Ho et al. Optometry and Vision Science, January 2021

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Table A1A. Adaptation of the Case History. Number of panelists, percentage of agreement and example of panelists’ comment on importance and feasibility of the recommendations on (a) adaptation of the case history, (b) management of patients at moderate-high risk of falling, (c) prescribing to patients at moderate-high risk of falling, (d) prescribing to patients following cataract surgery from the OA guidelines and whether they have done that in their practices in the first round of Delphi process.

Recommendations Sources Level of evidence¹

Feasibility Importance Doing in

their

practice Example of panelists’ comments

Agree

(3 or 4) Disagree

(0 or 1) Agree

(3 or 4) Disagree (0 or 1) 1. Adaptation of the case history

1.1 Ask about risk factors² for falls.*

Evidence synthesis

by OA 3-4 9 (82%) 1 (9%) 7 (64%) 0 (0%) 4 (36%) “Whilst including a question into case history does not sound difficult, the reality is that you must change practitioner behavior which is sometimes challenging to do.” (Panelist 8)

1.2 Take history of falls in the previous 12 months.*

Evidence synthesis

by OA 3-4 11 (100%) 0 (0%) 11 (100%) 0 (0%) 4 (36%) “Feasible to ask additional question but have not asked all patients unless there is a history of injury or observed balance/walking issue.”

(Panelist 11) 1.3 Ask when glasses are

actually worn.*

Evidence synthesis

by OA 4 11 (100%) 0 (0%) 10 (91%) 0 (0%) 11 (100%) “Falls can also happen inside their home. When we ask this question, this can be applied to lens choice, but falls may not be on top of mind.”

(Panelist 7) 1.4 Ask about any problems

with steps and stairs for bifocals/PALs wearer.*

Evidence synthesis

by OA 4 10 (91%) 0 (0%) 9 (82%) 1 (9%) 8 (73%) “If purpose of this question is given in relation to falls and pre/post cataract then it can be implemented easily. Appears to be random question otherwise.” (Panelist 5)

OA, Optometry Australia; PALs, progressive addition lenses.

Bolded recommendations indicate the recommendations related to fall prevention.

*Recommendations reached consensus with the two conditions: (a) ≥80% of the panel (10/12 members) rated “Agree” (3 or 4) or “Disagree (0 or 1) for Importance and/or Feasibility, and (b) ≤ 10% of the panel rated the opposite agreement for both Importance and Feasibility.

1Level 1 = systematic reviews; Level 2 = Randomized controlled trial; Level 3 = observational studies; Level 4 = case studies or expert opinion

2Intrinsic risk factors for falls include increasing age, female sex, gait and balance impairment, systemic conditions such as arthritis, postural hypotension, stroke, diabetes and Parkinson’s disease, sedative use, taking multiple medications, a history of falls and visual impairment. The extrinsic risk factors for falls include poor lighting, presence of trip hazards such as loose rugs, inappropriate footwear, unsafe

stairways, irregular floors, unsuitable bed and bath designs.

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Table A1B. Management of Patients at Moderate-High Risk of Falling.

their practice Example of panelists’ comments Agree

(0 or 1) Agree

(3 or 4) Disagree (0 or 1) 2. Management of patients at moderate-high risk of falling

2.1 Promote regular eye exams.* Evidence synthesis

by OA 2-4 11 (100%) 0 (0%) 10 (91%) 0 (0%) 8 (73%) “Need more awareness that large changes in refraction is related to increased chances of falls.” (Panelist 7)

2.2 Suggest early referral for first eye cataract surgery as appropriate.*

Evidence synthesis

by OA 2-3 10 (91%) 0 (0%) 9 (82%) 0 (0%) 11 (100%) “Only of required. Too early may not be suitable” (Panelist 3) 2.3 Advise to keep distance

glasses walking outside the home.*

Evidence synthesis

by OA 4 10 (91%) 0 (0%) 9 (82%) 0 (0%) 9 (82%) “Falls need to be on top of mind.” (Panelist 3) 2.4 Warn patients of magnification changes with new glasses.*

Evidence synthesis

by OA 3-4 11 (100%) 0 (0%) 10 (91%) 0 (0%) 8 (73%) “Whilst I do this at the time of writing the prescription, I usually not present at the delivery of spectacles, and are thus dependant on the optical dispensers to reiterate this message.” (Panelist 9) 2.5 Advise patients with visual

impairment to seek home modifications to prevent falls.*

Evidence synthesis

by OA 2 9 (82%) 0 (0%) 10 (91%) 0 (0%) 6 (55%)

“Pathways aren't currently clear. Currently, low vision patients can be referred to Low Vision services that will provide this, but the pathway for non-low vision patients with high risk of falls is less clear. Is it through general practitioners? Will it be covered by Medicare?” (Panelist 4)

2.6 Demonstrate the spectacle correction with trial frame.* Delphi pilot

round 4 9 (82%) 0 (0%) 9 (82%) 0 (0%) 9 (82%) “Required for large refractive changes.” (Panelist 6) 2.7 Adjust frames for PALs

appropriately particularly the pantoscopic tilt.*

Delphi pilot

round 4 10 (91%) 0 (0%) 9 (82%) 1 (9%) 8 (73%) “Dispensing staff are normally responsible for the adjustment.”

(Panelist 4) OA, Optometry Australia; PALs, progressive addition lenses; VA, visual acuity.

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Table A1C. Prescribing to Patients at Moderate-High Risk of Falling.

Recommendations Sources Level of

evidence¹ Feasibility Importance Doing in

their practice Example of panelists’ comments Agree

(0 or 1) Agree

(3 or 4) Disagree (0 or 1) 3. Prescribing to patients at moderate-high risk of falling

3.1 Avoid changing the correction by more than 0.75 DS/DC.*

Evidence synthesis

by OA 2-4 10 (91%) 0 (0%) 10 (91%) 0 (0%) 11 (100%) “Decision made in conjunction with patients and their lifestyle/visual needs.” (Panelist 7)

3.2 Make partial changes and provide appropriate advice.*

Evidence synthesis

by OA 2-4 11 (100%) 0 (0%) 11 (100%) 0 (0%) 11 (100%) “It is important to trial frame any changes, and to be

conservative with large jumps in prescription compared to their habitual correction.” (Panelist 2)

3.3 Be wary of using a monovision approach with 'at risk' patients.*

Evidence synthesis

by OA 4 10 (91%) 1 (9%) 9 (82%) 0 (0%) 10 (91%) “I tend to discourage elderly patients at risk of falls from having monovision, I may recommend this only if done if they have had a contact lens trial.“ (Panelist 3)

3.4

Do not prescribe bifocals/PALs if 'at-risk' patients currently wear single-vision glasses or are emmetropic or minimally ametropic and are used to walking about without glasses.*

Evidence synthesis

by OA 2 10 (91%) 1 (9%) 10 (91%) 1 (9%) 11 (100%)

“However, you might still prescribe PAL or bifocals to these patients for doing tasks such as knitting/reading whilst

watching TV etc but with the advice to take the specs off when they walk around.” (Panelist 8)

3.5

Advise long-term wearers of bifocals/PALs with minimal ametropia who are active to remove their glasses when walking outside their own home.

Evidence synthesis

by OA 2-4 3 (27%) 2 (18%) 4 (36%) 2 (18%) 2 (18%) “On a per case basis. Only if it is significantly better for the patient.” (Panelist 11)

3.6

Advise long term wearers of bifocals/PALs with significant ametropia who are active to use distance single vision glasses when outside their own home.

Evidence synthesis

by OA 2-4 4 (36%) 4 (36%) 3 (27%) 3 (27%) 3 (27%) “If patients have already adapted, may struggle to advise patients to change to single vision lenses due to the change in magnification.” (Panelist 9)

3.7 Advise long-term wearers of bifocals/PALs with significant ametropia who are inactive to wear bifocals/PALs for most activities.*

Evidence synthesis

by OA 2 10 (91%) 1 (9%) 9 (82%) 1 (9%) 10 (91%) “If the patients have adapted the current PALs, they should keep their spectacles on for most activities.” (Panelist 5) 3.8 Update spectacle correction if the improvement Delphi pilot 4 10 (91%) 0 (0%) 10 (91%) 0 (0%) 10 (91%) “Discussion with patients to decide the best option.” (Panelist

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3.9 Suggest two different spectacles for distance and near instead of PALs for patients with

anisometropia.*

Delphi pilot

round 4 9 (82%) 1 (9%) 8 (73%) 1 (9%) 9 (82%)

“This does depend on the patient. I would trial the

prescriptions in a trial frame to see how the patients tolerate the prescription. If they are longterm PAL wearers, we might try the prescriptions in that particular lens design, but with the understanding that the patients may not be able to tolerate it and would organize a review examination about 4 weeks after delivery to check how they are coping, and obviously caution patient to take care.” (Panelist 8)

3.10 Discourage changing from bifocals to PALs for wearers of bifocals. Delphi pilot

round 4 4 (36%) 3 (27%) 4 (36%) 3 (27%) 5 (45%)

“It is very rare to actually see a patient who wears bifocals nowadays apart from patients who have Hospital spectacles which only have the bifocal option. Most private patients are in PALs. This was an issue perhaps 10-20 years ago, and it was definitely discouraged.” (Panelist 8)

3.11 Provide reduced reading power bifocals/PALs for patients who wish to retain bifocals/PALs. Delphi pilot

round 4 7 (64%) 2 (18%) 6 (55%) 2 (18%) 6 (55%) “Really depends on patient’s financial situation.” (Panelist 3) DC, diopter cylinder; DS, diopter sphere; OA, Optometry Australia; PALs, progressive addition lenses; VA, visual acuity.

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Table A1D. Prescribing to Patients following Cataract Surgery.

their

practice Example of panelists’ comments

Agree

(0 or 1) Agree

(3 or 4) Disagree (0 or 1) 4. Prescribing to patients following cataract surgery

4.1 Ensure that the patient is involved in the decision making regarding their post- operative refractive error.*

Evidence synthesis

by OA 3 11 (100%) 0 (0%) 11 (100%) 0 (0%) 11 (100%) “ This is a conversation that I discuss at length with my patients, and will make a point to include the results of the conversation in the referral letter to the ophthalmologists.” (Panelist 8)

4.2 Make conservative changes in refractive correction, particularly astigmatic correction.

Evidence synthesis

by OA 2-4 5 (45%) 2 (9%) 5 (45%) 2 (9%) 6 (55%) “Depends on how they feel with trial frame and walking around”

(Panelist 4) 4.3 Reduce the use of bifocals and PALs in active older patients.

Evidence synthesis

by OA 2-3 3 (18%) 5 (36%) 3 (18%) 3 (27%) 3 (18%) “Only if this benefitted the patients. If they are proficient wearers of PALs or bifocals, I would not do this.” (Panelist 5)

4.4 Provide reduced reading power bifocals/PALs for patients who wish to retain bifocals/PALs.

Evidence synthesis

by OA 4 6 (55%) 3 (27%) 6 (55%) 3 (27%) 7 (64%) “Only if the patients who are mobile, but in most cases, partial reading power will only lead to dissatisfaction.” (Panelist 3) 4.5 Provide new lenses in between the first and second eye surgery.*

Evidence synthesis

by OA 3-4 9 (82%) 0 (0%) 8 (73%) 0 (0%) 8 (73%) “Depends on patients' financial situation.” (Panelist 4)

4.6 Only recommend monovision post second-eye surgery if they have trialled with contact lenses.

Delphi pilot

round 4 6 (55%) 3 (27%) 6 (55%) 3 (27%) 5 (45%)

“This does depend on when the second eye surgery is being conducted and the second eye refractive/vision status. Many patients are now having both eyes performed within a few months (or less) of each other, so in these situations, you might not provide new lenses. However, if the second eye is being done at greater than 6 months or some undefine period of time in the future, then I would absolutely suggest to update lenses.” (Panelist 5)

OA, Optometry Australia; PALs, progressive addition lenses; VA, visual acuity.