1. Eye care and public health: successes and challenges Department of Optometry & Visual Science Excellence in Eye Care Education and Research for over 100 years Professor John Lawrenson Dept of Optometry and Visual Science City University London

2. Lecture Outline Epidemiology of blindness and visual impairment Impact of visual impairment on quality of life Optometric workforce and equity of access Targeting hard to reach groups Screening for visual impairment Eye health promotion and preventative eyecare Department of Optometry & Visual Science

3. To raise awareness and understanding of eye health among the public, including those people most at risk of eye disease, to allow every individual to develop a personal responsibility for eye health and to achieve maximum eye health for all. To raise awareness of eye health among health and social care practitioners, and to ensure the early detection of sight loss and prevention where possible UK Vision Strategy (April 2008): UK Vision Strategy: a mission statement for ophthalmic public health Department of Optometry & Visual Science

4. Causes of Severe Visual Impairment in the UK Department of Optometry & Visual Science Source: Bunce et al. Eye (2010) 24, 1692–1699 Data from CVI submissions Does not provide data on absolute numbers due to under- reporting A significant proportion of severe visual impairment is preventable

5. Causes of Visual Impairment in an Elderly Population in the UK (MRC Trial) Department of Optometry & Visual Science Source: Evans et al. Br J Ophthalmol 2004;88:365–370.

6. Causes of Visual Impairment in an Elderly Population in the UK (MRC Trial) Department of Optometry & Visual Science Source: Evans et al. Br J Ophthalmol 2004;88:365–370.

7. Impact of Visual impairment on Quality of Life Department of Optometry & Visual Science Visual impairment is associated with: Falls Depression Reduced capacity to carry out everyday activities The need for residential care One of the highest risk factors for functional status decline in people living in the community

8. The Value of Vision: Time Trade Off Department of Optometry & Visual Science “How many years do you expect to live? Suppose there was a technology that guaranteed your vision will return to normal and remain normal in both eyes permanently. The technology always works, but it decreases survival. What is the maximum number of years—if any—you would be willing to give up if you could receive this technology and have normal vision in both of your eyes for the remainder of your life?”

9. The Value of Vision: Time Trade Off Department of Optometry & Visual Science Patients, with 6/9–6/15 visual acuity would be willing to lose 19% of their lifetime to get back normal visual acuity Patients with 6/60–3/60 visual acuity would give up 48% of their lifetime Blind people would give 60% Comparable utility values are seen in patients with AIDS (21%), bedridden and incontinent patients following a stroke (66%) Source: Knauer and Pfeiffer. Graefes Arch Clin Exp Ophthalmol (2008) 246:477–482

10. Future Visual Impairment projections Department of Optometry & Visual Science

11. UK Optometry Workforce 30% increase in the number of optometrists in the last 10 years Department of Optometry & Visual Science Source: Health and Social Care Information Centre

12. Activity statistics Department of Optometry & Visual Science 11.8 million NHS sight tests in England in 2009/10 In the last 10 years there has been a 18% increase in the number of NHS sight tests 35% increase in the number of domiciliary sight tests Significant regional variation

13. Equitable access to eyecare Poorer people are less likely to access eyecare Are more likely to present too late with advanced glaucoma Are more likely to have treatment for cataract at a more advanced stage of sight loss Are more likely to have more severe diabetic retinopathy Less likely to access new treatments for ARMD Department of Optometry & Visual Science

14. Equitable Access to Eyecare In France an inverse correlation was found between number of ophthalmologists and rates of visual impairment after adjustment for age and socioeconomic status Source: Lafuma et al. Health and Quality of Life Outcomes 2006, 4:34 Department of Optometry & Visual Science

15. Equity of Access Department of Optometry & Visual Science Mismatch between location of optometric premises and areas of high deprivation A significant proportion of the ‘at risk’ population do not have regular eye examinations despite their entitlement to a free examination Source: Day et al. Eye (2010) 24, 1478–1485

16. Equity of Access Department of Optometry & Visual Science Is it acceptable to rely on private high street optometry to provide primary eye care services in areas of high need? Source: Day et al. Eye (2010) 24, 1478–1485

17. Optometry business model Department of Optometry & Visual Science Optometry is a highly competitive market-driven system State of the art ophthalmic equipment Only a small proportion of an optometrists income derives from the NHS Business model relies on a large cross-subsidy from the sale of optical appliances

18. Barriers to Accessing Eyecare Lack of awareness Perceived cost of sight test and spectacles Language difficulties Transport Residential care Department of Optometry & Visual Science

19. Evidence for the effectiveness of vision screening ‘At present there are no robust trials available that allow the benefits of school vision screening to be measured. The disadvantage of attending school with a visual acuity deficit also needs to be quantified. The impact of a screening programme will depend on the geographical and socio- economic setting in which it is conducted.’ Department of Optometry & Visual Science

20. ‘The review found five studies in which vision was tested as part of a broader screening assessment. No improvement in vision was seen two to four years after screening compared to elderly people who were not screened’ Department of Optometry & Visual Science Evidence for the effectiveness of vision screening

21. Cost effective community screening Department of Optometry & Visual Science Harnessing technology RNIB have developed ‘Eyes Right’, a simple and easy-to-use screening tool for visual impairment

22. Cost effective community screening Department of Optometry & Visual Science

23. Qualitative Study of Glaucoma Awareness A study of patients with advanced glaucoma at Moorfields Eye Hospital found low levels of awareness of the disease prior to their diagnosis and assumed that symptoms were the ‘normal’ deterioration of eyesight. As symptoms have a gradual onset, participants had learnt to cope with diminishing sight ability. These findings suggest that health promotion is a priority to increase public awareness of the existence and symptoms of glaucoma among those at high risk Department of Optometry & Visual Science

24. Moorfields Glaucoma Awareness Study Effect of a public education campaign on awareness and help-seeking behaviour with respect to ocular health in an Indian population Source: Baker and Murdoch. Br J Ophthalmol 2008;92:1671–1675 Department of Optometry & Visual Science

25. Moorfields Glaucoma Awareness Study Source: Baker and Murdoch. Br J Ophthalmol 2008;92:1671–1675 Department of Optometry & Visual Science Not possible to demonstrate an improvement in health seeking behaviour

26. Lifestyle and Eye Disease Department of Optometry & Visual Science Optometrists are well placed to promote healthy living Their patients include a large percentage of the population who are ‘in health’ and therefore not in regular contact with healthcare professionals Source: Klein and Klein. Am J Ophthalmol 2007;144:961–69

27. Smoking and Eye Health Smoking nearly triples the incidence of AMD compared with non-smokers >25% of all cases of advanced AMD are attributable to current or past exposure to smoking Smoking cessation is associated with a significant decrease of the risk of progression to AMD, which is independent of former smoking intensity A recent survey found that only 6.2% of optometrists routinely asked about smoking habits at new patient consultations and 2.2% at follow up visits Department of Optometry & Visual Science

28. Challenges and Opportunities Public health interventions need to be evidence-based Equitable access to community eyecare - Integrate optometrists into primary care teams? - NHS Community Optometry? Screening for Eye Disease - Who? - How? Targeted eye health awareness Opportunities for health promotion Inter-disciplinary working Educating the profession in public health and advocacy Department of Optometry & Visual Science