Explanatory Notes

The College of Optometrist’s Clinical Management Guidelines (CMGs) provide a reliable source of evidence-based information on the diagnosis and management of 60 eye conditions that present with varying frequency in primary and first-contact care. Whilst they are intended specifically for specialist therapeutic prescribers, it is anticipated that all optometrists will find them a useful source of information. The intention from the outset was to ensure that the CMG’s conformed to evidence-based practice. The most frequently used definition of evidence-based practice is the ‘conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients’ (Sackett et al, 1986 BMJ 312:71-2). A standardised search protocol was used to establish the evidence base for each ophthalmic condition (see below).

Status of the CMGs

Statutory legislation to enable independent prescribing by optometrists was introduced in June 2008. The proposed amendments were subject to public consultation and advice to Ministers by the Commission on Human Medicines (CHM). The CHM's recommendation was that suitably qualified optometrists should be able to prescribe any licensed medicine (except for controlled drugs or medicines for parenteral (injected) administration) for conditions affecting the eye, and the tissues surrounding the eye, within their recognised area of expertise and competence. In making the recommendation, the Commission made it clear that the extent of therapeutic prescribing for optometrists would be controlled through clinical management guidelines produced by the College of Optometrists. The CMGs represent how the independent prescribing optometrist working in a primary care setting should manage each specific condition (provided the diagnosis and management of the condition falls within the optometrists area of expertise). CMGs may be referred to by the GOC when determining fitness to practice. An independent prescribing hospital optometrist working in secondary care may follow locally agreed guidelines.

Format of the CMGs

All CMGs conform to a common format. The clinical presentation and management of each condition is described under the following headings:

Aetiology
Predisposing Factors
Symptoms
Signs
Differential Diagnosis
Management by Optometrist
Non-pharmacologica
Pharmacological
Management category
Possible management by Ophthalmologist

Evidence base

The management category provides referral guidance for optometrist therapeutic prescribers. Conditions are defined as sight-threatening (A) or not normally sight-threatening (B). These categories are sub-divided as follows:
 
A: conditions that are sight-threatening
1: emergency (same day) referral to an ophthalmologist
2: first aid measures followed by emergency referral to an ophthalmologist
3: urgent (within 1 week) referral to an ophthalmologist
 
B: conditions that are not normally sight-threatening
1: possible prescription of drugs; routine referral
2: alleviation or palliation; no referral
3: management to resolution

 map

Levels of Evidence

The table below gives the hierarchy of evidence for therapeutic interventions
 

Level Therapy Prevention  
1a Systematic Review (with homogeneity) of RCTs   
1b Individual RCT (with narrow Confidence Interval)    
2a Systematic review (with homogeneity) of cohort studies
2b Individual cohort study (including low quality RCT; e.g., <80% follow-up)  
2c "Outcomes" Research  
3a SR (with homogeneity) of case-control studies
3b Individual Case-Control Study    
4 Case-series (and poor quality cohort and case-control studies)
5 Expert opinion without explicit critical appraisal   


Centre for Evidence-Based Medicine Levels of Evidence (May 2001

Prescribing Information

Several CMGs make reference to pharmacological interventions by optometrists; however they do not provide detailed prescribing information.
It is essential that optometrist prescribers reference a reliable and up to date source of medicines information e.g. the British National Formulary (BNF) or the e-formulary contained within the Electronic Medicines Information for Optometrists (EmedINFO).

Guideline Authorship and Peer Review

The CMGs have been produced by a team of Ophthalmologists and Optometrists under the direction of Professor Roger Buckley, Professor of Ocular Medicine, Anglia Ruskin University.

Guideline Development Group

Roger Buckley FRCS FRCOphth
John Lawrenson PhD MCOptom
Graham Macalister PhD MCOptom
Gwyneth Morgan FCOptom
Lindsey Smith FRCOphth

All CMGs were peer reviewed by the Primary Care Group (PECG); a multidisciplinary group of eyecare professionals convened by Vision 2020. The peer review process was co-ordinated by the co-chairmen of the PEGC: Richard Wormald MSc FRCS FRCOphth and Wendy Franks FRCS FRCOphth. Guidelines will be subject to an ongoing process of review and updating.

Glossary

Case-controlled Study
A case-controlled study compares individuals who have a specific disease ("cases") with a group of individuals without the disease ("controls") to find differences between the groups.

Case Series
Report of a number of patients with a particular disease and their response to a particular intervention. There is no comparison (control) group of patients

Cohort Study
A retrospective or prospective follow-up study of patients defined by the presence or absence of exposure to a particular intervention

Critical Appraisal
Critical appraisal is a process of systematically examining research evidence to assess its validity, results and relevance before using it to inform a decision

Evidence-based Medicine
‘The conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients’

Emergency Referral
Same day (or within 24 hours)

Historically Controlled Study
A control study recruiting control subject(s) for whom data were collected at a time preceding that at which the data are gathered on the group being studied

Mechanism-based reasoning
Involves an inference from mechanisms to claims that an intervention produces a patient-relevant outcome. Such reasoning will involve an inferential chain linking the intervention with a clinical outcome

Randomised Controlled Trial (RCT)
A comparative study in which participants are randomly allocated to intervention and control groups and followed up to examine differences in outcome between groups

Routine Referral
In due course

Systematic Review
Research that summarises the evidence on a clearly formulated question according to a predefined protocol that identifies and appraises relevant studies

Urgent Referral
Within one week