AOP site) According to the scheme protocol, Gloucestershire was chosen in 1999 as an exemplar site for the Action on Cataracts project. Concurrently, a merger between the two ophthalmology units in the area led to the one based in Cheltenham General. The cataract scheme followed, and was launched in late January 2000. The scheme allows the optometrist to refer directly to the HES, with the usual form copies being sent both to the HES and the patient’s GP. The patient also receives an information sheet. The scheme did not eradicate the traditional route. Instead, both routes ran in parallel, and direct referral was utilised when appropriate to refer directly to the HES. The scheme seems to particularly benefit from good communication between all parties, being GPs, ophthalmologists and optometrists. Costs: £37.50 per referral was eventually negotiated with Gloucestershire Health. In addition to this, the usual GOS sight test fee (STF) was also added. The fee is only payable for those patients who were referred directly and not when patients failed to meet the referral criteria. Also referring via the traditional route meant no additional fee to the GOS STF.

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45. Peterborough (AOP site) The Peterborough Cataract scheme means that the optometrist can telephone the cataract co-ordinator within the HES and book an operation the same day as the initial examination. The optometrist will also send a form to the patients GP as well as the HES. Once this has been checked by the co-ordinator, and the referral has been assessed by the consultant, the patient attends the HES, see the nurse for biometry and consents to surgery. If any problems exist, the operation will happen at a later date. Otherwise, the operation will happen on the same day as the first assessment with the nurse. Where patients do not meet protocol criteria on initial visit to the optometrist but wishes to have surgery, a form is sent to the GP and HES and an outpatient appointment is arranged. If the subsequent result means an operation is required, then the patient will be added to a waiting list for this. If an operation is not required, a management/ treatment plan is drawn up, and the patients discharged to the care of the optometrist (community). Those who have surgery are seen by the consultant one week later. Where no problems exist, the patient is discharged to the care of the optometrist. The scheme flow-chart is reproduced below. Cost: £35 (unclear who pays)

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46. Ayrshire (AOP site) This scheme is very similar to the South Gloucestershire scheme, with the addition of the nurse telephone call check to the patient 24 hours post-operatively, and also 2 weeks prior to appointment. The scheme is shown below in the diagram. Cost: £30 per visit (the pack does not detail who pays the fee, however it is assumed that the fee is paid by patient per visit to the optometrist).

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47. Kings Lynn (AOP site) This scheme includes two providers of cataract surgery- Queen Elizabeth Hospital in King’s Lynn, with the satellite being the South Cambridgeshire Hospital, and the Gayton Road Health and Surgical Centre. The latter has an operating suite within a GP practice. According to their website, this is the first GP practice in the country to offer such a service, and private operations are also available at an ‘all-inclusive fee of £950’.

The two schemes are therefore included the diagram below. As with other schemes, the initial examination with the optometrist may lead to a referral to the HES co-ordinator should surgery be deemed necessary. A copy of the surgery form will be sent to the GP to allow the GP to send medical information. The co-ordinator will however call the patient to conduct a prioritisation questionnaire, and if the patient has sufficient points from the scoring system, then they will be allocated either to the Gayton Road GP practice or Queen Elizabeth Hospital. At Gayton Road the patient is seen by the GP/ Ophthalmic Medical Practitioner (OMP) and will have surgery at Gayton Road. For Queen Elizabeth hospital referrals, the patient is seen by an ophthalmic nurse, and if no problems are found, surgery will be carried out on the same day. At 24 hours, the patient will be examined by the nurse, and again at 7 days. They are then discharged to the care of the optometrist with instructions for care. Where problems are found during the nurse assessment, the patient is seen by the ophthalmologist prior to a final decision regarding surgery. Where surgery is not recommended at this stage, a letter is sent both to the optometrist and the GP. Cost: None

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