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Clinical relevance: The ability to articulate clinical findings to patients through effective communication is a key skill in all health-care professions.\ud \ud Background: Unannounced standardised patients (SPs) are successful in measuring quality of clinical care provided by qualified optometrists but have not been used in optometry training. Final-year undergraduate optometry students examine members of the public during primary care clinics observed by visiting clinical tutors (VCTs) who provide individualised feedback, highlighting areas for improvement. This pilot study investigates whether unannounced SPs can be used as an additional resource providing enhanced feedback on communication skills in undergraduate optometry education.\ud \ud Methods: Two SPs received intensive training on reporting on students eye examinations and communication skills through completion of pre-designed checklists for each patient encounter. Each SP presented 16 times as an unannounced patient for routine eye examinations. SPs' comments on communication skills of 32 students during 32 examinations was compared to feedback from 10 VCTs. SPs' performance was monitored to ensure consistency. Evaluation of differences in quality and quantity of feedback provided by SPs and VCTs was performed using thematic analysis and chi-squared tests. Student feedback on the use of SPs was obtained on completion of the study.\ud \ud Results: Qualitative thematic analysis revealed six overarching themes emerging from 64 sets of feedback. SPs gave significantly more feedback, both positive comments and comments with recommendations, than VCTs for the (a) total number of comments for each theme (p = 0.0000) and (b) detail and depth of these comments. Students reported that SPs commented on aspects of communication (e.g., establishing rapport and body language) not noted by VCTs.\ud \ud Conclusions: Unannounced SPs can provide enhanced feedback on communication skills to final-year undergraduate optometry students. Students greatly valued VCTs feedback; however, they felt SPs commented on elements of communication not noted by VCTs.

Clinical relevance: Accuracy of tonometers is of vital importance in the detection and treatment of glaucoma.Background: This study investigates: agreement in intraocular pressure measurements between three tonometers and Goldmann applanation tonometry (GAT); inter-optometrist agreement for each tonometer; intra-optometrist agreement for GAT; association between central corneal thickness (CCT) and IOP measurements with each tonometer.Methods: IOP was measured using: CT-1P Non-Contact Tonometer (NCT) (Topcon Corporation, Tokyo, Japan), Pulsair IntelliPuff (Keeler Ltd., Windsor, UK) and Icare rebound tonometer (Icare, Helsinki, Finland) by two optometrists in a random order. Two GAT readings were obtained by each optometrist in a randomised masked manner. Mean differences, and 95% limits of agreement (LoA) for each measurement were calculated. CCT was measured by CT-1P pachymeter.Results: Forty-one participants' IOPs were measured. Mean differences (95% LoA) between NCT, Pulsair, Icare compared to GAT for one optometrist were: 0.8 (-5.4 to 6.9) mmHg, -1.7 (-8.2 to 4.8) mmHg, -1.6 (-9.0 to 5.9) mmHg. Mean differences (95% LoA) in inter-optometrist agreement for GAT, NCT, Pulsair and Icare were: 0.3 (-6.7 to 7.3) mmHg, 0.4 (-2.1 to 2.9) mmHg, -0.9 (-3.6 to 1.9) mmHg and -0.2 (-4.9 to 4.5) mmHg, respectively. Mean differences (95% LoA) for intra-optometrist agreement for GAT were 0.2 (4.3 to -4.7) mmHg and 0.1 (3.6 to -3.9) mmHg for each optometrist, respectively. There was a weak positive association between CCT and both GAT (r2 = 0.11) and NCT (r2 = 0.12).Conclusion: Pulsair and Icare may measure IOP lower than GAT. Mean differences for inter-optometrist agreement for all tonometers were < 1 mmHg; Pulsair showed a statistically significant difference. Intra-optometrist agreement for GAT was good. IOP measurements taken by two community optometrists are comparable using tonometers used in community practice.

Purpose\ud To assess accuracy and adherence of visual field (VF) home-monitoring in a pilot sample of glaucoma patients.\ud \ud Design\ud Prospective longitudinal feasibility and reliability study.\ud \ud Methods\ud Twenty adults (median 71 years) with an established diagnosis of glaucoma were issued a tablet-perimeter (Eyecatcher), and were asked to perform one VF home-assessment per eye, per month, for 6 months (12 tests total). Before and after home-monitoring, two VF assessments were performed in-clinic using Standard Automated Perimetry (SAP; 4 tests total, per eye).\ud \ud Results\ud All 20 participants could perform monthly home-monitoring, though one participant stopped after 4 months (Adherence: 98%). There was good concordance between VFs measured at home and in the clinic (r = 0.94, P < 0.001). In 21 of 236 tests (9%) Mean Deviation deviated by more than ±3 dB from the median. Many of these anomalous tests could be identified by applying machine learning techniques to recordings from the tablets’ front-facing camera (Area Under the ROC Curve = 0.78). Adding home-monitoring data to 2 SAP tests made 6 months apart reduced measurement error (between-test measurement variability) in 97% of eyes, with mean absolute error more than halving in 90% of eyes. Median test duration was 4.5 mins (Quartiles: 3.9 – 5.2 mins). Substantial variations in ambient illumination had no observable effect on VF measurements (r = 0.07, P = 0.320).\ud \ud Conclusions\ud Home-monitoring of VFs is viable for some patients, and may provide clinically useful data.

OBJECTIVE: This research aims to evaluate the wider health system effects of the introduction of an intermediate-tier service for eye care. \ud \ud SETTING: This research employs the Minor Eye Conditions Scheme (MECS), an intermediate-tier eye care service introduced in two London boroughs, Lewisham and Lambeth, in April 2013. \ud \ud DESIGN: Retrospective difference-in-differences analysis comparing changes over time in service use and costs between April 2011 and October 2014 in two commissioning areas that introduced an intermediate-tier service programme with changes in a neighbouring area that did not introduce the programme.\ud \ud DATA SOURCES: MECS audit data; unit costs for MECS visits; volumes of first and follow-up outpatient attendances to hospital ophthalmology; the national schedule of reference costs. \ud \ud MAIN OUTCOME MEASURES: Volumes and costs of patients treated. \ud \ud RESULTS: In one intervention area (Lewisham), general practitioner (GP) referrals to hospital ophthalmology decreased differentially by 75.2% (95% CI -0.918% to -0.587%) for first attendances, and by 40.3% for follow-ups (95% CI -0.489% to -0.316%). GP referrals to hospital ophthalmology decreased differentially by 30.2% (95% CI -0.468% to -0.137%) for first attendances in the other intervention area (Lambeth). Costs increased by 3.1% in the comparison area between 2011/2012 and 2013/2014. Over the same period, costs increased by less (2.5%) in one intervention area and fell by 13.8% in the other intervention area. \ud \ud CONCLUSIONS: Intermediate-tier services based in the community could potentially reduce volumes of patients referred to hospitals by GPs and provide replacement services at lower unit costs.

Purpose : The PrOVIDe study aimed to investigate the prevalence of a range of vision problems among people with dementias, aged 60-89 years and to examine the extent to which these conditions are undetected or inappropriately managed.\ud \ud Methods : The study had two stages, a cross-sectional prevalence study followed by qualitative research. In Stage 1, 708 people with dementia (389 living at home and 319 in care homes) had a domiciliary eye examination. The inclusion criteria were people with dementia (any type), aged 60-89 years; individuals lacking mental capacity to provide informed consent to participate required a consultee who could give approval on their behalf.\ud \ud Results : 22 percent reported not having had a test in the last two years: this included 19 participants who had not been tested in the last 10 years. Prevalence of visual impairment (VI) was 32.4% (95% Confidence Intervals (CI) 28.7 to 36.5) and 16.3% (CI 13.5 to 19.6) for the commonly-used criteria for VI of visual acuity (VA) worse than 6/12 and 6/18 respectively. Of those with VI, 44% (VA

OBJECTIVES: To explore views of all stakeholders (patients, optometrists, general practitioners (GPs), commissioners and ophthalmologists) regarding the operation of community-based enhanced optometric services.DESIGN: Qualitative study using mixed methods (patient satisfaction surveys, semi-structured telephone interviews and optometrist focus groups).SETTING: A minor eye conditions scheme (MECS) and glaucoma referral refinement scheme (GRRS) provided by accredited community optometrists.PARTICIPANTS: 189 patients, 25 community optometrists, 4 glaucoma specialist hospital optometrists (GRRS), 5 ophthalmologists, 6 GPs (MECS), 4 commissioners.RESULTS: Overall, 99% (GRRS) and 100% (MECS) patients were satisfied with their optometrists' examination. The vast majority rated the following as 'very good'; examination duration, optometrists' listening skills, explanations of tests and management, patient involvement in decision-making, treating the patient with care and concern. 99% of MECS patients would recommend the service. Manchester optometrists were enthusiastic about GRRS, feeling fortunate to practise in a 'pro-optometry' area. No major negatives were reported, although both schemes were limited to patients resident within certain postcode areas, and some inappropriate GP referrals occurred (MECS). Communication with hospitals was praised in GRRS but was variable, depending on hospital (MECS). Training for both schemes was valuable and appropriate but should be ongoing. MECS GPs were very supportive, reporting the scheme would reduce secondary care referral numbers, although some MECS patients were referred back to GPs for medication. Ophthalmologists (MECS and GRRS) expressed very positive views and widely acknowledged that these new care pathways would reduce unnecessary referrals and shorten patient waiting times. Commissioners felt both schemes met or exceeded expectations in terms of quality of care, allowing patients to be seen quicker and more efficiently.CONCLUSIONS: Locally commissioned schemes can be a positive experience for all involved. With appropriate training, clear referral pathways and good communication, community optometrists can offer high-quality services that are highly acceptable to patients, health professionals and commissioners.

Purpose: Cataract enhanced service (direct referral) schemes have been in existence for over 12 years. Such schemes make better use of the primary care practitioner's professional expertise and have the potential to reduce costs and provide an improved patient pathway. Surprisingly little has been published about these schemes, hence there is a lack of evidence to inform local decision making about existing and future services. The aim of this study was to provide more evidence by surveying the Local Optical Committees (LOCs) to obtain their views on their involvement or lack of involvement in cataract enhanced service schemes in the London region. Secondary aims were to compare how schemes operate and determine why schemes do not exist in some areas.\ud \ud Method: A structured survey of London’s 14 LOCs was carried out on two occasions (2007 and 2012). LOCs were contacted via e-mail, telephone or written letter. Some supporting information was obtained from PCTs. All data were analysed qualitatively.\ud \ud Results: In 2007, only two out of the 10 LOCs that had participated in the 2005 Cataract Choose and Book scheme were involved in running a full direct referral scheme. This had risen to six by 2012 with a total of 11 LOCs having participated in a trial/pilot scheme by that date. The remaining three LOCs have never participated in a scheme. Although there are similarities across schemes (e.g. requirement for accreditation, a referral fee etc), marked differences were found in patient booking arrangements, requirements during initial assessment and post-operative assessment. The percentage of LOCs involved in full schemes in the London region (43%) is lower than for the rest of England (69%). Where trial/pilot schemes had run but no full scheme had been implemented the major reasons reported were: lack of central funding; the schemes were only feasibility studies; and the requirement for a Unique Booking Reference Number (UBRN) for the Choose and Book process.\ud \ud Conclusions: Enhanced cataract service schemes do not always develop into full schemes even if the trial/pilot scheme has been deemed successful. Schemes may have a more prominent role in future with requirements on Clinical Commissioning Groups to provide an improved patient experience within tighter financial constraints. The co-ordinating activity across England of the Local Optical Committee Support Unit (LOCSU) and the newly formed Local Professional Networks for Eyecare should help increase uniformity of approach. All established cataract schemes will need to be re-procured during 2013/14 if they are to continue without interruption.

Purpose : Retail Pop-Ups in shopping centres/malls are increasingly commonplace. We report initial results from a “Feeling the Pressure” Pop-Up health check. We investigate the hypothesis that a Pop-Up combining an intra-ocular pressure (IOP) check with a general health check, such as blood pressure (BP), is more readily accepted by the general public than one offering an IOP check only. We also investigate public understanding of IOP compared to BP, and feasibility of using an Icare tonometer for measuring IOP in this setting.\ud \ud Methods : We took the Pop-Up (Fig 1) to 8 regionally different shopping centres/malls across England. Each shopping centre visit comprised two consecutive testing days; we compared public engagement when an IOP check was offered in conjunction with BP measurement, compared to when only an IOP check was offered. IOP and BP were measured using the Icare IC100 tonometer (Mainline Instruments Ltd) and EW3106 blood pressure monitor (Panasonic) respectively. A sample of those examined reported on comfort and acceptability of Icare using a questionnaire with items recorded on a 5 point Likert scale.\ud \ud Results : 768 participants were tested over 16 days. More participants attended the combined BP and IOP days (461; 60%; 95% confidence interval [CI] 56-64%) than IOP only days (307; 40%, 95% confidence interval [CI] 37-43%). We recorded IOP in 652 participants (116 declined IOP measurement) with a median (interquartile range) age of 54 (42, 68) years. Median (5th, 25th, 75th and 95th percentile) IOP was 13 (7, 11, 15, 19) mmHg. Of those asked (n= 858, includes 90 who declined to participate in the study), only 19% (95% CI 16-23%) reported knowledge of eye pressure in contrast to 71% (95% CI 66-75%) with knowledge of BP.\ud 350 participants completed the Icare questionnaire, with 87% (95% CI 83-90%) rating the tonometer very comfortable or comfortable, and 85% (95% CI 81-88%) stating that the Icare caused little or no anxiety.\ud \ud Conclusions : Examining IOP in large numbers of the public via a Pop-Up is feasible. Public engagement with the Pop-Up was greater when a BP check was offered alongside an IOP check. Reported public understanding of IOP was poor compared to their understanding of BP. Testing IOP with an Icare tonometer in a shopping centre Pop-Up was acceptable and comfortable in our population,\ud \ud This is an abstract that was submitted for the 2018 ARVO Annual Meeting, held in Honolulu, Hawaii, April 29 - May 3, 2018.