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1.  The Sight Loss and Vision Priority Setting Partnership (SLV-PSP): overview and results of the research prioritisation survey process 
BMJ Open  2014;4(7):e004905.
Objectives
The Sight Loss and Vision Priority Setting Partnership aimed to identify research priorities relating to sight loss and vision through consultation with patients, carers and clinicians. These priorities can be used to inform funding bodies’ decisions and enhance the case for additional research funding.
Design
Prospective survey with support from the James Lind Alliance.
Setting
UK-wide National Health Service (NHS) and non-NHS.
Participants
Patients, carers and eye health professionals. Academic researchers were excluded solely from the prioritisation process. The survey was disseminated by patient groups, professional bodies, at conferences and through the media, and was available for completion online, by phone, by post and by alternative formats (Braille and audio).
Outcome measure
People were asked to submit the questions about prevention, diagnosis and treatment of sight loss and eye conditions that they most wanted to see answered by research. Returned survey questions were reviewed by a data assessment group. Priorities were established across eye disease categories at final workshops.
Results
2220 people responded generating 4461 submissions. Sixty-five per cent of respondents had sight loss and/or an eye condition. Following initial data analysis, 686 submissions remained which were circulated for interim prioritisation (excluding cataract and ocular cancer questions) to 446 patients/carers and 218 professionals. The remaining 346 questions were discussed at final prioritisation workshops to reach agreement of top questions per category.
Conclusions
The exercise engaged a diverse community of stakeholders generating a wide range of conditions and research questions. Top priority questions were established across 12 eye disease categories.
doi:10.1136/bmjopen-2014-004905
PMCID: PMC4120376  PMID: 25056971
Sight loss; Vision; Research; Priorities; Partnership; James Lind Alliance
2.  The effectiveness of schemes that refine referrals between primary and secondary care—the UK experience with glaucoma referrals: the Health Innovation & Education Cluster (HIEC) Glaucoma Pathways Project 
BMJ Open  2013;3(7):e002715.
Objectives
A comparison of glaucoma referral refinement schemes (GRRS) in the UK during a time period of considerable change in national policy and guidance.
Design
Retrospective multisite review.
Setting
The outcomes of clinical examinations by optometrists with a specialist interest in glaucoma (OSIs) were compared with optometrists with no specialist interest in glaucoma (non-OSIs). Data from Huntingdon and Nottingham assessed non-OSI findings, while Manchester and Gloucestershire reviewed OSI findings.
Participants
1086 patients. 434 patients were from Huntingdon, 179 from Manchester, 204 from Gloucestershire and 269 from Nottingham.
Results
The first-visit discharge rate (FVDR) for all time periods for OSIs was 14.1% compared with 36.1% from non-OSIs (difference 22%, CI 16.9% to 26.7%; p<0.001). The FVDR increased after the April 2009 National Institute for Health and Clinical Excellence (NICE) glaucoma guidelines compared with pre-NICE, which was particularly evident when pre-NICE was compared with the current practice time period (OSIs 6.2–17.2%, difference 11%, CI −24.7% to 4.3%; p=0.18, non-OSIs 29.2–43.9%, difference 14.7%, CI −27.8% to −0.30%; p=0.03). Elevated intraocular pressure (IOP) was the commonest reason for referral for OSIs and non-OSIs, 28.7% and 36.1%, respectively, of total referrals. The proportion of referrals for elevated IOP increased from 10.9% pre-NICE to 28.0% post-NICE for OSIs, and from 19% to 45.1% for non-OSIs.
Conclusions
In terms of ‘demand management’, OSIs can reduce FVDR of patients reviewed in secondary care; however, in terms of ‘patient safety’ this study also shows that overemphasis on IOP as a criterion for referral is having an adverse effect on both the non-OSIs and indeed the OSIs ability to detect glaucomatous optic nerve features. It is recommended that referral letters from non-OSIs be stratified for risk, directing high-risk patients straight to secondary care, and low-risk patients to OSIs.
doi:10.1136/bmjopen-2013-002715
PMCID: PMC3717451  PMID: 23878172
3.  Glaucoma 
Clinical Evidence  2011;2011:0703.
Introduction
Glaucoma is characterised by progressive optic neuropathy and peripheral visual field loss. It affects 1% to 2% of white people aged over 40 years and accounts for 8% of new blind registrations in the UK. The main risk factor for glaucoma is raised intraocular pressure, but 40% of people with glaucoma have normal intraocular pressure and only 10% of people with raised intraocular pressure are at risk of optic-nerve damage. Glaucoma is more prevalent, presents earlier, and is more difficult to control in black people than in white populations.
Methods and outcomes
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of treatments for established primary open-angle glaucoma, ocular hypertension, or both? What are the effects of lowering intraocular pressure in people with normal-tension glaucoma? What are the effects of treatment for acute angle-closure glaucoma? We searched: Medline, Embase, The Cochrane Library, and other important databases up to May 2010 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
Results
We found 12 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
Conclusions
In this systematic review we present information relating to the effectiveness and safety of the following interventions: laser trabeculoplasty (alone or plus topical medical treatment), topical medical treatments, and surgical trabeculectomy.
Key Points
Glaucoma is characterised by progressive optic neuropathy and peripheral visual field loss. It affects 1% to 2% of white people aged over 40 years and accounts for 8% of new blind registrations in the UK. The main risk factor for glaucoma is raised intraocular pressure (IOP), but up to 40% of people with glaucoma have normal IOP and only about 10% of people with raised IOP are at risk of optic-nerve damage.Glaucoma is more prevalent, presents earlier, and is more difficult to control in black people (especially those of West African descent) than in white populations.Blindness from glaucoma results from gross loss of visual field or loss of central vision and, when the optic nerve is vulnerable, can progress quickly without treatment.
Lowering IOP by laser trabeculoplasty plus topical medical treatment may be more effective at reducing progression of glaucoma in people with primary open-angle or pseudoexfoliation glaucoma, compared with no treatment.
Topical medical treatment may reduce the risk of developing glaucoma in people with ocular hypertension, compared with placebo.
We don't know whether topical medical treatment, laser trabeculoplasty, or surgical trabeculectomy is more effective at maintaining visual fields and acuity in primary open-angle glaucoma. Surgery may increase the risk of developing cataracts.
We don't know whether reducing IOP with medical treatment alone or in combination with other treatments including surgery is more effective than no treatment at reducing progression of visual field loss in people with normal-tension glaucoma.
There is a consensus that medical and surgical treatments are beneficial in people with acute angle-closure glaucoma, although we don't know this for sure because it is unethical to withhold pressure-lowering treatment.
The consensus about how laser treatments compare with medical or surgical treatments in people with acute angle-closure glaucoma is currently uncertain, and more high-quality evidence is needed.
PMCID: PMC3275300  PMID: 21658300
4.  Geographical variation in certification rates of blindness and sight impairment in England, 2008–2009 
BMJ Open  2012;2(6):e001496.
Objectives
To examine and interpret the variation in the incidence of blindness and sight impairment in England by PCT, as reported by the Certificate of Vision Impairment (CVI).
Design
Analysis of national certification data.
Setting
All Primary Care Trusts, England.
Participants
23 773 CVI certifications issued from 2008 to 2009.
Main Outcome measures
Crude and Age standardised rates of CVI data for blindness and sight loss by PCT.
Methods
The crude and age standardised CVI rates per 100 000 were calculated with Spearman's rank correlation used to assess whether there was any evidence of association between CVI rates with Index of Multiple Deprivation (IMD) and the Programme Spend for Vision.
Results
There was high-level variation, almost 11-fold (coefficient of variation 38%) in standardised CVI blindness and sight impairment annual certification rates across PCTs. The mean rate was 43.7 and the SD 16.7. We found little evidence of an association between the rate of blindness and sight impairment with either the IMD or Programme Spend on Vision.
Conclusions
The wide geographical variation we found raises questions about the quality of the data and whether there is genuine unmet need for prevention of sight loss. It is a concern for public health practitioners who will be interpreting these data locally and nationally as the CVI data will form the basis of the public health indicator ‘preventable sight loss’. Poor-quality data and inadequate interpretation will only create confusion if not addressed adequately from the outset. There is an urgent need to address the shortcomings of the current data collection system and to educate all public health practitioners.
doi:10.1136/bmjopen-2012-001496
PMCID: PMC3532990  PMID: 23166126
Public Health; Ophthalmology
5.  The estimated prevalence and incidence of late stage age related macular degeneration in the UK 
Background
UK estimates of age related macular degeneration (AMD) occurrence vary.
Aims
To estimate prevalence, number and incidence of AMD by type in the UK population aged ≥50 years.
Methods
Age-specific prevalence rates of AMD obtained from a Bayesian meta-analysis of AMD prevalence were applied to UK 2007–2009 population data. Incidence was estimated from modelled age-specific prevalence.
Results
Overall prevalence of late AMD was 2.4% (95% credible interval (CrI) 1.7% to 3.3%), equivalent to 513 000 cases (95% CrI 363 000 to 699 000); estimated to increase to 679 000 cases by 2020. Prevalences were 4.8% aged ≥65 years, 12.2% aged ≥80 years. Geographical atrophy (GA) prevalence rates were 1.3% (95% CrI 0.9% to 1.9%), 2.6% (95% CrI 1.8% to 3.7%) and 6.7% (95% CrI 4.6% to 9.6%); neovascular AMD (NVAMD) 1.2% (95% CrI 0.9% to 1.7%), 2.5% (95% CrI 1.8% to 3.4%) and 6.3% (95% CrI 4.5% to 8.6%), respectively. The estimated number of prevalent cases of late AMD were 60% higher in women versus men (314 000 cases in women, 192 000 men). Annual incidence of late AMD, GA and NVAMD per 1000 women was 4.1 (95% CrI 2.4% to 6.8%), 2.4 (95% CrI 1.5% to 3.9%) and 2.3 (95% CrI 1.4% to 4.0%); in men 2.6 (95% CrI 1.5% to 4.4%), 1.7 (95% CrI 1.0% to 2.8%) and 1.4 (95% CrI 0.8% to 2.4%), respectively. 71 000 new cases of late AMD were estimated per year.
Conclusions
These estimates will guide health and social service provision for those with late AMD and enable estimation of the cost of introducing new treatments.
doi:10.1136/bjophthalmol-2011-301109
PMCID: PMC3329633  PMID: 22329913
Prevalence; incidence; AMD; UK; epidemiology; clinical trial
6.  Setting Standards for Glaucoma Care 
Community Eye Health  2012;25(79-80):47.
PMCID: PMC3588127  PMID: 23520414
7.  Glaucoma 
Clinical Evidence  2009;2009:0703.
Introduction
Glaucoma is characterised by progressive optic neuropathy and peripheral visual field loss. It affects 1% to 2% of white people aged over 40 years and accounts for 8% of new blind registrations in the UK. The main risk factor for glaucoma is raised intraocular pressure, but 40% of people with glaucoma have normal intraocular pressure and only 10% of people with raised intraocular pressure are at risk of optic-nerve damage. Glaucoma is more prevalent, presents earlier, and is more difficult to control in black people than in white populations.
Methods and outcomes
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of treatments for established primary open-angle glaucoma, ocular hypertension, or both? What are the effects of lowering intraocular pressure in people with normal-tension glaucoma? What are the effects of treatment for acute angle-closure glaucoma? We searched: Medline, Embase, The Cochrane Library, and other important databases up to November 2007 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
Results
We found 20 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
Conclusions
In this systematic review we present information relating to the effectiveness and safety of the following interventions: laser trabeculoplasty (alone or plus topical medical treatment); topical medical treatments; and surgical trabeculectomy.
Key Points
Glaucoma is characterised by progressive optic neuropathy and peripheral visual field loss. It affects 1% to 2% of white people aged over 40 years and accounts for 8% of new blind registrations in the UK. The main risk factor for glaucoma is raised intraocular pressure (IOP), but up to 40% of people with glaucoma have normal IOP and only about 10% of people with raised IOP are at risk of optic-nerve damage.Glaucoma is more prevalent, presents earlier, and is more difficult to control in black people (especially those of West African descent) than in white populations.Blindness from glaucoma results from gross loss of visual field or loss of central vision and, when the optic nerve is vulnerable, can progress quickly without treatment.
Lowering IOP by laser trabeculoplasty plus topical medical treatment may be more effective at reducing progression of glaucoma in people with primary open-angle or pseudoexfoliation glaucoma, compared with no treatment.
Topical medical treatment may reduce the risk of developing glaucoma in people with ocular hypertension compared with placebo.
We don't know whether topical medical treatment, laser trabeculoplasty, orsurgical trabeculectomyare more effective at maintaining visual fields and acuity in primary open-angle glaucoma. Surgery may increase the risk of developing cataracts.
We don't know whether reducing IOP with medical treatment alone or in combination with other treatments including surgery is more effective than no treatment at reducing progression of visual field loss in people with normal-tension glaucoma.
There is a consensus that medical and surgical treatments are beneficial in people with acute angle-closure glaucoma, although we don't know this for sure because it is unethical to withhold pressure-lowering treatment.
PMCID: PMC2907771
8.  Provision of eye care: commissioning change 
doi:10.1258/jrsm.2007.070407
PMCID: PMC2235923  PMID: 18263904
10.  Topical azithromycin: new evidence? 
Should mass distribution of azithromycin be in topical rather than oral formulation?
doi:10.1136/bjo.2006.107102
PMCID: PMC1954780  PMID: 17446502
11.  Masking is better than blinding 
BMJ : British Medical Journal  2007;334(7597):799.
Why the term “blinding” should not be used in clinical trials
doi:10.1136/bmj.39175.503299.94
PMCID: PMC1851996
12.  Is the NEI-VFQ-25 a useful tool in identifying visual impairment in an elderly population? 
BMC Ophthalmology  2006;6:24.
Background
The use of self-report questionnaires to substitute for visual acuity measurement has been limited. We examined the association between visual impairment and self reported visual function in a population sample of older people in the UK.
Methods
Cross sectional study of people aged more than 75 years who initially participated in a trial of health screening. The association between 25-item National Eye Institute Visual Function Questionnaire (NEI-VFQ) scores and visual impairment (defined as an acuity of less than 6/18 in the better eye) was examined using logistic regression.
Results
Visual acuity and NEI-VFQ scores were obtained from 1807 participants (aged 77 to 101 years, 36% male), from 20 general practices throughout the UK. After adjustment for age, gender, practice and NEI-VFQ sub-scale scores, those complaining of poor vision in general were 4.77 times (95% CI 3.03 to 7.53) more likely to be visually impaired compared to those who did not report difficulty. Self-reported limitations with social functioning and dependency on others due to poor vision were also associated with visual impairment (odds ratios, 2.52, 95% CI 1.55 to 4.11; 1.73, 95% CI 1.05 to 2.86 respectively). Those reporting difficulties with near vision and colour vision were more likely to be visually impaired (odds ratios, 2.32, 95% CI 1.30 to 4.15; 2.25, 95% CI 1.35 to 3.73 respectively). Other NEI-VFQ sub-scale scores were unrelated to measures of acuity. Similar but weaker odds ratios were found with reduced visual acuity (defined as less than 6/12 in the better eye). Although differences in NEI-VFQ scores were small, scores were strongly associated with visual acuity, binocular status, and difference in acuity between eyes.
Conclusion
NEI-VFQ questions regarding the quality of general vision, social functioning, visual dependency, near vision and colour vision are strongly and independently associated with an objective measure of visual impairment in an elderly population.
doi:10.1186/1471-2415-6-24
PMCID: PMC1523367  PMID: 16764714
13.  Leading causes of certification for blindness and partial sight in England & Wales 
BMC Public Health  2006;6:58.
Background
Prevention of visual impairment is an international priority agreed at the World Health Assembly of 2002- yet many countries lack contemporary data about incidence and causes from which priorities for prevention, treatment and management can be identified.
Methods
Registration as blind or partially-sighted in England and Wales is voluntary and is initiated by certification by a consultant ophthalmologist. From all certificates completed during the year April 1999 to March 2000, the main cause of visual loss was ascertained where possible and here we present information on the leading causes observed and comment on changes in the three leading causes since the last analysis conducted for 1990–1991 data.
Results
13788 people were certified as blind, 19107 were certified as partially sighted. The majority of certifications were in the older age groups. The most commonly recorded main cause of certifications for both blindness (57.2 %) and partial sight (56 %) was degeneration of the macula and posterior pole which largely comprises age-related macular degeneration. Glaucoma and diabetic retinopathy were the next most commonly recorded main causes. Overall, the age specific incidence of all three leading causes has increased since 1990–1991 – with changes in diabetic retinopathy being the most marked – particularly in the over 65's where figures have more than doubled.
Conclusion
The numbers of individuals per 100,000 population being certified blind or partially sighted due to the three leading causes – AMD, diabetic retinopathy and glaucoma have increased since 1990. This may to some extent be explained by improved ascertainment. The process of registration for severe visual impairment in England and Wales is currently undergoing review. Efforts must be made to ensure that routine collection of data on causes of severe visual impairment is continued, particularly in this age of improved technology, to allow such trends to be monitored and changes in policy to be informed.
doi:10.1186/1471-2458-6-58
PMCID: PMC1420283  PMID: 16524463
15.  Trends in provision of photodynamic therapy and clinician attitudes: a tracker survey of a new health technology 
Background
There has been debate about the cost-effectiveness of photodynamic therapy (PDT), a treatment for neovascular age-related macular degeneration. We have been monitoring trends for the provision of PDT in the UK National Health Service. The fourth annual 'tracker' survey took place as definitive National Institute for Clinical Excellence (NICE) guidance was issued. We assessed trends in PDT provision up to the point of release of the NICE guidance and identified likely sources of pressure on ophthalmologists to provide PDT.
Methods
National postal questionnaire survey of clinicians with potential responsibility for PDT provision. The survey explored reported local provision, beliefs about the effectiveness of PDT and what sources of opinion might influence attitudes towards providing PDT.
Results
The response rate was 73% (111/150). Almost half of the surveyed ophthalmology units routinely provided PDT, as part of a trend of steady growth in provision. The proportion of respondents who believed that further proof of effectiveness was required has also declined despite the absence of any new substantial evidence. Attitudes towards providing PDT were positive, on average, and were more strongly associated with perceived social pressure from local colleagues than from other sources. Local colleagues were seen as being most approving of PDT.
Conclusion
Those responsible for implementing the NICE guidance need to address ophthalmologists' beliefs about the evidence of effectiveness for PDT and draw upon supportive local individuals or networks to enhance the credibility of the guidance.
doi:10.1186/1472-6963-5-34
PMCID: PMC1142515  PMID: 15885142
16.  Bridging the gap to evidence-based eye care 
Community Eye Health  2004;17(51):40-41.
PMCID: PMC1705726  PMID: 17491814
17.  The evidence base for trachoma interventions 
Community Eye Health  2004;17(52):60.
PMCID: PMC1705741  PMID: 17491825
19.  Evidence-Base for Low Vision Rehabilitation 
Community Eye Health  2004;17(49):12.
PMCID: PMC1705710  PMID: 17491793
20.  Screening older people for impaired vision in primary care: cluster randomised trial 
BMJ : British Medical Journal  2003;327(7422):1027.
Objective To determine the effectiveness of screening for visual impairment in people aged 75 or over as part of a multidimensional screening programme.
Design Cluster randomised trial.
Setting General practices in the United Kingdom participating in the MRC trial of assessment and management of older people in the community.
Participants 4340 people aged 75 years or over randomly sampled from 20 general practices, excluding people resident in hospitals or nursing homes.
Intervention Visual acuity testing and referral to eye services for people with visual impairment. Universal screening (assessment and visual acuity testing) was compared with targeted screening, in which only participants with a range of health related problems were offered an assessment that included acuity screening.
Main outcome measures Proportion of people with visual acuity less than 6/18 in either eye; mean composite score of 25 item version of the National Eye Institute visual function questionnaire.
Results Three to five years after screening, the relative risk of having visual acuity < 6/18 in either eye, comparing universal with targeted screening, was 1.07 (95% confidence interval 0.84 to 1.36; P = 0.58). The mean composite score of the visual function questionnaire was 85.6 in the targeted screening group and 86.0 in the universal group (difference 0.4, 95% confidence interval -1.7 to 2.5, P = 0.69).
Conclusions Including a vision screening component by a practice nurse in a pragmatic trial of multidimensional screening for older people did not lead to improved visual outcomes.
PMCID: PMC261660  PMID: 14593039
23.  Deprivation and late presentation of glaucoma: case-control study 
BMJ : British Medical Journal  2001;322(7287):639-643.
Objective
To identify socioeconomic risk factors for first presentation advanced glaucomatous visual field loss.
Design
Hospital based case-control study with prospective identification of patients.
Setting
Three hospital eye departments.
Participants
Consecutive patients newly diagnosed with glaucoma (n=220). Cases (late presenters) were those presenting with advanced glaucoma (n=110), controls were those with early glaucoma (n=110).
Results
Median underprivileged area scores were higher among late presenters (29.5; interquartile range 9.0-42.2) than in the control group (21.3; 6.1-37.4) (P=0.035). Late presenters were more likely to be of lower occupational class (odds ratio adjusted for age and referral centre 20.1 (95% confidence interval 2.6 to 155) for group III compared with group I-II and 86.0 (11.0 to 673 for group IV-V compared with group I-II), to have no access to a car (2.2; 1.2 to 4.0), to have left full time education at age 14 or less (7.5; 2.3 to 24.7), and to be tenants rather than owner occupiers (local authority tenants 3.2; 1.7 to 5.8, private tenants 2.1; 0.7 to 5.8). Effects of deprivation were partly accounted for by family history of glaucoma, time since last visit to an optometrist, and lack of an initial diagnosis of glaucoma by an optometrist.
Conclusions
Area and individual level deprivation were both associated with late presentation of glaucoma. Existing evidence shows that late presentation is an important risk factor for subsequent blindness. Deprived groups thus seem to be at greater risk of going blind from glaucoma. Material deprivation may be associated with more aggressive disease as well as later presentation.
PMCID: PMC26542  PMID: 11250847
24.  Epidemiology in Practice: Screening for Eye Disease 
Community Eye Health  1999;12(30):29-30.
PMCID: PMC1706002  PMID: 17491988

Results 1-25 (26)