Graeme Mackenzie

Self correction of refractive error among young people in rural China: results of cross sectional investigation

Objective To compare outcomes between adjustable spectacles and conventional methods for refraction in young people. Design Cross sectional study. Setting Rural southern China. Participants 648 young people aged 12-18 (mean 14.9 (SD 0.98)), with uncorrected visual acuity ≤6/12 in either eye. Interventions All participants underwent self refraction without cycloplegia (paralysis of near focusing ability with topical eye drops), automated refraction without cycloplegia, and subjective refraction by an ophthalmologist with cycloplegia. Main outcome measures Uncorrected and corrected vision, improvement of vision (lines on a chart), and refractive error. Results Among the participants, 59% (384) were girls, 44% (288) wore spectacles, and 61% (393/648) had 2.00 dioptres or more of myopia in the right eye. All completed self refraction. The proportion with visual acuity ≥6/7.5 in the better eye was 5.2% (95% confidence interval 3.6% to 6.9%) for uncorrected vision, 30.2% (25.7% to 34.8%) for currently worn spectacles, 96.9% (95.5% to 98.3%) for self refraction, 98.4% (97.4% to 99.5%) for automated refraction, and 99.1% (98.3% to 99.9%) for subjective refraction (P=0.033 for self refraction v automated refraction, P=0.001 for self refraction v subjective refraction). Improvements over uncorrected vision in the better eye with self refraction and subjective refraction were within one line on the eye chart in 98% of participants. In logistic regression models, failure to achieve maximum recorded visual acuity of 6/7.5 in right eyes with self refraction was associated with greater absolute value of myopia/hyperopia (P<0.001), greater astigmatism (P=0.001), and not having previously worn spectacles (P=0.002), but not age or sex. Significant inaccuracies in power (≥1.00 dioptre) were less common in right eyes with self refraction than with automated refraction (5% v 11%, P<0.001). Conclusions Though visual acuity was slightly worse with self refraction than automated or subjective refraction, acuity was excellent in nearly all these young people with inadequately corrected refractive error at baseline. Inaccurate power was less common with self refraction than automated refraction. Self refraction could decrease the requirement for scarce trained personnel, expensive devices, and cycloplegia in children’s vision programmes in rural China.

The child self-refraction study results from urban Chinese children in Guangzhou

OBJECTIVE To compare visual and refractive outcomes between self-refracting spectacles (Adaptive Eyecare, Ltd, Oxford, UK), noncycloplegic autorefraction, and cycloplegic subjective refraction. DESIGN Cross-sectional study. PARTICIPANTS Chinese school-children aged 12 to 17 years. METHODS Children with uncorrected visual acuity ≤ 6/12 in either eye underwent measurement of the logarithm of the minimum angle of resolution visual acuity, habitual correction, self-refraction without cycloplegia, autorefraction with and without cycloplegia, and subjective refraction with cycloplegia. MAIN OUTCOME MEASURES Proportion of children achieving corrected visual acuity ≥ 6/7.5 with each modality; difference in spherical equivalent refractive error between each of the modalities and cycloplegic subjective refractive error. RESULTS Among 556 eligible children of consenting parents, 554 (99.6%) completed self-refraction (mean age, 13.8 years; 59.7% girls; 54.0% currently wearing glasses). The proportion of children with visual acuity ≥ 6/7.5 in the better eye with habitual correction, self-refraction, noncycloplegic autorefraction, and cycloplegic subjective refraction were 34.8%, 92.4%, 99.5% and 99.8%, respectively (self-refraction versus cycloplegic subjective refraction, P<0.001). The mean difference between cycloplegic subjective refraction and noncycloplegic autorefraction (which was more myopic) was significant (-0.328 diopter [D]; Wilcoxon signed-rank test P<0.001), whereas cycloplegic subjective refraction and self-refraction did not differ significantly (-0.009 D; Wilcoxon signed-rank test P = 0.33). Spherical equivalent differed by ≥ 1.0 D in either direction from cycloplegic subjective refraction more frequently among right eyes for self-refraction (11.2%) than noncycloplegic autorefraction (6.0%; P = 0.002). Self-refraction power that differed by ≥ 1.0 D from cycloplegic subjective refractive error (11.2%) was significantly associated with presenting without spectacles (P = 0.011) and with greater absolute power of both spherical (P = 0.025) and cylindrical (P = 0.022) refractive error. CONCLUSIONS Self-refraction seems to be less prone to accommodative inaccuracy than noncycloplegic autorefraction, another modality appropriate for use in areas where access to eye care providers is limited. Visual results seem to be comparable. Greater cylindrical power is associated with less accurate results; the adjustable glasses used in this study cannot correct astigmatism. Further studies of the practical applications of this modality are warranted. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found after the references.

Apply psychology and education

I am a full time, out of hours general practitioner. I admit patients to hospital for two reasons.1 Firstly, if my top differential diagnosis has a illness trajectory that might result in the patient coming to harm if he or she is not admitted. Secondly, if the functional state of the patient is such that …

Referral management centres: general practitioner colleagues could refer among themselves.

EDITOR—I have no real objections to my referrals being triaged by clinicians.1 Iam under no illusions that referral is used as an “option” for general practitioners, and that we use it sometimes inappropriately just to be seen to be doing something. Of course medicolegally it is a powerful defence, …

Old docs and new tricks: Efficiency is important.

Editor—In British general practice, where everyday demand exceeds capacity, the efficient general practitioner is king. That is one thing that experience should bring. If all general practitioners followed every guideline the system would collapse, and although a few patients would have exemplary care, many would have no care at all as they would just not get seen because they would find the wait intolerable. Perhaps this is what happens now in secondary care, where care delivered is often very good but access is less and less. Accepted practice is often developed for a “one issue patient.” Reality means multi-issue patients, who themselves have limited ability to follow all the investigation and “treatment” recommended by the single issue academic establishment. Many indications for treatment are immediately met with contraindications. Experience allows general practitioners to cut back on too much excess investigation and treatment while still striving to meet the guidelines. Protecting the patient from the iatrogenic harm of excess health care used to be a core skill of the general practitioner. Is this being taken away from us as well? A system that fails to value the soft end points and often efficient and effective care that experience brings will have to restructure to meet the demand and that inevitably will lead to a hugely expanded system with resource implications. I am not disputing the findings of the paper reported by Spurgeon, that the standard of care may drop with years spent in practice,1 but the immediate common sense illogically of its hypothesis and conclusions make me advise to proceed down this route with caution. Being a doctor is already a difficult job. Being advised that all your thoughtful patient experience has actually made you a worse doctor is demotivating. Perhaps experienced doctors and patients would have a different set of criteria about what good care is?

RAPID RESPONSES FROM BMJ.COM: Corticosteroid injections work!

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