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Relation between dietary n-3 and n-6 fatty acids and clinically diagnosed dry eye syndrome in women depression symptoms worsening generic 50 mg asendin amex. Efficacy of a new prescription-only medical food supplement in alleviating signs and symptoms of dry eye depression warning signs buy asendin once a day, with or without concomitant cyclosporine A depression workbook pdf generic asendin 50 mg with visa. Silicone versus collagen plugs for treating dry eye: results of a prospective randomized trial including lacrimal scintigraphy depression symptoms in dogs cheap asendin online. Effects of lacrimal occlusion with collagen and silicone plugs on patients with conjunctivitis associated with dry eye. Management of complications after insertion of the SmartPlug punctal plug: a study of 28 patients. Pilocarpine tablets for the treatment of dry mouth and dry eye symptoms in patients with Sjogren syndrome: a randomized, placebo-controlled, fixed-dose, multicenter trial. Allogeneic serum eye drops for the treatment of severe dry eye in patients with chronic graft-versus-host disease. Comparison of local acetylcysteine and artificial tears in the management of dry eye syndrome. Correlation of goblet cell density and mucosal epithelial membrane mucin expression with rose bengal staining in patients with ocular irritation. The effect of topical cyclosporine-A on clinical findings and cytological grade of the disease in patients with dry eye. Correlation of tear fluorescein clearance and Schirmer test scores with ocular irritation symptoms. Correlation of the Schirmer 1 and fluorescein clearance tests with the severity of corneal epithelial and eyelid disease. A multicentre, double masked, randomized, controlled trial assessing the effect of oral supplementation of omega-3 and omega-6 fatty acids on a conjunctival inflammatory marker in dry eye patients. Summary of the topic and Major Recommendations Dry eye is a multi-factorial disease of the tears and ocular surface that results in discomfort, visualdisturbance and tear film instability with potential damage to the ocular surface, and accompanied by increased tear osmolality and inflammation. The diagnosis of dry eye is often difficult because of lack of sufficiently discriminatory clinical diagnostic techniques that provide consistent and unambiguous results. Its management can be a frustrating experience for both patient and their eye-care providers. The conventional approach to the management of dry eye with tear substitutes is not enough in moderate to severe dry eye. The newer treatment approach is to target the underlying risk factors of dry eye instead of conventional symptomatic relief. Patient History Symptoms with duration; Exacerbating conditions Topical medications used, their frequency, and their effect on symptoms Contact lens wear, schedule, and care Allergic conjunctivitis history Chemical injury; Radiation of the orbit Ocular surgical history Punctal surgery; Eyelid surgery Menopause; oral hormonal therapy Systemic autoimmune connective tissue disorders Other systemic conditions Systemic medications Dry mouth, dental cavities, oral ulcers Atopy or other Dermatological diseases; Chronic viral infections Neurological conditions Smoking or passive smoking Technique of facial washing including eyelid hygiene Examination: the physical examination includes testing visual acuity, an external examination,and slitlamp biomicroscopy. A laboratory and clinical evaluation for autoimmune disorders should be considered for patients with significant dry eye Treatment Specific treatment recommendations depend on the severity and source of the dry eye. Treatments for dry eye disease should be based on the severity level of the disease. Specific therapies may be chosen from any category regardless of the level of disease severity, depending on physician experience and patient preference. Follow-up the frequency and extent of the follow-up evaluation will depend on the severity of disease, the therapeutic approach, and the response to the therapy. For example, sterile corneal ulceration associated with dry eye may require daily follow-up. Patients with pre-existing dry eye should be cautioned that refractive surgery may worsen their dry eye condition. Patients who have dry eye and are considering refractive surgery should have the dry eye treated before surgery. This document should be cited as follows: American Academy of Ophthalmology Cornea/External Disease Panel. Authors and reviewers of the guidelines are volunteers and do not receive any financial compensation for their contributions to the documents. The guidelines are externally reviewed by experts and stakeholders before publication. All those returning comments were required to provide disclosure of relevant relationships with industry to have their comments considered. Members of the Cornea/External Disease Preferred Practice Pattern Panel reviewed and discussed these comments and determined revisions to the document. The Academy has Relationship with Industry Procedures to comply with the Code (available at one. A majority (70%) of the members of the Cornea/External Disease Preferred Practice Pattern Panel 2012?2013 had no financial relationship to disclose. The Preferred Practice Pattern? guidelines are based on the best available scientific data as interpreted by panels of knowledgeable health professionals. In some instances, such as when results of carefully conducted clinical trials are available, the data are particularly persuasive and provide clear guidance. In other instances, the panels have to rely on their collective judgment and evaluation of available evidence. These documents provide guidance for the pattern of practice, not for the care of a particular individual. While they should generally meet the needs of most patients, they cannot possibly best meet the needs of all patients. These practice patterns should not be deemed inclusive of all proper methods of care or exclusive of other methods of care reasonably directed at obtaining the best results. The physician must make the ultimate judgment about the propriety of the care of a particular patient in light of all of the circumstances presented by that patient. The American Academy of Ophthalmology is available to assist members in resolving ethical dilemmas that arise in the course of ophthalmic practice. Preferred Practice Pattern? guidelines are not medical standards to be adhered to in all individual situations. The Academy specifically disclaims any and all liability for injury or other damages of any kind, from negligence or otherwise, for any and all claims that may arise out of the use of any recommendations or other information contained herein. References to certain drugs, instruments, and other products are made for illustrative purposes only and are not intended to constitute an endorsement of such. Such material may include information on applications that are not considered community standard, that reflect indications not included in approved U. Innovation in medicine is essential to ensure the future health of the American public, and the Academy encourages the development of new diagnostic and therapeutic methods that will improve eye care. It is essential to recognize that true medical excellence is achieved only when the patients? needs are the foremost consideration. All Preferred Practice Pattern? guidelines are reviewed by their parent panel annually or earlier if developments warrant and updated accordingly. Preferred Practice Pattern guidelines are funded by the Academy without commercial support. Where evidence exists to support a recommendation for care, the recommendation should be given an explicit rating that shows the strength of evidence. To locate ratings for specific recommendations, see Appendix 3 for additional information. Worsening of symptoms in the morning is typical of blepharitis, whereas symptoms that are worse later in the day are typical of aqueous deficient dry eye. Blepharitis is typically a chronic condition that cannot be permanently cured, and successful management is dependent on patient compliance with a treatment regimen. Costly new technologies (including devices using thermal pulsation) are available, but the current evidence is not sufficient to support their use in the treatment of blepharitis. Topical antibiotic ointments with or without corticosteroids or oral antibiotics can be used effectively in the treatment of blepharitis. Although azithromycin is used as a treatment for blepharitis, it may be hazardous when used orally in patients with cardiovascular problems. In patients with chronic blepharitis that does not respond to therapy, the possibility of carcinoma should be considered, particularly if associated with a loss of eyelashes. Early diagnosis and appropriate treatment can prevent disfigurement and may be lifesaving. Staphylococcal and seborrheic blepharitis involve mainly the anterior eyelid and can each be referred to as anterior blepharitis. Meibomian gland dysfunction, as defined by the International Workshop on Meibomian Gland Dysfunction (
This usually youth depression definition buy 50 mg asendin visa, but not always depression group activities buy asendin american express, happens in people who also take a steroid medicine which is being stopped or for which the dose is being lowered bipolar depression famous people purchase asendin without a prescription. If you already have a parasitic infection it should be treated before you start treatment with Dupixent mood disorder test free cheap 50 mg asendin otc. Asthma If you have asthma and are taking asthma medicines, do not change or stop your asthma medicine without talking to your doctor. Talk to your doctor before you stop Dupixent or if your asthma remains uncontrolled or worsens during treatment with this medicine. Eye problems (if you have atopic dermatitis) Talk to your doctor if you have any new or worsening eye problems, including eye pain or changes in vision. The safety and benefits of Dupixent are not yet known in children with atopic dermatitis below the age of 12. Other medicines for asthma Do not stop or reduce your asthma medicines, unless instructed by your doctor. If you are pregnant, think you may be pregnant, or are planning to have a baby, ask your doctor for advice before using this medicine. The effects of this medicine in pregnant women are not known; therefore it is preferable to avoid the use of Dupixent in pregnancy unless your doctor advises to use it. Driving and using machines Dupixent is unlikely to influence your ability to drive and use machines. Dupixent contains sodium this medicine contains less than 1 mmol sodium (23 mg) per 300 mg dose, i. How to use Dupixent Always use this medicine exactly as your doctor or pharmacist has told you. How Dupixent is given Dupixent is given by injection under the skin (subcutaneous injection). How much Dupixent you will receive Your doctor will decide which dose of Dupixent is right for you. Recommended dose in adults with atopic dermatitis For patients with atopic dermatitis, the recommended dose of Dupixent is: Recommended dose in adolescents with atopic dermatitis the recommended dose of Dupixent for adolescents (12 to 17 years of age) with atopic dermatitis is based on body weight: 118 Body Weight of Initial Dose Subsequent Doses Patient (every other week) less than 60 kg 400 mg (two 200 mg injections) 200 mg 60 kg or more 600 mg (two 300 mg injections) 300 mg Recommended dose in adult and adolescent patients with asthma (12 years of age and older) For patients with severe asthma and who are on oral corticosteroids or for patients with severe asthma and co-morbid moderate-to-severe atopic dermatitis or adults with co-morbid severe chronic rhinosinusitis with nasal polyposis, the recommended dose of Dupixent is: Injecting Dupixent Dupixent is given by injection under your skin (subcutaneous injection). You and your doctor or nurse should decide if you should inject Dupixent yourself. Before injecting Dupixent yourself you must have been properly trained by your doctor or nurse. Your Dupixent injection may also be given by a caregiver after proper training by a doctor or nurse. Read the Instructions for Use? for the pre-filled pen carefully before using Dupixent. If you use more Dupixent than you should If you use more Dupixent than you should or the dose has been given too early, talk to your doctor, pharmacist or nurse. If you forget to use Dupixent If you have forgotten to inject a dose of Dupixent, talk to your doctor, pharmacist or nurse. If you stop using Dupixent Do not stop using Dupixent without speaking to your doctor first. If you have any further questions on the use of this medicine, ask your doctor, pharmacist or nurse. Possible side effects Like all medicines, this medicine can cause side effects, although not everybody gets them. Dupixent can cause serious side effects, including very rare allergic (hypersensitivity) reactions, including anaphylactic reaction; the signs of allergic reaction or anaphylactic reaction may include: Other side effects Very Common (may affect more than 1 in 10 people) atopic dermatitis and asthma: You can also report side effects directly via the national reporting system listed in Appendix V. By reporting side effects you can help provide more information on the safety of this medicine. If necessary, pre-filled pens may be kept at room temperature up to 25?C for a maximum of 14 days. If you need to permanently remove the carton from the refrigerator, write down the date of removal in the space provided on the outer carton, and use Dupixent within 14 days. Do not use this medicine if you notice that the medicine is cloudy, discoloured, or has particles in it. Ask your doctor, pharmacist or nurse how to throw away medicines you no longer use. What Dupixent looks like and contents of the pack 120 Dupixent is a clear to slightly opalescent, colourless to pale yellow solution supplied in a pre-filled pen. Dupixent is available as 300 mg pre-filled pens in a pack containing 1, 2, 3, or 6 pre-filled pens. Tlf: +45 45 16 70 00 Tel: +39 02 39394275 Deutschland Nederland Sanofi-Aventis Deutschland GmbH sanofi-aventis Netherlands B. Tel: +353 (0) 1 403 56 00 Tel: +386 1 560 48 00 Island Slovenska republika Vistor hf. It contains 300 mg of Dupixent for injection under the skin (subcutaneous injection). You must not try to give yourself or someone else the injection unless you have received training from your healthcare professional. In adolescents 12 years and older, it is recommended that Dupixent be administered by or under supervision of an adult. If you need to permanently remove the carton from the refrigerator, write down the date of removal in the space provided on the outer carton, and use Dupixent within 14 days. Do not use the pre-filled pen if the liquid is discolored or cloudy, or if it contains visible flakes or particles. When placing the yellow needle cover on your skin, hold the pre-filled pen so that you can see the window. Press down Press the pre-filled pen firmly against your skin until you cannot see the yellow needle cover, and hold. If the window does not turn completely yellow, remove the pen and call your healthcare provider. After you have completed your injection pull straight up to remove pre-filled pen from the skin and dispose of immediately as described in section D. Dispose of the pre-filled pens, (needle inside), and green caps in a puncture resistant container right away after use. Do not dispose of (throw away) pre-filled pens (needle inside), and green caps in your household trash. Read all of this leaflet carefully before you start using this medicine because it contains important information for you. What Dupixent is and what it is used for What Dupixent is Dupixent contains the active substance dupilumab. What Dupixent is used for Dupixent is used to treat adults and adolescents 12 years and older with moderate-to-severe atopic dermatitis, also known as atopic eczema. Dupixent may be used with eczema medicines that you apply to the skin or it may be used on its own. Dupixent is used with other asthma medicines for the maintenance treatment of severe asthma in adults and adolescents (12 years of age and older) whose asthma is not controlled with their current asthma medicines. How Dupixent works Using Dupixent for atopic dermatitis (atopic eczema) can improve the condition of your skin and reduce itching. Dupixent has also been shown to improve symptoms of pain, anxiety, and depression associated with atopic dermatitis. In addition, Dupixent helps improve your sleep disturbance and overall quality of life. Dupixent helps prevent severe asthma attacks (exacerbations) and can improve your breathing. Dupixent may also help reduce the amount of another group of medicines you need to control your asthma, called oral corticosteroids, while preventing severe asthma attacks and improving your breathing.
Occasionally depression symptoms withdrawal buy asendin cheap, a plastic or glass foreign body or a shotgun pellet can be observed without surgery or until vitreoretinal traction occurs clinical depression symptoms uk order cheapest asendin. New technologies and techniques are being developed at an explosive pace depression mood swings order asendin 50 mg on line, producing great improvement in outcomes after vitreoretinal surgery depression cake cheap asendin 50mg without prescription. A retrospective cohort study in patients with tractional diseases of 431 the vitreomacular interface (ReCoVit). It receives the visual image, produced by the optical system of the eye, and converts the light energy into an electrical signal, which undergoes initial processing and is then transmitted through the optic nerve to the visual cortex, where the structural (form, color, and contrast) and spatial (position, depth, and motion) attributes are perceived. The anatomy of the retina is described in Chapter 1, Figure 1?17 showing its layers. Function and functional disturbance in the retina often can be localized to a single layer or a single cell type. These 433 photoreceptors are arranged such that there is an increased density of cones in the center of the macula (fovea), decreasing to the periphery, and a higher density of rods in the periphery. In the foveola, there is a nearly 1:1 relationship between each cone photoreceptor, its ganglion cell, and the emerging nerve fiber, whereas in the peripheral retina, many photoreceptors connect to the same ganglion cell. The fovea is responsible for good spatial resolution (visual acuity) and color vision, both requiring high ambient light (photopic vision) and being best at the foveola, while the remaining retina is utilized primarily for motion, contrast, and night (scotopic) vision. The rod and cone photoreceptors are located in the avascular outermost layer of the sensory retina. Each rod photoreceptor cell contains rhodopsin, a photosensitive visual pigment embedded in the double-membrane disks of the photoreceptor outer segment. The opsin in rhodopsin is scotopsin, which is formed of seven transmembrane helices. When rhodopsin absorbs a photon of light, 11 cis retinal is isomerized to all-trans retinal and eventually to all-trans retinol. Peak light absorption by rhodopsin occurs at approximately 500 nm, which is in the blue-green region of the light spectrum. Spectral sensitivity studies of cone photopigments have shown peak wavelength absorption at 430, 540, and 575 nm for blue-, green-, and red-sensitive cones, respectively. The cone photopigments are composed of 11-cis retinal bound to other opsin proteins than scotopsin. With this dark-adapted form of vision, varying shades of gray are seen but colors cannot be distinguished. As the retina becomes fully light-adapted, the spectral sensitivity of the retina shifts from a rhodopsin-dominated peak of 500 nm to approximately 560 nm, and color sensation becomes evident. An object takes on color when it selectively reflects or transmits certain wavelengths of light within the visible spectrum (400?700 nm). Daylight (photopic) vision is mediated primarily by cone photoreceptors, and twilight (mesopic) vision by a combination of cones and rods. It is responsible for phagocytosis of the outer segments of the photoreceptors, transport of vitamins, and reduction of light scatter, as well as providing a selective barrier between the choroid and retina. The retina can be examined with a direct or indirect ophthalmoscope or with a slitlamp (biomicroscope) and handheld or contact biomicroscopy lens. Retinal imaging techniques (Figures 2?28 to 2?33) are useful adjuncts to clinical examination, enabling identification of anatomical, vascular (both retinal and choroidal), and functional abnormalities. The clinical application of visual electrophysiologic and psychophysical tests is described in Chapter 2. Current evidence suggests genetic susceptibility involving the complement pathway and environmental risk factors, including increasing age, white race, female gender, and smoking. These insults include oxidative stress, inflammation, hypoxia, and changes in extracellular matrix. The new vessels leak serous fluid and/or blood, resulting in distortion and rapid decrease of central vision. Individuals with a pathogenic variant are more likely to develop the disease if they smoke or have a low intake of antioxidants. They may be identified clinically as indistinct, interlacing, yellowish lesions occurring in the macula, typically along the superior arcades, or with autofluorescence imaging as hypofluorescent lesions against a background of mildly increased autofluorescence. They are best seen on infrared imaging as hyporeflectant lesions against a background of mild hyperreflectance. They have been reported to fade with time, and choroidal new vessels may develop in these areas. Geographic atrophy is best monitored with autofluorescence imaging, appearing as marked hypofluorescence with different patterns correlating with different rates of disease progression. It has been suggested to arise as intraretinal vessels that extend posteriorly into the choroid in three stages. The first stage is characterized by formation of minute intraretinal new vessels that leads to separation of the neurosensory retina. In the second stage, the intraretinal neovascularization extends into the subretinal space with progression to the third stage of a retinochoroidal anastomosis. In the third stage, there is clear visualization of the retinochoroidal anastomosis, along with intraretinal or subretinal fluid as indicators of active disease. A: Superficial hemorrhage, retinal pigment epithelial detachment, and extensive exudation. B: Mid-venous phase of fundus fluorescein angiogram showing focal hyperfluorescence of retinochoroidal anastomosis and diffuse early filling of retinal pigment epithelial detachment. C: Optical coherence tomography showing punctuate hyperreflective foci (arrow) and intraretinal (arrowhead) and subretinal (outline arrow) fluid. It has not been developed as an ocular preparation but is widely used off-label with good results. Ranibizumab (Lucentis) is a recombinant, humanized Fab fragment of bevacizumab that has been affinity matured and specifically developed for intravitreal injection. Degenerative macular changes cause a slowly progressive loss of vision in the fifth decade. A: Choroidal vessels visible through atrophic retinal pigment epithelium and peripapillary atrophy. The peripheral chorioretinal changes of pathologic myopia include paving stone, pigmentary, and lattice degeneration that may lead to retinal breaks and 444 retinal detachment. Myopic foveoschisis is a splitting of the neural retina into a thicker inner layer and a thinner outer layer or a compound variant in which there is also splitting of the nerve fiber layer (Figure 10?4B). There may be reasonably good vision, but untreated, there tends to be slow progression to macular hole and/or retinal detachment. Chronic hyperglycemia, systemic hypertension, hypercholesterolemia, and smoking are risk factors for development and progression of retinopathy. Visual impairment is caused by macular edema or the complications of proliferative diabetic retinopathy comprising vitreous hemorrhage, tractional retinal detachment, and neovascular glaucoma. Retinopathy is rare in type 1diabetics prior to puberty, whereas one third of type 2 diabetics have retinopathy at initial diagnosis. The relative risk for developing diabetic retinopathy is higher in type 1 compared to type 2. Screening Early detection and timely treatment of diabetic retinopathy are essential for prevention of permanent visual loss. Screening should be performed within 3 years from diagnosis in type 1 diabetes, at diagnosis in type 2 diabetes, and annually thereafter in both types. Diabetic retinopathy may progress rapidly 445 during pregnancy, and screening should take place in the first trimester and then at least every 3 months until delivery. Seven-field photography after pupil dilation has been the gold standard, but using two 45? fields, one centered on the macula and the other centered on the disk, has been the method of choice in most screening programs. Recent advances in imaging particularly wide field fundus photography have improved detection of central and peripheral retinopathy. Chronic hyperglycemia leads to a metabolic response that is mediated by increased glycation end products, polyols, reactive oxygen species, eicosanoids, nitric oxides, and intercellular adhesion molecules, and activation of the protein kinase C pathway, leading to microvascular endothelial damage, retinal capillary leukostasis, and capillary closure. The earliest histopathologic changes are thickening of the capillary endothelial basement membrane and loss of pericytes, leading to outpouchings that form microaneurysms. Superficial flame-shaped hemorrhages in the nerve fiber layer arise from precapillary arterioles, and deep dot and blot hemorrhages arise from the venous end of the capillaries. Cotton-wool spots are evidence of axoplasmic stasis usually due to infarcts of the nerve fiber layer from occlusion of precapillary arterioles. Classification Diabetic retinopathy can be broadly classified into nonproliferative retinopathy, maculopathy, and proliferative retinopathy, of which the latter two may coexist. Moderate nonproliferative diabetic retinopathy showing microaneurysms, deep hemorrhages, flame-shaped hemorrhage, exudates, and cotton-wool spots. The criterion for treatment has been clinically significant macular edema (Figure 10?6), which is defined as any retinal thickening within 500?
M ostletterswere typed(G P referrals) depression va rating buy generic asendin 50 mg on-line, Itisunclearwh eth erth e G Ps H ospital depression definition apa asendin 50 mg free shipping, bypatientsinto andmostth atwere h andwrittenwere believedth atth ese details L ondon M oorfieldsEye deemedlegible vasomotor depression definition buy cheap asendin 50mg. H owever depression biological definition discount 50 mg asendin overnight delivery,anumber were notnecessarydue to H ospitalbetween containedmedicalh istoryand th e severitylevelofth e N ovember2006 medicationomissions. An up-to-date study would be useful in the context of shared-care and the associated proliferation of optometric and ophthalmic job roles within eye care services. Patients were registered between 1990 and 1999, and 87 sets of notes were studied (for 87 patients). The results suggested that compliance with treatment was poor in over a quarter of the study population (26%), and by the time the patient had been referred to hospital initially, more than half of these patients were aware of visual loss. This suggests that older patients? glaucoma is not being identified effectively, leading to potential sight loss later. This is particularly relevant in light of the fact that 23% of the patients could be registered blind at their first hospital low vision clinic assessment. It should be noted, however, that because the cohort was registered between 1990 and 1999, they may not have been screened extensively for glaucoma given they attended optometrists in the 1970s and 1980s when optometrists did fewer visual field checks. The characteristics of the patients may also indicate the need for enhancing services to older people who have particular mental health needs and hearing impairment. A third of the patients had hearing impairment, and dementia was identified in 24%. The paper warns that optometrists and optical businesses put themselves at risk unless they recognise the implications of the guideline and follow the [this] advice. Evidence from Smeeth and Iliffe (1998) also suggests that population screening for impaired vision among older people is not justified?, where the authors suggest that visual impairment can be treated, and therefore reduced. The screening tools and outcome measures were based upon self reported measures of visual impairment. Smeeth and Iliffe conclude that the accuracy and referral quality of opportunistic case-finding remains a high priority for eye care service personnel. Research Literature 16 research papers were found which involve optometrists in glaucoma care and referral schemes, referral quality or detection of glaucoma. A number of studies involve audits of referral reliability, as well as referral refinement and co-management schemes. Glaucoma Shared Care Schemes: A suite of papers One of the largest glaucoma shared-care schemes is the Bristol Glaucoma Shared Care scheme (Gray et al. Initially the study group researched the validity of visual parameter measurements taken by community optometrists (Gray et al. The results suggested that community optometrists could make measurements of comparable accuracy to those made in the Hospital Eye Service? (Gray: 431). In addition, patients were particularly satisfied with the community scheme in terms of waiting time. Whilst the authors acknowledged that some cases were missed, the study concluded that with glaucoma training, the optometrists could provide as reliable a service as junior ophthalmologists. Glaucoma screening and referral reliability within traditional frameworks In terms of glaucoma detection, Shah et al. The London based study utilised an actor presenting as a 44 year old of African racial origin who was having recent near sight difficulties, and was requesting new spectacles. The patient? had no family history of glaucoma and was thus examined in private practice. The findings suggested that 95% of optometrists visited by the actor carried out at least the minimum standard two tests for glaucoma, including optic disc assessment and tonometry. This suggests both a relatively high standard of eye testing, but also variability in the number of tests and types of tests utilised in glaucoma optometric screening services. Various studies of optometrists? referral reliability within traditional frameworks emerged (Bell and O?Brien, 1997, Newman et al. Vernon (1998) researched referral patterns in order to identify any changes over a five year period for suspect glaucoma. The retrospective analysis of referrals in 1988 and in 1993 revealed a reduction in the rate of true positive referrals from 48% to 34% at the two time points. However, measures were not taken between the time points and also represent relatively old data. Furthermore, the conclusions suggest that increases in the use of visual field measures were partly the reason for the decrease in true positive referrals. According to this study, optimal validity is achieved using all three, and therefore the number of screening tests used per examination may need to be increased by some practitioners. This suggests that certain forms of examination equipment do not necessarily lead to differing levels of sensitivity and specificity, and that all types of equipment in isolation are likely to lead to false positives. In addition, it was found that referral accuracy improved as the number of suspicious findings increases, suggesting the effect of previous experience and practice in revealing suspect glaucoma. A study of newly qualified optometrists and optometrists with more practice experience could strengthen this concept. Bell and O?Brien (1997) researched the referral accuracy of optometrists in the traditional Scottish referral system, prior to devolution and the emergence of more recent eye care pathways. Furthermore, it was suggested that combined approaches to screening for glaucoma gained the highest detection rate, and optometrists should combine methods in order to improve referral efficiency. The results suggested that glaucoma detection within optometric practice is highly variable in terms of the equipment employed, and therefore the tests conducted with patients could be equally variable. This could be viewed with concern, but may also suggest that optometrists are referring cases to be on the safe side, particularly in light of their duty to refer when any abnormality is revealed. As a result, many studies of referral accuracy should be treated with some caution due to the optometrists? duty of care. The majority of the referral letters were considered acceptable? according to the study criteria of acceptable? with 7% only being ideal? and the rest failing. Critique of glaucoma referral effectiveness measures Gilchrist (2000) presented a critique of the conventional use of specificity and sensitivity as measurements for the effectiveness of screening. As Gilchrist explains, sensitivity and specificity measure the association between screening test results and final diagnosis of all the patients screened (Gilchrist, 2000: 452). Gilchrist argues that diagnoses are gained only on those patients who are referred, and therefore the disease status of those not referred remains unknown. As this report includes a number of papers involving specificity and sensitivity, such arguments could provide a healthy consideration of alternative methods for measuring referral effectiveness, particularly where sensitivity and specificity may not be the best method for such important evaluations of optometric practice. Glaucoma referral refinement schemes As a result of high false positive rates over the past decade, some research has involved the implementation of refinement schemes in the Manchester community (Henson et al. According to this study the number of suspect glaucoma cases was reduced by 40% as a result of the scheme. It is of course possible that the training of the optometrist to become an accredited optometrist also reduced the number of false positives, though this is not reported. Economic evaluation of glaucoma services In terms of economic evaluations, Hernandez et al. Various findings suggested that technician screening was more effective than a traditional case-finding, opportunistic approach, though more costly, and screening by an accredited optometrist was more costly than technician screening. Furthermore, general population screening was deemed to be less cost-effective than screening at-risk groups, as many in the general population are too young to see the benefits of long-term screening. At-risk groups were those aged 40-50 with a risk factor, for example family history, and that screening should occur at 10 year intervals. 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