Referral patterns for common amblyogenic conditions

Referral Patterns in Neuro-Ophthalmology

BACKGROUND

Neuro-ophthalmologists specialize in complex, urgent, vision- and life-threatening problems, diagnostic dilemmas, and management of complex work-ups. Access is currently limited by the relatively small number of neuro-ophthalmologists, and consequently, patients may be affected by incorrect or delayed diagnosis. The objective of this study is to analyze referral patterns to neuro-ophthalmologists, characterize rates of misdiagnoses and delayed diagnoses in patients ultimately referred, and delineate outcomes after neuro-ophthalmologic evaluation.

METHODS

Retrospective chart review of 300 new patients seen over 45 randomly chosen days between June 2011 and June 2015 in one tertiary care neuro-ophthalmology clinic. Demographics, distance traveled, time between onset and neuro-ophthalmology consultation (NOC), time between appointment request and NOC, number and types of providers seen before referral, unnecessary tests before referral, referral diagnoses, final diagnoses, and impact of the NOC on outcome were collected.

RESULTS

Patients traveled a median of 36.5 miles (interquartile range [IQR]: 20-85). Median time from symptom onset was 210 days (IQR: 70-1,100). Median time from referral to NOC was 34 days (IQR: 7-86), with peaks at one week (urgent requests) and 13 weeks (routine requests). Median number of previous providers seen was 2 (IQR: 2-4; range:0-10), and 102 patients (34%) had seen multiple providers within the same specialty before referral. Patients were most commonly referred for NOC by ophthalmologists (41% of referrals). Eighty-one percent (242/300) of referrals to neuro-ophthalmology were appropriate referrals. Of the 300 patients referred, 247 (82%) were complex or very complex; 119 (40%) were misdiagnosed; 147 (49%) were at least partially misdiagnosed; and 22 (7%) had unknown diagnoses. Women were more likely to be at least partially misdiagnosed-108 of 188 (57%) vs 39 of 112 (35%) of men (P < 0.001). Mismanagement or delay in care occurred in 85 (28%), unnecessary tests in 56 (19%), unnecessary consultations in 64 (22%), and imaging misinterpretation in 16 (5%). Neuro-ophthalmologists played a major role in directing treatment, such as preserving vision, preventing life-threatening complications, or avoiding harmful treatment in 62 (21%) patients.

CONCLUSIONS

Most referrals to neuro-ophthalmologists are appropriate, but many are delayed. Misdiagnosis before referral is common. Neuro-ophthalmologists often prevent vision- and life-threatening complications.

Ophthalmology education in pediatric residency training programs

PURPOSE

To evaluate the status of ophthalmology education in pediatric residency programs in the United States.

METHODS

A mail survey was sent to 187 directors of pediatric residency programs in the United States, which included questions about current ophthalmology education, desire for additional programs, reasons for dissatisfaction, and types of education desired.

RESULTS

Of a total of 187 surveys mailed, 137 (73%) were returned. Pediatric ophthalmology is part of the curriculum at 72% of pediatric residency programs and not included at 28%. Program directors were satisfied with pediatric ophthalmology education at 76% of the residency programs and not satisfied at 24%. A formal program in ophthalmology was desired by 88% of directors. Reasons for dissatisfaction with ophthalmic education included lack of time during the pediatric residency and lack of ophthalmologists available for teaching. Desired educational programs included didactic lectures by pediatric ophthalmologists, a CD-ROM or web-based program, and rotations through pediatric ophthalmology clinics.

CONCLUSIONS

Most pediatric residency program directors want pediatric ophthalmology as part of their formal curricula, but one-fourth of programs are currently either lacking formal ophthalmic education or their directors are dissatisfied with their ophthalmic curricula. Pediatric ophthalmology training programs should be developed to assist those residency programs that are not satisfied with their ophthalmic education. Ophthalmologists are encouraged to participate in these efforts.

Evidenced-based medicine: treatment for amblyopia

Amblyopia is defined as reduced and uncorrectable vision in a structurally normal eye. Early detection of amblyopia is very important. This can be accomplished through screening programs designed to identify amblyopia risk factors. Testing can be performed by trained teachers, technicians, school nurses and pediatricians as well as by eye care professionals. Once a child is identified as having an amblyopia risk factor it is crucial that the parents follow up with a pediatric ophthalmologist for a comprehensive examination. Amblyopia is the leading cause of monocular vision loss in the United States for adults under the age of 40. Amblyopia is amenable to therapy and is cost effective to treat. It is believed that earlier therapy for amblyopia provides better outcomes, but treatment has been shown effective even in some older children. In this paper, studies are cited regarding treatment of amblyopia.

Overcoming barriers to pediatric visual acuity screening through education plus provision of materials

PURPOSE

The American Academy of Pediatrics (AAP) recommends that LEA and HOTV optotypes be used for vision screening and that adhesive tape be used to occlude one eye during testing. We have developed an educational program designed to improve the quality and efficiency of vision screening. The purpose of this study was to ascertain the effectiveness of this program.

METHODS

All 672 pediatric doctors and nurses in the state of Alaska were surveyed by mail to assess their screening protocol and the number of patients cared for annually. Respondents received educational material, including an instructional video, eye patches for visual acuity testing, and a critical line HOTV test box. Subjects were resurveyed 3 months later to determine whether the instructional intervention altered their established protocol.

RESULTS

Of the 672 practitioners contacted for the survey, 239 (35.6%) responded, representing 31,000 patients, or 62% of all preschool children in Alaska. Use of recommended optotypes was rare (Lea, 3%, HOTV, 7%) compared with the use of nonrecommended optotypes (including use of the E test by 40% of respondents). The postintervention survey was answered by 107 (16%) practitioners. Of these, 24 (23%) reported that they had begun using an adhesive patch for visual acuity testing, whereas 19 (18%) had begun using AAP-recommended testing optotypes.

CONCLUSIONS

In-office video education and provided adhesive eye patches increased the use of patches in primary care preschool vision screening. Mail delivery was less effective than anticipated.