Frequency of Eye Examinations – Report

1. Frequency of Eye Examinations – Report July 22, 2011

2. Study purpose • The main objective of this study is to provide a document based on current evidence and expert opinion supporting a frequency of eye examination guideline. • This guideline will be for typical optometric eye examinations as outlined by the CAO. • The frequency will be based on early detection of visual disorders and prevention of vision loss.

3. Grades for the Overall Quality of Evidence for each Recommendation Good: Evidence includes consistent results from well-designed, well-conducted studies in representative populations that directly assess effects on health outcomes. Fair: Evidence is sufficient to determine effects of health outcomes, but the strength of the evidence is limited by the number, quality, or consistency of the individual studies, generalizability to routine practice or indirect nature of the evidence of health outcomes. Poor: Evidence is insufficient to assess the effects of health outcomes because of limited number or power of studies, important flaws in their design or conduct, gaps in the chain of evidence or lack of information on important health outcomes.

4. Grades • Grades for individual studies are based on both study design and internal validity • Evidence from randomized controlled trials is considered to be the strongest. • Evidence from well-designed cohort or case-control analytic studies, preferably from more than one center comes after the experimental designs.

5. Critical Appraisal • All the studies providing evidence were evaluated using a template with extensive criteria and a global score was assigned to each study. • An example of how to quickly tell if an individual study has internal validity: • Cumming R.G. et al. “Improving Vision to Prevent Falls in Frail Older People: A randomized trial.” J Am Geriatr Soc 55:175-181, 2007.

6. Example • Abstract: “Conclusion: In frail older people, comprehensive vision and eye assessment, with appropriate treatment, does not reduce, and may even increase, the risk of falls and fractures.”

7. Example • What was done in the study: • Recruited 616 men and women 70 years and older from outpatient aged care centers • Randomized to intervention (seen by study optometrist) or control group • Higher number of falls and fractures recorded for the intervention group • 309 in the intervention group, 300 seen by optometrist, 92 received new eyeglasses • 307 in the control group, “a high proportion of control subjects reported seeing an eye care professional during the follow-up period”

8. Example • In the discussion section the researchers report: • There was a relatively high level of “contamination” of the control group • Bias was present • no masking • the control group was slightly frailer at baseline than the intervention group • “It is not possible to come to any firm conclusions from the current study.”

9. Overview of Methodology

10. Workshop What we did • Used a voting and discussion system to reach consensus regarding the guidelines for the frequency of eye examinations. Each age group was examined individually. • The purpose of this guideline is to inform the general population who are either asymptomatic or have symptoms that they do not recognize as being related to their eyes.

11. Workshop What we did not do • Advise which tests or testing procedure should be used. • Talk about treatment or management of problems.

12. Before Step 1: Literature Review • Five major causes of visual impairment or loss - refractive errors, glaucoma, diabetic retinopathy, macular degeneration and cataracts • (10,943 articles) Step 2: On-line bibliographic management program (Refworks) • Accepted articles: Screening (85) OR Epidemiological (166) Step 3: Comprehensive Summaries & Overview of Recommendations and Evidence

13. During • Expert group of 14 members of the optometric profession and one epidemiologist. • Representation from Ontario, Quebec and the east and west . • Previously received a summary of the findings of the literature review which highlighted where evidence currently exists for the frequency of eye examinations and where there are gaps in the information. • Voted on and discussed the appropriateness of each recommendation and reached consensus on eye examination guidelines for each age group using both the evidence and clinical experience.

14. After • Externally reviewed: Steps 5 & 13 of AGREE • Optometric patients at the UW optometry clinic • Consumer groups (e.g., CNIB, educators, GP`s etc.) • Optometrist and/or ophthalmologist who did not attend the workshop • Final Report • Transparent and defensible methodology • Clearly show where evidence exists and the level of evidence that is connected with each recommendation. • Identify where evidence is lacking and where further research is needed. • Documentation of the workshop and external review • Anticipate several academic papers will be published from this data. • Further dissemination is the responsibility of the CAO.

15. AGREE Instrument • Appraisal of Guidelines for Research & Evaluation (AGREE) Instrument: • Tool that assesses the methodological rigor and transparency in which a guideline is developed. • It is a methodological strategy and framework to: (1) Assess the quality of guidelines; (2) Develop clinical guidelines; and (3) Provide a structure to information reporting in the guidelines. • Six domains and 23 items • Rated on a scale from 1 to 7, strongly disagree to strongly agree.

16. Workshop ProcessFor Each Age Group

17. Based on evidence + clinical experiences • Expected harms greatly outweigh the expected benefits. • Two • Three • Four • Five - equal • Six • Seven • Eight • Expected benefits greatly outweigh the expected harms. • Harm: • Eye Exam itself (e.g. side effects, cost) • Disease isn’t detected • Patient develops disease • Impact on quality of life and productivity • Cost to society.

18. Results 1 – Recommendation is extremely inappropriate 2 3 4 5 Harms and benefits are about equal 6 7 8 9 – Recommendation is extremely appropriate • Median of 7,8,9 = the recommendation is appropriate • The median of a set of numbers is the value for which half the numbers are larger and half are smaller – the middle value.

19. Results Age Group Notes We were able to reach consensus for each group. The recommendations were primarily based on evidence. • Birth – 24 months • 2- 5 Years • 6 – 19 Years • 20 – 39 Years • 40 – 64 Years • 65 +

20. Guideline: Post workshop • * These recommendations are intended to inform individuals who are either asymptomatic or have symptoms they do not recognize as being eye-related and therefore, are not appropriate for all clinical situations. “The decision to follow or not follow the recommendation from a guideline must be made by the health professional on an individual basis, taking into account the specific condition of the patient. Deviations from guidelines for specific reasons are possible” [Schwartz et al. (1999). The legal implications of medical guidelines – A task force of the European Society of Cardiology. Eur Heart J, 20(16)].

21. Guideline: Post external review • * These recommendations are intended to inform individuals who are either asymptomatic or have symptoms they do not recognize as being eye-related and therefore, are not appropriate for all clinical situations. “The decision to follow or not follow the recommendation from a guideline must be made by the health professional on an individual basis, taking into account the specific condition of the patient. Deviations from guidelines for specific reasons are possible” [Schwartz et al. (1999). The legal implications of medical guidelines – A task force of the European Society of Cardiology. Eur Heart J, 20(16)].

22. Example • Is there evidence against routine eye exams? • Taylor HR, Vu HTV, McCarty CA, Keeffe JE. The need for routine eye examinations. Investigative Ophthalmology and Vision Science 2004;45:2539-2542.

23. Example • Abstract: • Conclusions. Frequent routine eye examinations of those with normal examination results will have a low yield and may not be cost effective. • COS guideline: • “Therefore, frequent routine eye examinations of those with initial normal examination results will have a low yield and may not be cost effective.”

24. Example • What was done in the study: • 3271 participants at baseline (VIP) • 2594 out of 3040 participated in 5 year follow-up • 1590 were used for this analysis (4 criteria) • 38 people developed BCVA < 6/12 or visual field loss in at least one eye • 24 or 63% noticed the vision loss • 14 or 0.88% of the whole cohort had unrecognized vision loss • 20 of the 38 had at least one eye examination during the time interval between baseline and follow-up

25. Example How frequently do people who do not have vision loss have their eyes examined? Why is the data missing? You cannot make statements on the value of routine eye examinations by presenting only half of the data required.!

26. Example How frequently do people who do not have vision loss have their eyes examined? (Hypothetical data) Relative risk of vision loss over 5 years = 61.3. In this hypothetical example you would be ~ 61 times more likely to have vision loss if you did not have your eyes examined.

27. Example • Is there evidence against routine eye exams? NO!

28. Getting to the final report • Next steps • Completion of external review • Final report presented to CAO