New AOA adult eye guideline offers 14 actions, provides fresh insight on exam frequency

Sobering statistics, 14 evidence- and consensus-based action steps, a partial list of systemic diseases with ocular complications, and a slight but significant shift in a recommendation on frequency of care—all are in the clarifying and pacesetting second edition of the AOA evidence-based clinical practice guideline, Comprehensive Adult Eye and Vision Examination, Second Edition, just released.

Originally published in 2015, the updated adult eye and vision examination guideline was developed over 16 months and “describes appropriate examination procedures for evaluation of the eye health and vision status of adult patients to reduce the risk of vision loss and provide clear, comfortable vision. It contains recommendations for timely diagnosis, intervention, and, when necessary, referral for consultation with and/or treatment by another health care provider.”

The guideline’s objectives include enabling doctors of optometry to:

• Recommend appropriate timetables for eye and vision examinations for adults.
• Select appropriate examination procedures for adults.
• Examine eye health, vision status and ocular manifestations of systemic disease in adults.
• Minimize/avoid the effects of eye and vision problems in adults through prevention, early detection and diagnosis, and patient management through education and counseling.
• Inform/educate individuals and other health care practitioners on the importance of good vision and the need for, and frequency of, comprehensive adult eye and vision exams.

“The goal of the Evidence-based Optometry (EBO) Committee is to develop a guideline that all of optometry can follow, to adjust their practice based on what the best evidence shows,” says Carl Urbanski, O.D., chair of the EBO Committee, who was also on hand for the release of the first adult eye guideline.

“Doctors of optometry are lifelong learners, and the committee took the most current evidence and delivered it in a format that works for our clinicians, so they can adjust their mode of practice to fit what the evidence shows is the best way to approach diagnosis and care of the patient. It also serves as a resource to other health care professions, as well as the public.”

Says AOA President Ronald L. Benner: “This update solidifies the work and commitments of the AOA to create an evidence-based guideline tool for our doctors to provide the care our patients deserve. The amount of volunteer time that was spent to produce and get this guideline right shows the commitment that the AOA has made to advance the patient care provided by optometry across the country.”

In an interview, Dr. Urbanski reveals more about the revised guideline.

What is new and significant?

The guideline is a valuable resource and a great refresher for all doctors of optometry. I’d recommend going to the background section and re-reading the section on the prevalence of eye disease and the predictions for say 2050 on how much is going to be developing. It really contains compelling data that there is a huge need for eye care. We know about the workforce of optometry vs. ophthalmology. Optometry is really going to need to fill the gap and supply the care that is needed. There is an enormous amount of need out there. Optometry is really going to have to step into that role, especially given our expanded scope.

Table 1  in the document is very relevant. It speaks to systemic disease that has ocular complications. In the patient education section, there are some papers that talk about effective ways to communicate with our patients and helping with adherence to treatment. Perhaps the single biggest change is the frequency of care.

How does the frequency of care depart from the first guideline’s consensus statement on eye exams for adults every two years?

We did not find specific evidence that said every adult should have an annual eye exam. There remains a gap in the evidence. But we did put together a strong consensus statement. We recommended comprehensive eye and vision examinations annually for people 18 to 39 years of age to optimize visual function, evaluate eye changes and provide for the earlier detection of sight-threatening eye and systemic health conditions. The clinician really needs to evaluate the risk factors present. Based on this consensus and the expert opinion of the committee, implementation of this recommendation will likely result in earlier diagnosis of eye and vision problems and prevention of vision loss. We are recommending annually for everyone as a more proactive approach. This new statement will give the clinician confidence to recommend an annual eye exam to their adult patients.

Producing a trustworthy guideline is a rigorous, systematic, 14-step process. Can you describe the process?

If you want to keep your guideline trustworthy and relevant, you have to go back and assess the evidence periodically and make sure it’s current. Anything that rose to the level of a clinical recommendation, we go back and re-research those areas and re-read those papers and grade them and see if anything else has been published. (The new guideline has 229 citations.) Obviously, we also look for any new evidence-based on the questions we are trying to answer for the new guideline. We also try to identify gaps in evidence. For example, if we couldn’t find good information on a topic before, we will go back and make sure we research where the prior gaps were and try and fill those in. As a committee, we try to evaluate and ask what the profession needs. We want to deliver content that’s useful to our clinicians, accessible through the AOA website and something they can put into action in clinical practice.

How does the committee want doctors and other health professions to use the guideline?

We hope doctors of optometry and their staff look at the evidence-based and consensus-based recommendations, for starters, because the guideline has very strong evidence, multiple citations for our clinical recommendations. Doctors may look up a certain treatment protocol. Maybe there’s a table they’re going to download and print. That’s what we would hope they would do. Take that information and make it part of their day-to-day practice, but then also go back to it when they need it and use it as a reference. They might, for instance, consult the guideline to see what instrument or exam technique is best to evaluate an ocular issue. We also hope that when doctors of optometry attend continuing education that our lecturers are using our guidelines as resources with the evidence-based recommendations as part of their delivery of content. We also hope the same applies to optometry schools, where they can look to these guidelines when they are developing curriculum for future clinicians.

Explain more about the hard-working EBO Committee.

That seems to be the reputation we have in the AOA. The committee is a mix of doctors from lots of different modes of practice. Myself and some of the other doctors are in private practice. We have a fair number of academic faculty who also have clinical roles with their respective institutions. And we have several doctors who work in multidisciplinary settings. We have content experts as well, on teams that specialize in the guideline topic we are writing. Overall, what we look for is someone who obviously is active in clinical practice and then we follow our 14-step process. Over the past two years or so, we have been running two different guidelines. One is the primary open angle glaucoma guideline, which we are still working on, and then there is this, the second edition of the adult eye guideline. We also may have a practicing physician or an ophthalmologist on the guideline team, depending on the topic. We have a patient and a patient advocate as well. We are careful to stick to our process and everyone is vetted as far as bias on the topic.

See all of the EBO Committee’s previously published clinical practice guidelines, myopia clinical report and consensus-based guidelines.