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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/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.

Background: Preoperative presenting visual acuity (PPVA) is not a commonly reported indicator for the delivery of cataract services. This study aimed to evaluate the PPVA of patients undergoing cataract surgery in rural and urban areas of Nepal. Design: A prospective, non-interventional study conducted from October 2007 to March 2008 in a tertiary hospital and outreach clinics of Nepal. Participants: A total of 3023 consecutive subjects from urban and rural settings (1323 from the tertiary hospital and1700 from outreach clinics) with cataract were included. Methods: Visual acuity was tested with a Snellen E-chart at 6 m by ophthalmic assistants. All Outreach Microsurgical Eye Clinic patients were examined by either ophthalmologists or senior ophthalmic assistants. Patients at the Tertiary Eye Care Centre were examined only by ophthalmologists. Main Outcome Measures: Preoperative presenting visual acuity of patients undergoing cataract surgery was measured in both the settings. Results: The sex ratio was 0.96 (male/female). Based on PPVA, 11.5% of patients operated were blind (PPVA

Aim : To assess the effectiveness of teachers in a vision screening program for children in classes 5th to 12th attending school in two blocks of a district of north central India. Materials and Methods : Ophthalmic assistants trained school teachers to measure visual acuity and to identify obvious ocular abnormalities in children. Children with visual acuity worse than 20/30 in any eye and/or any obvious ocular abnormality were referred to an ophthalmic assistant. Ophthalmic assistants also repeated eye examinations on a random sample of children identified as normal (approximately 1%, n=543) by the teachers. Ophthalmic assistants prescribed spectacles to children needing refractive correction and referred children needing further examination to a pediatric ophthalmologist at the base hospital. Results : Five hundred and thirty teachers from 530 schools enrolled 77,778 children in the project and screened 68,833 (88.50%) of enrolled children. Teachers referred 3,822 children (4.91%) with eye defects for further examination by the ophthalmic assistant who confirmed eye defects in 1242 children (1.80% of all screened children). Myopia (n=410, 33.01%), Vitamin A deficiency (n=143, 11.51%) and strabismus (n=134, 10.79%) were the most common eye problems identified by the ophthalmic assistant. Ophthalmic assistants identified 57.97% referrals as false positives and 6.08% children as false negatives from the random sample of normal children. Spectacles were prescribed to 39.47% of children confirmed with eye defects. Conclusions : Primary vision screening by teachers has effectively reduced the workload of ophthalmic assistants. High false positive and false negative rates need to be studied further.

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.

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.

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.