Visual health awareness,the Scottish community optometry service and Eyecare Integration Project: Breaking barriers in preventing visual impairment

Introduction

Sight loss

There are 1.86 million people living with sight loss in the United Kingdom (UK Vision Strategy, 2015), with an estimated registration of severe or partial sight impairment of 365,000 patients, and 34,492 are in Scotland in which 75% are aged over 65 (Royal National Institute of Blind People [RNIB], 2013; RNIB, 2014). With the increasing ageing population, it is predicted that by 2050, the number of people with sight loss will be nearly 4 million (Action for Blind People, 2012). Recently, new sight saving treatment options and ocular imaging technology for sight impairing disease have been introduced within the National Health Service (NHS) (The Royal College of Ophthalmologists [RCOphth], 2011; RCOphth, 2013).

The three leading causes for sight loss in the United Kingdom are age-related macular degeneration (ARMD), glaucoma and diabetic retinopathy (DR) (Liew, Michaelides, & Bunce, 2014; The Royal College of General Practitioners [RCGP]) (Figure 1). Early diagnosis of these conditions in older people is dependent on regular attendance for eye tests to community optometry, and compliance with the national DR screening service (Harding et al., 2003; National Health Service, Diabetic Eye Screening Programme [NHS DRS]). The introduction of anti-vascular endothelial growth factor (anti-VEGF) injections for wet ARMD has revolutionised visual outcome in this disease when previously these patients were registered with sight impairment (Liew et al., 2014; Minassian, Reidy, Lightstone, & Desai, 2011). Treatment is critically dependent on patients attending their optometrist as soon as they have visual symptoms, as optimal visual outcome requires treatment within 14 days of disease onset (Minassian et al., 2011).

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Figure 1.

Main causes of severe sight impairment (blindness) certifications in England and Wales, 2007–2008.

Method

A 14-point visual health questionnaire was designed with the help of the Fife Research and Development Department, and registered with the Fife Quality Improvements Register. The aim was to assess patient awareness and attendance of free annual eye tests, together with knowledge of the disease process and treatment of ARMD, glaucoma, and DR.

The questionnaire was distributed by two researchers to 100 consecutive patients, who were admitted for non-ophthalmological, other medical issues in the Fife Hospitals. Group 1 included 50 older patients on a rehabilitation ward awaiting discharge home. Group 2 included 50 slightly younger, middle-aged patients on a medical assessment ward.

All data were collated electronically on an excel spreadsheet, and every result was compared between the two groups for statistical significance with a t-test.

Results

Group 1 ranged in age from 57 to 101 years (average age 80.8 years) and Group 2, who were generally slightly younger, ranged in age from 19 to 88 years (average age 58.7 years) (p < .0001). The median age of the cohort was 75 years. Out of the 100 patients, although 82% knew about the free sight test service, 31% had not seen their optometrist for more than 2 years and 8% for more than 5 years.

There was reasonable knowledge of glaucoma with 77% of patients being aware of the disease, but less than half (43%) of the patients had heard about ARMD. Merely 24% and 17% of patients for glaucoma and ARMD, respectively, were aware of potential treatment to prevent sight loss (Figure 2). There was no statistically significant difference in awareness between the two groups of free eye tests and the chronic diseases of ARMD and glaucoma. There were only 25% in Group 2 and 14% in the older Group 1 who were aware of a free annual DR screening service. This response showed a significant difference between the two groups (p = .0263).

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Figure 2.

Results from the visual health questionnaire.

Overall, there was good knowledge of existing eye services but with variable usage. There was reasonable understanding of glaucoma but limited understanding of ARMD, and especially the treatment for both ARMD and glaucoma. This was particularly marked in the older group of patients who are most at risk of visual loss. For every response, the knowledge of the older group was poorer than the younger middle-aged group.

Discussion

Our study shows that both groups were aware of the free annual eye test service but regular attendance was poor. Other studies have also highlighted poor attendance for regular eye tests and in particular the older population (Shickle & Griffin, 2014). Studies specific to Scotland have shown that despite the provision of free eye tests, attendance at community optometry is variable (Dickey, Ikenwilo, Norwood, Watson, & Zangelidis, 2012). The reasons cited include difficulty with access to optometry services, because of associated co-morbidities rendering them poorly mobile especially in the older population, and undue pressure to purchase new spectacles. There are many who have not made the connection that optometry examination is not just routine spectacle correction but also screening for all eye disease if the vision is not correctable with appropriate lenses.

Both groups were more informed about the condition glaucoma, but lacked knowledge of other sight impairing diseases like ARMD and the availability of DR screening. This is perhaps because glaucoma screening was the first disease to be highlighted with the introduction of the first free eye tests in Scotland in 1989 (Information Service Division of NHS Scotland [ISD NHS Scot], n.d.). The national DR screening service was introduced only later in 2003 (Harding et al., 2003), and any macula disease is dependent on patient presentation when symptoms develop.

There was surprisingly very poor knowledge across the board of previous and latest treatments available for these sight impairing diseases. A total of merely 17 patients out of the 100 interviewed were aware of treatment for ARMD, and 24 patients for treatment for glaucoma. It was encouraging to know a larger proportion from the younger group were aware of a DR screening service. Hopefully, this means seeking treatment earlier, therefore reducing sight impairing disease in the future and other systemic complications associated with poor diabetic control.

Scotland is unique in offering a free annual comprehensive eye test to all age groups, that not only offers the best spectacle correction but also screening focusing on the three commonest causes of sight impairment, namely, ARMD, glaucoma, and DR. The national screening programme for diabetes set up in 2003 meant every diabetic is appointed annually and recalled if compliance is poor for ophthalmic screening (Harding et al., 2003; NHS DRS, n.d.). It is perhaps the link between routine testing for spectacle correction and examination for all other potential ocular disease that is missing in the public mind. The introduction of anti-VEGF treatment for wet ARMD has made a significant impact on disease progression, but this needs to be administered within 14 days of signs and symptoms for maximum result (Minassian et al., 2011). The Eyecare Integration Project helps facilitate this process, by allowing appropriate referrals to hospitals directly from attendance at community optometry with minimal delay.

Despite the benefits of having the Scottish eye care facilities, visual health especially in older people is still critically dependent on patients presenting for a sight test. There is an increasing appreciation among those involved with the care of the elderly that addressing issues around access, travel, and community care can improve disease detection in this vulnerable group with often multiple co-morbidities. The development of telestroke practice is an example where rapid assessment allows timely intervention which is key to optimum outcome (Birns, Bhalla, & Rudd, 2010). Likewise new ophthalmic services such as the Eyecare Integration Project endeavour to bring services closer to home, and the RCOphth are committed in supporting community eye care (Dua, 2014).

Conclusion

Our study shows poor understanding of sight impairing disease and new treatments for these conditions especially among the older population. New ophthalmic services stand to break barriers in improving screening and treatment delivery in a timely fashion. In Scotland, the Eyecare Integration Project will potentially address some of these issues, aiming to reduce and prevent deterioration of sight impairing disease through all age groups. Similar services are planned for the rest of the United Kingdom (RCOphth, 2014). The key to success, however, still lies within further publicity and education among the general public. All health professionals should be involved in promoting better visual healthcare, especially with the new evolving ophthalmic treatments and the concept of teleophthalmology.