Do junior house officers routinely test visual acuity and perform ophthalmoscopy ?

G. S. Ang, B. Dhillon*,

Royal Glamorgan Hospital, Llantrisant, South Wales, *Princess Alexandra Eye Pavilion, Chalmers Street, Edinburgh

Abstract: 

Our objective was to assess junior house officer (JHO) practice of visual acuity testing and ophthalmoscopy in clerking patients.

Design: Cross-sectional questionnaire-based study using a standardised structured interview technique.

Setting: A Scottish university teaching hospital employing 65 JHOs.

Participants: All medical and surgical JHOs from this hospital were interviewed over a three month period.

Main outcome measures: Questionnaire-based data on the subjective responses studying current practice of visual acuity testing, and direct ophthalmoscopy with and without topical mydriatics.

Results: 18.5% and 4.6% of participants perform daily ophthalmoscopy and visual acuity testing respectively. Most do not routinely use the Snellen chart (80.0%) or topical mydriatics during ophthalmoscopy (75.4%). JHOs claimed these were not easily available in the wards.

Conclusions: The majority of JHOs fail to test visual acuity or perform ophthalmoscopy in clerking patients. This study highlights the poor availability of Snellen charts, functioning ophthalmoscopes, and topical mydriatics in the wards. This warrants further investigation.

Key words: Junior house officer; visual acuity; Snellen chart; ophthalmoscopy; topical mydriatics

Introduction

Eye examination skills are taught at medical schools,
assessed at university finals examinations and postgraduate diplomas, and practiced in all medical and surgical disciplines. Ophthalmic examination by the non-specialist includes testing best corrected visual acuities and performing ophthalmoscopy following pupillary dilatation with topical mydriatics. This is important, especially in elderly patients, since various interventions can be done to improve the function and quality of life for those with low vision.1

A Liverpool study2 highlights the high prevalence of reversible visual impairment in elderly patients admitted to hospital; thus reinforcing the importance of routine eye examination in patients.

During the pre-registration year, junior house officers (JHOs) have the opportunity to practise and consolidate ophthalmic examination skills, screen patients for eye disease, and check for ophthalmic manifestations of systemic disease, such as diabetes mellitus and hypertension. It is assumed that testing visual acuity and examining the optic disc and macula by JHOs would be common good clinical practice. However, it was our impression that these were very often neglected during physical examination. The aim of this study was to establish the current practice of JHOs with regard to visual acuity testing and ophthalmoscopy.

Methods

Junior House Officers:

Junior house officers (JHOs) from the medical and surgical wards in the Royal Infirmary of Edinburgh were interviewed once using a questionnaire by Dr Ang. This occurred during a three-month period spanning mid-April to mid-July. They were not followed up after the interview.

Questionnaires for JHOs:

The questionnaire used during the interviews was designed by one of the authors (GSAng). The frequency and proportion rating scales used in this questionnaire were easy to administer, simple to score, but were arbitrary.

In this study, the subjects were asked to rank the frequency of using the ophthalmoscope and of examining visual acuity into four categories:

1. Daily

2. Weekly

3. Monthly

4. Rarely

JHOs were asked to comment upon the proportion of times when topical mydriatics were used when viewing the fundus, and when Snellen charts were used for testing visual acuity.

A proportion rating scale was used with these categories:

1. 0%

2. <10%

3. 10-50%

4. >50%

5. All the time

The same rating scale was used when JHOs were asked how frequently they would use topical mydriatics if they were easily accessible in the wards

JHOs were also asked:

1. What they looked at with the ophthalmoscope

2. If there was a working ophthalmoscope in

the ward

3. Whether or not the ophthalmoscope would

be used more frequently if one was easily

accessible in the wards

4. The reasons for not using topical mydriatics

Results

Sixty-five JHOs were interviewed. The total number of JHO training posts in the Royal Infirmary of Edinburgh at that time

was 65, thus giving a subject capture rate of 100%.

Sixty-one of the JHOs interviewed qualified from Scottish universities (93.8%). Fifty-five (84.6%) graduated from the University of Edinburgh, followed by five (7.7%) from the University of Aberdeen. The remaining four were from University College London, Berlin, Graz and Syria.

Visual acuity testing and direct ophthalmoscopy among JHOs was not routine practice. (Table I)

Forty-seven JHOs (72.3%) rarely tested visual acuity while only three (4.6%) tested it daily.

Twenty-two JHOs (33.8%) performed ophthalmoscopy on a monthly basis, 16 (24.6%) weekly, 15 (23.1%) rarely and 12 (18.5%) daily.

From Table II, we find that six JHOs (9.2%) were certain that a Snellen chart was present in the ward, while 26 (40.0%) were certain that there was not. Thirty-three JHOs (50.8%) did not know if a Snellen chart was present in the ward or not.

In comparison, 43 JHOs (66.2%) were certain that a working ophthalmoscope was present in the ward, while 13 (20.0%) were certain that there was not. Nine (13.8%) were unsure of the presence of a working ophthalmoscope in the ward.

Thirty-two JHOs (49.2%) would use the ophthalmoscope more frequently if a working one was easily available in the ward, compared to 33 (50.8%) who would not. The main reasons studied were:

1. Do not feel it necessary (21 JHOs or 32.3%)

2. Too busy (10 JHOs or 15.4%)

3. Unable to see anything useful with

the ophthalmoscope (9 JHOs or 13.8%)

4. Not confident of using the ophthalmoscope

(9 JHOs or 13.8%)

Table III demonstrates that 52 JHOs (80.0%) did not use the Snellen chart to test visual acuity. Only one JHO (1.5%) tested visual acuity using the Snellen chart "always".

Similarly, 49 JHOs (75.4%) did not use topical mydriatics during ophthalmoscopy. No JHO used topical mydriatics on more than 50% of occasions when ophthalmoscopy was performed.

In the part of the questionnaire that deals with the reasons for not using topical mydriatics, JHOs were allowed to select multiple answers if appropriate. The main reasons for not using topical mydriatics are:

1. Not being aware of any in the ward

(34 JHOs or 52.3%)

2. Not having time to look for topical mydriatics

(27 JHOs or 41.5%)

3. Not available in the ward (22 JHOs or 33.8%)

4. Able view the fundus well enough without

dilating the pupils (21 JHOs or 32.3%)

5. Worried about side effects (10 JHOs or 15.4%)

Figure 1 shows the comparison between current usage of topical mydriatics during ophthalmoscopy, and the postulated usage of topical mydriatics during ophthalmoscopy if they were easily available in the wards.

Four JHOs (6.2%) did not answer the question in this section according to the questionnaire options, but instead stated "Not sure" as their answer. Nevertheless, it still demonstrates an increase in those who would use topical mydriatics more frequently: an increase of 10 JHOs in the "10-50%" category, an increase of 11 JHOs in the ">50%" category, and an increase of eight JHOs in the "Always" category.

Sixty (92.3%) and 57 (87.7%) JHOs viewed the optic disc and retinal blood vessels respectively during ophthalmoscopy. Only 29 JHOs (44.6%) examined the macula.

Discussion

Visual acuity testing

Testing visual acuity and detecting causes for visual impairment is important, especially in elderly patients. There is a high prevalence of correctable undetected visual acuity deficit in elderly patients in the hospital setting3.

It is accepted that the Snellen chart is not the gold standard for measuring visual acuity in research.4 However, testing of visual acuity with the Snellen chart is simple, and is sensitive to most common causes of visual impairment, including cataract and uncorrected refractive error. The latter may be addressed by checking visual acuity with the distance glasses or pinhole.

Near visual acuity testing with reading correction may detect macular disease. Specific enquiry into visual symptoms and family history of eye disease should be routine in clerking elderly patients, particularly if admitted to wards for the management of diabetes, stroke or falls.

Figures from this study (Table I) show that visual acuity testing by JHOs was still not done routinely. Several possibilities may account for this, including:

1. Time constraints

2. Poor appreciation of the importance of

routine visual acuity testing

3. Lack of confidence in testing visual acuity

4. Availability of tools needed to test visual acuity

Data from this study (Table III) also demonstrates that most JHOs (80.0%) did not use the Snellen chart to test visual acuity. These maybe accounted for by several possibilities:

1. Poor accessibility and availability.

It is clear that many wards do not have Snellen

charts (Table II). This seems to correlate with the

low percentage of Snellen chart usage among

JHOs.

2. Poor instruction on testing visual acuity using

the Snellen chart

3. Time constraints

4. Non-conducive setting in hospital wards for

using the Snellen chart

Ophthalmoscopy

Whilst it is accepted that direct ophthalmoscopy is not a useful screening tool for detecting peripheral retinal diseases,5,6,7,8,9 it remains the method of choice for non-ophthalmologists to examine the optic nerve head and macula. Pharmacological pupillary dilatation using a topical short-acting mydriatic is mandatory. There will be small potential risks of acute angle closure glaucoma10 and toxicity,11 but these are rare and do not justify non-usage of topical mydriatics in routine practice.

The majority of JHOs (56.9%) did not carry out ophthalmoscopy as routine, and this risked missing a range of eye morbidities. This correlated with a study by Roberts et al,12 which showed patients to be missing out on routine ophthalmoscopy.

In considering these data, the following possibilities may explain why only 18.5–24.6% of JHOs conduct ophthalmoscopy with any degree of frequency:

1. Ophthalmoscope availability or poorly

functioning ophthalmoscope

2. Unfamiliarity with equipment location

3. Time constraints

4. Poor appreciation of the importance of routine

ophthalmoscopy

5. Lack of confidence in using the ophthalmoscope

6. Low clinical priority

It is clear that functioning ophthalmoscopes are still not easily available in all wards. (Table II) This is likely to affect routine ophthalmoscopy by JHOs. A total of 49.2% of JHOs have confirmed that they would perform ophthalmoscopy more frequently if a working ophthalmoscope was available in the ward.

Figures from this study (Table III) demonstrate that the most JHOs (75.4%) did not use topical mydriatics. Without dilating the pupil, views of the fundus are limited, which may lead to important clinical features being missed.13 Various reasons may account for this:

1. Accessibility and availability. This study (see

Fig 1) suggests a positive correlation between

easy accessibility and availability of topical

mydriatics in the wards to postulated increased

usage among ward JHOs

2. Time constraints

3. Worries about side effects

4. Attitudes toward using topical mydriatics

The possible reasons for a relatively low number of JHOs (44.6%) viewing the macula include:

1. Difficulty in examining this part of the retina,

especially in the undilated pupil

2. Poor appreciation of the importance of examining

the macula

3. Poor formal instruction on using the

ophthalmoscope to view the macula

Education

With 13.8% of JHOs feeling that they were unable to visualise clinically relevant features during ophthalmoscopy, and another 13.8% lacking in confidence in using the ophthalmoscope, this further highlights the importance of formal education and training at both the undergraduate and postgraduate levels.

Roberts et al found that most doctors felt that they had inadequate training for ophthalmoscopy.12 Medical students should be formally trained14 and assessed15 in ophthalmoscopy and eye examination skills. Regular ophthalmology skills workshops16 may help to maintain and improve eye examination skills at the postgraduate level.

Limitations

It is accepted that the individual practice regarding ophthalmoscopy and visual acuity testing may change as the JHO rotates through the different medical and surgical wards. This study did not examine differences in individual JHO practices as the JHO rotated through the different specialties.

Also, since the majority of JHOs (84.6%) interviewed were graduates from one medical school, a valid comparison could not be made with other medical school graduates.

Conclusion

Visual acuity testing and direct ophthalmoscopy are core clinical skills which were not practiced routinely by JHOs. Most JHOs did not use the Snellen chart to test best corrected visual acuity or use topical mydriatics during ophthalmoscopy.

Snellen charts and working ophthalmoscopes were not readily available in the wards. Topical mydriatics were not stocked in most wards. Around half of JHOs would examine the fundus more frequently if a functioning ophthalmoscope was available in the ward setting. There was a positive correlation between easy accessibility and availability of topical mydriatics in the wards regarding a change in usage among ward JHOs.

Increased emphasis on continued practice of eye examination skills is essential during the undergraduate curriculum and beyond.

More research involving greater numbers of JHOs and hospitals is required to explore the practice of visual acuity testing and ophthalmoscopy outside specialist eye units, and how JHO practice affects ophthalmic examination skills following the pre-registration year.

R e f e r e n c e s

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13 Siegel BS, Thompson AK, Yolton DP, Reinke AR, Yolton RL. A comparison of diagnostic outcomes with and without pupillary dilatation. J Am Optom Assoc 1990 Jan;61(1):25-34

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