Evgenia Konstantakopoulou

Changes in color vision with decreasing light level: separating the effects of normal aging from disease.

The purpose of this study was to obtain additional information about the health of the retina (HR) by measuring the rate of loss of chromatic sensitivity with decreasing light level. The HR(index) is introduced to separate the effects of normal aging from early stage disease. For normal subjects the HR(index is largely independent of age (r(2)~0.1), but ~11% of clinically normal, asymptomatic, older subjects exhibit values below the 2σ limit. The HR(index provides a single number that captures how light level affects chromatic sensitivity irrespective of age and can be used to screen for preclinical signs of retinal disease.

Capturing age-related changes in functional contrast sensitivity with decreasing light levels in monocular and binocular vision.

PURPOSE It is challenging to separate the effects of normal aging of the retina and visual pathways independently from optical factors, decreased retinal illuminance, and early stage disease. This study determined limits to describe the effect of light level on normal, age-related changes in monocular and binocular functional contrast sensitivity. METHODS We recruited 95 participants aged 20 to 85 years. Contrast thresholds for correct orientation discrimination of the gap in a Landolt C optotype were measured using a 4-alternative, forced-choice (4AFC) procedure at screen luminances from 34 to 0.12 cd/m(2) at the fovea and parafovea (0° and ±4°). Pupil size was measured continuously. The Health of the Retina index (HRindex) was computed to capture the loss of contrast sensitivity with decreasing light level. Participants were excluded if they exhibited performance outside the normal limits of interocular differences or HRindex values, or signs of ocular disease. RESULTS Parafoveal contrast thresholds showed a steeper decline and higher correlation with age at the parafovea than the fovea. Of participants with clinical signs of ocular disease, 83% had HRindex values outside the normal limits. Binocular summation of contrast signals declined with age, independent of interocular differences. CONCLUSIONS The HRindex worsens more rapidly with age at the parafovea, consistent with histologic findings of rod loss and its link to age-related degenerative disease of the retina. The HRindex and interocular differences could be used to screen for and separate the earliest stages of subclinical disease from changes caused by normal aging.

Retrospective economic analysis of the transfer of services from hospitals to the community: an application to an enhanced eye care service

Objective This research aims to evaluate the wider health system effects of the introduction of an intermediate-tier service for eye care. 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. 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. 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. Main outcome measures Volumes and costs of patients treated. 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. 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.

Clinical effectiveness of the Manchester Glaucoma Enhanced Referral Scheme

Background Glaucoma referral filtering schemes have operated in the UK for many years. However, there is a paucity of data on the false-negative (FN) rate. This study evaluated the clinical effectiveness of the Manchester Glaucoma Enhanced Referral Scheme (GERS), estimating both the false-positive (FP) and FN rates. Method Outcome data were collected for patients newly referred through GERS and assessed in ‘usual-care’ clinics to determine the FP rate (referred patients subsequently discharged at their first visit). For the FN rate, glaucoma suspects deemed not requiring referral following GERS assessment were invited to attend for a ‘reference standard’ examination including all elements of assessment recommended by National Institute for Health and Care Excellence (NICE) by a glaucoma specialist optometrist. A separate 33 cases comprising randomly selected referred and non-referred cases were reviewed independently by two glaucoma specialist consultant ophthalmologists to validate the reference standard assessment. Results 1404 patients were evaluated in GERS during the study period; 651 (46.3%) were referred to the Hospital Eye Service (HES) and 753 (53.6%) were discharged. The FP rate in 307 assessable patients referred to the HES was 15.5%. This study reviewed 131 (17.4%) of those patients not referred to the HES through the GERS scheme; 117 (89.3%) were confirmed as not requiring hospital follow-up; 14 (10.7%) required follow-up, including 5 (3.8%) offered treatment. Only one patient (0.8%) in this sample met the GERS referral criteria and was not referred (true FN). There were no cases of missed glaucoma or non-glaucomatous pathology identified within our sample. Conclusion The Manchester GERS is an effective glaucoma filtering scheme with a low FP and FN rate.

Clinical safety of a minor eye conditions scheme in England delivered by community optometrists

Objective The aim of this study was to monitor the activity and evaluate the clinical safety of a minor eye conditions scheme (MECS) conducted by accredited community optometrists in Lambeth and Lewisham, London. Methods and analysis Optometrists underwent an accredited training programme, including attendance at hospital eye services (HES) clinics. Patients who satisfied certain inclusion criteria were referred to accredited MECS optometrists by their general practitioners (GPs) or could self-refer. Data were extracted from clinical records. A sample of MECS clinical records was graded to assess the quality of the MECS optometrists’ clinical management decisions. Referrals to the HES were assessed by the collaborating ophthalmologists and feedback was provided. Results A total of 2123 patients (mean age 47 years) were seen over 12 months. Two-thirds of the patients (67.3%) were referred by their GP. The most common reasons for patients needing a MECS assessment were ‘red eye’ (36.7% of patients), ‘painful white eye’ (11.1%), ‘flashes and floaters’ (10.2%); 8.7% of patients had a follow-up appointment. Of the patients seen, 75.1% were retained in the community, 5.7% were referred to their GP and 18.9% were referred to the HES. Of the HES referrals, 49.1% were routine, 22.6% urgent and 28.3% emergency. Of the records reviewed, 94.5% were rated as appropriately managed; 89.2% of the HES referrals were considered appropriate. Conclusion The findings of this study indicate that optometrists are in a good position to work very safely within the remits of the scheme and to assess risk.

Pre‐receptoral spectral absorption, healthy ageing and pre‐clinical indications of retinal disease

Purpose The aim of this study was to investigate how chromatic sensitivity changes as a function of age and to establish the extent to which such changes can be attributed to pre-receptoral spectral absorption of short wavelength light and/or changes in retinal mechanisms caused by ageing. Methods The absorption of blue light by the macular pigment (MP) and the crystalline lens and the subjects’ sensitivity to rapid flicker were measured using the Macula Assessment Profile (MAP) test. Red-green (RG) and yellow blue (YB) chromatic detection thresholds were measured at the fovea for young and older subjects using the Colour Assessment and Diagnosis (CAD) test at 2.6, 26 and 65 cd/m2. The variables of interest included the spectral absorption of the lens, the optical density of the MP, subject’s age and retinal illuminance. Results The absorption of blue light by the lens increased with age. Absorption of blue light by pre-receptoral filters did not affect RG chromatic sensitivity at any of the light levels investigated but had an effect on YB thresholds. The considerably higher colour vision thresholds of some subjects and the subsequent worsening of their chromatic sensitivity at the lower light level may reflect changes in the retina brought about by accelerated aging effects. Conclusion The effect of pre-receptoral absorption of blue light on chromatic sensitivity is small. Ageing affects the amount and spectral composition of the light reaching the photoreceptors and the processing of retinal signals. As a result, flicker sensitivity declines and colour vision deteriorates. Such effects arise mostly from changes in the retina. The MAP and CAD tests help us to detect the effects of accelerated ageing and retinal disease.