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Smartphone-based fundus imaging (SBFI) is a low-cost approach for screening of various ophthalmic diseases and particularly suited to resource limited settings. Thus, we assessed how best to upskill alternative healthcare cadres in SBFI and whether quality of obtained images is comparable to ophthalmologists. Ophthalmic assistants and ophthalmologists received a standardized training to SBFI (Heine iC2 combined with an iPhone 6) and 10 training examinations for capturing central retinal images. Examination time, total number of images, image alignment, usable field-of-view, and image quality (sharpness/focus, reflex artifacts, contrast/illumination) were analyzed. Thirty examiners (14 ophthalmic assistants and 16 ophthalmologists) and 14 volunteer test subjects were included. Mean examination time (1st and 10th training, respectively: 2.17 ± 1.54 and 0.56 ± 0.51 min, p

Cataract surgery continues to evolve and advance in terms of new technology and improved techniques, offering a final result of better visual quality and faster visual recovery for our patients. Intraocular lens (IOL) delivery into the eye is a critical step in cataract surgery. Currently, eye surgeons load the IOL into the cartridge under the operating microscope or ophthalmic assistants load the IOL under their own direct vision. Because ophthalmic assistants load the IOL unaided, the IOL may be mishandled and lead to challenges such as IOL slippage, breakage, or incorrect orientation. In order to overcome these challenges and facilitate the surgical process, here we describe a novel technique by introducing a magnifier to the surgical table to aid ophthalmic assistants during this crucial step in cataract surgery. This not only saves time but also improves precision while loading IOL into the cartridge during cataract surgery.

Recently causes of blindness are changing in Nepal. The number of people blind due to retinal diseases is increasing. Age-related macular degeneration (AMD), diabetic retinopathy (DR), hypertensive retinopathy, and retinal vein occlusion are the major retinal problems in Nepal. As the prevalence of vitreoretinal disorders is increasing with age, it indicates that retinal disorders will be a major public health issue with longevity in future[1].A rapid assessment of blindness conducted in 2010 had reported posterior segment problems as the second common cause of blindness, after cataract in Nepal[2]. Retinal diseases are very difficult to treat. Results from low-income countries show that many patients present only when they lose vision in both eyes. Delay in presentation was acknowledged as a significant problem and is often due to inadequate primary eye care and to misdiagnosis. Thus, it was highlighted that all ophthalmologists should be trained to recognize and manage retina problems. As blindness from DR is preventable, if caught and treated early, DR provides an excellent opportunity for secondary prevention strategies, such as screenings[3]. So, early diagnoses and preventions are very important. The projected population of Province 3 and 4 in Nepal is 60, 26,626, and 24, 72,494 respectively in the year 2016. There are altogether 6 tertiary retina care centers in Province 3 and 1 tertiary retina center in province 4 of Nepal to cover that much of the population. But, few eye doctors can treat patients with retinal diseases in Nepal. It is also necessary to train ophthalmic assistants, optometrists, ophthalmic nurses, and other health workers who can assist the treatment of retinal diseases. So, strengthening retina eye care services is very important in Nepal. Retina Eye Care of Nepal (RECON) project was a joint program of BP Eye Foundation, Kathmandu, Nepal, and Tokushima University, Japan to strengthen 3 retina centers in Province 1 and 1 retina center in province 4. The project duration was from May 2016 to February 2019. The purpose of RECON was to strengthen retina eye care services in Nepal by training ophthalmic human resources, enhancing retina eye care facilities, and conducting retina-screening camp.

Background To compare the agreement and diagnostic accuracy of vision screening conducted by trained community eye-health workers (CEHWs) and teachers with reference to vision technicians in Movva Mandal (sub-district) in Krishna District in the Indian state of Andhra Pradesh. Methods As part of a large epidemiological study on visual impairment in children, vision screening was conducted in all the schools in a sub-district. The children were screened using a screening card with 6/12 tumbling E optotypes by trained CEHWs, teachers and a vision technician. Teachers were included if they had screened at least 100 children and had at least five children identified with visual impairment. Results Of a total 6,197 children from 75 schools, 4,929 children were screened by all three categories of examiners (one vision technician, five CEHWs and 79 teachers). The overall agreement between the vision technician and CEHWs was 0.84 (95 per cent CI: 0.79–0.9) with a range of 0.77–0.9. Overall sensitivity of CEHWs to detect visual impairment was 83.3 per cent (95 per cent CI: 73.6–90.6) with a range of 71.4–87.1 per cent. Overall agreement of the five teachers with the vision technician was 0.81 (95 per cent CI: 0.74–0.88) with a range of 0.32–0.92. The overall sensitivity of teachers to detect vision problem was 72.3 per cent (95 per cent CI: 61.4–81.6) with a range from 20 per cent to 85.7 per cent and specificity was near 100 per cent. Conclusion There was no significant difference in the agreement and diagnostic accuracy of CEHWs and teachers compared to those of the vision technician. There was a large variability among teachers, which needs to be considered in school vision screening programs.

Purpose: Vision 2020 and the Global Action Plan 2013–2019 prioritise primary eye care (PEC) as an important component of reducing avoidable blindness. Studies in sub-Saharan Africa have demonstrated that current PEC provision is poor. There has been no evaluation of the current practice of PEC among primary health care workers (PHCWs) in Nepal. Methods: A mixed methods descriptive cross-sectional study with semi-structured interviews and focus group discussions (FGDs) was carried out in Eastern Nepal. Government employed PHCWs working at health posts in three districts were invited to take part in a PEC knowledge and skills assessment. Each health post was assessed for ophthalmic equipment and medications. Three focus group discussions and eight semi-structured interviews were carried out with community ophthalmic assistants, PHCWs and a district health manager. Results: 107 PHCWs in 35 health posts took part in the quantitative study. Only 8.4% had received eye care training. 27.1% PHCWs could diagnose a corneal ulcer, 83.2% conjunctivitis, 75.7% cataract and 54.2% ophthalmia neonatorum. Only 14.0% could measure visual acuity, and 5.7% of HPs had a vision chart. Ophthalmic assistants described their concern for the low level of PEC at health posts. PHCWs were keen to receive training and highlighted the need for greater government support in the provision of eye care services. Conclusion: PEC knowledge and skills among PHCWs in eastern Nepal is inadequate to provide quality PEC services. There is a pressing need for PEC training in the region, provision of ophthalmic equipment and greater government support for eye care.

Background There is paucity of data on the inter-observer agreement and diagnostic accuracy between a primary-care technician (vision technician) and an ophthalmologist. Hence, the current study was conducted to assess the accuracy of vision technicians, to screen potentially sight-threatening ocular conditions at rural vision centres of southern India and their agreement with an ophthalmologist. Methods In July to August 2010, patients presenting to seven vision centres in Adilabad district (Andhra Pradesh) were selected and screened in a masked manner by seven vision technicians followed by an examination by a consultant ophthalmologist. Agreement was assessed between vision technicians and the ophthalmologist for screening of potential sight-threatening ocular conditions and decisions for referral. The ophthalmologist's findings were considered as the reference standard. Results Two hundred and seventy-nine patients were enrolled at seven vision centres with a mean age of 32.9 ± 21.8 years. Agreement for screening of ocular pathology was 0.82 (95 per cent CI, 0.8-0.83). There was excellent agreement for cataract (0.97; 95 per cent CI, 0.93-1), refractive error (0.98; 95 per cent CI, 0.96-1), corneal pathology (1.0; 95 per cent CI, 1.0-1.0) and other anterior segment pathology (0.95; 95 per cent CI, 0.9-1); the agreement was moderate to fair for detection of glaucoma suspects (0.43; 95 per cent CI, 0.28-0.60) and retinal pathology (0.39; 95 per cent CI, 0.14-0.63). Sensitivity for screening of anterior segment pathology was 94.6-100 per cent. There was a fair to moderate sensitivity for glaucoma suspect; 35.6 per cent (95 per cent CI, 21.9-51.2) and retinal pathology 26.3 per cent (95 per cent CI, 9.2-51.2). Specificity for screening of ocular pathology was 98.2 to 100 per cent. The kappa (κ) agreement for referral for any pathology was 0.82 (0.8-0.83) Conclusion As there is good agreement between the vision technicians and the ophthalmologist for screening and referral of anterior segment pathology but moderate to fair for glaucoma suspects and retinal pathology, vision technicians would be a good resource at the primary level to screen for anterior segment pathology; however, they may need further training to detect posterior segment pathology.

Background/Objectives Routine use of patient-reported outcome measures (PROMs) to assess quality of health care systems is mandated in many countries and has been implemented successfully in many specialities. Ophthalmology currently lags behind. To support and inform future implementation, we investigated paediatric ophthalmic clinicians’ experience of, and future training needs for, using child-appropriate vision PROMs and their views about the barriers and enablers to future routine implementation in clinical practice. Methods We conducted a pilot study, using an online survey to elicit the experience, attitudes, training needs and perceptions of barriers and enablers to routine PROMs use of ophthalmic health professionals in the Paediatric Ophthalmology Department at Great Ormond Street Hospital, London. A focus-group was undertaken to discuss survey results and preferences regarding presentation of PROM data. Analysis comprised descriptive statistics, presented alongside complementary qualitative data. Results Eighteen clinicians in the department completed the survey. Twenty-seven took part in the focus group. Clinicians had limited experience of using PROMs but high confidence in the potential positive impact on communication with patients, monitoring chronic conditions and clinical decision-making. Clinicians identified operational issues (collection and analysis of data) and impact (interpretation and application of data) as the two key areas for consideration. Training and information requirements before implementation were clearly articulated, alongside the benefits of using digital/electronic data capture ahead of consultations to allow efficiency and automated analysis, and presentation in an appropriate visual format alongside clinical data to ensure meaningful use. Conclusion The findings of this pilot study of ophthalmic clinicians working in a specialist paediatric ophthalmology department, suggest that ophthalmic clinicians recognise the potential benefits of routine PROMs use in clinical practice. Together with existing literature outside ophthalmology relating to overcoming barriers and exploiting enablers to routine implementation, findings may be applicable in planning routine PROM implementation in paediatric ophthalmology.

Purpose: Comparing the quality of care provided by a hospitalbased shared care glaucoma follow-up unit with care as usual. Patients and Methods: This randomized controlled trial included stable glaucoma patients and patients at risk for developing glaucoma. Patients in the Usual Care group (n=410) were seen by glaucoma specialists. In the glaucoma follow-up unit group (n=405), patients visited the glaucoma follow-up unit twice followed by a visit to a glaucoma specialist. The main outcome measures were: compliance to the working protocol by glaucoma follow-up unit employees; difference in intraocular pressure between baseline and at ≥18 months; and patient satisfaction. Results: Glaucoma follow-up unit employees closely adhered to the working protocol for the measurement of intraocular pressure, visual acuity and GDx (≥97.5% of all visits). Humphrey Field Analyzer examinations were not performed as frequently as prescribed by the working protocol, but more often than in the Usual Care group. In a small minority of patients that required backreferral, the protocol was disregarded, notably when criteria were only slightly exceeded. There was no statistically significant difference in changes in intraocular pressure between the 2 treatment groups (P=0.854). Patients were slightly more satisfied with the glaucoma follow-up unit employees than with the glaucoma specialists (scores: 8.56 vs. 8.40; P=0.006). Conclusions: In general, the hospital-based shared care glaucoma follow-up closely observed its working protocol and patients preferred it slightly over the usual care provided by medical doctors. The glaucoma follow-up unit operated satisfactorily and might serve as a model for shared care strategies elsewhere.

To assess clinical competency of 1-year trained vision technicians (VTs) in detecting and referring causes of visual impairment in India.Eye examination results and management plans for 328 patients examined by 24 VTs in 24 vision centers of LV Prasad Eye Institute in Andhra Pradesh were compared with those of a standard optometrist who examined the same patients. Eye examinations included retinoscopy and subjective refraction, slit lamp examination, applanation tonometry and undilated direct ophthalmoscopy. Data were analyzed for level of concordance in retinoscopy, spectacle prescription, disease detection and referral.VTs demonstrated moderate to good levels of agreement in refraction, disease detection and referral. Sensitivity and specificity for ocular pathology identification were 77.4% (95% confidence interval, CI, 69.4-84.2%) and 86.6% (95% CI 81.1-91.1%), respectively. The highest sensitivity was demonstrated in detecting significant cataract (91.5%) and refractive error (83.0%). VT spectacle prescriptions were accurate 76% of the time for mean spherical equivalent and 65% of the time for astigmatism. VT sensitivity in detecting posterior segment abnormalities was low (18.5%) resulting in failure to detect retinal conditions such as diabetic retinopathy and maculopathy. Despite lack of recognition of the specific pathology, referral decisions were correct in 78.4% of cases.VTs in India competently detect and manage or refer the two most common causes of visual impairment; uncorrected refractive error and cataract. Over two-thirds of patients received accurate and appropriate services from VTs, suggesting that they are a useful and competent cadre for rural and remote eye care.

Background/aims Prevalence estimates and treatment decisions for trachoma are based entirely on ocular clinical examination. The aim of the current study is to demonstrate that ophthalmic assistants can be trained and certified to provide trachoma grading within a single day. Methods Conjunctival photographs from an area with endemic trachoma were randomised into two sets of 60 cases. Photographs were graded for trachomatous inflammation—follicular (TF) and trachomatous inflammation—intense (TI) by three experienced graders. Inter-rater reliability of eight ophthalmic assistants and three experienced graders were compared before and after training. Results The mean κ agreement between the ophthalmic assistants and the consensus grades of the experienced graders for TF was 0.38 (95% CI 0.18 to 0.58) before training, and increased to 0.60 (95% CI 0.42 to 0.78) after training (p=0.07). The mean κ agreement for TI was 0.16 (95% CI 0.02 to 0.30) before training, and increased to 0.39 (95% CI 0.20 to 0.58) after training (p=0.02). Conclusion A single day of training improves agreement between prospective and experienced trachoma graders, and provides the basis for certification of workers who are able to accurately grade trachoma and generate reliable prevalence estimates.

Purpose Ophthalmic technicians (OT) work at health facilities in Mozambique and are trained to provide primary and secondary eye care services including basic refraction. This study was designed to assess OT competence and confidence in refraction, and investigate whether an upskilling programme is effective in developing their competence and confidence at refraction. Methods Thirty-one trainee OTs and 16 qualified OTs were recruited to the study. A background questionnaire was administered to determine the demographic profile of the OTs. A confidence levels questionnaire explored their self-reported skills. Clinical competencies were assessed in relation to knowledge (theory exam) and clinical skills (patient exams). 11 OTs were upskilled and the clinical evaluations carried out post training. Results Initial evaluations demonstrated that confidence and competence levels varied depending on the OTs training (location and duration), and their location of work (clinical load, availability of equipment and other eye care personnel). The qualified OTs were more competent than trainee OTs in most of the evaluations. Post upskilling results demonstrated significant positive impact on confidence and competence levels. Conclusion These evaluations identified factors affecting the refraction competencies of the OTs and demonstrated that upskilling is effective in improving confidence and competence levels for refraction. They demonstrate the need for a refraction competency framework. The overarching aim of this research was to inform the development of a nationwide programme of OT mentoring, upskilling and leading to the establishment of clinical competency standards for the new OT curricula, relevant to the professional demands.

Purpose: The aim was to develop and validate an instrument to measure job satisfaction in eye‐care personnel and assess the job satisfaction of one‐year trained vision technicians in India. Methods: A pilot instrument for assessing job satisfaction was developed, based on a literature review and input from a public health expert panel. Rasch analysis was used to assess psychometric properties and to undertake an iterative item reduction. The instrument was then administered to vision technicians in vision centres of Andhra Pradesh in India. Associations between vision technicians’ job satisfaction and factors such as age, gender and experience were analysed using t‐test and one‐way analysis of variance. Results: Rasch analysis confirmed that the 15‐item job satisfaction in eye‐care personnel (JSEP) was a unidimensional instrument with good fit statistics, measurement precisions and absence of differential item functioning. Overall, vision technicians reported high rates of job satisfaction (0.46 logits). Age, gender and experience were not associated with high job satisfaction score. Item score analysis showed non‐financial incentives, salary and workload were the most important determinants of job satisfaction. Conclusions: The 15‐item JSEP instrument is a valid instrument for assessing job satisfaction among eye‐care personnel. Overall, vision technicians in India demonstrated high rates of job satisfaction. Refereed/Peer-reviewed

Background There is an extreme paucity of eye-care personnel and training facilities in developing countries. This study was designed to develop a comprehensive framework of competency standards for ophthalmic technicians and optometrists, in Mozambique. This could then inform the evolution of socially responsive curricula for both cadres. Methods A modified Delphi technique was used with a ten member expert panel consisting of optometrists, ophthalmic technicians and ophthalmologists, all with experience of working in a developing country context. The competencies were derived from literature, primary research data and observations from a competency development workshop. The first round involved scoring the relevance of two frameworks, one for each cadre, using a nine-point Likert scale with a free-text option to modify any competency or suggest additional competencies. The revised frameworks were subjected to a second round of scoring and free-text comment. The final versions of the agreed frameworks were sent out to the relevant stakeholders. Results There was a 100 per cent response to round 1 and an 89 per cent response to round 2. The final versions of the competency frameworks contained six competencies, 20 elements and 88 performance criteria for optometry and six competencies, 17 elements and 61 performance criteria for ophthalmic technicians. Conclusions Application of a consensus methodology consisting of a modified Delphi technique with primary research data allowed the development of competency frameworks for ophthalmic technicians and optometrists. This will help to shape the development of curricula for both cadres and potentially could be replicated in other regions that wish to develop socially responsive education for eye-care professionals.

Objective: To compare performance on the Eyesi surgical simulator by users with different levels of experience in ophthalmology. Design: Multicentre cross-sectional study. Participants: Four medical students, 4 ophthalmic medical technologist trainees, 36 ophthalmology residents, 3 fellows, and 18 staff ophthalmologists. Methods: Subjects were recruited at the 2007 Canadian Ophthalmological Society Meeting and in the departments of ophthalmology at the University of Toronto, University of Ottawa, and University of Western Ontario. Subjects performed a standardized 20-minute session on the Eyesi simulator. The protocol consisted of a practice trial in the anterior segment module, followed by 3 scored trials in the anterior forceps, antitremor, and capsulorhexis modules. Results: In the forceps module, participants with greater experience achieved significantly higher total scores than those who were less experienced: staff ophthalmologists (Group D) = 67.9 (SD 18.4), senior residents and fellows (Group C) = 67.6 (SD 21.1), junior residents (Group B) = 52.9 (SD 29.4), medical students and ophthalmic medical technologist trainees (Group A) = 27.8 (SD 29.4) ( p = 0.011), with lower total task time ( p = 0.044) and fewer injuries to the cornea ( p = 0.001) and lens ( p = 0.026). In the antitremor module, subjects in Group D achieved significantly higher ( p = 0.004) total scores (46.7, SD 21.6) than Groups C (45.8, SD 25.1), B (41.2, SD 29.4), and A (8.5, SD 9.2) with lower total task time ( p = 0.005) and fewer errors ( p = 0.003). In the capsulorhexis module there was also a positive correlation between experience and total scores achieved ( p = 0.065). Conclusions: Subjects' level of training is a reliable predictor of their performance on the Eyesi anterior forceps and antitremor modules ( p

Objective To examine how the development of allied ophthalmic personnel training programs affects human resource capacity. Design Using a qualitative case study method conducted at a single Ontario institution, this article describes 6 years of establishing a 2-tiered allied ophthalmic personnel training program. Participants The Kingston Ophthalmic Training Centre participated in the study with 8 leadership and program graduate interviews. Methods To assess regional eye health workforce needs, a case study and iterative process used triangulations of the literature, case study, and qualitative interviews with stakeholders. This research was used to develop a model for establishing allied ophthalmic personnel training programs that would result in expanding human resource capacity. Results Current human resource capacity development and deployment is inadequate to provide the needed eye care services in Canada. A competency-based curriculum and accreditation model as the platform to develop formal academic training programs is essential. Access to quality eye care and patient services can be met by task-shifting from ophthalmologists to appropriately trained allied ophthalmic personnel. Conclusion Establishing formal training programs is one important strategy to supplying a well-skilled, trained, and qualified ophthalmic workforce. This initiative meets the criteria required for quality, relevance, equity, and cost-effectiveness to meet the future demands for ophthalmic patient care.

To determine the predictive value of ophthalmic screening tests with visually significant eye disease in a cohort of American Indian/Alaskan Natives from the Pacific Northwest.Validity assessment of a possible screening protocol.Ophthalmic technicians performed a screening examination including medical and ocular history, best-corrected visual acuity, limbal anterior chamber depth assessment, frequency-doubling technology perimetry (FDT, C-20-5), confocal scanning laser ophthalmoscopy, nonmydriatic digital photography, and tonometry on 429 participants. An ophthalmologist performed a comprehensive eye examination on subjects with 1 or more abnormal screening tests and a random selection of those with normal screening tests. We used univariate and multivariate logistic regression to determine the association between abnormal screening test results and visually significant eye disease. We also determined the predictive value of screening tests with ocular disease.Univariate analysis identified history of eye disease or diabetes mellitus (P.001), visual acuity20/40 (P.001), abnormal/poor-quality confocal scanning laser ophthalmoscopy (P.001), abnormal FDT (P.001), and abnormal/poor-quality nonmydriatic imaging (P.001) as associated with visually significant eye disease. A multivariate analysis found visually significant eye disease to be associated (P.001; receiver operating characteristic curve area = 0.827, negative predictive value = 84%) with 4 screening tests: visual acuity20/40, abnormal/poor-quality nonmydriatic imaging, abnormal FDT, and abnormal/poor-quality confocal scanning laser ophthalmoscopy.Ophthalmic technicians performing a subset of screening tests may provide an accurate and efficient means of screening for eye disease in an American Indian/Alaskan Native population. Confirmation of these results in other populations, particularly those with a different profile of disease prevalence, is needed.

BACKGROUND AND OBJECTIVE: Diabetic retinopathy (DR) screening is standard of care, but its utility diminishes unless high quality is maintained. This project describes the improvement in diagnostic accuracy achieved at a large health maintenance organization by implementing a centralized reading center. PATIENTS AND METHODS: Data were extracted from the electronic health records of patients with diabetes who underwent DR screening between January 1, 2009, and December 31, 2013, at 13 medical centers. Certified ophthalmic assistants and technicians were trained to read DR images under the supervision of a retinal specialist. This program was pilot-tested prior to full implementation. RESULTS: DR prevalence among the 13 centers in 2009 was 10.1%, far below the national average. After implementation, prevalence increased to 22.1%. The program also resulted in improved access to follow-up. CONCLUSION: The results demonstrate the value of a reading center in decreasing diagnostic error and achieving other improvements in a real-world setting. [ Ophthalmic Surg Lasers Imaging Retina . 2015;46:624–629.]

Purpose To compare axial lengths and intraocular lens (IOL) power calculations obtained with the Zeiss IOLMaster® by 2 observers with different training grades and to assess the agreement between optical and acoustic biometry. Setting Department of Ophthalmology, Pembury Hospital, The Laser Eye Clinic, Kent, United Kingdom. Methods In this prospective study, optical biometry was performed twice in 79 patients: first by a qualified ophthalmic nurse and second by 1 of several health care assistants without formal nursing training. In the same group of patients, the qualified nurse also obtained ultrasonic measurements to compare the 2 clinical methods. Results There was a high correlation coefficient for axial length and IOL power measurements (0.99 each) between the experienced examiner and the inexperienced examiners. The coefficient of repeatability (2 SD) was 0.58 diopter (D) for IOL power (mean 0.04 D) and 0.07 mm for the axial length (mean 0.00 mm). The correlation coefficient of IOLMaster measurements with A-scan measurements done by the same experienced ophthalmic nurse was 0.97 for IOL power and 0.98 for axial length. The limits of agreement (mean ± 2 SD) were between +0.50 and −2.40 D for IOL power calculations and between +0.7 mm and −0.2 mm for axial length measurements. Conclusions Optical biometry showed excellent repeatability using different examiners regardless of their medical training. The agreement with ultrasonic measurements and the precision of the method need further evaluation.

Purpose To evaluate the effects of the surgical assistant's level of resident training on operation time and surgical outcome in the surgical treatment of intermittent exotropia. Methods This study included 456 patients with intermittent exotropia who underwent lateral rectus recession and medial rectus resection and were followed up for 24 months after surgery. The patients were divided into two groups according to the surgical assistant's level of resident training: group F (surgery assisted by a first-year resident [n = 198]) and group S (surgery assisted by a second-, third-, or fourth-year resident [n = 258]). The operation time and surgical outcomes (postoperative exodeviation and the number of patients who underwent a second operation) were compared between the two groups. Results The average operation times in groups F and S were 36.54 ± 7.4 and 37.34 ± 9.94 minutes, respectively (p = 0.33). Immediate postoperative exodeviation was higher in group F (0.79 ± 3.82 prism diopters) than in group S (0.38 ± 3.75 prism diopters). However, repeated-measures analysis of variance revealed no significant difference in exodeviation between the two groups during the 24-month follow-up period (p = 0.45). A second operation was performed in 29.3% (58 / 198) of the patients in group F, and in 32.2% (83 / 258) of those in group S (p = 0.51). Conclusions No significant difference in operation time was observed when we compared the effects of the level of resident training in the surgical treatment of intermittent exotropia. Although the immediate postoperative exodeviation was higher in patients who had undergone surgery assisted by a first-year resident, the surgical outcome during the 24-month follow-up was not significantly different.

To determine the impact of a Digital Imaging and Communications in Medicine (DICOM) workflow on the linkage of demographic information to ophthalmic testing data.Evaluation of technology.Six hundred ninety-nine visual field testing encounters performed by 6 ophthalmic technicians and the transfer error queue of 37 442 ophthalmic test results.At 3 months before and 6 and 18 months after implementation of a DICOM workflow, technicians recorded the work required to enter, confirm, or edit patient demographics in each visual field device. We also determined the proportion of imaging tests sent to an error queue for manual reconciliation because of incorrect demographic information before and 3, 6, and 18 months after the DICOM workflow was established.The proportion of testing encounters for which staff had to enter, edit, or merge patient demographics and the proportion of misfiled images.Staff entered, edited, or merged data for 48% of patients before implementation (n = 237). This decreased to 24% within 6 months and 20% within 18 months of implementing the DICOM archive (n = 230 and n = 232, respectively). Staff could locate a patient in a DICOM work list for 97% of encounters at 3 months and 99% at 18 months. Before implementation, 9.2% of the images required additional intervention to be associated with the correct patient (n = 3581). This decreased by 85% over 6 months to 1.4% (n = 9979; P 0.01). There was an increase in the percentage of misfiled images between 6 and 18 months from 1.4% to 2.2% (n = 24 549; P 0.01), representing an overall 76% decrease over 18 months relative to the pre-DICOM period.Implementation of a DICOM-compatible workflow in an ophthalmology clinic reduced the need to enter or edit patient demographic information into imaging or testing devices by more than 50% and reduced the need to manage misfiled images by 76%. In a clinical environment that demands both efficiency and patient safety, the DICOM workflow is an important update to current practice.

The Beijing Eye Public Health Care Project was designed to screen all elderly subjects (age 55-85 years) of the rural region of Greater Beijing. It was developed as a preparatory step for a telemedicine-based public health care system in ophthalmology in China.Population-based public health care project.Elderly subjects (age 55-85 years) of the rural region of Greater Beijing.Project participants were visited, interviewed, and examined by 2500 high school graduates trained as ophthalmic technicians. If visual acuity was0.30, subjects were referred to primary health care centers where ocular photographs were taken. Using telemedicine, the photographs were transmitted to a reading center and causes for visual impairment were diagnosed.Practicability of a mass screening system in ophthalmology; prevalence of visual impairment and causes for it.Out of 692 323 eligible inhabitants, 562 788 (81.3%) subjects participated. Visual impairment in ≥1 eye was detected in 54 155 (9.62%) subjects, and among them, 30 164 (5.36%) subjects had bilateral visual impairment. Ocular fundus photographs were taken for 37 281 subjects. Cause for visual impairment was cataract in 19 163 (3.41%) of all screened subjects, glaucoma in 1606 (0.29%) subjects, diabetic retinopathy in 905 (0.16%) subjects, other macular diseases in 2700 (0.48%) subjects, pterygium in 1381 (0.25%) subjects, and corneal leukoma in 283 (0.05%) subjects. For 5853 (1.04%) subjects, a diagnosis of premature or mature cataract was made showing the urgent need of cataract surgery. After cataract surgery, visual acuity was ≥0.30 in 1464 (91.7%) of 1596 postoperatively reexamined subjects.Using a telemedicine approach, the Beijing Eye Public Health Care Project developed, applied and tested an infrastructure for ophthalmic mass screening of500 000 elderly inhabitants with a response rate of80%. Beside cataract, retinal diseases including diabetic retinopathy and glaucoma were major causes for visual impairment.The authors have no proprietary or commercial interest in any of the materials discussed in this article.

Objective: To determine the recruiting and training needs for ophthalmic medical personnel (OMP), assess the value of their certification, and compare the ophthalmic practice productivity and performance of non-certified and certified OMP, as rated by both ophthalmologists and OMP. Design: Comparative analysis. Participants: One hundred and sixteen Canadian ophthalmologists and 98 OMP. Methods: An invitation to complete an online survey on OMP recruitment, training, certification, and productivity performance in a clinical setting was sent to 1081 ophthalmologists and OMP. Results: Fifteen percent of ophthalmologists and 31% of OMP completed the survey. Ophthalmologists (61%) reported difficulty hiring OMP; employee referrals was the best method (40%). Awareness of formal OMP training programs was high and 50% of respondents supported developing additional training programs; 55% of OMP were encouraged by their employers to obtain certification. Personal challenge and achievement (79%) and improved skills (71%) were the main reasons for OMP to obtain certification. The majority of OMP and ophthalmologists felt that certified OMP enhanced most practice productivity measures. Higher wages associated with certification were reported by 73% of respondents. Conclusions: Training of qualified OMP was identified as a need by ophthalmologists. Ophthalmic practices can increase their overall productivity by adding certified OMP to their staff.

Diabetic retinopathy is the most common cause of blindness among adults of working age in the UK. If the disease is detected early effective treatment can be provided and this has resulted in calls for a systematic national screening programme. Using data on the screening of 3423 diabetics collected as part of an experimental programme in three UK centres, the relative cost-effectiveness of various screening options is assessed. The paper utilises direct evidence on a number of single modality screening options, including ophthalmoscopy undertaken by general practitioners or ophthalmic opticians, and non-mydriatic photography. With the objective of increasing the sensitivity of screening and using data collected in the study, options based on two further potential screening strategies are modelled and evaluated: combined screening using both ophthalmoscopy and non-mydriatic photography; and selective screening where high-risk diabetics are directly referred to an ophthalmologist and low-risk cases are either left unscreened or are screened by one of the single or combined modality screening options. Given the objective of early detection, effectiveness is assessed in terms of the sensitivity and specificity of the referral decisions of screening options. Both health service and private resource costs of the various screening options are estimated, the latter in terms of travel and the opportunity cost of time. Cost effectiveness is evaluated in terms of the expected cost per true positive case of diabetic retinopathy referred by the screening options. To narrow the choice between the options, those subject to three-way domination with respect to the three choice variables of sensitivity, specificity and expected cost per true positive are excluded. Amongst the remaining options, the choice is dependent on the trade-off between the higher specifics of unselective single modality screening options and the higher sensitivities and lower expected costs per true positive case detected of combined modality and selective screening options.

This paper describes a refresher training and continuing education programme in clinical and community ophthalmology for para-medical ophthalmic assistants (PMOAs) conducted by the Lions Aravind Institute of Community Ophthalmology. The course participants included 60 PMOAs working either in district hospitals, primary health centres or mobile units from the districts in Maharashtra. Each training programme was spread over 43 hours in 4 days and included lectures, practical demonstrations, and hands-on training in the outpatient, inpatient, and operation theatre of the training institution. Participants were given exposure to outreach activities in an eye camp and a satellite eye centre resembling a district hospital. The PMOAs found the training to be useful and it was seen that areas like patient counselling, instrument and equipment maintenance, and assistance in the operation theatre for newer surgical procedures which were lacking in the basic training were fulfilled in this training programme. Regional Institutes of Ophthalmology, upgraded medical colleges, and other eye-care institutions which have facilities and manpower could organise similar refresher and continuing education programmes for PMOAs so that they could be utilised more efficiently in the blindness-control activities in the country.

1. Increase knowledge of geometric optics and the optical system of the eye. 2. Increase familiarity with all optic tests. 3. Develop protocols for testing for common complaints.

The ophthalmic medical assistant (OMA) is a relatively new concept within the National Health Service in the United Kingdom. However, in the United States, OMAs have been recognised as important members of the eye team for some time. Neither nurse nor doctor, the OMA may perhaps best be described as a technician or doctor’s assistant. An OMA can undertake a number of tasks, including cataract preoperative counselling, clerking, biometry measurements, compilation of operating lists, postoperative examinations, and even discharge from clinic. Furthermore, their role need not be restricted to cataract surgery but can include all other aspects of ophthalmology. In some eye departments many of these tasks are already performed by extended role nurses or nurse practitioners. The major difference between the two roles is that an OMA is appointed to work with one particular consultant, whereas a nurse, by virtue of his or her mode of employment, will not be able to fulfil such a role. Since an OMA …

* BACKGROUND AND OBJECTIVE: To determine the intraoperative stress on surgeons and assistants during cataract surgery, 12 surgeons and 3 assisting nurses were assessed based on their level of professional experience. * METHODS: Surgeons were classified as inexperienced, intermediate, or experienced. Nurse assistants were classified as inexperienced or experienced. The intraoperative heart rates and urine adrenaline levels of each participant were measured. * RESULTS: Inexperienced surgeons and nurse assistants had the highest heart rates at the beginning of surgery, and the rates tended to decrease toward the end of surgery. All values were higher than the other two groups throughout surgery. In surgeons with intermediate experience, the heart rates were not as high as in the inexperienced personnel; however, the heart rates were high throughout the surgery. The heart rate in one intermediate surgeon was markedly increased when a surgery was simultaneously broadcast on closed-circuit television. In experienced surgeons and a nurse assistant, the measurements increased slightly. * CONCLUSIONS: The variations in heart rates and urine adrenaline levels showed characteristic patterns based on the experience of the surgical personnel. [Ophthalmic Surg Lasers 1999; 30: 27-30.]

Clinic monitoring is essential for the quality control of multicenter clinical trials. In studies of eye diseases, certification of visual function testers is integral to such monitoring. Routine site visits, while useful for evaluating clinic performance and certifying visual function testers, are expensive and not suitable for every study. As part of the Longitudinal Optic Neuritis Study (LONS), a follow-up study of the patients entered into the Optic Neuritis Treatment Trial (ONTT), we established a central system for clinic monitoring and visual function tester certification in lieu of performing site visits. We also established a centralized and well-defined system for maintaining patient contact in an attempt to enhance follow-up visit compliance. Both have been used over the first three years of the LONS. Coordinators at two of the participating clinical centers were selected to serve as regional coordinators; each was responsible for overseeing seven or eight clinics and 200 patients. Annually by phone these coordinators perform certification of each technician's visual function testing. Clinic monitoring is performed by monthly phone calls. Conference calls involving each clinic's personnel, the regional coordinator, and Data Coordinating Center personnel are held one or two times per year. Patient phone contact at four-month intervals between annual patient exams is done to evaluate visual and general health status, to review study information, and to coordinate and encourage annual protocol exams at the respective centers. This system has helped achieve a visit completion rate of over 90% for active study patients. Patient phone contact by the regional coordinators has been well received. Telephone certification of visual function technicians by the regional coordinators appears to be as effective as on-site certification. Clinic performance appears to be continuing at the same high level as during the period of annual site visits. Although site visits are valuable for clinical trials, if routine site visits are not feasible the methods we have implemented for remote monitoring may be useful.

1. The role of the ophthalmic assistant in radial keratotomy (RK) patient care involves three basic areas: patient preparation, suite preparation, and RK day. Complications as well as pros and cons of RK are covered. 2. A truly informed consent to RK must be achieved. 3. The key to managing refractive patients is preparation and organization. Every technician working with RK patients should know every detail of the RK practice. The patients must be prepared as well; there should be no real surprises during the postoperative course.

1. Metropolitan areas with a diverse population require reevaluation of training techniques. 2. Communication skills have to be reinforced by a multicultural approach followed by a hospital-based apprenticeship program. 3. Competence level is constantly being reassessed in workshops, student-mentor supervision, and frequent evaluations.

1. You can be connected to the information Highway by a local phone call. So, you will have a monthly charge for your access, but not a more expensive phone bill. 2. Mail lists are discussion groups; actually, they are "computer remailers." When you join a mail list, your e-mail address is entered into a computer, along with a group of people with common interest on the Net. 3. The World Wide Web is the graphical and multimedia part of the Internet--color, sound, video, and all! To access the World Wide Web, you'll need a browser. A browser is a piece of software that allows you to look at all the Web's various home pages and websites. Organizations, individuals, universities, and corporations have Web addresses (called URLs) that allow you to look at their "roadside stand" on this Information Highway.

PURPOSE. To determine the influence of several factors on standard automated perimetry test results in glaucoma.METHODS. Longitudinal Humphrey field analyzer 30-2 Swedish interactive threshold algorithm data from 160 eyes of 160 glaucoma patients were used. The influence of technician experience, time of day, and season on the mean deviation (MD) was determined by performing linear regression analysis of MD against time on a series of visual fields and subsequently performing a multiple linear regression analysis with the MD residuals as dependent variable and the factors mentioned above as independent variables. Analyses were performed with and without adjustment for the test reliability (fixation losses and false-positive and false-negative answers) and with and without stratification according to disease stage (baseline MD).RESULTS. Mean follow-up was 9.4 years, with on average 10.8 tests per patient. Technician experience, time of day, and season were associated with the MD. Approximately 0.2 dB lower MD values were found for inexperienced technicians (P CONCLUSIONS. Technician experience, time of day, season, and the percentage of false-positive answers have a significant influence on the MD of standard automated perimetry. (Invest Ophthalmol Vis Sci. 2012;53:7010-7017) DOI:10.1167/iovs.12-10268

1. Clinical nurse specialists should use common sense precautions for infection control in all office procedures to prevent the spread of HIV, especially handwashing and proper disinfection of all instruments. 2. Nurses should be fully informed of the appearance and mechanism of AIDS in ocular manifestations (especially cotton-wool spots and retinal hemorrhages) and the effects of cytomegalovirus and Kaposi's sarcoma on vision. 3. Prevention of infections by reducing the risk appears to be the only current defense against the transmission of HIV.

1. Every surgeon who performs phacoemulsification will encounter complications. Successful management of complications is enhanced by a combination of surgical skill, good judgment, and a well-trained, highly motivated first assistant. 2. The first assistant must have already mastered the names and uses of all instruments and equipment, and will have practiced the eye/hand coordination necessary to work comfortably with microscopes and loupes. A positive attitude and total concentration on the procedure and the surgeon is imperative. 3. A complete understanding of the management of the most common complications will enable the assistant to begin setting the stage to manage a complication during the anticipatory phase.

Every surgeon who performs phacoemulsification will encounter complications. Successful management of complications is enhanced by a combination of surgical skill, good judgment, and a well-trained, highly motivated first assistant. The first assistant must have already mastered the names and uses of all instruments and equipment, and will have practiced the eye/hand coordination necessary to work comfortably with microscopes and loupes. A positive attitude and total concentration on the procedure and the surgeon is imperative. A complete understanding of the management of the most common complications will enable the assistant to begin setting the stage to manage a complication during the anticipatory phase.

About half the 6 million blind people in sub-Saharan Africa have surgically curable cataract. The available manpower and resources can only provide services for less than 10% of the new blind cataract patients each year, and little is being done for the estimated 3 million "cataract backlog". A serious limiting factor to the development of prevention of blindness programmes is lack of trained manpower. Despite an increase in the number of ophthalmologists trained in cataract surgery (which varies greatly from country to country), this number is not keeping pace with increased demand for eye-care services, especially in large rural popultions. Initiatives that will help to overcome this dilemma are specific post-graduate courses in community ophthalmology in Africa, plans to develop a one-year diploma in ophthalmology course for English-speaking West African countries, and a proposal to upgrade a similar course in Zimbabwe. Additionally there is a need for the training of more ophthalmic assistants, cataract surgeons, and nurses in the diagnosis and management of common ophthalmic disorders. Experienced expatriate ophthalmologists also have an important role in the teaching of doctors and ophthalmic assistants how to select patients and carry out successful inexpensive cataract surgery with appropriate technology and limited facilities.

An in-house training program for ophthalmic assistants has many advantages, including a systematic way to train staff, a fair and consistent method of determining competency and salary scale, and improved efficiency, morale, and patient care. The student progresses through five levels, each with specific requirements and completion times. The student's progress is evaluated at all stages. The training program helps improve recruitment: it not only determines where a potential employee's skills fall, but it also allows an organization to augment staff as attrition takes place with trained personnel.

Of the estimated 35-40 million blindness worldwide, 17 million is caused by cataract and this proportion will double by year 2025. In Africa alone, it is estimated that there are about 3 million cataract blind. As life expectancy in Africa increases so will the incidence of cataract blindness. Existing resources of manpower and services cannot cope adequately with the present backlog of cataracts, let alone the anticipated increased load. The deployment of local ophthalmologists to deal with cataract load would be cost-effective in delivering appropriate eye care but the scarcity of ophthalmologists makes the option ineffective. The role of Western ophthalmologists will be considered in the provision of cataract surgical services and training of ophthalmic assistants, cataract surgeons and ophthalmologists.