Transcript Slide 1

Department of Optometry & Visual Science
Eye care and public health:
successes and challenges
Professor John Lawrenson
Dept of Optometry and Visual Science
City University London
Excellence in Eye Care Education and Research for over 100 years
Department of Optometry & Visual Science
Lecture Outline
• Epidemiology of blindness and visual impairment
• Impact of visual impairment on quality of life
• Optometric workforce and equity of access
• Targeting hard to reach groups
• Screening for visual impairment
• Eye health promotion and preventative eyecare
Department of Optometry & Visual Science
UK Vision Strategy: a mission statement for
ophthalmic public health
To raise awareness and understanding of eye health among
the public, including those people most at risk of eye
disease, to allow every individual to develop a personal
responsibility for eye health and to achieve maximum eye
health for all. To raise awareness of eye health among
health and social care practitioners, and to ensure the early
detection of sight loss and prevention where possible
UK Vision Strategy (April 2008):
Department of Optometry & Visual Science
Causes of Severe Visual Impairment in the UK
•Data from CVI submissions
• Does not provide data on
absolute numbers due to underreporting
• A significant proportion of
severe visual impairment is
preventable
Source: Bunce et al. Eye (2010) 24, 1692–1699
Department of Optometry & Visual Science
Causes of Visual Impairment in an Elderly
Population in the UK (MRC Trial)
Source: Evans et al. Br J Ophthalmol 2004;88:365–370.
Department of Optometry & Visual Science
Causes of Visual Impairment in an Elderly
Population in the UK (MRC Trial)
Source: Evans et al. Br J Ophthalmol 2004;88:365–370.
Department of Optometry & Visual Science
Impact of Visual impairment on Quality of Life
Visual impairment is associated with:
• Falls
• Depression
• Reduced capacity to carry out
everyday activities
• The need for residential care
One of the highest risk factors for functional status
decline in people living in the community
Department of Optometry & Visual Science
The Value of Vision: Time Trade Off
“How many years do you expect to live? Suppose there
was a technology that guaranteed your vision will return
to normal and remain normal in both eyes permanently.
The technology always works, but it decreases survival.
What is the maximum number of years—if any—you
would be willing to give up if you could receive this
technology and have normal vision in both of your eyes
for the remainder of your life?”
Department of Optometry & Visual Science
The Value of Vision: Time Trade Off
• Patients, with 6/9–6/15 visual acuity would be willing to
lose 19% of their lifetime to get back normal visual acuity
• Patients with 6/60–3/60 visual acuity would give up 48% of
their lifetime
• Blind people would give 60%
• Comparable utility values are seen in patients with AIDS
(21%), bedridden and incontinent patients following a
stroke (66%)
Source: Knauer and Pfeiffer. Graefes Arch Clin Exp Ophthalmol (2008) 246:477–482
Department of Optometry & Visual Science
Future Visual Impairment projections
Department of Optometry & Visual Science
UK Optometry Workforce
Source: Health and Social Care
Information Centre
• 30% increase in the number of optometrists in the last 10 years
Department of Optometry & Visual Science
Activity statistics
• 11.8 million NHS sight tests in England in 2009/10
• In the last 10 years there has been a 18% increase in the number of NHS
sight tests
• 35% increase in the number of domiciliary sight tests
• Significant regional variation
Department of Optometry & Visual Science
Equitable access to eyecare
• Poorer people are less likely to access eyecare
• Are more likely to present too late with advanced
glaucoma
• Are more likely to have treatment for cataract at a more
advanced stage of sight loss
• Are more likely to have more severe diabetic retinopathy
• Less likely to access new treatments for ARMD
Department of Optometry & Visual Science
Equitable Access to Eyecare
• In France an inverse correlation was found between number of
ophthalmologists and rates of visual impairment after adjustment for age
and socioeconomic status
Source: Lafuma et al. Health and Quality of Life Outcomes 2006, 4:34
Department of Optometry & Visual Science
Equity of Access
Mismatch between location
of optometric premises and
areas of high deprivation
A significant proportion of
the ‘at risk’ population do
not have regular eye
examinations despite their
entitlement to a free
examination
Source: Day et al . Eye (2010) 24, 1478–1485
Department of Optometry & Visual Science
Equity of Access
Is it acceptable to
rely on private high street
optometry to
provide primary eye care
services in areas
of high need?
Source: Day et al . Eye (2010) 24, 1478–1485
Department of Optometry & Visual Science
Optometry business model
• Optometry is a highly competitive market-driven system
• State of the art ophthalmic equipment
• Only a small proportion of an optometrists income derives from the
NHS
• Business model relies on a large cross-subsidy from the sale of
optical appliances
Department of Optometry & Visual Science
Barriers to Accessing Eyecare
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Lack of awareness
Perceived cost of sight test and spectacles
Language difficulties
Transport
Residential care
Department of Optometry & Visual Science
Evidence for the effectiveness of vision screening
• ‘At present there are no
robust trials available that
allow the benefits of school
vision screening to be
measured. The disadvantage
of attending school with a
visual acuity deficit also
needs to be quantified. The
impact of a screening
programme will depend on
the geographical and socioeconomic setting in which it is
conducted.’
Department of Optometry & Visual Science
Evidence for the effectiveness of vision screening
• ‘The review found five studies in
which vision was tested as part of a
broader screening assessment. No
improvement in vision was seen two
to four years after screening
compared to elderly people who were
not screened’
Department of Optometry & Visual Science
Cost effective community screening
• Harnessing technology
• RNIB have developed ‘Eyes Right’, a simple and easy-to-use
screening tool for visual impairment
Department of Optometry & Visual Science
Cost effective community screening
Department of Optometry & Visual Science
Qualitative Study of Glaucoma Awareness
• A study of patients with advanced glaucoma at Moorfields
Eye Hospital found low levels of awareness of the disease
prior to their diagnosis and assumed that symptoms were
the ‘normal’ deterioration of eyesight.
• As symptoms have a gradual onset, participants had
learnt to cope with diminishing sight ability.
• These findings suggest that health promotion is a priority
to increase public awareness of the existence and
symptoms of glaucoma among those at high risk
Department of Optometry & Visual Science
Moorfields Glaucoma Awareness Study
• Effect of a public education campaign on awareness and help-seeking
behaviour with respect to ocular health in an Indian population
Source: Baker and Murdoch. Br J Ophthalmol 2008;92:1671–1675
Department of Optometry & Visual Science
Moorfields Glaucoma Awareness Study
• Not possible to demonstrate an improvement in health seeking behaviour
Source: Baker and Murdoch. Br J Ophthalmol 2008;92:1671–1675
Department of Optometry & Visual Science
Lifestyle and Eye Disease
• Optometrists are well placed to
promote healthy living
• Their patients include a large
percentage of the population
who are ‘in health’ and therefore
not in regular contact with
healthcare professionals
Source: Klein and Klein. Am J Ophthalmol 2007;144:961–69
Department of Optometry & Visual Science
Smoking and Eye Health
• Smoking nearly triples the incidence of AMD
compared with non-smokers
• >25% of all cases of advanced AMD are
attributable to current or past exposure to
smoking
• Smoking cessation is associated with a
significant decrease of the risk of
progression to AMD, which is independent
of former smoking intensity
• A recent survey found that only 6.2% of
optometrists routinely asked about smoking
habits at new patient consultations and
2.2% at follow up visits
Department of Optometry & Visual Science
Challenges and Opportunities
• Public health interventions need to be evidence-based
• Equitable access to community eyecare
- Integrate optometrists into primary care teams?
- NHS Community Optometry?
• Screening for Eye Disease
- Who?
- How?
• Targeted eye health awareness
• Opportunities for health promotion
• Inter-disciplinary working
• Educating the profession in public health and advocacy