OBJECTIVE: To determine the rate of Medicare opt-out among optometrists and ophthalmologists and to contrast the differences in the characteristics and geographic distribution of these populations.
METHODS: A retrospective cross-sectional study.
METHODS: Using a publicly available Centers for Medicare & Medicaid Services (CMS) data set, we collated data for ophthalmologists and optometrists who opted out in each year between 2005 and 2023. We calculated the rate of opt-out annually in each year window and cumulatively from 2005 to 2023. Comparative analysis was used to identify clinician characteristics associated with opt-out.
METHODS: Both annual and cumulative rate of ophthalmologist and optometrist opt-out from Medicare.
RESULTS: The estimated prevalence of Medicare opt-outs was 0.52% (77/14,807) for ophthalmologists and 0.38% (154/40,526) for optometrists. Ophthalmologists opting out were predominantly male (67.5%), had a longer practice duration (average 31.8 years), and were more often located in urban areas (83.1%), compared to optometrists (53.2% male, average 19.6 years in practice, 59.1% in urban areas, p = 0.04, p<0.001, p<0.001 respectively). Approximately 83% of ophthalmologists were either anterior segment or oculoplastics specialties, while the majority (52.1%) of optometrists were in optometry-only practices; >75% of identified clinicians were in private practice. Geographical distribution across the US showed variable opt-out rates, with the top 3 states including Oklahoma (3.4%), Arizona (2.1%), and Kansas (1.6%) for ophthalmology and Idaho (4.3%), Montana (3.1%), and Wyoming (1.4%) for optometry.
CONCLUSIONS: Few ophthalmologists and optometrists opt-out of Medicare but this trend has significantly increased since 2012. Of those who disenrolled from Medicare, 83% of ophthalmologists were in urbanized areas while 41% of optometrists were in non-urbanized areas. Because reasons for Medicare opt-out cannot be solely determined by administrative data, further investigation is warranted given the potential impact on healthcare accessibility.

CONCLUSIONS: Diagnosis of glaucoma through telemedicine demonstrates moderate agreement with in-person ophthalmologist (MD) and in-person optometrist (OD) diagnosis, providing evidence that telemedicine is a timely, accurate screening method in settings where an in-person visit may not be feasible.
OBJECTIVE: To compare diagnostic agreement of glaucoma between in-person MD, in-person OD, and a simulated telemedicine program.
METHODS: A cross-sectional study of patients with normal optic nerve structural and functional imaging and new patients referred for glaucoma evaluation examined in-person by an MD for glaucoma with a dilated examination and structural and functional optic nerve testing (optical coherence tomography, photos, and visual field); examined in person by an OD with a dilated examination and optic nerve testing; and structural and functional optic nerve testing reviewed separately by 2 ophthalmologists [telemedicine ophthalmologist reviewer 1 (TMD1), telemedicine ophthalmologist reviewer 2 (TMD2)] with masking of prior MD and OD diagnoses. Interrater agreement between each diagnostic method (MD, OD, TMD1, and TMD2) of normal versus disease (open angle glaucoma, normal tension glaucoma, other types of glaucoma, other optic nerve disorders, ocular hypertension, and glaucoma suspect) for each eye was calculated (Cohen unweighted kappa).
RESULTS: A total of 100 patients with a median age of 66 years (interquartile range: 59-72), male (40%) and white (62%) were analyzed. There was moderate agreement between MD and telemedicine [TMD1 kappa 0.49 (95% CI: 0.37-0.61), TMD2 kappa 0.44 (95% CI: 0.32-0.56)] and between MD and OD diagnosis [0.41 (95% CI: 0.28-0.54)] and fair-moderate agreement between OD and telemedicine [TMD1: 0.46 (95% CI: 0.34-0.58), TMD2: 0.61 (95% CI: 0.50-0.72)].
CONCLUSIONS: The simulated telemedicine approach had comparable levels of agreement in glaucoma diagnosis with in-person fellowship-trained ophthalmologists, presenting a crucial complementary role in screening and increasing access to care, particularly in rural or underserved settings.

BACKGROUND: Uncorrected refractive errors pose a significant challenge globally, particularly in remote regions of low-middle income countries where access to optometric care is often limited. Telerefraction, which involves refraction by a trained technician followed by real-time consultation with remote optometrist, is a promising approach for such remote settings. This study aimed to evaluate the accuracy of this model.
METHODS: This prospective study, conducted in New Delhi, compared tele-refraction to in-person examinations. Trained technicians used a simple device, Click-check, to perform objective refraction and a tele-refraction platform to enter the findings of objective refraction. Final prescription was made after consulting a remote optometrist on that platform. Masked face-to-face optometrists served as the gold standard. The study involved refraction in 222 patients and 428 eyes.
RESULTS: Tele-refraction demonstrated a strong agreement with in-person optometry, achieving 84.6% in spherical correction and 81% conformity in spherical equivalent. The mean difference of spherical equivalent between the two arms was only 0.11 D. The consultation with a remote optometrist improved conformity of spherical equivalent by 14.8% over objective refraction. 82 percent eyes matched in best corrected visual acuity and 92 percent were within 0.1 logMAR difference. For cylindrical axis, 74% eye were within acceptable 10 degrees of difference. The mismatch amongst the individual trained technicians, in terms of difference between the tele-refraction arm and the face-to face optometrist arm was found to be significant for cylindrical axis and not for spherical power and spherical equivalent.
CONCLUSIONS: Our study found tele-refraction by a trained technician comparable to refraction done by face-to-face optometrist. Tele-refraction, coupled with remote optometrist guidance can address the optometry resource gap in underserved areas. Thus, this model offers a transformative approach to enhancing the accessibility and quality of eye care services, which can significantly contribute to our efforts in achieving the global targets set by the World Health Organization for effective refractive error coverage. More standardized training for these technicians on ClickCheckTM for detecting the cylindrical axis with better accuracy, can improve this model further.

OBJECTIVE: To evaluate the perception of optometrists on causes of professional discordance among eye care professionals and its impact on refractive error service delivery in Kenya.
METHODS: This was a prospective qualitative case study conducted between January and June 2022 among optometrists registered with the Optometrists Association of Kenya. The data was collected through telephonic interviews. Purposive sampling was used to recruit the participants. Descriptive statistics were presented using frequency, percentages and with p values. Thematic analysis was carried out for qualitative data using the NVivo Software, Version 11. It was an iterative process consisting of both deductive and inductive processes.
RESULTS: Out of the 100 respondents, 37 (37%) were female. The mean age for the participants was 30.5 years with majority being in the age group 30-34 years. There was no statistically significant difference between the ages of males and females (p = 0.132) Most participants 82 (82%) had practiced for more than 4 years. The participants reported; mistrust among eye care professionals, employment sector, specialty, undermining the potential of other cadres within the eye care ecosystem, confusion and misconception and negative attitude as the perception of optometrists on causes of professional discordance among eye care professionals on refractive error service delivery. All of the optometrists agreed that professional discordance exists among eye care professionals in Kenya which potentially impacts negatively on refractive error service delivery.
CONCLUSIONS: Professional discordance remains an underrated barrier which negatively impacts on refractive error service delivery. However, to achieve effective refractive error coverage, a strengthened team approach among eye care professionals is desirable in a country with limited human resource such as Kenya.

Qualifications required to practise optometry seek to provide assurance that those completing them have the necessary competencies to be safe and effective clinicians. Often, this assurance is gained via high stakes assessments such as objective structured clinical examinations. This paper introduces entrustable professional activities (EPAs) as a potential alternative approach to assessing optometric clinical competence. Entrustable professional activities are defined in the context of optometric practice and the potential advantages and challenges of using them are outlined.

OBJECTIVE: To assist policy-makers in improving access to eye care in under-served areas by analysing the relationship between motivational factors affecting the uptake of task-shifting in eye care and the recruitment and retention of optometrists in remote and rural areas.
BACKGROUND: The World Health Organization recommends two key strategies in tackling preventable blindness in under-served areas: improving human resources for health and task-shifting. The relationship between task-shifting and recruitment and retention of eye care workers in under-served areas is unknown. Ghana and Scotland are two countries from different levels of economic development that have notably expanded the roles of optometrists and struggle with rural recruitment and retention.
METHODS: Motivation was explored through semi-structured interviews with 19 optometrists in Ghana and Scotland with experience in remote and rural practice. Framework analysis was used to analyse interviews, explore the relationship between task-shifting and recruitment and retention and create recommendations for policy.
RESULTS: The main motivational considerations included altruism, quality of life, learning and career opportunities, fulfilling potential, remuneration, stress of decision-making and collaboration. Motivational and demotivational factors for task-shifting and recruitment/retention shared many similar aspects.
CONCLUSIONS: Recruitment and retention in remote and rural areas require staff be incentivised to take up those positions, motivated to remain and given the adequate resources for personal and professional fulfilment. Task-shifting also requires incentivisation, motivation to continue and the resources to be productive. Many motivational factors influencing recruitment/retention and task-shifting are similar suggesting these two strategies can be compatible and complementary in improving access to eye care, although some factors are culture and context specific. Understanding optometrists\' motivation can help policy-makers improve rural recruitment and retention and plan services.

BACKGROUND: Even though the burden of uncorrected refractive error could potentially be addressed through innovative and cost-effective approaches, integration of the services into the National Health Services (NHS) is desirable. However, minimal information exists on the current situation warranting the need for evidence about the integration of refractive error service provided by optometrists into the national health services in Kenya.
METHODS: A situation analysis of the Kenyan refractive error services provided by optometrists within the NHS was undertaken based on access to service delivery, service coverage, and human resource. A strengths, weaknesses, opportunities, and threats analysis was undertaken based on the existent evidence to identify the core factors that could potentially facilitate or hinder the integration of refractive error services provided by optometrists within the National Health Services. The proportion of optometrists to be integrated in the NHS was estimated based on the minimum ratios recommended by the World Health Organization.
RESULTS: A section of tertiary and secondary healthcare facilities in Kenya have specific services to address refractive errors within the NHS with most facilities lacking such services. Treatment of refractive error occurs at the level of eye care general services. There are 11,547 health facilities offering primary care services in Kenya. However, none of them offers refractive error services and only a section of facilities offering county health referral services provides eye care services which is limited to refraction without provision of spectacles. The existing workforce comprises of ophthalmologists, optometrists and ophthalmic clinical officers, together with nurses and other general paramedical assistants. Optometrists, ophthalmologists and ophthalmic clinical officers are allowed to undertake refraction. However, optometrists majorly practices in the private sector. Centralization of eye care services in urban areas, weak referral systems, and a shortage in the workforce per population was observed.
CONCLUSIONS: The Kenyan NHS should advocate for primary care and reorient the current hospital-based delivery approach for refractive error services. This is attributed to the fact that provision of refractive error services at primary care remains effective and efficient and could translate to early detection of other ocular conditions. The existing human resources in the eye health ecosystem in Kenya should maximize their efforts towards addressing uncorrected refractive error and optometrists should be integrated into the NHS.

BACKGROUND: To investigate the current prescribing patterns for correcting hyperopia among optometrists in clinical practice in Saudi Arabia and compare those to current international guidelines. And explore the factors that influence practitioners\' prescribing decision.
METHODS: This cross-sectional study employed 30 items online survey that encompass demographic data, current practice and cycloplegia use, numerical response to indicate the minimum level of hyperopia at which optometrists would consider prescribing spectacles to non-strabismic children and determine the diopter value required for prescribing correction for hyperopia if present with other factors.
RESULTS: A total of 104 optometrists responded to the survey (52 females and 52 males). They recruited from 35 cities across Saudi Arabia. Out of total, 44% of them considered cycloplegic refraction essential under 12 years and 56% of them extended the range to 18 years. Large variation were found between the optometrists\' responses and current guideline recommendations. Several factors influenced the decision-making of the practicing optometrist including signs and symptoms, bilateral hyperopia, average dioptric value, reading difficulty, and accommodative function.
CONCLUSIONS: There are some matches between the international guidelines and the practice patterns that followed by optometrists in Saudi Arabia, however, the optometrists did not report that they are following them purposefully. These findings highlight the need to improve optometrists\' practice about spectacle prescription in pediatric population.

OBJECTIVE: Implementing teleophthalmology into the optometric referral pathway may ease the current pressures on hospital eye services caused by over-referrals from some optometrists. This study aimed to understand the practical implications of implementing teleophthalmology by analysing lived experiences and perceptions of teleophthalmology in the optometric referral pathway for suspected retinal conditions.
METHODS: Qualitative in-depth interview study SETTING: Fourteen primary care optometry practices and four secondary care hospital eye services from four NHS Foundation Trusts across the UK.
METHODS: We interviewed 41 participants: patients (17), optometrists (18), and ophthalmologists (6) who were involved in the HERMES study. Through thematic analysis, we collated and present their experiences of implementing teleophthalmology.
RESULTS: All participants interviewed were positive towards teleophthalmology as it could enable efficiencies in the referral pathway and improve feedback and communication between patients and healthcare professionals. Concerns included setup costs for optometrists and anxieties from patients about not seeing an ophthalmologist face to face. However, reducing unnecessary visits and increasing the availability of resources and capacity were seen as significant benefits.
CONCLUSIONS: Overall, we report positive experiences of implementing teleophthalmology into the optometric referral pathway for suspected retinal conditions. Successful implementation will require appropriate investment to set up and integrate new technology and remunerate services, and continued evaluation to ensure timely feedback to patients and between healthcare professionals is received.
BACKGROUND: ISRCTN18106677.

OBJECTIVE: Optometrists are well positioned to help expand low vision (LV) services and improve their availability and accessibility. Determinants of participation in LV service provision must be well understood to facilitate successful service expansion. This survey aimed to investigate optometrists\' professional confidence in the delivery of LV services and attitudes towards further learning.
METHODS: An online survey was emailed to a sample of College of Optometrists members. Respondents rated their confidence in different areas of core optometric practice; confidence in LV was compared with confidence in other areas. Respondents also rated their confidence in undertaking multiple tasks involved in LV service delivery and in routine optometric practice; confidence was compared between optometrists who do and do not work in a LV service. Attitudes towards learning more about assessing and supporting patients with a vision impairment (VI) were recorded.
RESULTS: The survey received 451 recorded responses (15.1% response rate). Optometrists who do not work in a LV service reported significantly lower confidence in LV than in other areas of core optometric practice, whereas optometrists who work in a LV service reported significantly higher confidence in LV than in other areas. Additionally, optometrists who do not work in a LV service reported significantly lower confidence in all tasks involved in LV service delivery than optometrists who work in a LV service (p < 0.001 for all tasks). Approximately 80% of respondents were interested in learning more about assessing and supporting patients with a VI.
CONCLUSIONS: Optometrists who do not work in a LV service have relatively low confidence in LV, which could contribute to low motivation to participate in LV service provision. There is sizeable interest in learning more about assessing and supporting patients with a VI, which could help to increase motivation to participate in LV service provision.