Our results show that paper records are significantly more complete than EPR. This is the case for two different EPRs and three separate sites. We propose additional training to aid data-collection; improving the design of EPRs by investigating factors such as layout and use of forced choice fields.

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Purpose: To evaluate ophthalmology trainees' perception of their gonioscopy learning experience in the Ophthalmology Specialty Training programme. Materials and methods: A cross-sectional electronic survey was conducted amongst ophthalmology trainees across London Deaneries. The 10 questions survey collected parameters including training grade, previous level of gonioscopy training, confidence in performing the procedure, level of satisfaction with the training formats received, potential barriers and improvements to the training programme. The respondents were also invited to express any additional comments. Results: Fifty-seven complete responses were analysed. Respondents included 25 junior trainees (ST1-3) and 32 senior trainees (ST4-7 and fellow). One fifth of the respondents (11/57) were unconfident in performing gonioscopy, majority being junior trainees (9/11). Over a quarter of the respondents were dissatisfied with the quantity of the gonioscopy training received. Teaching formats such as consultant teaching (mean 8.0), self-directed learning (mean 8.0) and small-group tutorials (mean 7.6) were all well received. Overall, lack of clinical time was considered as the major barrier to gonioscopy training; however lack of training was considered as the major barrier in the low confidence group. Conclusion: This study highlighted ophthalmology trainees' dissatisfaction in the current gonioscopy training curriculum and a lack of confidence in performing the procedure. Appropriate modifications to the Ophthalmology Specialty Training programme could enhance trainees' gonioscopy learning experience.

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Ophthalmologists were concerned about the risk of SARS-COV-2 transmission via droplets given the close proximity to the patient during slit lamp examination. There is a need to design a simple, low-cost, waterproof breath shield to minimise risk of infection.Dimensions of the Haag-Streit slit lamp (model BM 900) were recorded to guide accurate design of the breath shield. A questionnaire was circulated among slit lamp users on their perceived risk and concern about SARS-CoV-2 transmission and their perception of how effective different designs of breath shields would be at protecting them from an infection. A number of breath shield prototypes were designed and trialled. Plan, Do, Study, Act (PDSA) cycles were used to improve the design. Materials used to create the breath shields included transparent A3 laminating pouches and laminator, two sheets of A4 paper, scissors, hole punch and a ruler. The breath shield was designed to fit over the objective lens on the slit lamp after temporarily removing the standard, manufacturer-provided breath shield, before replacing it. The breath shields were cleaned after every patient with alcohol wipes and removed for deep cleaning with hand soap and water after each session. We used a proof of concept experiment using fluorescein instilled spray to test the effectiveness of each breath shield at preventing droplet transmission to the slit lamp user.Following four PDSA cycles, a breath shield that is user-friendly, easy to clean was produced. The percentage of confidence that the final design would be effective at preventing droplet transmission increased from 5.6% to 80%.Implementation of a low cost, simple to make, transparent, waterproof breath shield together with other forms of person protective equipment (PPE) creates a safe working environment for clinicians and patients. This intervention can be readily replicated and modified for other slit lamp models.

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Letter to the editor, Many thanks for the opportunity to respond to the comments Qadir and Kadyan make concerning our study. The interesting point is that the data they share shows exactly the same findings as we report. With specific reference to our methodology: 1 We sampled the data over 3 sites with 2 different EPR systems as we believe this reduced the bias of analysis based on a specific EPR. 2 Data collection was over period of time that allowed staff training and familiarization of the systems as they were being introduced. 3 Our table 1 showed the results of both EPR systems separately and combined together to allow readers to interpret the data in detail independently. For the Moorfields City Road data, we identified the samples of new patients with a stamp in the medical notes to indicate full documentation of the entry on EPR, based on the discretion of the clinicians. The fact IOP was only recorded in 90% of the Openeyes entry we speculatewas due to it not being a forced choice option. 4 Both electronic and paper data entry in all three sites can be performed by clinicians, trained ophthalmic nurses and technicians. The final entries were all completed by the clinicians. For the paper entry, structured paper new patient proformas were used across 3 sites. Whilst we agree electronic records are the 'way of the future', the findings of both our study and the findings of Qadir and Kadyan highlight the need for regular and continuous evaluation of an EPR. This evaluation will ensure safety and reliability in the transition to a 'paperless', or at least 'paperlight', NHS.