Chapter 7

QualityEye Care

• Principle 2. Quality eye care is needed to attain; preserve, andrestore best possible vision for every American.

Significanceof the Principle

Quality eye care is defined as excellent eye care that is at or nearly atthe level of excellence attainable relative to the current state of knowl­edge, skill, and technology in the field. Eye care, as noted in Chapter6, Eye Care Integral to Health Care, is defined as services by or underthe direction of a qualified health professional for the prevention,diagnosis, or treatment of a refractive error, disease, Injury, or disabil­ity affecting the eye, adnexal structures, visual system, or relatedsystems.

Basically, quality eye care is excellent eye care. Quality. or excel­lence, at or approaching the summit of medical art and science, isneeded in eye care. Anything less is inadequate eye care and willresult in unnecessary loss of vision. Thus this principle assumes sig­nificance because it is an essential element in a national plan toattain, preserve, and restore best possible vision for every American.

Major Issues andRelated Principles

Major issues pertaining to quality eye care extend broadly over theeducation and career-long continuing education of eye care profes­sionals; the availabtltty of eye care resources including facilities, med­ications, devices, and technology; the humanistic concerns for theindividuals receiving eye care; the public information conducive toInjury prevention and timely self-referral; and the research requiredto improve treatment of eye disease. Quality eye care embraces allfacets of art and science that have elevated eye care to its presentdegree of effectiveness and offer promise of further enhancement inthe future.

Principles related most closely to quality eye care are:• Principle 1. Eye care is an integral component ofhealth care.• Principle 3. Access to quality eye care includes direct and

referral access to ophthalmologistsfor all Americans.• Principle 5. Ophthalmologists and other eye care professionals

are expected to continue education throughout their careers, tosustain high professional standards, and to use scientificadvances that enhance eye care.

• Principle 6. Public awareness and dissemination of eye careinformation are needed to reduce the prevalence of prevent­able, undiagnosed, and untreated eye injury and disease.

• Principle 7. Research in vision science is essenttalfor improve­ment in eye care.

48

The timing, frequency,and indications for eye

examinations are ofvital importance to

quality eye care.

Ey e Care f or th e American People

EvaluationQuality eye care encompasses all aspects of medical science andhumanistic service to attain. preserve. and restore best possiblevision for every individual. Major elements in quality eye care are thequalifications of professionals and the types of eye examinations. thetiming. frequency. and indications for eye examinations. quality pro­cess and outcome. and quality assessment and assurance.

Eye Examinations:Qualifications of Professionals

and Types of ExaminationsEye examinations are of critical importance in quality eye carebecause these constitute the entry point for care. For the ultimatebenefit of the public. the qualifications of eye and health care profes­sionals and the types of eye examinations performed by these profes­sionals must be clearly differentiated.

Ophthalmologic Eye Examination is a comprehensive medicalexamination of the eyes and visual system performed by an ophthal­mologist. a doctor of medicine who is a specialist in the eye andvisual system (Chapter 4. Current Status of Eye Care. and Chapter10. Education and Standards of Eye Care Professionals). Theophthalmologic eye examination includes measurement and treat­ment of refractive errors and the application of knowledge and skillsto the prevention. diagnosis. medical therapy. and surgical treatmentof disease, Injury, and other abnormalities affecting the eye andvisual system. Special knowledge and skills of the ophthalmologistencompass visual function in health and disease. the full range ofrefractive. medical. and surgical conditions affecting the eye andvisual system. and the diagnosis of systemic disease when manifestin eye signs or symptoms. The ophthalmologist is the only eye careprofessional qualified by education. training. experience. and licen­sure to diagnose and treat all refractive errors. visual functionabnormalities. diseases. injuries. and disabilities affecting the eyeand visual system.

Physician Eye Examination is carried out by a physician who isnot an ophthalmologist but a doctor of medicine with special knowl­edge and skills in pediatrics. family medicine. internal medicine,geriatric medicine. neurology. or other field. This eye examination isgoverned by the education. training. experience. and licensure of thephysician. Generally. it is focused on diagnosis of eye and visualsystem disease as well as systemic disease manifest in the eye.

Refractive Eye Examination for measurement of optical proper­ties and binocular function is performed by an ophthalmologist aspart of an ophthalmologic eye examination. by an optometrist. or byan ophthalmic technician working under appropriate supervision. Anoptometrist is a doctor of optometry who is a specialist in measure­ment of refraction. binocular vision measurement. optical fitting anddispensing. and detection of some categories of eye disease. In certainstates. licensure permits optometrists to use drugs in diagnosis andtreatment. An ophthalmic technician is a technical specialist workingunder appropriate supervision. The ophthalmic technician is gener­ally qualified in measurement of refraction. binocular vision measure­ment. and other procedures that are components of a refractiveexamination

Quality Eye Care

Other Eye Examinations are performed by public health nurses.registered nurses. orthoptists, and other eye care or health careprofessionals. These examinations are oriented to screening for visionimpairment and eye disease.

When eye examination by a nonophthalmologtst indicates thepossible presence of vision-threatening disease. prompt referral to anophthalmologist is necessary, Additional consideration of the inte­gration of eye care and health care as well as referral gutdellnes arepresented in Chapter 6, Eye Care Integral to Health Care.

Eye Examinations:Timing, Frequency,

and IndicationsThe timing and frequency of and indications for eye examinationsare also ofvital importance to quality eye care because these contrib­ute to timely correction of refractive errors and to early diagnosis andtreatment of eye disease. The timing and frequency of eye examina­tions and screening procedures should be based on the presence andprobability of impaired vision or eye and visual system disease. Amer­icans who have no symptoms or signs of eye disease and who are atlow risk of developing eye or visual system disease should follow aschedule of eye examinations designed to detect significant refractive

Figure 7.1/ Timing and Frequency ojEye Examinations.

Guidelinesfor Infants and Children

All infants should have an eye examination by an obstetrician, pediatrician. orother qualified health professional at or shortly after birth. Premature infantswith risk of retinopathy of prematurity should have an ophthalmologic eyeexamination in the premature care unit of the hospital before discharge.

Infants with risk factors such as a family history of retinoblastoma, congenitalcataract. metabolic disease. and genetic disease should have an ophthalmologiceye examination in the hospital or within the first month of life.

All infants should have an eye examination by a pediatrician, family physician.ophthalmologist, or optometrist by six months of age to evaluate fixationpattern. binocular alignment, and eye disease.

Older infants and chllclren with risk factors such as a family history of vision­threatening developmental eye disease. genetic eye disease. or significantepidemiologic factors should have an ophthalmologic eye examination ininfancy or childhood

All chllclrenshould have an eye examination by a pediatrician. family physician.or other eye or health care professional by age three to four years for visualacuity. binocular alignment, and eye disease.

Chllclren four years of age and older should participate in vision screeningprograms conducted by eye care professionals. school personnel. or volunteerorganizations on an annual basis.

When vision-threatening eye disease is suspected as a result of an eyeexamination or screening procedures by a nonophthalmologist. referral toan ophthalmologistfor an eye examination is necessary.

Prtndple

2Quality eye care is needed

to attain, preserve. andrestore best possible vision

for every American.

49

50 Eye Care for the American People

errors and eye disease efficiently and at a relatively early stage. Peri­odic eye examinations are recommended for children less than fiveyears of age and for adults forty or more years of age because thesepopulation groups demonstrate greater prevalence of significant re­fractive error and eye disease (see Figure 7.1I,

In addition to eye examinations for all Americans during child­hood and in older age. timing and frequency of eye examinations aregenerally influenced by risk factors that indicate an increased likeli­hood of impaired vision or sight-threatening disease'. Among thesefor infants and children are prematurity with low birth weight. familyhistory of retinoblastoma. family history of congenital cataract. meta­bolic disease. and battered child syndromes, For older adults. riskfactors for eye disease include diabetes mellitus. family history ofglaucoma. family history of cataract. and treatment of systemicdisease with medications known to have adverse effects on the eyeand vision. Some Americans have multiple risk factors that acttogether to increase the likelihood of disease and of loss of visionfrom that disease (e.g. family history of glaucoma in a black personls.Based on periods of greater disease prevalence and increased riskfactors for eye disease. general guidelines for eye examinations ininfants and children (see Figure 7.1l and in adults (see Figure 7.2)are presented. These guidelines represent reasonable standards ofcare but are subject to variation in accordance with judgment ofhealth care professionals and change in response to new knowledgeand scientific advance.

Figure 7.2/Timing and Frequency ojEye Examinalions

Guideltnesfor Adults and the Elderly

All adultswith decrease in visual acuity for distant or near objects should havean ophthalmologic eye examination or refractive eye examination.

All adults should have an eye examination by a family physician. internist, orother health care professional as a component of regular health care.

Adults with risk factors such as a family history of glaucoma cataract, retinaldetachment. or significant degenerative eye disease should have ophthal­mologic eye examination early in adult life and at medically appropriateintervals thereafter.

Adults with diabetes mellitus should have an ophthalmologic eye examinationat the time of diagnosis and at medically appropriate intervals thereafter.

Adults with systemic disease and/or medical treatment known to be associa­ted with increased risk of eye disease should have an ophthalmologic eyeexamination at time of diagnosis and/or treatment onset.

All elderly adults 65 or more years ofage should have an ophthalmologic eyeexamination at least every two years.

Adults should participate in vision screening programs conducted by eye careand health care professionals, industry representatives. or volunteer organi­zations on an annual or every two years basis.

When Vision-threatening eye disease is suspected as a result of eye anexamination or screening procedure by a nonophthalmologist, referral to anophthalmologistfor eye examination is necessary.

Quality Eye Care

Figure 7.3/Eye Health Checklist

Signs and Symptoms Suggesting the Need.for Ophthalmologic Eye Examin­ation and Care

If you have any of the signs or symptoms listed below. contact yourophthalmologist

o Blurry vision uncorrectable by lenseso Double visiono Dimming of vision that comes and goes. or sudden loss of visiono Red eyeo Eye paino Loss of side visiono Haloes (colored rays or circles around lights)o Crossed. turned. or wandering eyeo 1\vitching or shaking eyeo Flashes or streaks of lighto New floaters (spots. strings. or shadows)o Discharge, crusting. or excessive tearing of the eyeo Swelling of any part of the eyeo Bulging of one or both eyeso Difference in size of the eyes

Augmenting these general guidelines. ophthalmologic eye exam­ination is always indicated-often on an emergency or urgent basis­if there is significant injury to the eye or adjacent structures. if thereis presence of sign. symptom. or other factor suggesting need forreferral to an ophthalmologist (see Figure 6.2). and if there issignificant sign or symptom suggestive of eye disease (see Figure7.3).

In summary. timing and frequency of eye examinations andscreening procedures reflect recommendations for:

• Examination of all Americans in infancy-childhood and in adult­elderly life.

• Examination related to increased risk factors for eye and visualsystem disease.

• Examination in accordance with referral guideltnes.• Examination because of sign or symptom suggestive of vision­

threatening eye disease.These eye examinations are the entry point for quality eye care.

As noted previously. if vision-threatening eye disease is suspected ordiagnosed as a result of examination by other than an ophthal­mologist. referral to an ophthalmologist is necessary.

Quality Processand Outcome

Ophthalmologic eye examination. physician eye examination. refrac­tive eye examination. or examination by another category of eye careprofessional initiates the process of eye care. Quality of care there­after depends on the process and the outcome. The specialized

Prtnciple

2Quality eye care is needed

to attain, preserve. andrestore best possible vision

for every American.

51

52

Quality eye and healthcare should emphasize

the promotion ofhealth, the preventionof disease or disability,and the early detectionand treatment of such

conditions.

Ey e Carefor the American Peopl e

knowledge. skills, procedures. and technology of the ophthalmologistand of other eye care professionals are both unique to eye care and acomponent of health care.

For overview, it is appropriate to relate quality of eye care to theelements deemed important for all of health care. The American Med­ical Association Council on Medical Service recently endorsed eight"essential elements of quality," the first seven of which focus on theprocess and the eighth of which focuses on the outcome of cares,What follows is a brief discussion of these elements of quality healthcare (modified to be consistent with definitions and scope of thisreport) and their application to eye care.

Element 1Quality eye and health care should emphasize the promotion ofhealth, the prevention of disease or disability, and the early detectionand treatment of such conditions.

Several categories of eye care professionals are involved in eyecare: ophthalmologists, other physicians, optometrists, opticians, andothers (Chapter 4, Current Status of Eye Care). While one means ofachieving early detection, diagnosis, and treatment is greater coordi­nation among health care professionals and improved screeningmechanisms (Chapter 6, Eye Care Integral to Health Care), anothermeans of attaining this element of quality care is having morepatients see ophthalmologists for most or all of their eye care. Oph­thalmologists are the eye care professionals best equipped to promotethe patient's total eye care, to educate patients about prevention ofeye disorders and disabilities, and to diagnose and treat all refraciveerrors, diseases, and injuries.

Element 2Quality eye and health care should be provided in a timely manner.without either undue delay in initiation of care, inappropriate cur­tailment or discontinuity, or unnecessary prolongation of care.

Element 2 requires that eye care professionals be skilled in themanagement of refractive errors and eye diseases in order to assessthe need for beginning treatment, the appropriate length of time forcontinuing treatment. and the appropriate follow-up care.

Element 3QUality eye and health care should seek to achieve the informedcooperation and participation of the patient in the care process andin decisions concerning that process.

Informed participation and cooperation of the patient in thecare process is particularly important in treating chronic eye diseasessuch as glaucoma While early diagnosis of glaucoma is important inpreventing blindness from this disease, treatment of glaucoma is dif­ficult. It often requires instilling eye drops in both eyes several timesdaily and may also require regular use of oral medications. Manypatients experience unpleasant side effects from topical eye dropsand oral medications. As a result, these patients may become dis­couraged and discontinue treatment, threatening their vision. Oph­thalmologists must work closely with glaucoma patients to ensurethat they understand the importance of conttnulng treatment and toenhance patient motivation for regular treatment.

Element 4QUality eye and health care should be based on accepted principles of

Quality Eye Care

medical science and the proficient use of appropriate technologicaland professional resources.

While primary care physicians and optometrists are trained inthe detection and diagnosis of some eye diseases. there are eye dis­eases that are difficult even for the ophthalmologist to detect anddiagnose. Glaucoma. diabetic retinopathy. and choroidal melanomaare examples of such diseases. Ophthalmologists are the only eye careprofessionals trained to use the full battery of knowledge and tech­nology available for the diagnosis and treatment of eye disease. There­fore. ophthalmologists are best equipped to provide this element ofquality care.

Element 5QUality eye and health care should be provided with sensttrvtty to thestress and anxiety that illness can generate. and with concern for thepatient's overall welfare.

Eye disease that carries the risk of blindness is likely to be par­ticularly anxiety-producing. calling for a great deal of sensttrvtty andcompassion on the part of the eye care professional. Similarly, whenvisual impairment or blindness cannot be prevented. ophthalmolo­gists. other physicians. optometrists. or other health care profession­als must continue to work with patients to help them make the bestuse of vision that remains or learn to cope with blindness.

Element 6Quality eye and health care should make efficient use of the technol­ogy and other health system resources needed to achieve the desiredtreatment goal.

Attaining this element of quality care requires that eye care pro­fessionals exercise judgment to make the best use of health careresources available for the treatment of each patient.

Element 7Quality eye and health care should be sufficiently documented in thepatient's medical record to enable continuity of care and peer evalu­ation.

Attaining this element of quality care requires that the clinicalrecord-keeping of ophthalmologists and other eye care professionalsbe detailed and complete. Such documentation enables ophthalmolo­gists and other eye care professionals to render optimal care. toimprove disease management. and to participate in peer evaluation.

ElementSQuality eye and health care should produce the optimal improvementin the patient's physiologic status, physical function, emotional andintellectual performance. and comfort at the earliest possible time.consistent with the best interest of the patient.

This element describes the outcome or the expected result ofquality eye and health care. For ophthalmologists and other eye careprofessionals. this means striving to help each patient attain, pre­serve. and restore the best possible vision. While thts element mayappear to be broad in scope. it is the element that is most easilybroken down into its component parts and measured.

The elements of quality are designed to serve as measurableparts of eye and health care. In concept, if each element is provided,the process of medical care is satisfactory and the outcome is as

Principle

2Quality eye care is needed

to attain, preserve, andrestore best possible vision

for every American.

53

54

Quality eye and healthcare should makeefficient use of the

technology and otherhealth system

resources needed toachieve the desired

treatment goal.

Eye Care for the American People

favorable as possible. Precisely applied to the care of specific eye dis­eases, such as rhegmatogenous retinal detachment or cataract, or tospecific systemic medical diseases, such as myocardial infarction orstroke, these elements form the basis for evaluating the quality ofcare. Collectively, the elements are used in quality assessment andquality assurance.

Quality Assessmentand Quality Assurance

Quality assessment refers to the retrospective assessment of eye orhealth care to determine the degree of excellence utilized throughoutthe care process and to assess the results of care. It involves carefulanalysis of process and outcome to develop measurable standardsthat relate realistically and reliably to the quality or excellence of bothcare and outcome.

Quality assurance refers to the prospective assessment of eye orhealth care to determine the measurable elements that are correlatedwith excellent care and favorable outcome. Both quality assessmentand quality assurance are relatively new aspects of eye and healthcare. Methodologies and techniques for efficiently and reliably meas­uring quality of care are under development.

Ultimately, quality assessment and assurance are expected tohave direct and meaningful impact on eye and health care as prac­ticed by the individual professional and by all professionals. Withhealth care a major industry that is of extreme importance to indi­viduals, families, and all of society, the public has every right toexpect and indeed demand a product that is measurable in processand outcome as well as in the all too evident cost. Health care profes­sionals are also likely to benefit by performing services that aremeasurable in process and outcome as well as in cost.

Even at this relatively early stage in the development of metho­dology for quality assessment and assurance, there are a number ofmeasures that help to ensure quality eye care. These include accredi­tation of ophthalmology residency training programs, licensing of eyecare facilities such as hospitals. certification by the American Boardof Ophthalmology of ophthalmologists who have passed the certifica­tion examination, and peer review of eye care provided in a number ofdifferent settings.

Peer review affords the most detailed assessment of the qualityof care provided by ophthalmologists and other eye and health careprofessionals. In assessing eye care, peer review measures shouldaccount for variables such as patient age, sex, ltvtng environment.and attitude toward illness as well as the treatment provtded to thepatient and the outcome.

Additional research is needed to develop more precise andmeaningful measures of quality eye care. measures which take intoaccount both the process and outcome of care.

ConclusionQuality eye care is excellent eye care that is at or nearly at the level ofexcellence attainable with the current state of knowledge, skill, andtechnology in the field. Quality eye care requires consideration of thequalifications of professionals and the types of eye examinations andthe timing, frequency, and indications for eye examinations, withparticular emphasis on infants and children as well as on older

Quality Eye Care

adults and the elderly. Quality eye care also requires evaluation ofboth process and outcome of treatment and the important factors ofquality assessment and assurance. Evaluation of these aspects ofquality eye care forms the basis for recommendations.

Recommendations1. Quality eye care applied to prevention. diagnosis. or treatment of arefractive error. disease. injury. or disability affecting the eye and vis­ual system is recommended for every American.2. To achieve quality eye care, eye examinations by ophthalmologists.nonophthalmologtst physicians. optometrists. and other eye care pro­fesstonals are recommended. with attention to the qualification ofprofessionals and the types of eye examinations. and to the timing.frequency. and indications for these examinations. When vision­threatening eye disease is suspected or diagnosed. or there is anyother finding indicating that ophthalmologic care is appropriate. ref­erral to an ophthalmologist is necessary.3. To promote and enhance quality eye care. we recommend studiesof quality process and outcome. quality assessment. and qualityassurance.

PrInciple

2Quality eye care is needed

to attain; preserve. andrestore best possible vision

for every American.

55

References 1. American Academy of Ophthalmology. Frequency ofOcular exam­Inations (Policy Statement). San Francisco: American Academy ofOphthalmology. 1983.

2. American Academy of Ophthalmology. lrifant and Children's EyeCare (Information Statement). San Francisco: American Academyof Ophthalmology. 1980.

3. American Academy of Ophthalmology. Excess Risk oj Glauco­matous Blindness In Blacks (Information Statement). SanFrancisco: American Academy of Ophthalmology. 1984.

4. Care assessment guidelines endorsed. Am Med News 1986;29(251:14.