Establishment and review of educational programs to train optometrists in laser procedures and injections.

Current scope of practice for optometrists in many countries include topical and oral medication with injectable and lasers being added more recently to scope in the United States (US), Canada, the United Kingdom (UK) and New Zealand (NZ). This expanded scope of optometric practice improves access to eyecare and is critical since an ageing population with a higher prevalence of vision disorders and higher healthcare costs looms. Expanded scope has been shown alongside strong safety records. This review paper aims to investigate the expansion of optometric scope of practice regarding lasers and injectables in the US, UK, Canada, Australia and NZ. The design and delivery of post-graduation educational programs, curriculum frameworks for advanced skills and the metrics of laser procedures performed by optometrists will be discussed. The State of Oklahoma in the US was first to authorise optometrists to use lasers and injectables in 1988. As of 2024, qualified optometrists in the UK, in twelve states in the US, and specialist optometrists in NZ perform laser procedures. However, lasers and injectables are not within the current scope of optometric practice in Australia and Canada. Training courses such as Northeastern State University Oklahoma College of Optometry Advanced Procedures Course and Laser Procedures Course have been successfully designed and implemented in the US to train graduate optometrists. The outcomes of over 146,403 laser procedures performed by optometrists across the US have shown only two negative outcomes, equating to 0.001%. These metrics outline the effectiveness of these procedures performed by optometrists and show strong support for future optometric scope expansion. Eye health professionals, relevant educational institutions, advocacy groups, and policymakers are called upon to work collaboratively to expand the optometric scope of practice globally.

Acute community ophthalmology services provided by independent prescribing optometrists supporting hospital eye services during the COVID-19 outbreak

Background: Specialised Independent Prescribing (IP) community optometrists provided acute eye care during the COVID-19 crisis ensuring that over-stretched hospital emergency eye care was supported, therefore local overall urgent eye care provision was not affected.Subjects/methods: Number of cases seen by hospital Rapid Access Clinic (RAC) between January 2020 and June 2020 were compared to number of cases seen by IP optometrists in community Acute Primary Care Ophthalmology Service (APCOS) during the same time period. Specifically, comparisons were made between the number of cases seen in RAC and the number of cases seen by APCOS during the period before COVID-19 emergency (January–March 2020) and for a similar timeframe thereafter (April–June 2020). Numbers treated by APCOS alone and those referred to RAC were also determined. The change in case numbers between the different healthcare settings was also studied.Results: Increase in cases seen by APCOS between April (n = 391) and June (n = 641). Number of cases seen by RAC declined from 652 in March to 372 in April, increasing to 610 by June. This was still below maximum number of monthly cases seen by RAC pre-lockdown in January (861). Most of the cases seen by APCOS were managed in the community with 4% referred to RAC.Conclusions: Ophthalmology services delivered by IP specialised optometrists can safely and efficiently treat and manage the vast majority of urgent cases and mitigate the reduced capacity within hospital emergency eye clinics. Our experience provides insights into care pathways for urgent eye cases in the future. (AU)

Acute community ophthalmology services provided by independent prescribing optometrists supporting hospital eye services during the COVID-19 outbreak.

BACKGROUND: Specialised Independent Prescribing (IP) community optometrists provided acute eye care during the COVID-19 crisis ensuring that over-stretched hospital emergency eye care was supported, therefore local overall urgent eye care provision was not affected. SUBJECTS/METHODS: Number of cases seen by hospital Rapid Access Clinic (RAC) between January 2020 and June 2020 were compared to number of cases seen by IP optometrists in community Acute Primary Care Ophthalmology Service (APCOS) during the same time period. Specifically, comparisons were made between the number of cases seen in RAC and the number of cases seen by APCOS during the period before COVID-19 emergency (January-March 2020) and for a similar timeframe thereafter (April-June 2020). Numbers treated by APCOS alone and those referred to RAC were also determined. The change in case numbers between the different healthcare settings was also studied. RESULTS: Increase in cases seen by APCOS between April (n = 391) and June (n = 641). Number of cases seen by RAC declined from 652 in March to 372 in April, increasing to 610 by June. This was still below maximum number of monthly cases seen by RAC pre-lockdown in January (861). Most of the cases seen by APCOS were managed in the community with 4% referred to RAC. CONCLUSIONS: Ophthalmology services delivered by IP specialised optometrists can safely and efficiently treat and manage the vast majority of urgent cases and mitigate the reduced capacity within hospital emergency eye clinics. Our experience provides insights into care pathways for urgent eye cases in the future.

Standardized patient methodology to assess refractive error reproducibility.

PURPOSE: Standardized patient (SP) methodology is the gold standard for evaluating clinical practice. This approach was used to investigate the content of typical optometric eyecare in England and the reproducibility of refractive error measurement using prescriptions obtained by three SPs. METHODS: The three SPs were independently examined by three to four expert optometric clinicians to obtain "benchmark" estimates of refractive error. One hundred two community optometrists consented to be visited by three SPs who were trained to provide accurate responses during the examinations. The spectacle prescriptions obtained by the SPs were analyzed for spherical equivalent refraction, spherical power and cylindrical power using astigmatic decomposition. RESULTS: The spherical equivalent refractions were found to be within +/-0.25 D of the benchmark on average 81% of the time and within +/-0.50 D 97% of the time. The spherical power was within +/-0.25 D 90% of the time and within +/-0.50 D 98% of the time. The cylindrical power agreed within +/-0.25 D 93% of the time and within +/-0.50 D 100% of the time. Based on reproducibility limits data obtained for all six eyes, any two optometrists would differ in their estimation of spherical equivalent refraction by no more than 0.75 D in 95% of repeated measures. The astigmatic data (C0 and C45) show that optometrists will differ in their estimation of the C0 component by between 0.25 and 0.61 D and for the C45 component by between 0.22 and 0.47 D in 95% of repeated measures. CONCLUSIONS: The agreement between our data and the results of other similar studies support the conclusions that subjective refractive findings are reproducible to approximately +/-0.75 D when performed by multiple optometrists in patients of different age groups and levels of ametropia. SPs are an effective way of measuring reproducibility of refractive error and should be considered for further comparative analysis in different age groups and different levels of ametropia.

The content of optometric eye examinations for a presbyopic patient presenting with symptoms of flashing lights.

BACKGROUND: Standardised patients (SPs) are the gold standard methodology for evaluating clinical care. This approach was used to investigate the content of optometric eyecare for a presbyopic patient who presented with recent photopsia. METHODS: A total of 102 community optometrists consented to be visited by an actor for a recorded eye examination. This actor received extensive training to enable accurate reporting of the content of the eye examinations, via an audio recording and a checklist completed for each clinical encounter. The actor presented unannounced (incognito) as a 59-year-old patient seeking a private eye examination and complaining of recent onset flashing lights. The results of each clinical encounter were recorded on a pre-designed checklist based on evidence-based reviews on photopsia, clinical guidelines and the views of an expert panel. RESULTS: The presence of the symptom of photopsia was proactively detected in 87% of cases. Although none of the optometrists visited asked all seven gold standard questions relating to the presenting symptoms of flashing lights, 35% asked four of the seven questions. A total of 85% of optometrists asked the patient if he noticed any floaters in his vision and 36% of optometrists asked if he had noticed any shadows in his vision. The proportion of the tests recommended by the expert panel that were carried out varied from 33 to 100% with a mean of 67%. Specifically, 66% recommended dilated fundoscopy to be carried out either by themselves or by another eyecare practitioner, and 29% of optometrists asked the patient to seek a second opinion regarding the photopsia. Of those who referred, 70% asked for the referral to be on the same day or within a week. CONCLUSION: SP encounters are an effective way of measuring clinical care within optometry and should be considered for further comparative measurements of quality of care. As in research using SPs in other healthcare disciplines, our study has highlighted substantial differences between different practitioners in the duration and depth of their clinical investigations. This highlights the fact that not all eye examinations are the same but inherently different and that there is no such thing as a 'standard sight test'. Future optometric continuing education could focus on history taking, examination techniques and referral guidelines for patients presenting with symptoms of posterior vitreous detachment, retinal breaks and secondary retinal detachment.

The content of optometric eye examinations for a young myope with headaches.

BACKGROUND: A recent review found standardised patient (SP) methodology to be the gold standard methodology for evaluating clinical care. We used this to investigate the content of optometric eye care for a young myopic patient with headaches suggestive of migraine. METHODS: We recruited 100 community optometrists who consented to be visited by an unannounced actor for an eye examination and to have that eye examination recorded. The actor received extensive training to enable accurate reporting of the content of the eye examinations, via an audio recording and a checklist completed for each clinical encounter. The actor presented as a 20-year-old student seeking a private eye examination and complaining of symptoms suggestive of migraine headaches. The results of each clinical encounter were recorded on a pre-designed checklist based on evidence-based reviews on headaches, clinical guidelines and the views of an expert panel of optometrists. RESULTS: The presence of headache was detected in 98% of cases. Eight standard headache questions were considered to be the gold standard for primary care headache investigation. Although none of the optometrists asked all of these questions, 22% asked at least four of the eight questions. Sixty-nine per cent of practitioners asked the patient to seek a medical opinion regarding the headaches. The proportion of the tests recommended by the expert panel that was carried out varied from 33% to 89% and the durations of the eye examination varied from 5 to 50 min. CONCLUSION: SP encounters are an effective way of measuring clinical care within optometry and should be considered for further comparative measurements of quality of care. As in research using SPs in other healthcare disciplines, our study has highlighted substantial differences between different practitioners in the duration and depth of their clinical investigations. This highlights the fact that not all eye examinations are the same and that there is no such thing as a 'standard sight test'. We recommend that future optometric continuing education could usefully focus on migraine diagnosis and assessment.

Technical Note: A comparison of a novel direct ophthalmoscope, the Optyse, to conventional direct ophthalmoscopes.

Despite the current popularity of binocular indirect ophthalmoscopy, direct ophthalmoscopes are still commonly used by clinicians for fundus examination. They are considered to be expensive, however, and it has been suggested that this cost can prevent their use by healthcare professionals in developing countries. The Optyse Lens Free Ophthalmoscope is a novel direct ophthalmoscope, without a lens focus system, that allows for comparatively inexpensive manufacture and supply. We compared the clarity of view with the Optyse to that with standard direct ophthalmoscopes, over a sequential cohort of patients with a variety of refractive errors and ocular conditions. The grade of clarity of view with the Optyse Lens Free Ophthalmoscope was less than conventional ophthalmoscopes (Wilcoxon signed rank test, p < 0.0001). This grade of clarity of view was not associated with the ametropia of the ophthalmoscopic observation (Spearman r < or = 0.03, p > or = 0.28) but was with the presence of cataracts (chi2 test, p < 0.0001) with both the Optyse and the conventional ophthalmoscopes. Despite its limitations, the retinal view with Optyse was often within acceptable clinical limits suggesting that this relatively inexpensive ophthalmoscope may have a place when cost prohibits any other type of ophthalmoscope use.

Visual stimuli are common triggers of migraine and are associated with pattern glare.

OBJECTIVE: To investigate the associations between interictal pattern glare, visual stress, and visual triggers of migraine. BACKGROUND: There has been relatively little research on the visual stimuli that can trigger migraine episodes. This is surprising, since if practitioners can obviate such triggers, then some attacks may be prevented. The existing literature suggests that patients who are prone to visually triggered migraines report more illusions on viewing striped patterns ("pattern glare") and that colored filters may be an effective intervention for these people. METHODS: Headache symptoms and headache triggers were investigated in migraine and control groups in 2 separate experiments. In one experiment, we also determined, for each participant, pattern glare, whether it was reduced by colored filters and, if so, what the optimum color of filter was. Color vision was also assessed with the D15 test. RESULTS: People with migraine saw significantly more illusions on viewing each striped pattern and experienced greater pattern glare. They were also more likely to select a colored filter to aid visual comfort, particularly colors in the blue-to-green sector of the spectrum. Color vision was impaired subtly but significantly in migraine. Principal component analyses grouped common headache triggers into 5 broadly equal components: food, visual triggers, alcohol, stress and tiredness, and the environment. In a second analysis, the overall number of illusions seen in striped patterns was associated with visual triggers while pattern glare, use of colored filters, and interictal light sensitivity together formed a sixth component interpreted as visual stress. CONCLUSIONS: It is suggested that clinicians should ask migraine patients whether visual stimuli trigger their migraine, about interictal visual symptoms, and use the pattern glare test to ensure that those who may benefit from optometric interventions are appropriately managed.

Subtle binocular vision anomalies in migraine.

A literature review reveals old references to an association between migraine headache and binocular vision anomalies, but a lack of scientific evidence evaluating these claims. In a masked case control study, we investigated binocular vision using standard clinical tests in people with migraine and in controls. Some test results suggest that heterophoria and fixation disparity are more common in the migraine group. The migraine group also had slightly reduced stereopsis. We found significant correlations between some migraine variables and some binocular vision variables (e.g., duration of worst headache and impaired stereopsis) but our analyses do not suggest that a causal relationship is likely. In conclusion, people with migraine have on average a slightly higher prevalence of heterophoria and aligning prism, and reduced stereopsis compared with controls. However, the differences are subtle and our data do not support the use of binocular vision interventions prescribed solely on the basis of the presence of migraine.

The correlation between migraine headache and refractive errors.

PURPOSE: A literature review reveals historical references to an association between migraine headache and refractive errors, but a lack of scientific evidence relating to these claims. METHODS: In a masked case-controlled study, we investigated the four aspects of refractive errors that have been implicated in the literature as correlated with migraine: spherical refractive error, astigmatic refractive error, anisometropia, and uncorrected ametropia. We also compared the calculated scalar value of refractive error, aided and unaided visual acuity, and spectacle use in migraine and control groups. We then investigated the relationship between refractive components and key migraine headache variables. RESULTS: Compared with the control group, the migraine group had higher degrees of astigmatic components of refractive error assessed both objectively (C, p = 0.01; C(0), p = 0.01; C(45), p = 0.05) and subjectively (C, p = 0.03; C(0), p = 0.03; C(45), p = 0.05), uncorrected astigmatic components of refractive error (C(0), p = 0.02; C(45), p = 0.04), and anisometropia (p = 0.06). CONCLUSIONS: Perhaps the historical literature is indeed correct that low degrees of astigmatism and anisometropia are relevant in migraine. Our most significant finding was of higher degrees of astigmatism in the migraine group. This study does indicate that people who experience migraine headaches should attend their optometrist regularly to ensure that their refractive errors are appropriately corrected.

Frequency doubling technology perimetry and standard automated perimetry in migraine.

The literature suggests that visual field defects may be more common in people who experience migraine. The Humphrey frequency doubling (FDT) visual field instrument selectively examines the magnocellular visual pathway, but has not previously been used to investigate visual function in migraine. In a masked controlled study we compared Humphrey FDT and Humphrey Swedish Interactive Threshold Algorithm fields of 25 migraine sufferers with 25 age- and gender-matched controls. Although both mean deviation and pattern standard deviation were a little worse in the migraine group, these differences did not reach statistical significance. There were no inter-eye visual field differences in the migraine group compared with controls. Comparing the mean of all the contrast thresholds in each hemisphere, there were no more inter-hemifield visual field differences in the migraine group compared with controls. There was no significant difference between the migraine and control groups in intra-ocular pressures. The visual field parameters were not correlated with the interval since the last migraine headache, the severity of migraine headache, the duration of migraine headache or the number of migraine headaches per annum. In our data, there was no evidence of visual field deficits, a magnocellular deficit, or indications of glaucomatous pathology.

The pupillary light reflex in migraine.

The literature suggests that there may be pupil size and response abnormalities in migraine headache sufferers. We used an infra-red pupillometer to measure dynamic pupil responses to light in 20 migraine sufferers (during non-headache periods) and 16 non-migraine age and gender matched controls. There was a significant increase in the absolute inter-ocular difference of the latency of the pupil light response in the migraine group compared with the controls (0.062 s vs 0.025 s, p = 0.014). There was also a significant correlation between anisocoria and lateralisation of headache such that migraine sufferers with a habitual head pain side have more anisocoria (r = 0.59, p < 0.01), but this was not related to headache laterality. The pupil changes were not correlated with the interval since the last migraine headache, the severity of migraine headache or the number of migraine headaches per annum. We conclude that subtle sympathetic and parasympathetic pupil abnormalities persist in the inter-ictal phase of migraine.

The optometric correlates of migraine.

Migraine is a common, chronic, multi-factorial, neuro-vascular disorder typically characterised by recurrent attacks of unilateral, pulsating headache and autonomic nervous system dysfunction. Migraine may additionally be associated with aura; those focal neurological symptoms that may precede or sometimes accompany the headache. This review describes the optometric aspects of migraine headache. There have been claims of a relationship between migraine headaches and errors of refraction, binocular vision anomalies, pupil anomalies, visual field changes and pattern glare. The quality of the evidence for a relationship between errors of refraction and binocular vision and migraine is poor. The quality of the evidence to suggest a relationship between migraine headache and pupil anomalies, visual field defects and pattern glare is stronger. In particular the link between migraine headache and pattern glare is striking. The therapeutic use of precision-tinted spectacles to reduce pattern glare (visual stress) and to help some migraine sufferers is described.