Article Text

Download PDFPDF

Effectiveness of Community versus Hospital Eye Service follow-up for patients with neovascular age-related macular degeneration with quiescent disease (ECHoES): a virtual non-inferiority trial
  1. Barnaby C Reeves1,
  2. Lauren J Scott1,
  3. Jodi Taylor1,
  4. Simon P Harding2,
  5. Tunde Peto3,
  6. Alyson Muldrew4,
  7. Ruth E Hogg4,
  8. Sarah Wordsworth5,
  9. Nicola Mills6,
  10. Dermot O'Reilly7,
  11. Chris A Rogers1,
  12. Usha Chakravarthy4
  1. 1Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
  2. 2Department of Eye and Vision Science, Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
  3. 3NIHR BMRC at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
  4. 4Centre for Experimental Medicine, Queen's University Belfast, Belfast, UK
  5. 5Health Economic Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
  6. 6School of Social and Community Medicine, University of Bristol, Bristol, UK
  7. 7Centre for Public Health, Queen's University Belfast, Belfast, UK
  1. Correspondence to Professor Usha Chakravarthy; u.chakravarthy{at}


Objectives To compare the ability of ophthalmologists versus optometrists to correctly classify retinal lesions due to neovascular age-related macular degeneration (nAMD).

Design Randomised balanced incomplete block trial. Optometrists in the community and ophthalmologists in the Hospital Eye Service classified lesions from vignettes comprising clinical information, colour fundus photographs and optical coherence tomographic images. Participants' classifications were validated against experts' classifications (reference standard).

Setting Internet-based application.

Participants Ophthalmologists with experience in the age-related macular degeneration service; fully qualified optometrists not participating in nAMD shared care.

Interventions The trial emulated a conventional trial comparing optometrists' and ophthalmologists' decision-making, but vignettes, not patients, were assessed. Therefore, there were no interventions and the trial was virtual. Participants received training before assessing vignettes.

Main outcome measures Primary outcome—correct classification of the activity status of a lesion based on a vignette, compared with a reference standard. Secondary outcomes—potentially sight-threatening errors, judgements about specific lesion components and participants' confidence in their decisions.

Results In total, 155 participants registered for the trial; 96 (48 in each group) completed all assessments and formed the analysis population. Optometrists and ophthalmologists achieved 1702/2016 (84.4%) and 1722/2016 (85.4%) correct classifications, respectively (OR 0.91, 95% CI 0.66 to 1.25; p=0.543). Optometrists' decision-making was non-inferior to ophthalmologists' with respect to the prespecified limit of 10% absolute difference (0.298 on the odds scale). Optometrists and ophthalmologists made similar numbers of sight-threatening errors (57/994 (5.7%) vs 62/994 (6.2%), OR 0.93, 95% CI 0.55 to 1.57; p=0.789). Ophthalmologists assessed lesion components as present less often than optometrists and were more confident about their classifications than optometrists.

Conclusions Optometrists' ability to make nAMD retreatment decisions from vignettes is not inferior to ophthalmologists' ability. Shared care with optometrists monitoring quiescent nAMD lesions has the potential to reduce workload in hospitals.

Trial registration number ISRCTN07479761; pre-results registration.

  • AMD
  • Wet AMD Reactivation
  • Optical Coherence Tomography

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See:

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.