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Purpose: Socioeconomic deprivation is associated with an increased incidence of sight-loss. To inform potential developments in eyecare, General Ophthalmic Service (GOS) sight-testing activity was explored in relation to deprivation for GOS contractors submitting National Health Service (NHS) claims in England., Methods: Data on NHS sight-test claims for the financial year 2022-2023 were sought from NHS England (NHSE), including number of sight-tests by GOS contractors, their unique Organisation Data Service codes and postcodes and age-bands of patients accessing sight-testing. Deprivation scores were assigned to contractor practices using the Index of Multiple Deprivation (IMD) and the average number of sight-tests for all contractors within each IMD decile calculated, allowing rate of sight-testing per 1000 population per decile of deprivation to be estimated using Office of National Statistics (ONS) Lower Layer Super Output Area mid-year population estimates. Inequality was examined using the Odds Ratio (OR) and slope and relative index of inequality measures (SSI and RII)., Results: Overall, 12.94 million NHS sight-tests were provided by 5622 GOS contractors in England in 2022-2023. Most affluent decile GOS contractors undertook an average ~2200 NHS sight-tests, while in the most deprived decile, average NHS sight-tests per contractor was ~1100. Rate of sight-testing per 1000 population in the most deprived decile was one quarter of that in the most affluent, with an OR of 5.29 (95% CI 5.27-5.30), indicating those in the most affluent areas were ~five times more likely to access NHS sight-tests. Overall, SII and RII were 333.5 (95% CI 333.52-333.53) and 6.4 (95% CI 6.39-6.40), respectively, findings reflective of substantial inequality in uptake., Conclusion: There remains substantial unwarranted variation in uptake of NHS sight-testing, with those in more affluent areas accessing sight-testing substantially more than those in more deprived areas. Strategies are required to facilitate primary care optometry to provide more equitable access to eyecare., (© 2024 The Author(s). Ophthalmic and Physiological Optics published by John Wiley & Sons Ltd on behalf of College of Optometrists.)

Background: Internationally, systematic screening for sight-threatening diabetic retinopathy (STDR) usually includes annual recall. Researchers and policy-makers support extending screening intervals, citing evidence from observational studies with low incidence rates. However, there is little research around the acceptability to people with diabetes (PWD) and health care professionals (HCP) about changing eye screening intervals., Methods: We conducted a qualitative study to explore issues surrounding acceptability and the barriers and enablers for changing from annual screening, using in-depth, semistructured interviews analysed using the constant comparative method. PWD were recruited from general practices and HCP from eye screening networks and related specialties in North West England using purposive sampling. Interviews were conducted prior to the commencement of and during a randomised controlled trial (RCT) comparing fixed annual with variable (6, 12 or 24 month) interval risk-based screening., Results: Thirty PWD and 21 HCP participants were interviewed prior to and 30 PWD during the parallel RCT. The data suggests that a move to variable screening intervals was generally acceptable in principle, though highlighted significant concerns and challenges to successful implementation. The current annual interval was recognised as unsustainable against a backdrop of increasing diabetes prevalence. There were important caveats attached to acceptability and a need for clear safeguards around: the safety and reliability of calculating screening intervals, capturing all PWD, referral into screening of PWD with diabetic changes regardless of planned interval. For PWD the 6-month interval was perceived positively as medical reassurance, and the 12-month seen as usual treatment. Concerns were expressed by many HCP and PWD that a 2-year interval was too lengthy and was risky for detecting STDR. There were also concerns about a negative effect upon PWD care and increasing non-attendance rates. Amongst PWD, there was considerable conflation and misunderstanding about different eye-related appointments within the health care system., Conclusions: Implementing variable-interval screening into clinical practice is generally acceptable to PWD and HCP with important caveats, and misconceptions must be addressed. Clear safeguards against increasing non-attendance, loss of diabetes control and alternative referral pathways are required. For risk calculation systems to be safe, reliable monitoring and clear communication is required.

Aims: To determine how the workload of an ophthalmology department changed following the introduction of an organised retinal screening programme., Methods: Information was collected from the hospital medical record of people with diabetes attending eye clinics over 4 years. The first year was before screening, the next 2 years the first round, and the fourth year the second round., Results: The total number of people with diabetes referred each year over the 4 year period was 853, 954, 974, 1051 consecutively. The number of people with diabetes in the county rose by 1400 per annum. The total number of referrals for an opinion about diabetic retinopathy was 227, 333, 363, 368, for cataract was 64, 57, 77, 93, and for glaucoma was 57, 62, 61, 68. The total number of patients referred for laser treatment over the 4 years was 77, 124, 111, and 63, Conclusion: This study suggests that the workload in the eye clinic increases in the first round of screening but in subsequent rounds it does not fall below the pre-screening level, except for laser treatment. This may be partly because of increasing numbers of people with diabetes. With the introduction of a national screening programme, this has significant workload implications for the National Health Service.

Aim: To measure the cumulative incidence of any retinopathy, maculopathy and sight-threatening diabetic retinopathy (STDR), and calculate optimal screening intervals by retinopathy grade at baseline for patients with Type 1 diabetes attending an established systematic retinal screening programme., Methods: All patients with Type 1 diabetes registered with enrolled general practitioners, excluding only those attending an ophthalmologist, were studied if retinopathy data was available at baseline and at least one further screen event. Screening utilized non-stereoscopic 3-field mydriatic photography and modified Wisconsin grading. STDR was defined as moderate pre-proliferative retinopathy or greater and/or significant maculopathy in any eye., Results: Patients (n=501) underwent 2742 screen events. Cumulative incidence of STDR in patients without baseline retinopathy was 0.3% (95% CI 0.0-0.9) at 1 year, rising to 3.9% (1.4-5.4) at 5 years. Rates of progression to STDR in patients with background and mild pre-proliferative retinopathy at 1 year were 3.6% (0.5-6.6) and 13.5% (4.2-22.7), respectively. Progression to STDR was greater in patients with a higher grade of baseline retinopathy (P=0.001) or a longer disease duration (P=0.003). For a 95% likelihood of remaining free of STDR, mean screening intervals by baseline status were: no retinopathy 5.7 (95% CI 3.5-7.6) years, background 1.3 (0.4-2.0) years and mild pre-proliferative 0.4 (0-0.8) years., Conclusions: Screening at 2-3 year intervals, rather than annually, for patients without retinopathy in Type 1 diabetes is feasible because of the low risk of progression to STDR, and may result in significant cost savings for a screening programme. Patients with higher grades of retinopathy require screening at least annually or more frequent.

Purpose: To evaluate the feasibility and cost of screening for diabetic eye disease in homebound nursing home residents not attending a systematic screening programme., Methods: Postal survey identification of residents with diabetes in all nursing homes in Liverpool. An ophthalmologist and nurse performed Bailey-Lovie logmar visual acuity (VA), portable slit-lamp examination, fundus photography, and subjective assessment of ability to cooperate with treatment in a sample of homes. Modified Wisconsin photographic grading was performed. Screen-positive patients were invited to a dedicated assessment clinic. Sight-threatening diabetic eye disease (STED) was defined as any of: moderate preproliferative retinopathy or worse, circinate maculopathy, or exudate within 1 disc diameter of fixation., Results: A total of 54 (78%) nursing homes responded reporting 199/2427 (8.2%) residents with diabetes. Of these, 64/80 (80%) residents in 17 homes were examined: VA possible in 50 (78%); slit-lamp examination in 56 (88%); gradable photographs in at least one eye in 34 (53%); STED in 12 (35%) patients. In all, 35 (70%) patients had Snellen-equivalent VA worse than 6/12 in the better eye, of whom 13 (26%) were worse than 6/60. Of 29 screen positive patients, 12 attended the assessment clinic: one was unable to cooperate outside the home; 11 continue under ophthalmic review, four for previously undetected STED of which one listed for laser photocoagulation. Total cost pound 16,980; cost per screen event pound 60.30., Conclusions: Systematic eye screening in homebound patients with diabetes detects disease but follow-up and treatment is only feasible in a small proportion and at high cost. Alternative targeted assessment is recommended.

Background/aims: Preschool screening for amblyopia has controversially been abandoned in some localities within the United Kingdom, on the basis that there is no clear evidence of benefit to support its continuation. Data collected within a birth cohort study were used to examine visual outcomes at 7(1/2) years in children who did or did not receive preschool vision screening., Methods: Monocular logMAR visual acuity with and without a pinhole was assessed by orthoptists. Contemporary records were used to identify children who had been offered and/or received preschool screening., Results: Of 6081 children, 24.9% had been offered preschool screening and 16.7% had attended. The prevalence of amblyopia was approximately 45% lower in the children who received preschool screening than in those who did not (1.1% v 2.0%, p = 0.05). The mean acuity in the worse seeing eyes after patching treatment was better for amblyopic children who received preschool screening than for those who did not; 0.14 v 0.20 logMAR (p <0.001). These effects did not persist in an intention to screen analysis., Conclusions: Preschool screening at 37 months was associated with an improved treatment outcome for individuals with amblyopia. However, the improvement was clinically small and disappeared when considering all children offered screening rather than only those who received it. Further research is needed into improving the effectiveness of vision screening for preschool children, while in the interim these data do not conflict with current recommendations for school entry screening by orthoptists.

Aim: To describe a Manchester-based glaucoma referral refinement scheme designed to reduce the number of false-positive referrals to the hospital eye service. To report on the first years results of this scheme and its financial costs to the NHS., Methods: Patients with suspected glaucoma, instead of being referred to their GP and then on to the hospital eye service, were referred to a group of specially trained community optometrists working to an agreed set of referral criteria. Those patients who did not meet the referral criteria were returned to the referring optometrist, while those who met the referral criteria were referred directly to Manchester Royal Eye Hospital. The patient's GP was informed in all cases., Results: The number of suspect glaucoma cases referred to the Manchester Royal Eye Hospital was reduced by 40%. This figure is close to the percentage of false-positive referrals measured at Manchester Royal Eye Hospital prior to the onset of this study. The information accompanying referral has been improved and the scheme produces a small financial cost saving to the NHS of approximately 17 pounds sterling per patient., Conclusion: Community refinement of suspect glaucoma offers some important benefits over the current referral pathway.

Aims: To develop a model for evaluating screening strategies and to use it to determine the cost effectiveness of varying the screening method and the screening interval., Methods: A discrete event simulation was designed, validated and run for a population of 500000. Most parameters were derived from peer-reviewed publications., Results: Standard methods of screening save up to 50% of the potential sight years lost. They give up to 85% of the sight years saved by an idealized gold standard programme using mydriatic seven-field photography reported by an ophthalmologist. The mobile camera, used for annual screening and 6-month follow-up after the detection of background retinopathy, had an estimated cost of pound 449200 per year with pound 2842 per sight year saved. It is less efficient to screen Type 2, rather than Type 1 diabetes mellitus patients, but they contributed to almost three-quarters of the sight years saved., Conclusions: The model can evaluate screening intervals and methods on a national or health authority basis. Results indicate that it appears more cost effective to continue to screen outside an ophthalmology clinic, until treatment is needed. Programmes with annual screening, and more frequent screening for those with background retinopathy, are robust to realistic fluctuations in compliance and screening sensitivity.

Objective: To assess the effectiveness of early treatment for amblyopia in children., Design: Follow up of outcomes of treatment for amblyopia in a randomised controlled trial comparing intensive orthoptic screening at 8, 12, 18, 25, 31, and 37 months (intensive group) with orthoptic screening at 37 months only (control group)., Setting: Avon, southwest England., Participants: 3490 children who were part of a birth cohort study., Main Outcome Measures: Prevalence of amblyopia and visual acuity of the worse seeing eye at 7.5 years of age., Results: Amblyopia at 7.5 years was less prevalent in the intensive group than in the control group (0.6% v 1.8%; P=0.02). Mean visual acuities in the worse seeing eye were better for children who had been treated for amblyopia in the intensive group than for similar children in the control group (0.15 v 0.26 LogMAR units; P<0.001). A higher proportion of the children who were treated for amblyopia had been seen in a hospital eye clinic before 3 years of age in the intensive group than in the control group (48% v 13%; P=0.0002)., Conclusions: The intensive screening protocol was associated with better acuity in the amblyopic eye and a lower prevalence of amblyopia at 7.5 years of age, in comparison with screening at 37 months only. These data support the hypothesis that early treatment for amblyopia leads to a better outcome than later treatment and may act as a stimulus for research into feasible screening programmes.

Over recent years the British Government has pursued a policy encouraging the integration of primary and secondary health care. This drive to promote the efficient delivery of primary care at local centres has seen the forging of co-operative alliances between various healthcare practitioners. A notable development has been the growth of optometric practice-based schemes for monitoring the eyecare of diabetic patients. This paper reports on the first twelve months operation (April 1995-March 1996, inclusive) of such a 'collaborative care' scheme operating in the Kettering Health Area of Northamptonshire. With the co-operation of their general medical practitioner (GMP) and under the case-review of the hospital-based specialist, diabetic patients attended participating optometric practices for an annual sight test and eye examination including mandatory fundus assessment under mydriasis. A brief 'ticked menu' report was subsequently forwarded to the patient's GMP for filing or action as necessary. A copy was also sent to the hospital clinic to enable updating of the diabetic patient database and for the authorisation of the supplementary fee payable to the examining optometrist. An audit of the first year of operation has indicated that those 92% of optometrists in the locality who participated in the programme logged 34% of the projected diabetic population of the Kettering Health Area. Of these individuals, 10.8% were identified as requiring referral for ophthalmological assessment, including 0.7% who needed urgent intervention. Approximately 80% of the referrals were assessed in the Ophthalmology Clinic within the twelve month timeframe of this first year audit; one-third of these patients received treatment and/or a second review over this period, the net outcome being that one-half of the original referrals were returned to the programme for continued routine annual screening. The scheme has received a funding allocation for a further financial year, with the possibility of its extension county-wide being kept under review.