Areas for improvement in community optometry:flashes and floaters take priority

The TRiaDS in Optometry study is funded by NHS Education for Scotland. This study was conducted as part of the TRiaDS programme of research. We would like to thank Rumana Newlands, Lesley Rousselet, Patricia Graham, Cynthia Fraser, the TRiaDS administrative team, Optometry Scotland and all participating optometrists.Peer reviewedPublisher PD

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

Macular and serum carotenoid concentrations in patients with malabsorption syndromes

The carotenoids lutein and zeaxanthin are believed to protect the human macula by absorbing blue light and quenching free radicals. Intestinal malabsorption syndromes such as celiac and Crohn’s disease are known to cause deficiencies of lipid-soluble nutrients. We hypothesized that subjects with nutrient malabsorption syndromes will demonstrate lower carotenoid levels in the macula and blood, and that these lower levels may correlate with early-onset maculopathy. Resonance Raman spectrographic (RRS) measurements of macular carotenoid levels were collected from subjects with and without a history of malabsorption syndromes. Carotenoids were extracted from serum and analyzed by high performance liquid chromatography (HPLC). Subjects with malabsorption (n = 22) had 37% lower levels of macular carotenoids on average versus controls (n = 25, P < 0.001). Malabsorption was not associated with decreased serum carotenoid levels. Convincing signs of early maculopathy were not observed. We conclude that intestinal malabsorption results in lower macular carotenoid levels