Building partnerships with local schools.

BACKGROUND: Medical schools have a responsibility to support their students in developing an understanding of the complex concepts of a 'VUCA' (volatile, uncertain, complex and ambiguous) world. To achieve this, service learning approaches have been increasingly successfully employed for students to learn through participating in activities addressing local community priorities. Sharing outcomes and lessons from such programmes is essential for advancing service learning. We present the evaluation of a new service learning module co-designed at Imperial College London with local schools and wider stakeholders. APPROACH: Students partnered with local schoolteachers to design and implement inclusive science-based after-school sessions for secondary school pupils. The module aimed to foster critical reflection on social accountability, power and privilege whilst encouraging aspirations for higher education in school pupils. EVALUATION: Our evaluation draws on the perspectives of stakeholders in the first iteration of the module in 2021. Qualitative data were collected through university student reflections, presentations and debriefs (n = 20); semi-structured interviews with schoolteachers (n = 6); and questionnaires with wider stakeholders (n = 6). The evaluation revealed mutual benefits, as students reflected on their own societal roles, whilst considering the complexities of concepts such as inclusivity, power and privilege. Schoolteachers highlighted students' impact as inspiring role models for pupils, fostering aspirations for higher education. IMPLICATIONS: This module provides a replicable framework for supporting students in developing their reflections on their role in our VUCA world whilst addressing the priorities identified by local schools. The evaluation highlighted the importance of working collaboratively with community stakeholders when embarking on service learning projects.

Visual Behaviours (ViBes) in Cerebral Visual Impairment: Validating a Descriptive Tool to Support Diagnosis and Monitoring.

Introduction: Cerebral visual impairment (CVI) is the most common cause of visual impairment in children in the UK. Diagnosis is based on identification of visual behaviours (ViBes) relating to visual dysfunction. Examination techniques and inventories have been developed to elicit these in children with a developmental age of two years or more. The absence of a structured approach to recording visual behaviours in children with complex needs is a barrier to diagnosis. The aim of the study was to develop a matrix of visual behaviours seen in pre-verbal and pre-motor children with visual impairment and establish its content validity and inter-rater reliability. Methods: ViBe content validation:: Visual behaviour descriptors relating to visual function were collated and categorised by expert consensus of vision professionals into a matrix composed of three functions (attention, field/fixation, motor response) and five levels (0 = no awareness; 1 = visual awareness; 2 = visual attention; 3 = visual detection; 4 = visual understanding).ViBe inter-rater reliability:: The participants (two orthoptists, an optometrist, an ophthalmologist and two qualified teachers of the visually impaired) used the ViBe matrix to independently score each of 17 short video clips of children demonstrating visual behaviours seen in CVI. Results: The ViBe matrix will be presented. Cohen's kappa for the matrix was 0.67, demonstrating moderate-to-strong inter-rater reliability. Conclusion: The development of standardised descriptors can support clinicians and teachers in identifying areas of concern for children with complex needs. In addition, the ViBe matrix could be utilised in research, clinical and diagnostic reports to clearly communicate the areas of visual dysfunction and track progress resulting from interventions. Key Points: The absence of a structured approach to recording visual behaviours in children with complex needs is a barrier to diagnosis.The ViBe matrix offers descriptors relating to visual behaviours and has demonstrated acceptable inter-rater reliability.The tool may support the identification and diagnosis of cerebral visual impairment in a population of children who cannot access standard testing.

Make it easier: 3-word strategies to help children with cerebral visual impairment use their vision more effectively.

INTRODUCTION: Cerebral Visual Impairment (CVI) is the most common cause of visual impairment in children in the United Kingdom. Management relies on identifying strategies and adaptations which enable the child to use their vision effectively and efficiently. The majority of published strategies involve lengthy inventories used in a specialist setting. Feedback from parent support groups cite the provision of immediate advice on strategies at the time of diagnosis as a key indicator of good care. The aim of the study was to use the Delphi technique to construct a set of three-word phrases to succinctly describe strategies for common visual dysfunctions in children with CVI. METHOD: A panel of twelve experts across health, education and those with lived experience was recruited. Four rounds of questionnaires were used to reach consensus on candidates symptoms and suggestions for 3-word-phrases. Consensus was defined as 70% agreement. RESULTS: Response rates were 92, 67, 92 and 91% for each round respectively. The 3-word phrases reaching consensus were: Big Bold Bright; Keep it Still; Eyes or Ears; Show It High; Better on Left/Right; Clear the Clutter; Keep It Short; Give Me Time, My Vision Varies, Just One Thing. CONCLUSION: The intention is for the phrases presented to act as a 'starter' at the point of diagnosis and are appropriate for children of any developmental or visual ability. The real-life validation of this set of expert-consensus phrases will require further studies, evaluating both their effectiveness in terms of mapping to an intervention and impact on visual development.

Clinical assessment, investigation, diagnosis and initial management of cerebral visual impairment: a consensus practice guide.

Cerebral Visual Impairment (CVI) is a common condition in the UK. Patients with conditions associated with CVI are frequently seen in paediatric ophthalmology clinics offering eye care professionals an opportunity to identify children proactively. In most cases CVI occurs as part of a neurodevelopmental condition or as a feature of multiple and complex disabilities. However, CVI can also be seen in children with apparently typical development. In some cases, high contrast visual acuity is normal and in other cases severely impaired. As such, identification of CVI requires evaluation of aspects of visual performance beyond high contrast acuity and consideration that visual function of those with CVI may fluctuate. Few paediatric ophthalmologists have received formal training in CVI. The detection and diagnosis of CVI varies across the UK and patients report hugely different experiences. A diagnosis of CVI is made based on professional clinical judgement and it is recognised that individual perspectives and local practice in the specific methodologies of assessment will vary. A systematic review and survey of professionals is underway to attempt to reach agreement on diagnostic criteria. Nonetheless, established pathways and published protocols can offer guidance on how a paediatric ophthalmology service can approach assessment of the child with suspected CVI. The purpose of this paper is to present a summary of research and clinical practice methods for detecting and diagnosing CVI in a paediatric ophthalmology outpatient setting. It represents current understanding of the topic and acknowledges the evolving nature of both practice and the evidence-base. A rapid literature review was undertaken to identify articles relating to clinical investigation of children with CVI. A focus group of QTVI and subject matter experts from sight loss charities was undertaken to address areas which were not covered by the literature review.

Referral thresholds for an integrated learning disability eye care pathway: a consensus approach.

INTRODUCTION: Local Optometric Support Unit (LOCSU) have published their refreshed clinical pathway for eye care for people with a learning disability. The document sets out the adjustments to practice that a community optometrist might make in order to provide optimal care for a person with learning disability attending a primary eye care assessment. The pathway specifically points to the need to retain patients in primary care where appropriate and 'reduce the number of people with learning disability who are inappropriately referred into the Hospital Eye Service (HES).' Pivotal to this refreshed pathway is the integration with secondary care, with local arrangements to facilitate referral and hospital management where appropriate. There are few ophthalmologists nationally who frequently encounter patients with a learning disability in their hospital practice and knowing where to start when creating referral criteria or KPIs may create a barrier to services becoming established. In order to address this gap in experience, we set about developing a set of consensus statements regarding referral thresholds for ocular conditions commonly encountered in adults with learning disability. METHOD: A series of video interviews were undertaken with eye health professionals with a range of experience in eye care for people with learning disability. Each contributor commented on the usability and clarity of each element of the referral criteria. In addition, each contributor was asked to express the overriding principles by which they make decisions regarding referral thresholds for patients with learning disability. These were collated into the final document which was circulated and agreed by all participants. RESULTS: A table setting out referral thresholds for commonly encountered eye conditions in adults with learning disabilities is presented. CONCLUSION: We have presented a succinct set of consensus statements relating referral thresholds for common presentations of visual problems in adults with learning disability in the UK distilled from the collective experience of a group of eye health professionals. The intention was not to present a comprehensive review of management of each condition. Rather, the consensus statements may form the starting point from which each area could develop locally agreed criteria, as is suggested by the LOCSU pathway guidance.

"BURSTING THE BUBBLE": Service learning in schools.

BACKGROUND: At Imperial College, we developed a novel teaching programme for medical students based within a local primary school, with the aim of developing students' teaching skills and centring social accountability in our curriculum. Similar service-learning programmes have shown significant benefit for student participants, including: improving communication skills, developing an understanding of the social determinants of health, and increased empathy. In partnership with a local primary school, the programme involved a group of medical students designing, developing and delivering a teaching session to primary school children. METHODS: Medical students completed written reflections on the programme and semi-structured interviews were conducted with teachers who had participated in the programme. These were then thematically analysed. RESULTS: Themes from student reflections included: improvement in teaching and communication skills; and an increased awareness of social accountability. Themes from teacher interviews included: benefits of an aspirational figure in the school; engagement of the children; and the ongoing inspirational benefit for the pupils. DISCUSSION: Our analysis suggested students and the school community benefitted. Students reported the experience was an effective way to learn teaching skills and to improve their communication with children. The programme delivered skills transferrable to other clinical contexts including leadership and behavioural management, adaptability and creative thinking. Teacher interviews suggested the programme was mutually beneficial. The framing of medical students as role models raised the possibility that such programmes may help tackle the challenge of widening participation in medicine. We would recommend medical educators to consider developing other mutually beneficial service-learning programmes.

Are all children with visual impairment known to the eye clinic?

INTRODUCTION: There is a growing body of evidence that children with special needs are more likely to have visual problems, be that visual impairment, visual processing problems or refractive error. While there is widespread provision of vision screening in mainstream schools, patchy provision exists in special schools. The aim of the study was to determine the unmet need and undiagnosed visual problems of children attending primary special schools in Bradford, England. METHODS: Children attending special schools who were not currently under the care of the hospital eye service were identified. Assessments of visual function and refractive error were undertaken on site at the schools by an experienced orthoptist and/or paediatric ophthalmologist. RESULTS: A total of 157 children were identified as eligible for the study, with a mean age of 7.8 years (range 4-12 years). Of these, 33% of children were found to have visual impairment, as defined by WHO and six children were eligible for severe sight impairment certification. DISCUSSION: The study demonstrates significant unmet need or undiagnosed visual impairment in a high-risk population. It also highlights the poor uptake of hospital eye care for children identified with significant visual needs and suggests the importance of providing in-school assessment and support, including refractive correction, to fully realise the benefits of a visual assessment programme.

ICO-OSCAR for pediatric cataract surgical skill assessment.

Pediatric cataract surgical skill assessment is important to ensure the competency of the trainees, especially pediatric ophthalmology fellows. Using a rubric would ensure objectivity in this process. The ICO-OSCAR pediatric cataract surgery rubric has been developed with global variations in techniques of pediatric cataract surgery in mind.

Validity of ophthalmology surgical competency assessment rubric for strabismus surgery in resident training.

The Accreditation Council for Graduate Medical Education (ACGME) requires US residency programs to assess ophthalmology residents for competency in 6 core areas. Ophthalmic surgical skills are currently part of the ACGME "Patient Care" competency, although some have advocated for a seventh competency, "Surgical Skills." The Ophthalmology Surgical Competency Assessment Rubric for Strabismus Surgery in Resident Training ( OSCAR: Strabismus) tool was designed to aid in the assessment of surgical skills using procedure specific behavioral anchors. The present study evaluated inter-rater agreement of the OSCAR: Strabismus tool in the assessment of resident performance. OSCAR: Strabismus evaluations of resident surgical strabismus cases were performed by a multinational group of faculty strabismus surgeons. Cronbach α statistical analysis of the completed evaluations revealed high inter-rater agreement, indicating the OSCAR: Strabismus is a reliable tool to facilitate assessment of resident strabismus surgical skills.

Assessing visual function in children with complex disabilities: the Bradford visual function box.

BACKGROUND: Assessment of children with complex and severe learning disabilities is challenging and the children may not respond to the monochrome stimuli of traditional tests. The International Association of Scientific Studies on Intellectual Disability recommends that visual function assessment in poorly or non-cooperative children should be undertaken in an objective manner. We have developed a functional visual assessment tool to assess vision in children with complex and multiple disabilities. METHODS: The Bradford visual function box (BVFB) comprises a selection of items (small toys) of different size and colour, which are presented to the child and the response observed. The aim of this study is to establish its intertester validity in children with severe learning disability. The visual function of 22 children with severe learning disability was assessed using the BVFB. The children were assessed by experienced practitioners on two separate occasions. The assessors were unaware of each other's findings. RESULTS: In 15/22 of the children, no difference was found in the results of the two assessors. The test was shown to have a good intertester agreement, weighted κ=0.768. CONCLUSIONS: The results of this clinical study show that the BVFB is a reliable tool for assessing the visual function in children with severe learning disability in whom other tests fail to elicit a response. The need for a tool which is quick to administer and portable has previously been highlighted. The BVFB offers an option for children for whom other formal tests are unsuccessful in eliciting a response.

Accuracy of Intraocular Pressure Measurement With the Icare Tonometer in Children.

PURPOSE: The aim of this study was to evaluate the difference between intraocular pressure (IOP) measurements in children with the Icare tonomer (IT) and applanation (AT), pneumatic (PT), or digital tonometers (TT). DESIGN: A randomized prospective trial of children younger than age 16 attending the pediatric ophthalmology department of Manchester Royal Eye Hospital was conducted. METHODS: Children had IOP measured twice, once with an IT and again with a TT, PT, or AT during the same clinic appointment. RESULTS: Forty-four children (88 eyes) were included, with a mean [range (R)] age of 57 (2-144) months. Twelve eyes had anterior segment pathology (ASP), defined as aniridia, congenital glaucoma, or Peters anomaly. Regardless of the presence or absence of ASP, total mean difference (MD), R, positive bias (PB), and limits of agreement (LOA) between IT and other instruments were as follows: PT: MD = 3.2, R = 0 to 8, PB = 2.9, LOA = -1.0 to 6.9; TT: MD = 2.6, R = 0 to 6, PB = 0.9, LOA = -1.8 to 3.5; and AT: MD = 1.4, R = -3 to 5, PB = 0.6, LOA = -4.2 to 7.3. In eyes with ASP, IT comparisons with PT were as follows: MD = 3.9, R = 0 to 8, PB = 3.9, LOA = -0.9 to 8.8. CONCLUSIONS: In children with ASP, IOP measured with IT is higher than expected when compared with other tonometers, in some cases by up to 8 mm Hg. We found an overestimation of IOP in children using the IT with a positive bias of 4 mm Hg. We propose that the IT overestimates IOP measurements in children compared with standard tonometers. Further work should be carried out on a much larger cohort to establish a suitable correction factor for such children.

The ophthalmology surgical competency assessment rubric for strabismus surgery.

PURPOSE: To produce an internationally valid tool to assess skill in performing strabismus surgery. METHODS: A panel of 7 content experts adapted a previously published tool for assessing phacoemulsification by using a modified Dreyfus scale of skill acquisition and providing behavioral descriptors for each level of skill in each category. The tools were then reviewed by 12 international content experts for their constructive comments. The main outcome measure was a consensus of the experts on the final rubric. RESULTS: Experts' comments were incorporated, establishing face and content validity. CONCLUSIONS: The tool (Ophthalmology Surgical Competency Assessment Rubric for Strabismus Surgery (ICO-OSCAR: strabismus) has face and content validity. It can be used globally to assess strabismus surgical skill. Reliability and predictive validity are yet to be determined.

Strabismus surgical skills assessment tool: development of a surgical assessment tool for strabismus surgery training.

PURPOSE: To develop a structured tool to assess strabismus surgical skills and to determine the face and content validity of this tool. DESIGN: Development of a surgical assessment tool and its validation by an expert panel. METHODS: A structured subjective evaluation form was developed to evaluate a trainee's technique and skill in strabismus surgery. The tool consists of strabismus surgery-specific components, such as conjunctival incision, muscle exposure, and suture placement, and global indices, such as hemostasis, tissue control, and knowledge of instruments. Each of these components was evaluated on a 5-point Likert scale. A survey of experienced strabismus surgeons was performed to establish the face and content validity of the tool. The results of the survey were used to amend the tool. RESULTS: The final tool comprises 10 strabismus surgery-specific competencies and 7 global indices. The final version of the tool was deemed to address the vital aspects of a strabismus surgical procedure (face validity), and the components of the assessment tool were deemed to assess appropriate competencies and skills associated with the procedure (content validity). CONCLUSIONS: The strabismus surgery skill assessment tool is a structured quantitative instrument designed to aid surgical evaluation and training of ophthalmic surgical trainees. The Strabismus Surgical Skill Assessment Tool is a paper-based tool that is easy to use, provides the trainee with detailed feedback and a measure of progression of their surgical skills, and stimulates discussion between trainee and trainer to direct further training.

Nd:YAG laser goniopuncture after deep sclerectomy: outcomes.

PURPOSE: This study aimed to investigate the safety and efficacy of Nd:YAG laser goniopuncture (LGP) in lowering intraocular pressure (IOP) after deep sclerectomy (DS). METHODS: We reviewed the outcomes in 258 eyes of 258 consecutive patients who underwent DS or combined phacoemulsification and DS between August 2001 and December 2003. Mitomycin C was used during surgery in 192 eyes (74.4%). RESULTS: Mean follow-up was 40 +/- 11 months after DS and 31 +/- 12 months after LGP. Laser goniopuncture was performed in 173 eyes (67.0%). The mean interval between LGP and DS was 10.3 +/- 8.7 months. The probability of LGP being performed was 63.1% (95% confidence interval [CI] 57.3-69.4) at 36 months after surgery. At 2 years after LGP, the probability of maintaining IOP < 15 mmHg with a 20% decrease from the pre-laser IOP and no further glaucoma procedure or medication was 49.7% (95% CI 41.9-57.1). Iris covering the trabeculo-Descemet's membrane was the only factor significantly associated with the failure of LGP (hazard ratio 3.0, p < 0.001). Complications observed after LGP included peripheral anterior synechiae in 23 (13.2%), hypotony in seven (4.0%), late acute IOP rise in three (1.7%), delayed bleb leak in one and blebitis in two eyes. Argon laser iridoplasty was performed in 45 (26.0%) and needle revision in 41 (23.7%) eyes. CONCLUSIONS: ND:YAG laser goniopuncture is an effective procedure to further lower IOP after DS. An IOP of < 15 mmHg is achieved and maintained for > or = 2 years in about 50% of cases after a single LGP procedure. There are potentially serious complications associated with the procedure. Regular gonioscopy is recommended following LGP to detect any occlusion of the goniopuncture by the iris.

An audit of the Royal College of Ophthalmologists strabismic amblyopia treatment protocol: a departmental review.

INTRODUCTION: Children presenting with strabismus and mixed (anisometropic/strabismic) amblyopia are managed by a local protocol as per guidelines from the Royal College of Ophthalmologists. Decisions regarding intervention for occlusion are currently delayed until a 22 week review allowing for refractive adaptation, with intermediate reviews at 6 and 14 weeks. PURPOSE: The purpose of this audit was to determine adherence to the protocol and the benefit of the 14 week review. MATERIALS AND METHODS: We performed a prospective data collection of all children attending the orthoptic department with strabismus without pathology, both with and without unequal vision, from October 2007 to July 2008 managed using the protocol. RESULTS: 26 patients were eligible. Mean age at presentation was 3.3 years (1.4 to 6.5). Cycloplegic spherical equivalent (SE) mean was 2.6 dioptres (-2.25 to +7.25). Five patients failed to comply with the protocol; one patient was listed surgery, four patients commenced premature occlusion. At presentation 8 patients had equal vision (defined as < 0.1 logMAR difference) between the two eyes or would only perform BEO vision, by week 14, over 60% were found to have a difference in vision between the eyes, despite refraction correction (mean 0.4 logMAR, range 0 to 1.4 logMAR). In a subgroup of patients (n = 8 at 6 weeks) with a small discrepancy of vision between the eyes (0.1 to 0.5 logMAR) there was no progressive worsening of vision during the period of observation and 50% of patients improved spontaneously, although two patients were lost to follow up. In the subgroup (n = 10 at 6 weeks) with a large discrepancy between the eyes (> 0.5 logMAR), all patients ultimately required occlusion, and there was minimal improvement in only three patients. CONCLUSION: Recorded vision at 6 weeks is more informative for making treatment decisions than that recorded at presentation. The 14 week review confers no benefit to those with reliable and improving visual acuity. Those patients presenting with a large discrepancy in visual acuity do not improve after 14 weeks and we feel that these patients could be occluded at 6 weeks. We propose a new algorithm for the treatment of this patient group.