There are many things in optometry where there is not one correct answer and a flexible approach is required. When we decided to write about grading scales, I was looking forward to reading about all the different scales, and expected the experts to come back exalting the values of them for all clinical scenarios. 

I was surprised to hear a more balanced approach, where grading scales are considered very useful for documenting findings in some instances, but other factors should hold more weight in others. Patient symptoms might be more important than the grade of a cataract, for example. 

My takeaway from the article is that grading scales are useful for assessing and accurately documenting baseline findings that may change: for example before a contact lens fitting or at routine examination, or for conditions which may progress or respond to treatment on a fairly straightforward sliding scale. For example, grading cells accurately in uveitis can help to show if the patient is responding to treatment. On the other hand, a grading scale for retinal detachment is less useful than simply describing the salient features, as there is such a wide range of presentations. The approach to using grading scales depends on the condition in question.

Restoring natural accommodation in presbyopes has been a dream of vision scientists

Similarly, there are many different approaches to treatment that will not only depend on the exact nature of the condition, but must also take into account the patient as a whole. This is particularly important in glaucoma management, where the choice of treatment can have a significant impact on quality of life. Careful consideration is required. What is the pre-treatment IOP? What is the target IOP? How bad is the glaucoma already? What is the patient’s life expectancy? Is the patient able to instil eye drops? Does the patient tolerate eye drops well? Does the patient always use the eye drops? Is the patient suitable for laser or surgery? Which of the suitable treatments does the patient actually want? One option, minimally invasive glaucoma surgery (MIGS), has been an emerging field for some years now, and our article provides an excellent review of recent developments and clinical considerations.

And the most flexible approach of all? Restoring natural accommodation in presbyopes has been a dream of vision scientists for some time now. Presbyopia is something humans have tried to solve since ancient times, with a number of interesting (or perhaps now entertaining) theories regarding the pathophysiology of the condition explored by the ancient Greeks (Barbero, 2013). There was talk of developing eye drops to restore clear near vision some years ago, but a commercially available solution never materialised in the UK. Research in this exciting area is picking up again, as discussed in our recent article. It seems we are not quite there yet. In the meantime, we will continue to bend over backwards to meet our patients’ needs with the options available to us.

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