Section/s Comments College response

Transcription

1 of Optometrists Consultation comments and response August 2017 Council Member Council Member Section/s Comments response learning, patients who present as an emergency Overall A.73 - I would recommend altering toxin to read toxic (specifically speaking toxin in a medical context refers to a biologically produced poison, iatrogenic causes may be chemical rather than biological). A suggest changing to...participate in an NHS or government-funded scheme... - the EHEW scheme in Wales is funded by Welsh Government specifically, and includes acute eye care. See Annex A A73 bullet on Toxin replaced by Alcohol or drug iatrogenic A.203 changed as suggested We have reversed the change to the title in Table A54. We have taken out the hospital eye service interval and moved it to a separate point in A55. The table's intervals are based on custom and practice however we agree more evidence is needed in this area. A62 amended to include assessing near vision in children Thank you for these links, they will be added 1

2 of Optometrists Consultation comments and response August 2017 Section/s Comments response A patient may fall into multiple categories, and we would expect practitioners to refer to the examining young children section as well as examining learning if they were examining children or young people with learning Representative of a stakeholder organisation Overall See Annex B Regarding the suggested change to A79: whether to use local anaesthetic drops first would be up to the professional judgement of the optometrist. The disadvantage of using such drops is that they may sting as much as the cycloplegic drops, and the patient may then be naturally wary of the optometrist approaching them to put in the cycloplegic drops, even though these would be painless. We will not, therefore be changing A79 A81 changed as suggested Learning disability section updated to include messages around spectacles and aftercare support We do not cover the issue of GOS vouchers in the Guidance Thank you for these links, they will be added 2

3 of Optometrists Consultation comments and response August 2017 Section/s Comments response A18 amended to reflect A21 In A20 the top-level bullets are a must such as patient s personal records as they are from the GOC standards. What follows is a should as it is the s view of what this should normally include. Added relevant to A22 A54 we have changed this back due to comments made A91 changed to use GOC wording We have taken A102 s wording from GOC standard 7.6 Representative of a stakeholder organisation Overall See Annex C A112 we accept that it can sometimes be difficult however it is a must as it is from the GOS regulations. A113 Domiciliary visits must only be conducted in the best interests of the patient. There may be instances where the patients asks for a visit but is not entitled to GOS. The optometrist can then do the consultation privately if it is in the patient s best interests. A164 locums have a responsibility to know the correct local pathway We have included guidance about seeking advice from your insurer in A217 and A231 We agree regarding A314 however it is not a legal or regulatory requirement so cannot be a must 3

4 of Optometrists Consultation comments and response August 2017 Section/s Comments response learning a) I accept that what is recommended is best practice, including: pre-exam visit, going through the Telling the optometrist about me form, briefing from the patient and (with consent) the carer, a full eye exam (often spending longer than usual), using additional tests as the patient needs require (including dilation & cyclo), explaining and showing them all the equipment, finding and providing information in an accessible format, providing reports to GP and others, advice on spectacle to schools etc. b) However, all the above is not feasible under the NHS and I think that for the to be listing all this as should will antagonise Members and Fellows and indicate a that is out of touch with the realities of a 20 sight test. c) Some of these things are not necessary in every case. For example, if a child with Down s syndrome uses glasses constantly, and always has since starting school, does every eye exam need to produce a letter to teachers? I suggest changing many of the items in this section to may rather than should. a and b: The Guidance is the s view of good practice, irrespective of the funding mechanism. The Guidance covers items of service, such as contact lens fitting, and examining a patient who presents with flashes and floaters, which are outside the terms of the GOS contract. Some areas have specifically commissioned services to enable optometrists to spend more time examining patients who have a learning disability. c. Should is used when the would normally expect an optometrist to follow that course of action. If an optometrist decides not to take that action they must be able to justify their decision. The example given would fall within that category, although the optometrist would still need to give the child a copy of their prescription. 4

5 of Optometrists Consultation comments and response August 2017 Section/s Comments response A248 Is blank Thank you. This will be deleted. A252 & A253 Why is this a must. Should seems more appropriate. Must is appropriate as it is a regulatory requirement in GOC Standards 7.6 and (continued from above) Overall A279 Many optometrists only fit straightforward cases with simple lenses (e.g. disposable soft lenses). Such practitioners should practise within their capabilities. Why should they have access to more complex diagnostic contact lenses? A283 Avoid exposure of contact lenses to all water? I don t think that is what you mean to say. A279 changed to access to more complex diagnostic contact lenses if appropriate We intend this to read that contact lenses should not be exposed to water, but will remove all as it is redundant. A335& A344 I think that this should read You must regularly assess the general ocular status of the patient or receive assurances that another practitioner is making such assessments. This is necessary to cover the scenario when a patient has routine eyecare at one practice and contact lens checks at another. A335 and A344 changed as suggested 5

6 of Optometrists Consultation comments and response August 2017 Section/s Comments response Visual discomfort removed from title of section. Reference to weak evidence removed from key points and from A89 (continued from above) See Annex D A88 now reads There is currently no strong evidence that tinted lenses are effective in improving visual function in difficulties. However, optometrists who practise in this area report that some patients find these interventions helpful. A89 now follows on from this, stating that you should explain this to the patient. With regards to the point that there are other areas of optometric practice where there is no strong evidence, we would argue that where there is no strong evidence there is clinical consensus. Currently, there is no firm clinical consensus on tinted lenses and their effectiveness in improving visual function in difficulties. 6

7 of Optometrists Consultation comments and response August 2017 Section/s Comments response difficulties or visual discomfort A88/89 The evidence SO FAR might be considered 'weak' but experience suggests much more work needs to be done with randomised trials. Having personally seen hundreds of SpLD over many years, my experience is that a small but significant proportion of these patterns are definitely helped by the use of precision tinted lenses. Indeed there are plenty of examples of children that I assessed over 20 years ago, who were educationally well behind their peers, who now enjoy successful academic achievement which they attribute in some part to their coloured lenses (sometimes still used). This is of course anecdotal but there are other areas of optometric practice where the evidence might be considered to be even weaker. This change in the guidance could well discourage patients from seeking help and practitioners from continuing work in developing this important sub specialism. 7

8 of Optometrists Consultation comments and response August 2017 Section/s Comments response Should be added: Specific learning Difficulties-precision tinted lenses do help Visual stress and pattern glare which is a common complaint in some s of migraine. Non- optometrist Should be removed: Weak evidence that Precision tinted lenses work. In my 14 years of running dedicated SpLD and visual stress clinics, I have never doubted the benefit of precision tints in helping manage visual stress in patients. What is important in my opinion is a proper work up so colour is used appropriately. It will be a shame to undermine this lifeline for patients whose lives are impacted by visual stress. Also, seeds of doubt amongst Optometrists and people in the education will reduce the referrals and thereby deprive Visual stress sufferer's of their needs from being met. 8

9 of Optometrists Consultation comments and response August 2017 Section/s Comments response The is making a very bad mistake with regard to the use of colour and learning difficulties. Having used the Intuitive Colorimeter for 27 years I am certain that the use of specific tints significantly helps the carefully prescreened children and specific adults with symptoms of visual stress. The problems arise because of nonqualified personnel prescribing colour overlays and possibly some optometrists who do not follow the strict protocol of a very thorough eye examination and binocular vision/orthoptic assessment prior to a screening with overlays and assessment of the effect of any overlay using a test to determine the effect. Only after the above first protocol has been followed should the preferred overlay be dispensed for a prolonged prognostic trial to reduce the chance of a placebo choice. Then, and generally only then, should colorimetry be carried out and a Cerium Precision tint prescribed. 9

10 of Optometrists Consultation comments and response August 2017 Section/s Comments response The current advice on the use of tinted lenses has been removed. Irrespective of the strength of the evidence to support the use of tinted lenses there is evidence to support its use. What is critical is that the clinical use of tinted lenses follows the established protocols for prescribing which is set out in the current guideline A 86. A major area of concern is the indiscriminate use of colour by professionals including optometrists and teachers and the availability of both overlays and ready tinted spectacles on the internet, some of which are supplied for use by children by optometrists. Whilst research based evidence is important in reaching decisions about prescribing, clinical experience also plays an important role and due weight must be given to this. The current guidance remains valid irrespective of any other considerations in relation to the strength of research based evidence. Given that there is evidence that coloured filters alleviate symptoms of visual stress, including reading performance and alleviation of visual discomfort, including headaches, the wording of the advice in A88 and A89 is unduly critical and gives a biased and negative impression which has the potential to deter people with visual stress problems for seeking advice from qualified s of the profession and will simply drive people in the direction of Irlen and other unqualified suppliers who supply without a full eye examination which often reveals other optometric problems which account for the symptoms. The change in advice seems to have been driven by the Griffiths review in 2016 which, in itself is flawed. The advice is inaccurate in that it it refers to visual function whereas Visual Stress is more symptom related and likely to be neurologically based. In my practice I tell parents and patients that 'there is evidence to suggest that coloured lenses can alleviate symptoms in people with visual stress and can improve reading performance. Colour is not prescribed without clear evidence that it is appropriate for the individual patient. 10

11 of Optometrists Consultation comments and response August 2017 Section/s Comments response Sp LD, optometrists need special training, not in the core capabilities of optometrist training.(85) If the patient has the problem, precision tinted lenses certainly help. They will not help all sp LD. I can show evidence that there is a large improvement in reading ability, confidence and balance if PTL are prescribed to a patient with specific problems. That is why specific training is necessary.(88) (89) evidence is weak, should be removed, and replaced by, PTL will aid certain problems, such as visual stress, but does not correct all visual problems. 11

12 of Optometrists Consultation comments and response August 2017 Section/s Comments response Spld The evidence that there is no strong evidence is controversial in itself and represents a single paper and a few published letters. The overall evidence for and against is not compelling. The guidance should say only that the evidence remains controversial. The appears to have been seduced by the evidence based lobby and the proposed change is not based on sufficient evidence to be authoritative. It is unwise and I would strongly you suggest is open to challenge although I agree it probably does need changing. The proposed guidance will potentially bring the into disrepute because it is evidence of bias. Furthermore it is vital to include the need of a thorough assessment of accommodation, convergence and fusion also range before prescribing PTLs from am any providers Should be removed: Reference to lack of evidence pg 29 for PTLs add instead evidence is controversial. See above. 12

13 of Optometrists Consultation comments and response August 2017 Section/s Comments response On page 29 : difficulties or visual discomfort I believe the statements There is currently no strong evidence that tinted lenses are effective in improving visual function in difficulties. Interventions carry a cost to the patient and so you should explain that the evidence is weak should be amended or removed. Patients who are helped with precision tinted lenses suffer Visual Stress, which is essentially difficulties of perception. The evidence is that lenses improve their perception of repeating patterns (including text on a page) and relieve their symptoms, not improve their visual function per se. The whole statement is overly negative in its emphasis. There are many practitioners, including myself, who have a special interest in this area and would be able to offer countless testimonials from patients who have enjoyed significant benefits in the use of precision tinted lenses. As a of the college I feel my interest in this area is not just being overlooked, but negatively disparaged by these guidelines. It is important that children are being assessed by Optometrists when they are suffering reading difficulties - these guidelines may reduce the number of children presenting with such issues if doubts are being presented regarding the appropriateness of Optometric intervention. Children will then be more likely to be seen by those outside of Optometric practice who offer colour assessments without any assessment of their visual function or ocular health. I would urge the to revisit these guidelines and offer a more balanced approach, which recognises the experience and clinical expertise many Optometrists offer in this field. 13

14 of Optometrists Consultation comments and response August 2017 Section/s Comments response The section on Specific Learning Difficulties (p.29) is too critical and has not taken into account the number of patients who have been successfully treated and whose symptoms have been alleviated. I can provide testimonials from Patients teachers SENCOs and parents from my successful child and adult patients. No account has been taken that the number of inappropriate dispensing of filters from teachers and sencos or less experienced practitioners who perhaps have not used a specific method ( ie the colorimeter) and who have not first carried out an extensive orthoptic work-up and have perhaps prescribed before an extended placebo period to ensure the dispenses are likely to be specific helpful and long lasting. I feel the advice is overly critical and unhelpful as this specialist area is not being recognised for what it is all be it a small percentage of pxs. Section A88 I have video evidence that precision coloured lenses can make a dramatic difference to reading performance and visual acuity. I would not want to work without this facility to help both dyslexics and migraine sufferers. Ditto yoked prisms. Should be removed: A89 before you prescribe tinted lenses you should explain that the evidence is weak 14

15 of Optometrists Consultation comments and response August 2017 Section/s Comments response Should be removed: A89 - before you prescribe tinted lenses you should explain the evidence is weak. Section A88 A89 I feel it is wrong to say that There is currently no strong evidence that tinted lenses are effective in improving visual function in patients based upon what seems to be only one report whilst ignoring many reports that suggest otherwise. Changes regarding use of tinted lenses and overlays should not be made (sections A82-89). Current standards are reasonable based on a number of papers. Removal of these guidelines based on one study is rash and leaves practitioners who have been successfully treating visual stress for 20 yrs or more vulnerable and the public confused. The idea that the thousands of patients helped by a treatment conducted under current guidelines is mass hysteria is reckless for a professional body. As above As above 15

16 of Optometrists Consultation comments and response August 2017 Section/s Comments response A88 - I think this section needs work as there is evidence to support the improvement in symptoms that patients gain with tinted lenses when suffering from with Visual stress and also Migraine and these conditions need to be carefully assessed and treated appropriately with colour. Your statement regarding no 'strong evidence' suggests that what evidence there is, is not valid - this is not true. Yes more work must continue in this area but to state that the 'evidence is weak', discredits the work that has been done and the overarching improvement in symptoms that some patients gain who suffer from visual stress and migraine by the use of colour. As above A89 - do not agree that there is weak evidence for prescribing tinted lenses. As above 16

17 of Optometrists Consultation comments and response August 2017 Section/s Comments response REF: Specific Learning Difficulties: 1.The section appears to be biased against practitioners involved in Meares-Irlen syndrome wrongly implying that PTLs may be over prescribed. If the correct protocol is followed that the has recommended over the last yrs (ref Bruce Evans etc) then only a few patients go on to require PTLS as the overlay process eliminates those that don't benefit. 2. The evidence is weak for other practices that we follow ( e.g. see Should glasses be prescribed for all children with moderate hypermetropia? Editorial, Am Ac of Ophthalmology Vol123 No 4 April 2016). You could replace hypermetropia with Visual Stress!!! If as Optometrists we apply good practice and listen to symptoms, balanced with the best evidence we have to date, this should result in well informed the correct visual solutions. Until we have RCTs for all aspects of optometry ( which we don't) there might need to be a little flexibility in this area so that patients are not penalised. As above Remove the reference to the cost of lenses in this section, as it implies that opticians are influenced by this in their recommendations for prescribing PTLs. s are honourable, I think, and the is our representative body. 17

18 of Optometrists Consultation comments and response August 2017 Section/s Comments response The requests that practitioners warn patients that the evidence basis for an intervention with coloured lenses is weak. In fairness, if such a judgement is to be made this should apply to all interventions where the evidence is weak, not simply to precision tints. Many aspects of the optometric examination are without a good evidence base. Further, interventions for which there is no good evidence of efficacy or benefit include: Antiglare coatings Low plus lenses There is more evidence of efficacy for the use of coloured lenses than there is for the above interventions. The issue with coloured lenses is not that of the quantity or even the quality of the evidence, but rather the current controversy surrounding their use. It would therefore be more appropriate to warn patients of the controversy than the weakness of the evidence. Although most patients elect to purchase precision tints because of the evidence of their own eyes, our Delphi study provides a basis for clinicians decisions [1]. At the beginning of any new treatment there is likely to be controversy, and particularly so when more research is needed to fully understand the (neurological) mechanism for the benefit reported by patients. The current controversy has been occasioned by a biased review of precision tints [2], which sought an answer to the wrong question, and identified my Rate of Reading Test as a source of bias. Reviews of this kind, which classify the putative sources of bias in research studies need to demonstrate the reliability of the classification they use, for without reliability there cannot be validity. When two groups of judges have used methods of this kind under double-masked conditions, the correlation between judgments has been very low indeed, 0.1, indicating little or no agreement between groups of judges [3]. The opinions expressed in the review are therefore likely to have little or no validity, no matter how strongly they are held. The appears to be paying unwarranted attention to this review. As above 18

19 of Optometrists Consultation comments and response August 2017 Section/s Comments response Section examining px with difficulties or visual discomfort As a Behavioral Optometrist and clinician prescribing specific tinted lens for 25 years and more, I disagree to the changes made in this section. I feel the key point you should be competent to examine px with spld should remain I also think the the point you should satisfy tints benefit before prescribing should remain Those optometrists who have been trained and have attended courses in this subject and have experience of many years with px have seen the benefits tinted lens can have. There has also been further study in the benefits of tints for migraine and Brain injury with many patients getting significant relief. You have also removed A 82 The comments made by Evans in response to the Griffiths paper are not commented on I feel the guidelines give a very negative view in a controversial area where further study is needed I agree, but the college appears to have made their decision when I feel there is support from our Academics and patients need to be given an option rather than be told evidence is weak. I have seen many people continue to benefit from tints prescribed years ago. In some cases the tints have in their words been life changing. This all depends on the clinician covering all aspects of the visual and perceptual needs of the px and understanding the condition of SPLd As above I think the following comments should be removed in specific learning difficulties There is currently no strong evidence that tinted lenses are effective in improving visual function in specific learning difficulties. Interventions carry a cost to the patient and so you should explain that the evidence is weak. 19

20 of Optometrists Consultation comments and response August 2017 Section/s Comments response Member Overall I agree with the changes made to the Guidance Thank you for your response Member Overall I agree with the changes made to the Guidance Thank you for your response Member Overall I agree with the changes made to the Guidance Thank you for your response Member Overall I agree with the changes made to the Guidance Thank you for your response Member Overall I agree with the changes made to the Guidance Thank you for your response 20