Optometry and Vision Sciences - Theses
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ItemThe role of home monitoring in chronic eye disease using smart devices.( 2023-03)Chronic eye disease affects millions of people worldwide and requires ongoing specialist care. Ever-increasing patient numbers has created pressure on the healthcare system, an issue that has been intensified by the COVID-19 pandemic. There is a pressing need to develop new models of eyecare to prevent vision loss. Home monitoring (HM) of vision in-between scheduled clinical visits could help prioritise valuable hospital chair time to those with the highest risk. Smart devices, such as desktops, laptops, tablets, and smartphones are ubiquitous in the community making them an ideal platform for HM due to familiarity of use. Most older individuals use smart devices to access the internet and it is this age group that is at a higher risk for developing chronic eye disease. This thesis considers the role of HM with the Melbourne Rapid Fields (MRF) vision testing application (for the Apple iPad) in the context of two common chronic eye diseases; glaucoma and age-related macular degeneration (AMD). MRF is new technology without a proven clinical record. Chapter 2 reports the clinical application of MRF as a routine and regular test of visual field (VF) by comparing 2-monthly VF testing to that found using the Humphrey Field Analyzer (HFA) for glaucoma patients in-clinic. We find the MRF has a strong correlation to the HFA with excellent medium-term repeatability (6-month period). This means that MRF can produce the same outcomes as the HFA when performed under supervision in the clinic. Chapters 3 and 4 apply the MRF to a weekly HM regime where participants tested themselves at home under application generated audio instructions and in the absence of clinical supervision. HM was undertaken for 12-months, and all participants had access to a clinical assistant who could be contacted to resolve technical difficulties. Chapter 3 finds that glaucoma participants had an uptake of 88% to HM and a weekly compliance of 72% with same-day reminders. A strong correlation was observed between the MRF at-home and the HFA in-clinic, and progression was detected in two participants using MRF home monitoring. Chapter 5 reports the HM uptake to be 85% in patients with intermediate AMD (iAMD) with a weekly compliance of 61% in the absence of reminders. Here, the HM included visual acuity as well as macula visual field sensitivity. Good correlation was observed between MRF and clinical measures with the Early Treatment Diabetic Research Study (ETDRS) letter chart and the Macular Integrity Assessment (MAIA) microperimeter. The overall findings of this thesis are that patients with chronic eye disease are receptive to the concept of HM with smart devices due to promising uptake. The finding of moderate compliance to weekly testing can be considered as a reduced number of tests received from home but, can still provide valuable information for clinical decision making. A survey of participant perceptions reveals that the MRF is easy to use and more comfortable than clinical perimeters. Larger, randomised, clinical trials are required to expose the true ability of MRF to detecting progression before it can be implemented as a new model of patient eye care.
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ItemThe utility of clinical audit and point-of-care tools to support optometric evidence-based practice in age-related macular degeneration( 2021)Age-related macular degeneration (AMD) is a leading cause of vision impairment worldwide. Currently, there are no approved therapies for earlier stages of AMD. Furthermore, treatments available for later stages of the disease may not reverse vision loss. Of key importance for reducing patients’ risk of progression to sight-threatening late-stage AMD, is the early identification and management of modifiable risk factors. Optometrists in Australia have a key role in providing primary eye care to people who are at risk of developing, or who have earlier stages of, AMD. They are therefore ideally placed to ask and counsel their patients about lifestyle modifications that can reduce the risk of disease progression. Our research team has recently developed the Macular Degeneration Clinical Care Audit Tool (MaD-CCAT), which is designed to audit the optometric care provided to people with AMD, relative to current best-practice standards. The first research project described in this thesis used self-audit data, collected by optometrists using the MaD-CCAT, to both characterise current optometric AMD practice patterns, and evaluate whether the process of clinical self-audit and receiving analytical feedback could improve AMD care. The second project involved a randomised, placebo-controlled trial to evaluate the efficacy of a novel AMD point-of-care clinical tool, delivered either in hardcopy (paper) or online format, for improving optometrists’ AMD knowledge and documented clinical care. In the first project it was found that there are several areas for improvement relating to optometrists’ documentation patterns for key areas relating to AMD care. In addition, self-audit with feedback significantly improved optometrists’ clinical record documentation, including: AMD risk factors, clinical examination techniques, AMD severity classification, and management, post-audit. The optometric practice patterns observed in this study were used to inform the development of two new AMD clinical tools designed to support evidence-based care. In the second study, use of the point-of-care AMD clinical tools, particularly in a paper-based format, was found to improve clinical record documentation, post-intervention (p<0.05), for documenting: patients’ current smoking status, nutritional supplementation intake, accurate AMD severity classification, discussing patient’s risk of progression to late-stage AMD, and providing advice regarding appropriate dietary and nutritional supplementation intake. Clinical self-audit with analytical feedback is a valuable method for improving clinical record documentation of key aspects of AMD care provision by optometrists. Furthermore, AMD point-of-care clinical tools, particularly in a paper-based format assist in documentation of patient risk factors, AMD severity classification, and facilitating communication with patients regarding modifiable risk factor advice. These studies provide insight into the efficacy of different clinical methods for enhancing optometric AMD care provision, to align with current, best available research evidence.