How accessible is primary eye care for children in England?

The Role of Orthoptists in Refraction

Purpose

In 2022, the General Optical Council initiated a call for evidence concerning the Opticians Act. This consultation aimed to gather input and evidence relevant to potential modifications to the Opticians Act. One piece of research that was commissioned aimed to investigate the role of orthoptists in refraction.

Method

We invited a range of eye care practitioners to participate in an online virtual focus group. Focus group discussions were audio-recorded, transcribed, and thematically analysed.

Results

Two focus group discussions involving sixteen eye care professionals were completed. Findings confirm some orthoptists are already performing refraction tasks within the hospital eye service, primarily with young children using cycloplegic retinoscopy. Participants indicated that, at present, orthoptists refract on behalf of ophthalmologists who issue spectacle prescriptions based on the findings of the orthoptist's refraction. Potential benefits of orthoptists undertaking refraction responsibilities were discussed including the ability to conduct retinoscopy in hospital paediatric clinics where services are in high demand and there is often a shortage of refraction appointments. This shift could lead to decreased NHS waiting times, fewer patient appointments, improved clinical decision-making, and facilitate the assessment of accommodative dysfunction. Overall, the group were positive towards orthoptists conducting refractions and issuing optical prescriptions but with specific conditions: limited to hospital settings, necessitating adequate postgraduate training, supervision by a hospital eye service consultant, and regular ocular health assessments.

Conclusion

This study assessed the involvement of orthoptists in present and prospective refraction services, including their potential to legally issue optical prescriptions. The research outlined both the potential benefits and mitigating strategies to address concerns if orthoptists could issue optical prescriptions.

Access to primary care for children and young people (CYP) in the UK: a scoping review of CYP's, caregivers' and healthcare professionals' views and experiences of facilitators and barriers

OBJECTIVES

To examine children and young people's (CYP), caregivers' and healthcare professionals' (HCPs) views or experiences of facilitators and barriers to CYP access to UK primary care services to better understand healthcare inequity. To explore differences across CYP subpopulations with greater health needs from deprived areas, identifying as ethnic minorities, with experiences of state care, special educational needs or disabilities, chronic conditions or mental health problems.

DESIGN

Scoping review.

ELIGIBILITY CRITERIA

Included studies were in English, published 2012-2022 and reported: the views/experiences of CYP (0-25 years), caregivers or HCPs about accessing UK primary care; using quantitative or qualitative empirical methods.

DATA SOURCES

PubMed, CINAHL, Web of Science, PsycINFO and Scopus.

RESULTS

We included 47 reports (46 studies). CYP/caregivers' decision to access care was facilitated by CYP/caregivers' or their family/friends' ability to identify a health issue as warranting healthcare attention. Barriers to accessing care included perceived stigma (eg, being seen as a bad parent), embarrassment and discrimination experiences. CYP and caregivers believed longer opening hours could facilitate more timely access to care. Caregivers and HCPs reported that delayed or rejected referrals to secondary or adult care were a barrier to having needs met, especially for CYP with poor mental health. CYP and caregivers in numerous studies emphasised the importance of communication and trust with HCPs, including taking their concerns seriously, being knowledgeable and providing continuity of care for CYP. Common barriers reported across high-need subpopulations were caregivers needing knowledge and confidence to advocate for their child, gaps in HCP's knowledge and a lack of connectedness between primary and secondary care.

CONCLUSIONS

Connecting general practices and community health workers/services, improving CYP/caregivers' understanding of common childhood conditions, addressing HCP's knowledge gaps in paediatric care and integrated approaches between primary and secondary care may reduce inequity in access.

Incidence and distribution of ocular disorders in the first year of life

PURPOSE

To describe the incidence and distribution of eye diseases affecting children in the first year of life in Olmsted County, Minnesota.

METHODS

We conducted a population-based, retrospective medical record review of infants (≤1 year of age) residing in Olmsted County diagnosed with an ocular disorder from January 1, 2005, through December 31, 2014.

RESULTS

A total of 4,223 infants were diagnosed with an ocular disorder, yielding an incidence of 20,242/100,000 births per year, or 1 in 4.9 live births (95% CI, 19,632-20,853). The median age at diagnosis was 3 months, and 2,179 (51.5%) were female. The most common diagnoses included conjunctivitis, in 2,175 (51.5%), nasolacrimal duct obstruction, in 1,432 (33.6%), and pseudostrabismus, in 173 (4.1%). Visual acuity was decreased in one or both eyes in 23 (0.5%) infants because of strabismus in 10 (43.5%) and cerebral visual impairment in 3 (13.0%). A majority of the infants (3,674 [86.9%]) were diagnosed and managed by a primary care provider, and 549 (13.0%) were evaluated and/or managed by an eye care provider.

CONCLUSIONS

Although ocular disorders occurred in 1 in 5 infants in this cohort, most conditions were evaluated and managed by primary care providers. Understanding the incidence and distribution of ocular diseases among infants is useful for planning clinical resources.

An investigation of barriers and enablers to community eye care for children in England: A qualitative descriptive study

PURPOSE

Research suggests that there are challenges in the accessibility of eye care for children in England. This study explores the barriers and enablers to eye examinations for children under 5 years of age from the perspective of community optometrists in England.

METHODS

Optometrists working in community settings were invited to participate in virtual focus group discussions using an online platform based on a topic guide. The discussions were audio-recorded, transcribed and thematically analysed. Themes were derived from the focus group data based on the study aim and research question.

RESULTS

Thirty optometrists participated in the focus group discussions. The overarching themes identified as barriers to eye examinations for young children in a community setting were as follows: 'Time and Money', 'Knowledge, Skills and Confidence', 'Awareness and Communication', 'Range of Attitudes' and 'Clinical Setting'. The key themes for enabling eye examinations for young children were as follows: 'Improving behaviour', 'Enhancing training and education', 'Enhancing eye care services', 'Raising awareness', 'Changes in professional bodies' and 'Balancing commercial pressures and health care'.

CONCLUSION

Time, money, training and equipment are perceived by optometrists as key factors in providing an eye examination for a young child. This study identified a need for improved training and robust governance related to eye examinations for young children. There is a need for change within eye care service delivery such that all children, regardless of age and ability, are examined regularly, and by conducting these examinations, optometrists remain confident.

Refractive prescribing for preschool children by optometrists in England

PURPOSE

Correction of refractive error in children is important for visual and educational development. The aim of this questionnaire-based study was to explore paediatric refractive correction by optometrists in England.

METHODS

An online questionnaire was piloted and distributed to optometrists in England. The questionnaire asked about respondents' characteristics (such as type of practice), management of refractive error in 1- and 3-year-old children and sources of information used as a basis for decisions on prescribing refractive error in children.

RESULTS

Two hundred and ninety-three questionnaires were returned, although only 139 (47%) were fully completed. In an average month, about half of respondents examined no children between 0 and 2 years of age, and about half examined no more than five children aged 3-4 years. A significant proportion indicated they would refer children aged 1 or 3 years with refractive error and no other signs or symptoms into the hospital eye service. Almost a quarter would prescribe in full or in part an isometropic refractive correction of +2.00 D for a 3-year-old (within the normal range) with no other signs or symptoms, suggesting a degree of unnecessary prescribing. Almost all would act in cases of clinically significant refractive error. Respondents made similar use of their colleagues, optometric or postgraduate/continuing education, professional guidance and peer-reviewed research as sources of evidence on which to base decisions about prescribing for paediatric refractive errors. Most reported 'never' or 'rarely' using Cochrane reviews.

CONCLUSIONS

These results suggest optometrists often defer management of paediatric refractive error to the hospital eye service, with implications in terms of underutilisation of community optometric expertise and burden on the National Health Service. In some cases, the results indicate a mismatch between respondents' reported management and existing guidance/guidelines on paediatric prescribing.