COOKIE Issue 08: The ebook version (The Ophthalmology-Optometry Crossover Issue)

THE WORLD’S FIRST FUNKY OPTOMETRY MAGAZINE

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THE OPHTHALMOLOGY-OPTOMETRY CROSSOVER ISSUE

August 2022

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LETTER TO READERS

Seeing Eye to Eye Interprofessional collaboration is key to addressing better eye care services

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n general, the public still gets confused about the roles of the three “O’s” in the eye care industry: optometry, ophthalmology and opticianry. This is perhaps because there are overlaps and crossovers as to what each “O” is allowed to do in different countries.

In the majority of the countries, optometrists are recognized as primary eye care providers who examine, diagnose, treat and manage various conditions of the visual system and associated structures — including diseases, injuries and disorders.

However, in some jurisdictions, the boundary between optometry and ophthalmology is blurred because both can diagnose and manage errors of refraction, dry eye, binocular vision anomalies, anterior segment diseases, posterior segment diseases, and other problems. But when there is no law regulating either profession, vision care can be practiced by practically anyone.

On the other hand, regulation can also heighten the confusion. Case in point: At the Wenzhou School of Optometry and Ophthalmology in China, one can become an optometrist and an ophthalmologist at the same time in a span of five to eight years — right out of secondary school. In the United States, 50 States allow optometrists to prescribe therapeutics and a few states allow optometrists to perform COVID-19 injections. Four states allow advanced surgical authority — meaning optometrists have laser privileges beyond foreign body removal, and 10 states allow optometrists to perform additional surgical procedures as authorized by a state’s board of optometry.

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Meanwhile, in the Philippines, Republic Act 8050 defines optometry as the science and art of examining the human eye, analyzing the ocular function, prescribing and dispensing ophthalmic devices, as well as conducting ocular exercises, vision training, orthoptics, installing prosthetics, and using authorized diagnostic pharmaceutical agents (DPA) and other preventive or corrective measures or procedures for the aid, correction, rehabilitation or relief of the human eye (or to attain maximum vision and comfort).

The need to address uncorrected refractive error (URE), which comprises a big percentage of avoidable blindness, requires collaboration between optometrists and ophthalmologists. I believe both professions should work together and innovate to be part of the solution rather than the problem. Education and legislation are key drivers in the successful provision of quality eye care in all parts of the world, and ophthalmologists and optometrists play a vital role in this.

In fact, there are a lot of opportunities to serve. Cataracts, dry eye, myopia, glaucoma and retinopathy are common eye conditions that are usually treatable, and early diagnosis and good interprofessional collaboration and referral systems are key components that are vital to addressing preventable blindness and other eye conditions around the world.

Faced with ever-increasing health issues and dwindling resources, the trend toward collaborative health care is inevitable. Optometrists and ophthalmologists cannot remain oblivious to this, and they should start building bridges to better serve the vision care needs of their patients.

For this issue of COOKIE magazine, we tackle the importance of MDs and ODs working together for better eye care delivery — from cataract and keratoconus treatments, to managed care settings and eConsult service.

As always, we hope you enjoy this issue!

Best, Carmen Abesamis-Dichoso OD, MAT, FIACLE, FPCO, FAAO

IN THIS ISSUE...

Optics

Cool Optometry Matt Young

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Two Sides of the Treatment Coin The roles of optometrists and ophthalmologists in the management of keratoconus

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Patient First Effective cataract co-management strategies between optometrists and ophthalmologists for maximum patient care

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Cohorts in Eye Care Co-management settings help keep patients’ satisfaction in sharp focus

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The OCULUS Myopia Master Experts’ ally in effective myopia management

CEO & Publisher

Hannah Nguyen COO & CFO

Robert Anderson Media Director

Gloria D. Gamat Chief Editor Editors

Brooke Herron Mapet Poso International Business Development

Ruchi Mahajan Ranga Brandon Winkeler Writers

Andrew Sweeney April Ingram Ben Collins Chow Ee-Tan Joanna Lee Matt Herman Roman Meitav Tan Sher Lynn

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He Eye Specialist Hospital

Windows to the Soul 10 serious health issues an eye exam can catch

Kudos

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A Force for Sight Worldwide Helen Keller International continues its co-founder’s legacy

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Eye Health Heroine Dr. Suit May Ho champions sustainable eye care and training programs

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Society Friend

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Embracing Crossovers or Staying in Your Own Lane?

Bridging the gap between ophthalmology and optometry for better eye care delivery

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Media MICE Pte. Ltd.

Not All Frames are Created Equal How to choose the right frames for patients who have high prescriptions

Cover Story

Maricel Salvador

Published by

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Enlightenment

Innovation

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Mapping Out Future Lenses Latest developments in corneal topography and tomography

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Better in Tandem Assessing the feasibility of eConsult service between optometrists and ophthalmologists

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Visual Check The importance of charting visual acuity in low vision patients

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Optometrist vs. Ophthalmologist Which doctor does your patient need?

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How to Upgrade Your Practice Wise words from our experts

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ADVISORY BOARD MEMBERS

Dr. Carmen Abesamis-Dichoso OD, MAT, FPCO, FIACLE, FAAO

Dr. Carmen Abesamis-Dichoso received her Doctor of Optometry from the Central Colleges of the Philippines in 1989, and earned her Master of Arts in Teaching from the Central Colleges of the Philippines in 2001. Her specialties include special contact lens design for keratoconus, children and high astigmatism; and visual assessment of the mentally challenged, autistic, ADHD, cerebral palsy and learning disabilities. In addition, Dr. AbesamisDichoso has been an orthokeratology practitioner in the Philippines since 2005. Since 1998, she has been self-employed in a private practice at Medical Plaza Makati.

She was awarded Outstanding Optometrist of the Year in 2017 by the Optometric Association of the Philippines. Currently, Dr. Abesamis-Dichoso serves as the International Affairs Committee chair of the Optometric Association of the Philippines; director of the Special Olympics Opening Eyes in the Philippines; program manager of Optometric Association of the Philippines Vision Screening

Dr. Joseph J. Allen is a practicing optometrist in Minnesota (USA) and the founder of Doctor Eye Health – an educational YouTube channel with more than 640K subscribers. In that channel he provides information about eye health, ocular disease and vision products. His videos cover a range of topics that his subscribers frequently ask about: eye floaters, glaucoma, dry eye syndrome,

Program and provision of eyeglasses with the United Nations Development Program in 10 areas and four Regions in the Philippines; and chairperson of the Special Olympics Healthy Athletes Program in the Philippines.

Dr. Abesamis-Dichoso is a fellow of the American Academy of Optometry; a founding fellow at the Philippine College of Optometrists; a fellow of the International Association of Contact Lens Educators; an Asia-Pacific Regional advisor for the Special Olympics Opening Eyes; treasurer at the Asia-Pacific Council of Optometry; and is an AsiaPacific Council of Optometry (APCO) representative for the World Council of Optometry, in addition to being a member of the Legislation, Registration and Standards Committee. She has also authored numerous published papers and is a popular lecturer at industry meetings. carmen.dichoso@gmail.com

contact lenses, eyeglasses, and more. Dr. Allen has been featured in Ask Men and Oprah Daily and was awarded the Media Advocacy Award from the American Optometric Association in 2021. In his free time, he enjoys rock climbing, running, playing video games, hiking, and biking. hello@doctoreyehealth.com

Dr. Joseph Allen OD, FAAO, Dipl ABO

Dr. Monica Chaudhry MSc

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Dr. Monica Chaudhry is a consultant optometrist and educator who have more than three decades of experience as an academic and a clinician. With her extraordinary skills in optometry education, she has recently ventured to be a freelancer educator, strategy advisor and practitioner. She is the founder of an online optometry up-skilling education platform – Learn Beyond Vision. Also, she has instituted some centers of excellence and vision centers, which aim to be a unique referral, academic and research units. Her name is well-known as a contact lens and low vision specialist and has a far and wide patient referral in India. Dr. Chaudhry has served at the All India Institute of Medical Sciences (AIIMS) in New Delhi, had academic experience with various universities, including the Indira Gandhi National Open University (IGNOU) and Amity University (India), and has recently retired as director of School of Health Sciences at Ansal University (Gurgaon, India). She has been associated with leading eye care companies such as Menicon, Johnson&Johnson , Baush +Lomb , Alcon, Essilor,

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among others, as a key opinion leader, faculty, consultant or advisor.

In recognition of her contribution to the field of academic medical service, she has been awarded the Shreshtshree Award by the Delhi Citizen Forum, the Australian Leadership Fellowship award in 2012 and the IACLE Contact Lens Educator of the Year (Asia Pacific) award in 2015.

Dr. Chaudhry was chairman of the Optometry Council of India. She has been actively involved in organizing conferences, seminars, national and international workshops, faculty development programs and many corporate training programs. She has chaired many scientific sessions and presented many papers in national and international optometry and ophthalmology conferences. She has travelled abroad extensively and attended many international trainings and conferences. She has written chapters in books and has published three books. monica.rchaudhry@gmail.com

ADVISORY BOARD MEMBERS Dr. Kristie Nguyen is a board-certified optometrist.

She currently serves as a contract doctor for Perez and Associates and Phan-Tastic Eye Care in Altamonte Springs, Florida, USA.

Dr. Kristie Nguyen OD

After graduating in the top 10 of her high school class with honors, she went on to obtain her Bachelor of Science degree from the University of Houston, Texas. While at U of H, she volunteered at a local hospital and worked as an optometric assistant. Dr. Nguyen obtained a Doctorate of Optometry (O.D.) in 2005 from Nova Southeastern University College of Optometry in Fort Lauderdale, Florida. She conducted her medical internships at the Chickasaw Nation Health Clinic in Ardmore, Oklahoma and the Lake Mary Eye Care in Lake Mary, Florida.

Dr. Nguyen is a member of the American Optometric Association, the Florida Optometric Association, Young ODs of America, OD Divas, Optometry Divas and the Central Florida Optometric Society. In addition, she has been an executive board member for Optometry Divas for the past two years. She is also a brand ambassador for an independent eyewear brand called Kazoku Lunettes and director of business development for an online optical company called Optazoom. She is also an independent consultant for Rodan+Fields, which is a global clinically tested skincare brand.

Dr. Nguyen is married and has two beautiful daughters. She enjoys going to the beach, hanging out at Disney, and reading. kristie817@gmail.com

With almost twenty years of experience, Dr. Mark Eltis has practiced Optometry in New York, California, and Toronto. He is a graduate of the University of Waterloo School of Optometry and has taught there for over a decade.

Dr. Mark Eltis OD, FAAO

Dr. Eltis is a fellow of the American Academy of Optometry and a diplomate of the American Board of Optometry. He is also a faculty member of the Academy of Ophthalmic Education and has completed his California Glaucoma Certification at UC Berkeley. Dr. Eltis has served as an examiner for national licensing assessment in both Canada and the United States. He has presented and published internationally and has been sought as an expert on optometric issues for national television and print.

In 2013, Dr. Eltis was honored as a member of the Optometric Glaucoma Society (OGS) having “demonstrated excellence in the care of patients with glaucoma through professional education and scientific investigation.” Dr. Eltis is a reviewer for over a dozen publications including Journal

Dr. Elise Brisco OD, FAAO, CCH, FCOVD

Dr. Elise Brisco is the founder of NearSight – a new vision wellness company that is revolutionizing solutions to keep people comfortable and productive on their devices in our digital culture.

Dr. Brisco has dedicated her career to helping others through her multidisciplinary wellness group and integrative optometric and homeopathic practice. She has written many articles, been a Key Opinion Leader, and has presented lectures extensively. She has been interviewed in over 400 TV, radio, internet, and print.

She sold her practice in 2019 to focus on launching NearSight. She continues her mission to educate and motivate others to live their best

of Glaucoma and Canadian Journal of Optometry.

In 2017, he was recognized for his “outstanding contribution in reviewing” by the editors of Journal of Optometry and Elsevier. He is also on the editorial board of scholarly publications and is a US optometric residency program evaluator.

Dr. Eltis has been a consultant for academic institutions overseas, contact lens/pharmaceutical companies, law firms, and a subject matter expert for competency evaluations. He serves on the board of directors of the Council for Healthy Eyes Canada and was elected to council at the College of Optometrists of Ontario.

Dr. Eltis is currently focusing his practice on dry eye patients employing the latest diagnostic and therapeutic options. He loves connecting with optometry students and the public by sharing his eye care tips on social media. drmarkeltis@vieweyecare.com

life as a Health, Beauty and Fitness Influencer.

She collaborates with wellness and fashion brands to promote healthy living through social media.

You can find her on Instagram @HollywoodEyes or Facebook and YouTube Hollywood Eyes – Dr. Elise Brisco.

Dr. Brisco is also the reigning Ms. Woman California United States and a runway and published model.

Her platform is Healthy Living for Healthy Aging. In her personal life she is passionate about her family, boxing, fitness and travel. elisebrisco@hollywoodeyes.net

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COOL OPTOMETRY | KERATOCONUS

Two Sides of the Treatment Coin

The roles of optometrists and ophthalmologists in the management of keratoconus by Nick Eustice

brings about blurred vision, as well as increased light sensitivity.

Dr. Kramer described the development of this visual impairment, noting that as time goes on, a patient’s vision begins to diminish starting on the posterior side of the cornea. This deformation makes its way to the front side of the cornea, creating what's called irregular astigmatism.

As this condition advances, it manifests in visual impairment that cannot be corrected with conventional treatments, such as glasses and contact lenses. At this point, patients experience even more blurry vision, as well as halos, distortion, glare and other visual disturbances.

Though causes of keratoconus are not completely understood, a number of risk factors and contributing conditions have been identified. It is known to have a genetic component, and family history makes a patient far more likely to develop the condition.

Eye rubbing — especially when done vigorously — is a recognized contributing factor as well. For this reason, and perhaps others, patients with hay fever and allergies are much more likely to develop keratoconus.

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n this issue, we’re focusing on cooperation between optometrists and ophthalmologists and how, by working together, the two professions could be more effective at treating patients than either one can be alone.

In this article, we’ll be talking about a condition where that very cooperation is absolutely vital to helping patients live better lives: keratoconus. As a condition that is highly treatable these days, keratoconus provides a perfect example of an area where a tag-team approach to treatment brings about excellent results for patients whose vision is in jeopardy.

Advances in surgical and non-surgical treatments have expanded the options for ophthalmologists in stopping the development of the condition. At the same time, new technologies in lenses have allowed optometrists to implement restorative solutions that improve patients’ day-to-day eyesight.

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To learn more about this condition and how optometrists and ophthalmologists can work better together, we spoke with Dr. Elise Kramer, an optometrist who specializes in treating keratoconus.

Based in South Florida, Dr. Kramer has a strong track record of treating a high volume of keratoconus patients in her practice each year.

Elements of the condition “Keratoconus is a condition that occurs when the cornea begins to progressively become irregular and starts to continuously become thinner and a little bit more distorted,” explained Dr. Kramer.

When this occurs, the cornea — already domed in shape — becomes more extreme in its distension and goes from a healthy, consistent ovoid shape to a more pointed shape, resembling a cone.1 This change in shape often

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Other certain conditions, such as retinitis pigmentosa, Down syndrome and Ehlers-Danlos syndrome, have also been linked to a higher instance of keratoconus. And although keratoconus typically occurs in both eyes, it is usually more present in one eye than the other. Keratoconus usually starts to show signs in patients between the ages of 10 and 25 and can progress slowly for 10 years or more.

Treatments then and now For many years, Dr. Kramer said, the only option available for keratoconus was penetrating keratoplasty or a full-cornea transplant, where doctors remove a full-thickness portion of the patient’s central cornea and replace it with donor tissue.

While corneal transplants are still performed for cases of extreme corneal thinning, or where severe

corneal scarring has taken place, new technology has taken center stage in treating most instances of keratoconus: a procedure called collagen corneal cross-linking.

In collagen corneal cross-linking,2 the cornea is treated with a significant amount of vitamin B (riboflavin) eye drops. Soon thereafter, a special device shines a focused beam of ultraviolet (UV) light rays at a patient’s cornea for close to 30 minutes. This special light activates the riboflavin in the cornea, helping to form new bonds between the collagen fibers within the cornea. These newly-formed connective bonds are the cross-linking for which the procedure is named, and these connections stiffen the cornea to prevent further shape changes.

Another relatively new treatment option available is that of intracorneal ring segments (ICRS).3 With this treatment, crescent-shaped plastic rings are surgically implanted under the stroma of the cornea. What this does, Dr. Kramer explained, is that it basically flattens the curvature of the cornea, and in doing so, it can help improve the vision among certain patients with high refractive error and keratoconus.

At the same time as these procedures, on the other side of the treatment equation are Dr. Kramer’s specialty: contact lenses. These, she pointed out, are not really a treatment, but a corrective device used for patients to help correct their vision so they can see properly. Advances in lenses have made correcting keratoconus patients’ vision a much more achievable goal than it was in years past.

Dr. Kramer said that the best type of contact lens to use for someone with keratoconus is something gas permeable that maintains its shape once it's put in the eye — so that it can help correct visual division.

Together with procedures to help stop the condition from advancing, these lenses can allow for a very significant improvement in a patient’s vision.

Procedures and lenses: Two sides of the treatment coin Returning to the subject of cooperation

and coordination, we asked Dr. Kramer about the different roles optometrists and ophthalmologists play in this type of combined treatment.

“I was talking to you about cross-linking — that’s something that is done by an ophthalmologist,” she said. “Specialty contact lenses can be done by ophthalmologists as well. But I would say the vast majority of people who do it are optometrists.”

Dr. Kramer explained that the coordinated efforts of the two specialties provide the best care that a patient can receive. On the one hand, the best and easiest way to correct vision in someone with keratoconus is with a specialty contact lens, which allows for instant visual correction. On the other hand, procedures like corneal collagen cross-linking slow down or stop the progression.

While the ophthalmological options are key to addressing the problem at its root, they don’t necessarily lead to improved vision right away. Thus, both aspects of treatment are necessary.

“One is necessary to correct vision,” said Dr. Kramer, “and the other is necessary to stop the progression of the condition. And I tell my patients all the time, I can correct their vision with a specialty contact lens, but I cannot stop their condition from progressing.

So, in order to do that, they have to get collagen corneal cross-linking. It's the combination of those two things that provides optimal treatment for the patient.”

Dr. Kramer added that when both of these specialties work together, the results are usually very good, with one specialist focused on stopping the progression of the condition, and another whose goal is making the patient’s vision better.

One last piece of the treatment puzzle In closing, Dr. Kramer noted how critical specializations are in the treatment of keratoconus. The unique lenses which she fits in her practice are not “off the shelf” like many ordinary

lenses these days, which can be ordered online. Rather, they require special fitting by a trained expert.

By that same token, most optometrists are not familiar with the unique procedures involved in corneal collagen cross-linking. Here, too, specialization is really vital. It is through cooperation and co-management that these experts are able to combine their fields of focus to bring patients the best possible course of treatment.

References 1.

Keratoconus. Mayo Clinic. Available at: https:// www.mayoclinic.org/diseases-conditions/ keratoconus/symptoms-causes/syc-20351352.

Accessed on July 21, 2022.

2.

Corneal Cross-Linking. American Academy of Ophthalmology. Published January 6, 2022.

Available at: https://www.aao.org/eye-health/ treatments/corneal-cross-linking-2. Accessed on July 21, 2022.

3.

Intacs or Intracorneal Ring Segments (ICRS).

M Kellog Eye Center. Available at: https://www. umkelloggeye.org/conditions-treatments/refractivesurgery/intacs. Accessed on July 21, 2022.

Contributing Doctor Dr. Elise Kramer is a residencytrained optometrist in Miami, Florida, who specializes in ocular surface disease and specialty contact lens design and fitting.

Her doctorate degree was awarded in optometry from the Université de Montréal in 2012. During her fourth year, she completed her internship in ocular disease at the Eye Centers of South Florida and went on to complete her residency at the Miami VA Medical Center. Her time there included training at the Bascom Palmer Eye Institute, the nation’s top eye hospital. After her residency, Dr. Kramer became a fellow of the Scleral Lens Education Society (SLS) and now serves as the treasurer for the SLS. Dr. Kramer is a member of the American Optometric Association and the International Association of Contact Lens Educators, as well as a Fellow of the American Academy of Optometry and the British Contact Lens Association.

She is also the Delegate of International Relations for the Italian Association of Scleral Lenses. Dr. Kramer has published several important articles and reviews and participates in clinical research trials. She enjoys lecturing all around the world in several different languages about ocular surface diseases and specialty lenses. elise@miamicontactlens.com

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COOL OPTOMETRY | CATARACT CARE

Patient First Effective cataract co-management strategies between optometrists and ophthalmologists for maximum patient care by Nick Eustice

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hile many different conditions require that a patient receive the care of both an optometrist and an ophthalmologist, by far the most common is cataract.

Cataracts affect an estimated 24.4 million Americans aged 40 or older.

This number rises to about half of all Americans by the time they reach 75.

And for this reason, cataract surgery isn’t just the most commonly performed ophthalmic procedure, but the most commonly performed surgery in any area of medicine.

Due to a large number of patients in need of cataract procedures, a lot more optometrists and ophthalmologists are finding themselves needing to treat, refer and manage these patients than ever before. Increasingly, this includes cataract centers — specialty clinics where eye care professionals work together to specifically diagnose, treat and manage cataracts.

While cataract centers are excellent examples of how optometrists and ophthalmologists can work together to provide a more patient-centered approach to cataract treatment, they are neither the beginning nor the end of that subject. The best way to ensure that a patient receives the best education, counseling and emotional support is through co-management among the specialists from whom they receive treatment.

A key influencer in cataract co-management

Dr. Black brings a unique perspective to this subject, having worked with cataract patients in general optometric practice, a cataract and refractive focused practice, and most recently as the head of Professional Strategy for Surgery Americas for Johnson & Johnson Vision.

In this capacity, Dr. Black describes her job as one of helping out practices.

She works with optometrists and ophthalmologists to educate them on strategies to effectively work together.

Her work also involves educating other clinical staff with the goal of helping them to be more efficient, especially in communicating to patients in a way that is reassuring and informative.

Because of her experience in these different areas of cataract care, and over a time frame where much has changed in the field, Dr. Black has the distinct ability to see co-management from a number of different perspectives.

But the perspective she reminds us of may be the most important, and one which the field of cataract care has sometimes forgotten too easily — that of the patient.

Changing approaches to surgery and patient care We asked Dr. Black why she feels collaboration is so important in treating cataract patients. To answer this question, she shared her reflections on how doctors’ approaches to treatment have changed over the years.

To learn more about how optometrists, ophthalmologists and other eye care professionals can work together in treating cataract patients more effectively, we spoke with an expert on the subject, Dr. Sondra Black.

“When we talk about a cataract surgeon, per se, cataract surgery has changed,” Dr. Black said. “It has become a refractive procedure. This is in contrast to when I first graduated when doctors would wait till the cataract was ‘ripe.’” This is to say, the

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doctors would not attempt to diagnose a cataract as it developed, but would rather allow it to develop to a point where it caused substantial visual impairment.

The effect of this course of treatment — or rather, lack of it — was significant interference in patients’ lives. Dr. Black recalled that before receiving treatment, patients usually couldn't see and couldn't function. At the same time, these same patients were so happy to have had their cataract removed that they didn't have much opinion or involvement in what treatment options were available to them. These patients were rarely aware that different artificial lenses were available to correct different aspects of their visual field, and would sometimes be content to receive no intraocular lens (IOL) at all.

Since that time, however, Dr. Black has seen a number of significant improvements in the ways that eye care professionals approach cataract treatment.

“As technology has gotten better and

office in this. For it is frequently the optometrist with whom patients develop long-term relationships, seeing them regularly over the course of many years.

In this more comfortable and familiar environment, a patient can have time to discuss treatment options, weighing the pros and cons of each.

Dr. Black recommends a good supply of pamphlets and literature on surgical options be made available in the optometrist’s office, where patients are likely to feel somewhat more at ease.

“That way,” she said, “they have something that they can take home, so they can talk to their friends and family and digest some of the options in front of them before they get to the clinic.”

better, and as patients’ expectations have increased, we have seen this become a refractive procedure,” she explained. “And we have had to start thinking about it differently. We're not just going to treat a disease, but perform a refractive procedure and everything that comes with that.”

Education is a two-way street While this shift in consciousness has provided a vast improvement in patient care, it still presents a host of problems. Many of these problems boil down to education, both between specialists and from those specialists to their patients. An increasingly wide array of treatment options are available on the market, and the patients need to be educated on what these are, along with their benefits and potential drawbacks.

Dr. Black said that she sees patient education beginning in the optometrist’s office, and she included education on surgical procedures germane to the ophthalmologist’s

This potential for a shock on the patient’s part can often lead to making decisions too quickly. Early in her role with Johnson & Johnson, Dr. Black spent a lot of time shadowing patients during their visits to clinics.

Quickly she realized that several misconceptions seemed common to the majority of patients she met. The first of these was that their vision would be immediately and perfectly restored by cataract surgery. This belief can lead to serious disappointment when a patient discovers that, though they experience an overall improvement in vision, some areas of sight may not be as good as they were before.

Another misconception patients experienced was that they didn’t take into account the permanent nature of cataract surgery. “They think that it's like glasses or contacts,” Dr. Black said, “and if they make the wrong decision today, they can exchange it. Number one, you have to tell them that this is a once-in-alifetime decision. This is it for the rest of your life, every waking moment of every day, this is going to affect your life.”

Going along with this sort of patient education, Dr. Black pointed out that doctors must be engaged in understanding their patients. Whether one is an ophthalmologist or a cataract specialist optometrist, it is important to have the input and participation of an optometrist who has known and worked

with the patient for a long time.

Just as a patient’s understanding of their condition and treatment options are crucial to their well-being, so too is a doctor’s understanding of that patient’s character and emotional state.

While doctors and patients must know the ins and outs of cataract treatments, it is also vital for doctors to get to know their patients and make sure they are caring for the whole person.

Co-management requires respect Dr. Black made it clear that she feels there have been enormous improvements in the levels of communication and respect between optometrists and ophthalmologists, as well as between specialists and generalists in both fields. Nonetheless, she still feels that there is much work to be done in order to shift the focus of cataract management onto the patient where it belongs.

“I just think that there has to be mutual respect,” she said. “I think that we have to work together. And I think it needs to be all about the patient.

That needs to be the goal of everyone involved: “Let's just make the patient happier,” Dr. Black concluded.

Contributing Doctor Dr. Sondra Black, OD, FAAO, graduated from the University of Waterloo School of Optometry in 1980. She practiced optometry for 20 years in private practice.

She then joined TLC as a clinical director for the TLC Custom LASIK center in Toronto, Canada. In 2009, Dr. Black left TLC to become the VP-Clinical Operations for Crystal Clear Vision.

She left practice in November 2017 to focus exclusively on consulting both to industry and individual practices.

Her expertise lies in cataract, refractive surgery, and patient management and counseling, and now works full time for Johnson & Johnson Vision as the head of Professional Strategy Surgical Americas. sblack15@its.jnj.com

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COOL OPTOMETRY | CO-MANAGEMENT CARE

Cohorts in Eye Care

Co-management settings help keep patients’ satisfaction in sharp focus

by Tan Sher Lynn

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raditionally, ophthalmologists and optometrists have separate practices, and the idea of co-managing patients could be controversial. But as healthcare evolves, and with the rapid growth of laserassisted in-situ keratomileusis (LASIK) in the 1990s, the role of optometrists has become more crucial in refractive surgery practices.

Benefits of co-management

Today, effective teamwork is globally recognized as an essential tool for constructing a more effective and patient-centered healthcare delivery system.

When both optometrists and ophthalmologists work together, it can greatly benefit both practitioners, as well as provide better patient care.

Optometrists and ophthalmologists benefit by being more focused on doing what they were trained to do, while patients benefit from a wider spectrum of eye care and quicker access to it.

Furthermore, combining optometric and ophthalmic expertise can increase productivity in an eye care practice and enable greater contributions to the field at large.

According to the American Academy of Ophthalmology, co-management is a relationship between an operating ophthalmologist and a non-operating practitioner for shared responsibility in the postoperative care when the patient consents in writing to multiple providers.1 The services being performed are within the providers' respective scope of practice, and there is written agreement between the providers to share patient care.

“Co-management in whatever setting is beneficial for both the optometrist and ophthalmologist, as well as the patient,” shared Dr. Carmen AbesamisDichoso, an optometrist from Manila, Philippines. “There is always space for each eye care practitioner in the management of eye conditions.

For example, diagnosis of a patient with cataracts can be done by either practitioner. Correcting the best corrected visual acuity and monitoring

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the progression of the disease can be done by the optometrist. But once it has progressed to a level where it needs surgical intervention, the ophthalmologist will do the surgery.

Meanwhile, post-operative care — through the provision of the best corrective spectacles — will be the role of the optometrist,” she explained. “As a result, the patient can enjoy good and healthy vision before and after the surgery.”

Furthermore, a well-executed comanagement can be a practice builder.2 When patients have a good experience at the referred office, their confidence in the practitioner increases, resulting in more loyalty to his/her practice, which will, in turn, generate increased revenue and word-of-mouth referrals.

“Optometrists can benefit from an inter-referral system — acknowledging that you have certain boundaries in eye care and referring patients to the ophthalmologist who can manage the patients' diabetic retinopathy, hypertensive retinopathy, glaucoma, or

high myopia for example is important,” added Dr. Abesamis-Dichoso. “We gain the respect of patients, and they are satisfied with the service as they come full circle with complete eye care.”

Ophthalmologists and optometrists who worked in a co-management setting before agree that this sort of collaboration has brought them success in various areas and has enabled them to keep patients’ satisfaction and the growth of their practice in sharp focus.

Things to note in a comanagement setting Nevertheless, some challenges can surface in a co-management system.

These include the need for constant, seamless communication, explaining to patients the different roles each practitioner plays, and resolving any optometrist-ophthalmologist relationship issues.

“Some common challenges that may occur in a co-management setting between an optometrist and ophthalmologist include differences in management style and procedure that may confuse patients,” explained Dr. Abesamis-Dichoso. “This can be avoided or remedied by having open communication. For example, the optometrist should write professional letters of communication, stating exactly the working history of the patient, the treatments given, and the reason for the referral.” She added that this is a good starting point for ophthalmologists when they begin their treatment. “On the other hand,” she added, “the ophthalmologist should also write (and thank) the optometrist for referring and stating exactly what was done to the patient, why it was done, and the continuous care to be given — and vice versa.”

As with any partnership, it takes commitment to ensure the success of the practice. Collaborators have to be able to trust each other to do the right thing for the practice, even when it might not benefit them personally.3 Having well-defined roles that do not overlap is also crucial. For example, a referral center in the United States does not provide any primary care.3 Their optometrists serve as consultants to referring doctors of optometry by assessing patients for surgery, assisting referring doctors of optometry with follow-up care as needed, and managing patients referred for secondary medical care. Meanwhile, their surgeons spend very little time in the clinic as their focus is surgery.

Optometrists and ophthalmologists within the group focus on what they do best and do not overlap services. This approach optimizes everyone's strengths and expertise.

Having a similar work ethic and tolerance for risk is helpful as well, while communication is key to mutual understanding.2 Hence, sometimes it is essential to be brutally honest in conversations about money and people.

One must know when to talk and when to listen.3 Last but not least, maintain one’s co-management network.2 One must not become complacent with one’s current network. New specialists and optometrists join or open practices daily, so be aware of these new options and try to familiarize yourself with their work. Doing so allows patients to be able to enjoy the best care possible.

The future of integrated eye care setting The integrated model of eye care will

References 1.

Comprehensive Guidelines for the Co-Management of Ophthalmic Postoperative Care. American Academy of Ophthalmology. Published on September 7, 2016. Available at: https://www.aao.org/ethicsdetail/guidelines-comanagement-postoperative-care. Accessed on July 30, 2022.

2.

The Ultimate Guide: Optometry & Ophthalmology Co-Management. Published on August 23, 2021.

Eyes on Eyecare. Available at: https://eyesoneyecare.com/resources/the-ultimate-guide-optometryophthalmology-co-management/. Accessed on July 30, 2022.

3.

Co-management: 4 steps to success. American Optometric Association. Published on October 29, 2019. Available at: https://www.aoa.org/news/practice-management/perfect-your-practice/comanagement-4-steps-to-success?sso=y. Accessed on July 30, 2022.

4.

likely become more common in the future, as ophthalmologists are called on to perform more surgeries, leaving optometrists to provide non-surgical eye care in all its forms. Dedication to growing and maintaining relationships between ophthalmologists and optometrists is a worthwhile investment for practitioners, staff members, and patients alike.4

Contributing Doctor Dr. Carmen Abesamis-Dichoso received her Doctor of Optometry from the Central Colleges of the Philippines in 1989, and earned her Master of Arts in Teaching from the Central Colleges of the Philippines in 2001. Her specialties include special contact lens design for keratoconus, children and high astigmatism; and visual assessment of the mentally challenged, autistic, ADHD, cerebral palsy and learning disabilities.

In addition, Dr. Abesamis-Dichoso has been an orthokeratology practitioner in the Philippines since 2005. Since 1998, she has been self-employed in a private practice at Medical Plaza Makati.

She was awarded Outstanding Optometrist of the Year in 2017 by the Optometric Association of the Philippines. Currently, Dr. AbesamisDichoso serves as the International Affairs Committee chair of the Optometric Association of the Philippines; director of the Special Olympics Opening Eyes in the Philippines; program manager of Optometric Association of the Philippines Vision Screening Program and provision of eyeglasses with the United Nations Development Program in 10 areas and four Regions in the Philippines; and chairperson of the Special Olympics Healthy Athletes Program in the Philippines.Dr. Abesamis-Dichoso is a fellow of the American Academy of Optometry; a founding fellow at the Philippine College of Optometrists; a fellow of the International Association of Contact Lens Educators; an AsiaPacific Regional advisor for the Special Olympics Opening Eyes; treasurer at the Asia-Pacific Council of Optometry; and is an Asia-Pacific Council of Optometry (APCO) representative for the World Council of Optometry, in addition to being a member of the Legislation, Registration and Standards Committee. She has also authored numerous published papers and is a popular lecturer at industry meetings. carmen.dichoso@gmail.com

Successful Ophthalmology-Optometry Models. CRSTEurope. Published in October 2016. Available at: https://crstodayeurope.com/articles/2016-oct/successful-ophthalmology-optometry-models/. Accessed on July 30, 2022.

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OCULUS CORNER

The OCULUS Myopia Master Experts’ ally in effective myopia management

by Hazlin Hassan

A

ccording to the Brien Holden Vision Institute, one in two people could be affected by myopia by the year 2050. And those affected have a greater risk of developing severe eye diseases, such as cataracts and retinal detachment, or even blindness.

As such, early detection and careful management of myopia are becoming more and more important.

The Myopia Master® (OCULUS Optikgeräte GmbH, Wetzlar, Germany) is the world’s first device to combine the three important measurement parameters for myopia management: refraction, axial length and central corneal radii — making myopia assessment and management easier — and more reliable — than ever.

Every diopter matters Neilson Eyecare in Toowoomba, Australia, is one optometry practice using the Myopia Master to help better manage myopia progression in patients.

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“We know all too well what risk factors high myopia brings — cataracts, retinal detachment, maculopathy, glaucoma, and high levels of myopia lead to worse outcomes for the patient — so every diopter matters,” shared Dr. Abby Ussher, an optometrist at Neilson Eyecare.

“We use the OCULUS Myopia Master to help predict future myopes, especially in children; to monitor progressing myopes; and to help understand late-onset myopes. It’s also handy for anisometropia,” explained Dr. David Neilson, optometrist and owner of Neilson Eyecare. They also use the Myopia Master for hyperopes, especially if they are anisometropic.

The Myopia Master is an all-in-one device that uses non-contact, noninvasive interferometry technology to measure axial length, keratometry (K) and autorefraction.

“Each of these features gives us quantitative data, and we then assess

August 2022

those numbers. The axial length is plotted on a normative growth curve, which is derived from the Brien Holden Vision Institute data, calculated from approximately 24,000 children (Caucasian and Asian database),” said Dr. Ussher.

She shared an image [see Figure on p.13] from a 15-year-old patient to illustrate how the Myopia Master has become an integral component to monitor and measure myopia progression. In the image, the right eye’s axial length is 23.59 mm and 23.80 mm in the left. Dr. Ussher first measured his axial length in November 2021 and the patient wears ortho-K lenses.

“I re-measured his axial length again six months later in June 2022, and the length hasn’t changed — his myopia is stable. In the box on the right, you can select the treatment; in this case, ortho-k is purple, highlighting that he’s been in ortho-k lenses since November 2021.”

an OCULUS Myopia Master. The community appreciates that we have the most up-to-date technology and that they do not have to travel to Brisbane for it,” shared Dr. Neilson.

He continued: “We can now offer the ‘gold-standard’ of myopia measurement of axial length and monitoring progression. It pays for itself. We don’t have to refer to an ophthalmologist to measure axial length and we accept referrals from other practices, too.”

Figure showing a 15-year-old patient’s axial length, autorefraction and keratometry on the left and the axial length plotted against normative growth curves on the right using the OCULUS Myopia Master.

Assessing myopia faster and more efficiently “The Myopia Master makes assessing myopia very efficient in our busy, threeoptometrist practice,” continued Dr. Neilson. “The scan itself only takes about a minute per eye. Because it takes three different measurements, it is a time-saver.”

The Myopia Master instantly uploads the results onto the computer, allowing practitioners to show the child and parents information about their eye length, where they lie on the curve, and their prediction. “We then identify risk factors and explain to their parents why it’s important for their myopia to be limited or addressed,” Dr. Neilson continued.

Detailed background information is taken, such as family history, if parents are myopic, how many hours a day are spent outdoors, and the amount of time spent on near-work activity.

Due to the constantly-evolving demands of today’s lifestyles, they now see unexpected cases. “I now have farmers becoming myopic. It took me a while to work it out,” shared Dr. Neilson.

“They have computers and TVs in their tractors — the GPS drives the tractor and they watch TV all day!”

The Myopia Master: An asset to every practice The Myopia Master can also be an

asset in uncooperative patients.

“It is especially useful if you show a progression, or show that their prediction is going to be -5.00D by the time they’re 18. For example, if you have a child who wasn’t using their low-dose atropine drops and their myopia was progressing, you can re-measure their axial length and show them that their eyes have gotten worse and then recommend that they recommence their treatment,” explained Dr. Neilson. “This helps to reinforce if treatments are working or not, and if the patient is compliant.”

The Myopia Report generated by the Myopia Master includes all results and recommendations and helps with understanding the scientific background behind it all.

“The first page contains their refraction, keratometry, axial length, and any treatments and lifestyle changes you have recommended, as well as a review date. The second page has their predicted growth curve, the third page explains what shortsightedness is, and the fourth page explains the risks of myopia. It’s a very good tool for explaining everything,” he continued.

When patients return for repeat scans and see that their treatment is working and their axial length has not grown significantly, it gives both patient and practitioner peace of mind.

“We use this machine every day and wish we had it sooner. It’s been valuable in so many ways,” concluded Dr. Neilson.

Contributing Doctors Dr. David Neilson graduated with a Bachelor of Optometry in 1989 at the University of New South Wales, Australia. He has been in practice for over 30 years, honing his skills in not only the science but the art of optometry. The belief that people should not have to work hard to see is at the core of his approach. Originally from Sydney, Dr. Neilson has practiced in different locations, including the United Kingdom, before moving to Toowoomba with his family in 2005. He is the owner of Neilson Eyecare, which he founded in 2018.

Dr. Abby Ussher completed her Master of Optometry with distinction in 2018 at QUT in Brisbane QLD, Australia. She has worked in the industry since 2010 as a trainee dispenser on the Mid North Coast of NSW before moving to Brisbane and commenced employment as an Optical Assistant at Gerry & Johnson Optometrists when she started her optometry studies in 2014. She has worked closely with and has learnt a lot from the “queen of myopia control” Dr. Kate Gifford, especially with her PhD data collection. She completed a semester exchange to the University of Waterloo in Ontario, Canada in 2018. She has worked at Neilson Eyecare since graduation in 2018.

“We are the only private practice in Queensland other than QUT to have

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COVER STORY

Embracing

by April Ingram

O

ften, the differences between an optometrist and an ophthalmologist need to be explained to patients or members of the general public.

“They’re all eye doctors to me!”

There are distinct differences between the two — however, by creating collaborative, co-management environments based on the strengths of each profession, one would expect to be able to deliver better and more comprehensive eye care.

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Some would agree, while others (from either side) would fiercely be against bridging the gap between the two eye care professions.

Focusing on effective comanagement strategies Dr. Casey D. Claypool, OD, is an optometric physician at Empire Eye Physicians in the Spokane Valley of Washington, USA. Within this practice, surgeon ophthalmologists work alongside optometrists in order

August 2022

to deliver the best possible care to patients in their area.

Empire Eye initiated this care model in the 1980s, with ophthalmologists deciding to work more closely with optometry in the co-management of cataract patients, and to act as a liaison between community ODs and the surgical practice.

“The best model is when both fields are able to practice at the top of their training and specialties. The goal in our practice is to have our

ophthalmologists, who are all excellent surgeons, spend more time in surgery.

That's where they can really help people,” Dr. Claypool said, describing how ODs and MDs can work seamlessly together. “Another important goal is to have our optometrists, who are astute clinicians, practicing at the top of their clinical skills with prescribing, refracting, treating ocular disease, managing expectations, and so on.

We respect each others’ strengths and abilities, and we focus first on patient care,” he added.

Embracing overlaps while respecting boundaries Dr. Gabriel Chu, MD, and Dr. Joseph King, MD, are two surgeon ophthalmologists and members of the Fraser Valley Cataract and Laser (FVCL) surgical team. They focus on medical and surgical eye conditions, delivering specialized ophthalmic care to people in Surrey, Abbotsford and Coquitlam in British Columbia, Canada.

Their practice model is unique in British Columbia — and perhaps in all of Canada — with ODs and MDs collaborating under one umbrella for approximately the last 10 years.

Dr. Chu and Dr. King described how their practice model has been so successful. “The roles between MDs and ODs in our practice have significant overlap, but there are general rules that let us work well together, allowing us to effectively and efficiently split the work for our new and follow-up patients,” they explained.

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whoever they are seeing on a particular visit, they have access to their entire ocular and diagnostic history.

A controversial issue: Stay in your lane!

There have always been groups within the ophthalmic and optometric professions that refuse to acknowledge that ophthalmologists and optometrists can work together in harmony.

This all seemed to come to a very public head in 2004, when the American Academy of Ophthalmology (AAO) made the controversial decision to exclude optometrists from the educational portion of its annual meeting. Many thought that this decision to preclude optometrists was harmful to an already complex relationship between the specialties and potentially detrimental to patient care.

The AAO stated that these programs in question “are developed for ophthalmologists who possess the educational foundation of medical school, internship and residency.”

The reason may be fine; however, the logic did not hold up, as allied health professionals, nurses and ophthalmic technicians were not prohibited from attending.

Further probing into the rationale for the decision uncovered that it was prompted by “surgery” being included in the Optometry Practice Act in

some U.S. states, intended to allow optometrists to perform some base procedures. The viewed encroachment into ophthalmology’s space raised concerns about optometrists attending events and expanding their scope of practice.

This prompted cries of displeasure — “Don’t overstep!” and “Stay in your lane!” — widening any existing rift, rather than appreciating these courses as an opportunity for networking and education for better eye care delivery.

It should go without saying that receiving a continuing medical education (CME) credit after attending a one-hour event is simply a CME credit, not a pass to receive surgical privileges.

Keeping our eyes on the same prize — communication, collaboration and education within both professions — delivers benefits to patient care.

The ‘all hands on deck’ attitude is key More ODs are graduating and entering the care stream each year compared to the increasing number of MDs that are reaching retirement. And many new trainees are moving towards a subspecialty, rather than general ophthalmology, resulting in a bottleneck in accessing basic eye care.

In order to address the eye care demands of our aging population,

“The MDs must perform the surgical procedures and necessary medical work, and the ODs act largely in a supportive role, providing primary screening care,” Dr. Chu added. “We share the same electronic medical records (EMR), and patients flow freely between optometry and ophthalmology. It allows us to serve our patients better by providing quicker and broader service, as well as more consistent service under one clinic.”

This is extremely valuable to patients.

Having reliable and consistent care under the umbrella of a single facility reduces the potential of patients being lost to follow-up, and ensures that

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COVER STORY

collaboration is going to be key. The “all hands on deck!” attitude is going to need to prevail. Ophthalmologists need to optimize the time that they can spend doing what they’re skilled at — managing complex conditions and performing surgery, and supported by optometrists providing primary and some post-operative care.

We need to think of each practitioner as an essential member of the patient care team. In order to achieve this ideal collaborative vision, will compromises or concessions need to be made by each of the specialties?

Dr. Chu and Dr. King shared that their practice model works so well because there have been some compromises made by each of the disciplines. “MDs and surgeons compromise by having ODs provide follow-up medical and surgical care. We [MDs] will also stop doing primary screening examinations and dedicate most of our time doing the necessary medical and surgical work,” they explained.

“Optometrists in our practice compromise by giving up a part of their discipline, such as routine refractions, and dedicate almost all their time doing medical and pre-/post-surgical work,” Dr. Chu added.

In Canada, there are rules to how often and who can bill for certain procedures

and assessments. “We all have to compromise by templating patient care visits into the British Columbia medical billing rules, so patients have a minimal delay in receiving their medical or optometric care,” Dr. Chu explained.

Reaching compromises and overcoming challenges Dr. Claypool believes that there are limited compromises that the specialties make in his practice.

However, he also acknowledges that some challenges definitely exist within eye care overall.

“The ODs and MDs in our office respect and support each other,” he shared.

“Perhaps some ODs and MDs would need to make compromises as they work closely together to give up old prejudices.”

“Sadly, there have been — and still are — ‘turf battles’ where each specialty points fingers at the other saying they are not giving a good standard of care,” he continued. “But gratefully, many of these biases are beginning to fade away and stay away throughout our state and nation.”

Like any successful relationship, personal or professional, communication and trust are key. Dr. Claypool couldn’t agree more. “I believe

communication is the biggest hurdle that at times needs to be addressed,” he shared. “When patients are comanaged within a clinic or outside a clinic, the ODs and MDs need to have consistent and open communication to cover patient expectations, surgical planning and long-term management.

Gratefully, with the modern world of EMRs and secure emailing, this can be done more easily than in the past with busy physician schedules,” he explained.

Dr. Claypool added that mutual trust is essential for ODs and MDs in order for each to seamlessly work together.

“Trust involves communication and sharing of ideas and treatment options for the best interest of the patient, which will in turn, reward each profession. Sometimes there has been a significant lack of trust, which has undermined patient care and prevented communication and timely referrals,” he said.

In many parts of the world, it is very common for ODs and MDs to exist in their own bubbles. Dr. Chu shared that this is also true in Canada.

“Traditionally ODs and MDs in Canada run completely separate practices, even though there is significant overlap in what we do,” he disclosed.

Both Dr. Chu and Dr. King also acknowledged that some of the old feelings still exist. “In order for our model to work, we all need to be aware of certain sensitivities that exist. For example, our referring optometrists (indirectly) request that we do not overlap with their primary income streams, such as working in primary family care, providing refractions, or selling glasses and contact lenses.

In turn, they are a primary source of referrals for our clinics,” the doctors shared.

“Some optometrists asked us to return patients for follow-up to their clinic, instead of seeing the optometrists that we have in the FVCL team. There are other territorial concerns that we try to accommodate the best we can without sacrificing on the quality-ofcare standards that we have within our practice,” Dr. Chu added. “Another compromise for our medical doctors is to be aware of, and be comfortable

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August 2022

with, the current scope of practice for optometrists and be on call for any possible issues or feedback/trends that may arise.”

Creating patient trust and optimizing manpower In some eye care practices, when optometrists are brought into the team, they shadow the ophthalmologist for a period of time, working closely together to understand the needs associated with different diseases and surgical procedures.

This allows for continuity of care, as the optometrists act as an extension of the ophthalmologists. Providing that regular contact for the patient with a doctor they already know within the same practice creates a sense of trust.

As well, being able to access a full spectrum of comprehensive eye care and expertise within the same location is appreciated by patients and their families.

Delivering eye care in different environments and geographies can have very unique needs. For some subspecialty ophthalmologists, there may be less of a role for an optometrist.

However, in areas with limited access to medical and surgical eye care, optometrists may be best suited to fill those gaps, maintaining basic eye care and making referrals as needed.

The key is optimizing resource allocation to ensure that the care is available for those who need it, when they need it, and where they need it.

In some regions, optometrists travel to outreach clinics, assessing and determining which patients require medical or surgical intervention, and referring them to ophthalmologists that stay in the clinic or operating rooms.

Delivering the best possible care to patients is the goal, but are there things that each profession can do to optimize this shared care/collaborative care model?

Changing old-school mindsets

attitudes will go a long way. “The biggest hurdle with this model is inset traditional thinking that ODs and MDs cannot work together,” he said. “Preset thinking, ego and uncertainty of the scopes of each profession are the main barriers. It takes time to break down these barriers to allow for better and more efficient patient care.”

There are no one-size-fits-all practice models, and the goals and roles of each individual provider must be carefully assessed.

Dr. Chu offered some tips for success.

“The key is to find members with

similar and strong mindsets. Both must be willing to consider compromises in order for their ideals and principles to be achieved. A lot of thought needs to be put into rules and templates to allow for organized and efficient patient sharing between ophthalmologists and optometrists,” he concluded.

Co-management between ODs and MDs is the direction that eye care is evolving, despite the opposition of some. Patients can only benefit when the primary focus is on their care, not on antiquated ego-driven or territorial squabbles.

Contributing Doctors Dr. Casey Claypool, OD, graduated cum laude from Brigham Young University with a bachelor’s degree in chemistry and completed his optometric studies with honors at Pacific University College of Optometry. He received a competitive Health Professions Scholarship from the Air Force and served for three years at Malmstrom Air Force Base in Great Falls, Montana.

His practice specialties are dry eye disease management, corneal refractive surgery, glaucoma, ocular disease, and optimizing integrated care between optometry and ophthalmology. He also fits specialty contact lenses for keratoconus and post-corneal transplant eyes. Dr. Claypool has lectured around the country on topics covering complex eye diseases and is an active member of the American Optometric Association and the Optometric Physicians of Washington. A native of Spokane, Dr. Claypool is grateful to call the Inland Northwest home. Dr. Claypool and his wife, Shaillé, are the proud parents of five wonderful children. In his spare time, he enjoys racquetball, the outdoors, volunteering at his church, and playing with his kids. He is fluent in Spanish after previously serving a two-year mission for his church in Ecuador.

EmpireEye.com Dr. Gabriel Chu, MD, graduated from the University of Alberta School of Medicine. He then completed his surgical training at the University of Western Ontario, Ivey Eye Institute in

London, Ontario, Canada. As a comprehensive ophthalmologist whose expertise is in eyelid, cataract and glaucoma surgeries, he has performed thousands of procedures in British Columbia and Ontario. Dr. Chu is also a clinical assistant professor at the University of British Columbia, has hospital privileges at Chilliwack General Hospital and Abbotsford Regional Hospital, and has active practices in Abbotsford, Surrey and Coquitlam. info@fvcl.ca Dr. Joseph King, MD, graduated from the University of British Columbia School of Medicine.

He completed his postgraduate medical and surgical internship in Victoria. As a dual citizen of the United States and Canada, Dr. King’s ophthalmology specialty training was performed at Case Western Reserve University, St. Luke’s Medical Center in Cleveland, Ohio, where he served as Chief Resident.

After his ophthalmology residency, Dr. King completed an additional year of training in laser vision correction at the University of South Florida Eye Institute. Dr. King has extensive experience in laser vision correction and cataract surgeries in British Columbia and Alberta, Canada, as well as the Pacific Northwest region of the United States. info@fvcl.ca

Dr. Chu believes that a change in

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Tips for a smooth, integrated ophthalmology-optometry practice

Open the communication line between each profession to promote an excellent collaborative relationship, which results in enhanced patient outcomes and optimal patient experience.

Demonstrate mutual respect and focus on delivering high-quality, patient-centered care.

Consider a two-way referral (co-management) system where ophthalmology does not compete with optometric practices, providing primary eye care services.

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August 2022

Allow each profession to practice at the highest level of their capabilities.

Be patient. As with any new partnership, there is a period of adjustment.

Be aware and respectful of sensitivities that may exist.

Invest in training and education to improve the knowledge base of the entire care team.

Optimize resource allocation to ensure that care is available for those who need it, when they need it, and where they need it.

References Dr. Casey D. Claypool, OD, Empire Eye Physicians, Spokane Valley, Washington, USA Dr. Gabriel Chu, MD, Fraser Valley Cataract & Laser, British Columbia, Canada Dr. Joseph King, MD, Fraser Valley Cataract & Laser, British Columbia, Canada

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OPTICS |

EYEGLASSES

Not All Frames are Created Equal How to choose the right frames for patients who have high prescriptions

by Ben Collins

A

s if suffering from astigmatism, farsightedness (hyperopia), or nearsightedness (myopia) wasn’t challenging enough already, patients classified at the “high” end of the spectrum with these afflictions can also have difficulty finding frames and lenses that are both functional and fashionable.

Generally speaking, if the power of your patient’s prescription is greater than 5 diopters, they have a high prescription.

High prescription lenses are usually thicker, especially at the edges, are difficult to fit onto certain frames, and can even distort the outward appearance of the patient's eyes — think “bug eyes.”

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Luckily, help is at hand! Advances in lens technology, the development of a wider range of fashionable frames, and some sage advice from your friendly local optometrist can ensure that even the highest prescription glasses are also the height of fashion and comfort.

Ask an optometrist (or two) The monsters (writers) at COOKIE magazine were lucky enough to be able to pick the brains of Malaysian optometrist Mr. Ryan Ho to gain insight into the particular challenges facing high prescription patients.

Here are some of his valuable tips.

August 2022

Consider your patient’s lifestyle "Everyone's facial muscles and bone structure are different. Thus, when choosing a frame it is always important to focus on the key elements: functionality, fitting and aesthetic,” shared Mr. Ho. “What does this mean?

Well, firstly as an optometrist, we need to understand the lifestyle of our patients and choose the correct type of frame for them. This will help with their functionality. For example, if they are a pilot, a lawyer or an engineer, different materials or shapes of eyeglasses play an important role in the functionality for the patient,” he explained.

Consider both visual appeal and comfort In choosing frames for a high prescription wearer, you are aiming to fit a lens that will look appealing without the thick edge protruding out on the sides of the frames. In addition, an overall lighter weight is more comfortable on the nose, especially in patients with a lower nose bridge.

Take into account your patient’s pupillary distance “We have to select a frame that fits their pupillary distance. The width of the frame must be a match to the face width,” explained Mr. Ho. “Temple length is important to have a snug/tight fit, and also pantoscopic tilt (the angle formed by the lens tilt in the vertical plane relative to the patient's visual axis) would be an important factor to consider.”

Understand your patient’s personality

Follow a guide, such as below As a guide, let’s look at two classes of high prescription wearers.

A. High prescription lenses: from -6.00D to -10.00D Index of lens preferred: 1.67 and above Frame: Smaller lens size width (A-size to be appropriate for the face). This will depend on the face structure of the wearer. If the frame is too small, it will look awkward on a large face.

Avoid large frames that protrude out from the edge of the eyes towards the ears. Best frame shapes are oval, panto or quadro, and avoid aviator-shaped ones.

If you prefer a thin-rim frame or a rimless frame, then choose a higher index lens, such as 1.74 and above.

B. Higher prescription lenses: above -10.00D

In summary…

Armed with a few simple tips, even the highest prescription lenses can be fitted with comfortable and fashionable frames.

• Consider high index lenses. A high index lens is thinner and gives you more options in terms of frame choice.

• Choose function over form. It’s all very well having great-looking frames, but if they don’t fit your face properly they are not going to work very well. Matching frames with pupillary distance and temple length and establishing correct pantoscopic tilt are crucial.

• Think about lifestyle, occupation, age, etc., when choosing appropriate frames. Children will have different form and functionality requirements when it comes to frames as compared with adults or elderly folks. Likewise, someone who works outside in the elements will also require a different frame than an office worker.

Fu n c t i

on

a l?

Y

“As an optometrist and eyewear stylist, it is important to understand Index of lens preferred: 1.70 and above your patient's personality,” added Mr. Ho. “You need to dress them up for Frame: More critical in selection than in different occasions — whether it is the the previous example. Choose a smaller red carpet or for a first date, lens size (A-size), and they will our selection is important. look better with a thicker h i o n a b l e? N o .

Eyewear is an investment frame rim to hide the Fa s . es as usually it's what extra edge thickness people define you as, of the lens. The especially now during same shape applies COVID times where as in the previous most of us are still example. masked up.”

Avoid rimless, nylon or thin wire frames — and it’s preferable to have adjustable nose pads for ease of fitting.

Contributing Doctor Mr. Ryan Ho is a skilled optometrist with over 15 years of experience.

He obtained his first degree in B.Sc. at the University of Kansas, USA, and continued to pursue his passion for his Bachelor of Optometry (Hons) in Malaysia. His opinions on the treatment of ortho-k, monovision, progressive lens fitting, and myopia in children have been well sought after on national television stations, such as RTM, TV3 and national newswires, as well as publications such as Bernama, The Star, and more. He has helped build Malaya Optical from a family-owned business of three generations to become a two-time award winner of the prestigious Brand Laureate Award. During his leisure time, Mr. Ho enjoys riding his road bike on numerous road adventures. ryan@malayaoptical.com

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OPTICS |

EYE EXAM

Windows to the Soul 10 serious health issues an eye exam can catch

By Roman Meitav

Academy of Ophthalmology (AAO), recommend yearly comprehensive eye exams (CEE).

"An eye exam is one of the few exams where, without doing blood tests, invasive imaging or surgery, we can actually look inside the body,” Brian Stagg, MD, an ophthalmologist and retina specialist at the University of Utah's John A. Moran Eye Center told the American Association of Retired Persons (AARP).1 “I can see blood vessels and nerve tissue that actually runs all the way to the brain.”

Here are 10 conditions you may find during an eye exam: 1. Heart Disease A team of U.K. researchers found that a simple eye examination, combined with other medical data, could predict the risk of a heart attack.

The pattern of blood vessels in the retina can create a unique retinal variation profile, and eye exams can detect several cardiovascular conditions, including clogged arteries, often before the patient even knows there's a problem. And while diagnostic methods are still being studied, our eyes can also display evidence of ischemia, decreased blood flow due to heart disease.1,2

2. Diabetes

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including blood vessels, nerves and connective tissues, the eyes can help catch many significant health risks in their early stages.

Because of its delicate structure,

So, when was the last time your patient had a comprehensive eye exam? If it’s been a few years, it’s long overdue.

Major health organizations, including the Centers for Disease Control and Prevention (CDC) and the American

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hen it comes to eye examinations, patients might assume that sharpness of vision is all there is to it. However, the eyes — or “windows to the soul” — offer much greater insight into our well-being. In fact, some of the health conditions that can be detected through eye exams could prove quite serious.

Diabetes could cause diabetic retinopathy, a condition where blood vessels inside the eye start to leak blood and fluid into the retina, causing damage and even potential vision loss. Diabetic retinopathy could complicate further and cause diabetic macular edema, a condition where the center of the retina begins to swell.

A simple diabetic eye exam, which

focuses on the health of the retina and blood vessels, could detect diabetic conditions early on.3

3. Cancer Eye cancer, or eye melanoma, is considered quite uncommon, and most likely there is nothing to worry about.

Although people with dysplastic nevus syndrome or BAP1 cancer syndrome, who are at higher risk of eye melanoma, might want to pay more attention. The exam itself is quite simple: During a routine eye exam, an optometrist might notice a dark spot at the back of the eye. If such a thing is found, it should be looked at regularly by an ophthalmologist.4

4. High Blood Pressure Although not the first thing one might think of, high blood pressure can affect blood vessels in the eye — and this can cause a myriad of conditions, like blurred vision or blindness, as a result of blood flow irregularities to the retina.

As a result, related conditions like cardiovascular damage and other eye diseases, such as glaucoma, macular degeneration and diabetic retinopathy could follow.5

5. High Cholesterol High cholesterol could sometimes cause either a blue or yellow ring to form around the cornea. There might also be cholesterol deposits or plaque left behind in the blood vessels in the retina, which could also indicate high cholesterol levels.6

6. Brain Tumors A routine eye test examining the back of the eye can sometimes detect issues that could indicate the presence of a brain tumor.

Swelling of the optic disc and signs of pressure on the optic nerve could be caused by intracranial hypertension, a build-up of pressure around the brain. Even if a

brain tumor isn’t cancerous, it can still wreak havoc on brain activity.7

7. Multiple Sclerosis Multiple sclerosis is a relatively rare disease, only about 400,000 people in the U.S. suffer from it. As rare as it may be, it’s still a crippling neurological disorder. However, a simple eye exam could detect inflammation in the optic nerve, one of the earliest signs of the disease.8

8. Thyroid Disease Thyroid-associated ophthalmopathy (TAO) is the most common autoimmune inflammatory disorder of the orbit and periorbital tissue. Those with conditions like hyperthyroidism, an overactive thyroid gland, will many times have protruding eyeballs or retracting eyelids and other small signs that suggest thyroid disease.9

Early diagnosis means timely action Being diagnosed with a serious health issue, like multiple sclerosis or a brain tumor, can be a difficult experience. However, an optometrist could potentially catch signs faster than another medical expert — giving precious time for treatment and vastly improving an individual’s ability to properly combat the condition.

If such a diagnosis does occur, advise your patients to remain calm and follow your recommendations. Closer examinations or routine check-ups might be in order, as well as treatment with doctors from other fields.

References 1.

8 Health Problems That Can Be Detected Through an Eye Exam. Available at: https:// www.aarp.org/health/conditions-treatments/info2021/eye-exam-health.html. Accessed on July 18, 2022.

2.

Simple eye examination could predict heart attack risk, says study. Available at https://www. theguardian.com/society/2022/jun/12/simpleeye-examination-could-predict-heart-attack-risksays-study. Accessed on July 18, 2022.

3.

What Is a Diabetic Eye Exam? Available at: https://www.optometrists.org/general-practiceoptometry/guide-to-eye-conditions/guide-todiabetes-and-the-eyes/what-is-a-diabetic-eyeexam/. Accessed on July 18, 2022.

4.

Can Eye Cancer Be Found Early? Available at: https://www.cancer.org/cancer/eye-cancer/ detection-diagnosis-staging/detection.html.

Accessed on July 18, 2022.

5.

Can High Blood Pressure Affect the Eyes?

Available at: https://www.optometrists.org/ general-practice-optometry/guide-to-eyehealth/17768-2/. Accessed on July 18, 2022.

6.

High Cholesterol and the Eyes: Signs and Symptoms. Available at: https://www. verywellhealth.com/high-cholesterol-and-theeyes-signs-and-symptoms-5188484. Accessed on July 18, 2022.

7.

Brain Tumor Symptoms. Available at: https:// www.braintumourresearch.org/info-support/ symptoms-of-a-brain-tumour. Accessed on July 18, 2022.

8.

Optometry’s role in multiple sclerosis. Available at: https://www.optometrytimes.com/view/ optometrys-role-multiple-sclerosis. Accessed on July 18, 2022.

9.

Thyroid Eye Disease In Your Exam Lane.

Available at: https://www.reviewofoptometry. com/article/thyroid-eye-disease-in-your-examlane. Accessed on July 18, 2022.

10.

Lyme Disease and the Eye. Available at: https://chicago.medicine.uic.edu/departments/ academic-departments/ophthalmology-visualsciences/our-department/media-center/eye-facts/ lyme-disease/. Accessed on July 18, 2022.

11.

Lobo AM, Gao Y, Rusie L, Houlberg M, Mehta SD. Association between eye diagnosis and positive syphilis test results in a large, urban sexually transmitted infection/primary care clinic population. Int J STD AIDS. 2018;29(4):357-361.

9. Lyme Disease Lyme disease is a tick-borne disease that often goes unrecognized until it has affected many parts of the body, including the eyes. Although its effect on the eyes isn’t substantial, one might notice a condition similar to pink eye or inflammation of different segments of the eye, with inflammation of the optic nerve having the potential to incur vision loss.10

10. Sexually Transmitted Diseases Similar to Lyme disease, sexually transmitted diseases (STDs) may affect a lot of people who may not even realize they’ve contracted them.

Syphilis, in particular, can lead to complications and symptoms involving the eye, including inflammation, redness and blurred vision. These complications are referred to as ocular syphilis.11

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KUDOS |

EYE CARE ORGANIZATION

A Force for Sight Worldwide Helen Keller International continues its co-founder’s legacy by Matt Herman

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elen Keller is perhaps the most powerful symbol for blindness in the United States, if not the world. Stricken by an illness as an infant that left her without sight and hearing, her life is emblematic of triumph over extreme adversity.

Keller’s ability to adapt to and conquer the extraordinary circumstances thrust upon her have been inspirational to people from all walks of life, and well beyond her death in 1968. Nowhere is the power of her legacy more apparent than in the organization she co-founded that bears her name, Helen Keller International (HKI).

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Trachoma also holds a special place among the causes that Helen Keller International supports — Helen Keller’s beloved teacher Anne Sullivan was mostly blind from the ravages of the disease. Today, Helen Keller International sponsors programs in six African countries and partners with local organizations to provide screening, treatment and education programs in an attempt to put an end to the scourge that took Anne Sullivan’s sight.

SAFE at home from trachoma in Mali Helen Keller International’s work in Mali alongside the National Blindness Prevention Program (PNLC), among other organizations, encapsulates its impact on blinding diseases worldwide. It all started with the WHO-developed SAFE (Safety, Antibiotics, Facial cleanliness and Environmental improvement) protocol for eliminating trachoma in communities where it is endemic.

Since its inception in 1915, HKI has committed itself to a variety of causes. The organization currently operates 107 programs in 21 countries across the globe, spanning a wide range of issues — from the prevention of tropical disease to food security and malnutrition.

But none is more recognized or synonymous with the Helen Keller name than the charity’s expansive vision initiatives. HKI’s outreach programs in the vision space encompass a wide range of subspecialties, including cataract, river blindness, trachoma and diabetic retinopathy. And while HKI may be best known for the lives it has saved and changed for the better, the organization’s impact extends even further as a beacon of interdisciplinary teamwork and efficiency in the eye care world.

widespread. In this disease, which the World Health Organization (WHO) estimates is responsible for the blindness or visual impairment of about 1.9 million people around the world,1 infection causes the eyelashes to grow inward, scraping the cornea away as sufferers blink themselves into irreversible blindness.

The trouble with trachoma One of the organization’s major fronts in the fight against blindness is trachoma, a blinding disease caused by the bacterium chlamydia trachomatis.

Trachoma is one of those insidious diseases of poverty — found largely in poor communities with substandard sanitation — and is preventable, treatable and exasperatingly

August 2022

With HKI’s involvement in SAFE implementation, the results have been stunning. By 2013, the surgical backlog for trachoma patients was down by almost half, and the need for mass drug administration of antibiotics was eliminated in 84% of districts.2 This, combined with community awareness and assistance in constructing sanitation infrastructure, has led to an outcome many thought impossible. Mali began conducting surveys in 2019 in support of its WHO validation dossier officially proclaiming the elimination of trachoma.3

In its fight against the disease, Mali has taken up Helen Keller’s legacy of triumph in the face of the impossible — in a country wracked by civil war, instability and poverty, HKI’s support has helped strike a decisive blow in the fight against blindness.

Battle of the blur Helen Keller International doesn’t just draw the line at blinding diseases. The organization’s commitment is to eyes and vision all around the world, and its programs providing eye exams and glasses to underprivileged children and adults alike are core to its mission.

Though there are degrees of blindness, in the public eye it is a health issue of harsh extremes. Blindness is darkness when there should be light, the privation of one of the senses that maintains our connection to reality.

Uncorrected refractive errors and blurry vision seem deceptively unimportant by comparison, but the economic reality strongly suggests otherwise. A 2019 study4 has shown the staggering toll of uncorrected vision on the world economy; distance impairment alone is estimated to cost the world USD202 billion a year.

But for HKI, the importance of screening for poor vision and providing corrective lenses goes beyond

gargantuan economic losses. At the core of HKI’s initiatives are the human cost of poor vision and all it affects.

According to the charity’s website,5 80% of how people learn, comprehend and accomplish things is through the eyes. Helen Keller International is making sure people around the world, young and old, can tap into that full 80% with outreach aimed at screening, prescribing and fitting glasses.

Improving access in the US and beyond HKI Europe’s PlanVue project in France is an example of just how the organization puts its vision into practice. Initiated in 2018 as a program to address uncorrected refractive errors in children, PlanVue adopts the same blueprint HKI used in Mali to end trachoma — they bring the clinic to those who need it most. Adolescents and children spend up to 40% of their time in school in France,5 and so school doubles as a staging point for reaching students who need vision correction.

PlanVue educates students, teachers and parents about the importance of screening; screens students; makes ophthalmologist referrals; and prescribes and fits eyeglasses.

Despite the pandemic, its efforts in its most recent year saw over 1,000 students screened, 385 referrals to

ophthalmologists, and 140 pairs of eyeglasses (and counting) delivered.5 In the U.S., Helen Keller International has been hard at work implanting its playbook of community-based outreach for decades. Currently operating in California, Minnesota, New Jersey, and its home state of New York, HKI funds affiliate optometrists to go onsite in schools and community hubs for screening and prescribing glasses. Over the past 30 years, the organization has seen more than two million Americans screened, and 350,000 members of vulnerable communities have been outfitted with eyeglasses.6

The promise of a 20/20 future For almost a century, Helen Keller International has been perpetuating its founding mission of improving the quality of life of the world’s most vulnerable people. In more than 100 years of operation, the organization has stood fast in the face of unimaginable obstacles to deliver its world-class roster of programs in eye care and beyond.

“It’s a terrible thing to see and have no vision,” reads a famous quotation widely attributed to Helen Keller herself. Fortunately for all of us, Helen Keller International’s vision to preserve eyesight is evergreen — and it is a remarkable thing to see.

References 1.

Trachoma. World Health Organization. Published on March 7, 2022. Available at https://www. who.int/news-room/fact-sheets/detail/trachoma.

Accessed on July 26, 2022.

2.

Programme National de Lutte contre la Cécité, Helen Keller International, Carter Center.

Mali: achieving success along the path to trachoma elimination. Community Eye Health.

2013;26(83):58-59.

3.

Trachoma Control Program. The Carter Center.

Available at: https://www.cartercenter.org/health/ trachoma/index.html. Accessed on July 26, 2022.

4.

Honavar SG. The burden of uncorrected refractive error. Indian J Ophthalmol.

2019;67(5):577-578.

5.

Helen Keller Europe PlanVue. Available at: https://hkieurope.org/projet-planvue/. Accessed on July 26, 2022.

6.

Helen Keller International Protecting Vision in the United States. Available at: https://www.hki. org/us-vision/. Accessed on July 26, 2022.

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KUDOS |

WOMEN IN OPTOMETRY

Eye Health Heroine Dr. Suit May Ho champions sustainable eye care and training programs by Chow Ee-Tan

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ith a career as an optometrist spanning 30 years, Dr. Suit May Ho’s proudest achievement is introducing optometry into Vietnam.

Dr. Ho is an Australian-registered optometrist for public health and international eye health.

She has worked extensively in the development and implementation of sustainable eye care and education programs in various countries in Asia-Pacific (Vietnam, Cambodia, China, Sri Lanka, Timor-Leste, Papua New Guinea) and Africa (Kenya, South Africa), as well as in Haiti and Moldova.

After 10 years of working closely with the in-country team and partners, Dr. Ho and colleagues successfully implemented and developed the first two optometry education programs in Vietnam. Dr. Ho led and oversaw the project design, planning, implementation, monitoring and evaluation of the programs, as well as working with local stakeholders.

Presently an optometry and primary care adviser at The Fred Hollows Foundation, Dr. Ho started as an optometrist at the Australian College of Optometry, which runs the largest public optometric service in the country. Prior to that, she was employed at the Brien Holden Vision Institute Foundation, most recently as director of education and development.

involved in supervising and training optometry students, as well as mentoring fledgling optometrists,” shared Dr. Ho. “It was something I really enjoyed doing. I’ve always wanted to work in places where optometry services were not available.”

Spearheading optometry training and education

“The Australian College of Optometry provides clinical training for optometry students. As part of my job, I was

One such opportunity arose when the Rotary Club was looking for optometrists to provide eye care and glasses in Vanuatu.

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“In my application, I proposed to identify someone in Vanuatu whom we could teach basic refraction so that they could provide glasses when visiting optometrists were not there,” she said. “Twenty years later, the person we trained continues to provide these services and has trained others to help him.”

To prepare for the training, Dr. Ho got in touch with the International Centre for Eye Care Education (now the Brien Holden Foundation), which was developing a refraction manual to field test and provide feedback. She was

later engaged by the organization to conduct refraction and primary eye care training for some nurses in Timor Leste as she could speak Bahasa.

“In Cambodia, I was responsible for overseeing the development of the National Refraction Training Centre (NRTC) with the Cambodian National Program for Eye Health,” she continued. “Over a period of 10 years, the Brien Holden Foundation and The Fred Hollows Foundation worked with the government partners to develop refraction training and the NRTC, which has been handed over to the Cambodian Ministry of Health.”

Developing sustainable eye care programs In 2005, Brien Holden approached Dr. Ho to work for the Foundation. It was there that her interest grew and she worked on developing sustainable eye care programs and training, culminating in two optometry education programs in Vietnam.

Hollows Foundation where she is part of the medical team, providing technical support and advice to the country program teams, particularly in the areas of primary eye care and uncorrected refractive errors. As The Foundation also supports programs in Cambodia, she continues to work with the partners there to strengthen the National Refraction Training Centre.

Optometry runs in the family Optometry is the family’s business in Malaysia, where Dr. Ho is from.

She grew up hanging around her grandfather’s optical shop and watched opticianry evolve into optometry.

“My uncles trained in New Zealand as optometrists in the early 1970s and returned to work in the optical shop.

This coincided with the introduction of contact lenses into Malaysia, which required skilled eye care practitioners to manage complications,” she recalled.

“Even at a young age, I could see the difference between being properly educated to provide eye care versus not.”

“I must admit that I went into optometry for the lifestyle it could offer me: good hours, ‘clean’ healthcare profession, and enough remuneration that I could work part-time and pursue other interests. Little did I know that optometry would become the ‘other interests,’” she joked.

Dr. Ho started postgraduate studies upon graduation and worked part-time at the only public health optometry clinic in Australia.

“I have always wanted to provide care and work with the underprivileged communities. I found delivering eye care services to people in the community with low-income and pensioners very rewarding,” she enthused.

“In Vietnam, I led in the design, development and delivery of the optometry schools,” Dr. Ho shared.

“These optometry programs were based at the Hanoi Medical University, Hanoi, and Pham Ngoc Thach Medical University, Ho Chi Minh City. We had more than 300 students enrolled, which added around 230 optometrists to the eye health workforce in Vietnam.”

For her tireless work in training eye health workers in Vietnam, Cambodia, and Timor-Leste, Dr. Ho received an international honor and was named an “Eye Health Hero” in 2018 by the International Agency for the Prevention of Blindness (IAPB.) The Eye Health Hero’s initiative recognizes and celebrates those whose work in the field and engagement with the community make a difference in restoring sight and preventing blindness.

“It is a recognition of the contribution that I have made to eye care — not as an individual but collectively with the partners and colleagues. It is an honor that I share with them,” Dr. Ho said modestly.

Dr. Ho is now working at The Fred

Dr. Suit May Ho at work — spearheading optometry training and education.

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KUDOS |

WOMEN IN OPTOMETRY

She has since taken up various roles and responsibilities in the development and delivery of refraction, low vision, primary eye care and training of trainers, as well as courses for various cadres of health workers, including mid-level ophthalmic personnel, optometrists and ophthalmologists.

At The Fred Hollows Foundation, Dr. Ho is also responsible for the development of e-Learning for their cataract quality improvement project. She was also part of a myopia education team that developed online myopia education programs. In addition, she also managed and delivered Advocacy for Eye Health courses in collaboration with the World Council of Optometry (WCO).

Over 50 optometry leaders from the six WCO regions were trained as eye health advocates through this course.

Touching lives and leaving a legacy For Dr. Ho, the biggest challenge in eye care is the lack of optometrists that provide good quality refractive error services, particularly for children.

“In many low- and middle-income countries, an eye care workforce that can adequately manage refractive errors and functional disorders of vision in children simply does not exist,” Dr. Ho explained. “This is of great concern with the rise in myopia, particularly in Asian countries.”

Her work has connected her with people who are also passionate about equitable

and accessible eye care around the world.

“The people whom I have trained and mentored continue the work, both in providing care to patients and educating others. And the dedication and commitment of some of them to the profession are outstanding,” she commended. "It is gratifying to know that the work will go on way past my involvement.”

Paving the way for more women optometrists According to Dr. Ho, there are many notable women optometrists in Southeast Asia, but their achievements are sometimes not as recognized due to societal factors, and women are often quiet achievers.

Dr. Ho added that on a personal level, many of the people whom she has trained and worked with have become good friends. “I enjoy spending time with them. These last two years have been difficult, but with the opening of international borders, I am making up for the lost time to reconnect with them both professionally and personally,” she shared happily.

“This is changing as more women step up into leadership positions. We can see this happening in the Philippines where the optometry associations are led by women,” she proudly shared.

“More and more women are taking up the once male-dominated profession of optometry. In Vietnam, for example, women optometrists and optometry students outnumber men.

Optometrists, by adding to the eye care workforce, will be able to provide much-needed care to members of the community.

“In time, this will lead to a change in representation and leadership, and the recognition of the contribution of women in our field,” Dr. Ho concluded.

“Optometrists work in the community delivering care where people live. This is central to the concept of integrated people-centered care highlighted in the World Health Organization (WHO) World Report on Vision,” Dr. Ho continued.

“With the increasing number of people becoming myopic in Asia, optometrists have a big role to play in prevention, correction and management of the progression of myopia — and contributing to the prevention of blindness and visual

Dr. Suit May Ho (sixth from the left) with the equally passionate people she has worked with in the eye care industry.

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impairment in the region,” she said.

August 2022

Contributing Doctor Dr. Suit May Ho is an Australianregistered optometrist working in public health and international eye health for the past 30 years.

Currently, she is optometry and primary care adviser at The Fred Hollows Foundation. She started as an optometrist at the Australian College of Optometry. Before joining The Foundation, she was employed at the Brien Holden Vision Institute Foundation, most recently as director of education and development.

Dr. Ho has worked extensively in the development and implementation of sustainable eye care and education programs in various countries in the Asia-Pacific and Africa regions. Another area of interest is research, where she has been involved in key publications on myopia, presbyopia, refractive errors and low vision. Dr. Ho also contributed to the “IAPB School Eye Health Guidelines for Low-and Middle-Income Countries” and IAPB position papers on refractive errors and their correction. She currently serves on the World Council of Optometry Public Health Subcommittee, Optometry Victoria South Australia Education Advisory Committee, IAPB School Eye Health Working Group, and Low Vision Working Group. sho@hollows.org

INDUSTRY UPDATE

Eyeing APAC’s Eye Care Market Alcon introduces latest innovation products for dry eyes and quality eye care by Joanna Lee

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ision impairment has resulted in a global loss of productivity of approximately $400 billion. Yet, 90% of vision impairment is preventable or treatable. Stepping up to the plate with this in mind, Alcon’s newly appointed Vice President of Vision Care for the Asia Pacific (APAC) Region Stephanie Waugh spoke about her plans to meet the region’s needs.

“One of the exciting parts of my role is connecting the dots between global and local,” she said. On a global level, Waugh said several trends are on the rise: the aging population and their growing healthcare needs, increasing wealth and growth from emerging economies, innovations improving the quality and access to eye care, as well as an increasingly virtual world with new demands on eyes.

“At APAC, these trends all come together,” she said. The latest innovations behind Systane Complete, Precision1, and Total are bringing new technologies to consumers in the region. “We’re feeding back local trends to the innovation teams so they can design for the future.”

Apart from that, Waugh said tackling the increasingly virtual world isn’t only about bringing in new products, but it’s also about changing the way the company engages with consumers, especially getting in touch with “where, when, and how they choose to connect with our brands.”

Looking far ahead for myopia needs Alcon’s research has shown that parents’ education and engagement along with eye care professionals’ recommendations are two key drivers influencing myopia management. “We have also introduced new products in our portfolio to meet the needs of patients who will need vision correction and ocular health products to

relieve dry, tired eyes,” she said.

One example of this is the introduction of multi-dose preservative-free (MDPF) lubricating eye drops, which she said is driving new growth in the category and delivering on an unmet need for patients with sensitive eyes.

Waugh sees the key priorities in her new role as growing access to vision care products while driving deeper penetration for contact lenses in the Asia-Pacific region, which has an estimated singledigit market penetration compared to the double-digits of the developed world. “We are doing so with contact lenses that are designed for first-time lens wearers, like Precision1,” said Waugh.

“For developed contact lens markets, our Total product line with its water gradient technology reduces end-of-day dryness,” she added. The water content approaches nearly 100% at the outermost surface of the lens. “It’s designed to be a superpremium lens positioned to compete at the highest levels across the contact lens market,” she said.

“We’re also very excited to bring Alcon’s latest innovative products to meet the evolving needs and preferences of consumers in this region, such as our Systane Complete preservative-free lubricant eye drops,” she added.

Having launched new colors for Freshlook contact lenses in the daily disposable lenses segment, Waugh said they’re looking forward to more launches ahead in 2022.

“The Dailies Total is the first and only daily disposable contact lens to offer water gradient technology, while the Precision1 is the first daily disposable silicone hydrogel contact lens with Alcon’s proprietary SmartSurface technology to

support a stable tear film. This delivers lasting visual performance from morning to night,” Waugh explained.

“We are also excited about our dry eye and ocular health blockbuster — the multidose preservative-free Systane Complete — which continues to launch across the region, including Australia, throughout 2022.

“Its formula works to provide all-in-one dry eye relief with one drop by hydrating and protecting all layers of the tear film,” continued Waugh. “Alcon’s proprietary formula uses intelligent moisture and lipid delivery to enhance dispersion across the surface of the eye to stabilize the tear film. Its advanced, nanodroplet technology allows for fast-acting hydration, tear evaporation protection, and long-lasting relief for a patient’s eyes.”

The future outlook for the APAC market With the Asia-Pacific region becoming one of the most rapidly aging regions in the world, Alcon Vision Care is committed to creating “more holistic and equitable eye care ecosystems for these segments through innovation and consumer education.” One such innovation is the adaptation of the water gradient feature of Dailies Total 1 for the reusable contact lens market by the launch of Total30.

Waugh continued: “We’re seeing an increased incidence of dry eye. To meet this growing need, we introduced multidose preservative-free formulations of our leading Systane Ultra and Hydration formulations.

“Innovation remains our highest capital priority and continues to generate strong returns while strengthening our position as the leader in eye care,” she concluded.

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INNOVATION |

CORNEAL MAPPING

Clinicians can use various methods to observe how a contact lens alters the shape and quality of the tear film and cornea, assess the ocular surface prior to contact lens fitting, and keep an eye on the relationship between the eye and the contact lens.

Way back, corneal topography was only used to map out the anterior surface of the cornea. In modern times, devices can identify both the anterior and posterior corneal surfaces, creating a three-dimensional map. Advances in computer processing, digital photography, and new technologies have vastly increased the capabilities and precision of corneal topography.

Mapping Out Future Lenses Latest developments in corneal topography and tomography by Roman Meitav

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magine you are a special ops soldier out on a navigation drill in some distant, unpopulated mountain range.

It is raining, visibility is getting worse and the night will fall soon — and with it, your hopes of completing this grueling experience. Your only allies?

Your trusty compass and a topographic map detailing where your next objective is. Without them, you’d be lost for sure.

shape of the cornea, similar to how one would characterize a mountain using a topographic map.

Corneal topography, then and now

What does this have to do with corneal topography, you may ask? Well, corneal topography is used to characterize the

Over the past 150 years, the use of corneal topography has developed substantially — from the mapping of the cornea’s curvature to the evaluation of corneal and ocular surface characteristics.

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The first technology to have been developed for the measurement of corneal surface shape, which is still the most widely used today, is Placido topography.1 This technology maps out the corneal surface by assessing the reflection of a set of concentric rings off the anterior corneal surface. While the image from the Placido disc is projected on the cornea, some of the light is reflected off the tear film-air interface like a mirror. The pattern which is reflected reveals the shape of the anterior surface of the cornea.

A second technology for corneal topographic assessment is the scanning slit technique, which uses rapidly scanning projected slit beams of light, while a camera captures the reflected beams to create a map of both the anterior and posterior corneal surface.1 In a third technique, known as Scheimpflug tomography, sagittal sections of the anterior segment are photographed using Scheimpflug optics, which increases the depth of focus and enables simultaneous imaging of the cornea, anterior chamber and lens.2 Scheimpflug tomographers can analyze the very center of the cornea and image both the anterior and posterior corneal surfaces. Unlike Placido disk-based devices, however, the optics cannot image the ciliary sulcus and like slitscanning devices, require extremely high resolution to detect curvature differences.

Corneal topography is useful for preoperative assessment of the corneal shape and thus suitable for

laser refractive surgeries, such as photorefractive keratectomy and laserassisted in situ keratomileusis (LASIK), as well as monitoring postoperative corneal recovery to detect undesirable outcomes, including corneal ectasia.3

Placido topography The ZEISS Atlas (Carl Zeiss Meditec AG, Jena, Germany) report uses a Placido disc image and several maps that provide information regarding tangential curvature, axial curvature and elevation.1 A tangential or instantaneous map is very similar to an axial map, which is less sensitive at measuring the corneal curvature and thus, is used mainly for screening purposes. It is a slightly more accurate way of characterizing the corneal curvature but appears “noisier” and irregular.

Similar to a ZEISS Atlas report, the NIDEK (NIDEK Co. Ltd., Aichi, Japan) imaging report provides a Placido disc image and an axial curvature map.

NIDEK also provides keratometry data, which are simulated measurements providing the dioptric refractive power in the two primary meridians.1 The patient's refractive error is approximated using both wavefront (WF) and autorefraction (REF) measurements, and this refraction estimate is available in the auto-refraction window of the NIDEK report. Two additional maps are included from the NIDEK testing that is not available by other modalities: the optical path difference (OPD) and the Internal OPD maps.

Scanning-Slit imaging The Orbscan II (Bausch & Lomb, New York, USA) device uses both Placidodisc and scanning-slit technology to combine assessment of the anterior and posterior corneal surfaces with keratometry measurements. The combination of the two allows viewing a 3D reconstruction of the cornea. The Orbscan II projects 40 slits from two sides (20 from each) onto the cornea and records the backscattered light.

The software used by Orbscan II does not provide a quality score for capture.

Instead, it automatically assesses the quality of measurements and discards

those deemed to be unacceptable.

Scheimpflug tomography The Pentacam (OCULUS Optikgeräte GmbH, Wetzlar, Germany) is a rotating Scheimpflug camera system for anterior segment analysis, it rotates 180 degrees around the eye in a staggering two seconds, producing 138,000 elevation points to create a 3D representation of the cornea, capturing 50 images of both corneal surfaces.

Similar to Orbscan, the data must be translated and aligned to reduce errors due to eye movement during capture.

Corneal thickness data provided by the Pentacam can be used for the construction of distribution graphs, including corneal thickness spatial profile and percentage thickness increase graphs, which can show the annular pachymetric increase from the thinnest point to the periphery.3 The Sirius (CSO Ophthalmic, Florence, Italy) is another Placido-Scheimpflug hybrid device that records one keratoscopic measurement and captures 25 Scheimpflug images in less than one second. The Galilei (Ziemer Ophthalmic Systems AG, Brügg, Switzerland) is a Placido-Scheimpflug analyzer that uses two Scheimpflug cameras as opposed to just one. Elevation data is averaged out from each camera, which occupies the gaps in the Placido rings. To fill in said gaps, two Placido images are recorded with cameras oriented both horizontally and vertically. Measurement errors due to the angle of orientation and ocular decentration are greatly reduced, thanks to the use of two overlapping cameras.2

Corneal mapping and scleral contact lenses Beyond the various methods that can be used for corneal topography, many modern systems have additional features that apply to the mapping process and contact lens care.

Contact lens fitting software allows clinicians to simulate a contact lens on the ocular surface and order lenses that incorporate the entire shape of the cornea in a more precise way, including peripheral eccentricities, to provide a

more customized contact lens fit. The software in question has been shown to be effective at predicting even the fit of a corneal keratoconus lens.

While corneal topography technology is on the rise in recent years, it has always been an important technology for measuring the shape and power of the cornea to better fit scleral contact lenses.

The various technological methods allow practitioners not only to fit contact lenses to match the power and shape of the cornea in a much more precise manner than before, but also help them to evaluate the intricacies of the contact lens’ relationship with the ocular surface. As these systems continue to develop, methods to better evaluate corneal surfaces and tear film become better suited to produce a satisfactory product, providing more specific and advanced management to their contact lens patients.

An oldie but still a goldie While we are currently encountering a significant development of optical technologies exhibiting faster scanning speed and employing more reliable tracking systems, conventional Placidoring topography might still provide the most realistic projection of the corneal surface. It is therefore unlikely that classical corneal topography will be completely replaced by corneal tomography.

In the future, combining technologies in order to create more versatile devices would be the most viable option.4

References 1.

Corneal Imaging: An Introduction. Eye Rounds.

Org. Available at: https://webeye.ophth.uiowa. edu/eyeforum/tutorials/Corneal-Imaging/Index. htm. Accessed on July 18, 2022.

2.

Scheimpflug Imaging. Science Direct. Available at: https://www.sciencedirect.com/topics/ medicine-and-dentistry/scheimpflug-imaging.

Accessed on July 18, 2022.

3.

Shih KC, Tse RHK, Lau YTY, Chan TCY. Advances in Corneal Imaging: Current Applications and Beyond. Asia Pac J Ophthalmol (Phila). 2019. [Online ahead of print.]

4.

Kanclerz P, Khoramnia R, Wang X. Current Developments in Corneal Topography and Tomography. Diagnostics (Basel).

2021;11(8):1466.

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INNOVATION |

TELEMEDICINE

Better in Tandem

Assessing the feasibility of eConsult service between optometrists and ophthalmologists by Tan Sher Lynn

March 2019 and February 2020 demonstrated that allowing optometrists to solicit specialist advice from ophthalmologists was acceptable and feasible. Results show that there was an overall positive response from both optometrists and ophthalmologists.

There was praise for the ability to share color diagnostic images, and the platform was described as beneficial for saving patients’ and specialists’ time.

In 72% of cases closed, optometrists were able to confirm a course of action they originally had in mind, and 77% of optometrists described the pilot as having a lot of educational value.

An optometrist’s take on eConsult service Having started virtual/teleconsultations with patients during the pandemic lockdown, Dr. Mark Eltis from Canada said that eConsult is an interesting concept and that he started offering telemedicine himself to patients while offices were mandated to shut down for a few months by the government.

E

lectronic consultation (eConsult) is a secure, asynchronous webbased tool that allows requesting providers, usually primary care physicians, timely access to nonurgent specialist advice for all patients and often eliminates the need for an in-person specialist visit.1 eConsult provides various benefits, including improved access to specialty care, reduction of face-to-face visits with specialists, lower costs and high physician satisfaction.

The eConsult vision pilot project In certain areas around the world, access to specialty eye care can be challenging. When eye diseases or conditions are left undetected or untreated, they can lead to vision impairment or even blindness.

In Ontario, Canada, the inequity of access to eye care has been made worse by factors such as an aging population,2 restrictions on travel and

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in-person appointments as a result of the COVID-19 pandemic, challenges accessing specialty care in rural and remote areas, and policies that have deinsured routine eye care examinations — largely affecting populations with a lower socioeconomic status.3 The eConsult Vision Pilot Project,1 launched by the Ontario eConsult, is a collaborative, multidisciplinary pilot project (survey) that enabled optometrists in one region of Ontario to connect with ophthalmologists in the same region via eConsult and encompass all areas of ophthalmology.

The project leveraged existing clinics and primary care experts with a roster of patients (optometrists) and connected them with an existing service (Ontario eConsult) that already onboarded specialists for eye care (ophthalmologists). The survey was distributed via email in December 2019 to the participating optometrists (n = 13) and ophthalmologists (n = 8).

Data sent in by optometrists between

August 2022

“Obviously, it didn’t replace an in-office visit totally, but it provided care very quickly on demand to patients, even outside office hours,” shared Dr. Eltis.

“I found that I could help patients in most situations, and the overwhelming majority were extremely satisfied. I dreamed of virtual consults long before the pandemic as a way to provide care to a wider audience in my areas of expertise. I would also love to advise doctors in other countries or consult on complex cases.”

He continued: “I am a night owl, so it was really convenient for me to accommodate patients’ schedules. Even now with the office reopening, patients that can’t make it while we are open feel reassured by a teleconsult in the evening or if I am away at a lecture or regulatory body meeting. If I could access specialists to discuss complex cases, it would save some trips to the hospital as well, and potentially save patient’s sight in some cases.”

Dr. Eltis noted that challenges arise in some conditions or situations which need the sophisticated equipment that is in a medical office. “That can’t

be replaced with words or a remote consult. The key is for the doctor to know when those situations arise and for the patient to understand when an eConsult may not be enough,” he concluded.

Looking ahead, Dr. Eltis believes that telemedicine will have an expanded place post-COVID. He also noted that being able to access quick consultations between optometrists and specialists is also important as the wait time can be extremely long.

References 1.

Liddy C, Guglani S, Ratzlaff T, et al. Expanding the scope of an eConsult service: acceptability and feasibility of an optometry–ophthalmology pilot project. Can J Ophthalmol. 2022;S00084182(22)00010-2. doi: 10.1016/j. jcjo.2022.01.007. Online ahead of print.

2.

Flaxman SR, Bourne RRA, Resnikoff S, et al. Global causes of blindness and distance vision impairment 1990–2020: a systematic review and meta-analysis. Lancet Glob Health.

2017;5(12):e1221-e1234.

3.

Jin Y-P, Buys YM, Hatch W, Trope GE. Deinsurance in Ontario has reduced use of eye care services by the socially disadvantaged. Can J Ophthalmol, 2012;47(3):203-210

Contributing Doctor With almost twenty years of experience, Dr. Mark Eltis has practiced Optometry in New York, California, and Toronto.

He is a graduate of the University of Waterloo School of Optometry and has taught there for over a decade. Dr. Eltis is a fellow of the American Academy of Optometry and a diplomate of the American Board of Optometry. He is also a faculty member of the Academy of Ophthalmic Education and has completed his California Glaucoma Certification at UC Berkeley. Dr. Eltis has served as an examiner for national licensing assessment in both Canada and the United States. He has presented and published internationally and has been sought as an expert on optometric issues for national television and print.

In 2013, Dr. Eltis was honored as a member of the Optometric Glaucoma Society (OGS) having “demonstrated excellence in the care of patients with glaucoma through professional education and scientific investigation.”

Dr. Eltis is a reviewer for over a dozen publications including Journal of Glaucoma and Canadian Journal of Optometry. In 2017, he was recognized for his “outstanding contribution in reviewing” by the editors of Journal of Optometry and Elsevier. He is also on the editorial board of scholarly publications and is a US optometric residency program evaluator.

Dr. Eltis has been a consultant for academic institutions overseas, contact lens/pharmaceutical companies, law firms, and a subject matter expert for competency evaluations. He serves on the board of directors of the Council for Healthy Eyes Canada and was elected to council at the College of Optometrists of Ontario. Dr. Eltis is currently focusing his practice on dry eye patients employing the latest diagnostic and therapeutic options.

He loves connecting with optometry students and the public by sharing his eye care tips on social media. drmarkeltis@vieweyecare.com

INDUSTRY UPDATE

‘Double Danger’ of Counterfeit Lenses Discussed at a BCLA Webinar

A

recent British Contact Lens Association (BCLA) webinar discussed the ‘disastrous' combination of the widespread availability of counterfeit corrective lenses and a rise in self-fitting.

Research has shown that counterfeit contact lenses may be supplied in contaminated solution and that the optics of counterfeit lenses may be inferior to genuine lenses. Examination of negative reviews of websites selling contact lenses reveals some customer complaints that are highly suggestive of faulty and counterfeit lenses.

In 2019, a survey of customers purchasing contact lenses online found that 387 of those surveyed (30.6%) had fitted themselves with contact lenses in the first instance without any input from an eye care professional. People who are

self-fitting contact lenses may have very little education as to the care of contact lenses and their eyes. The session was presented by Claire McDonnell who said: “The combination of a self-fitted contact lens wearer and counterfeit lenses could prove disastrous. Awareness needs to be raised among eye care practitioners of counterfeit lenses and the practice of self-fitting.”

She added: “Eye care practitioners should raise the topic of contact lens wear with all spectacle patients and their parents (in the case of children) so that patients are aware of the importance of being fitted by an eye care practitioner. The public should be made aware of the dangers of counterfeit lenses and the importance of purchasing lenses from a trusted source.”

The webinar followed the success of the recent Love Your Lenses Week and was

part of the BCLA’s ongoing education program for 2022, with a range of online and face-to-face events scheduled to give members access to the very latest learning and technological advances in the field of contact lenses and anterior eye.

Claire McDonnell is an optometry lecturer at the Technological University Dublin with a special interest in contact lenses.

She is the communications officer for the British and Irish University and College Contact Lens Educators. She has worked in private practice, refractive surgery, and education in Ireland, the UK, and New Zealand, and has presented at both optometric and educational conferences around the world.

The webinar, which was open to both BCLA members and non-members, was held online on July 12, 2022. For more information, visit www.bcla.org.uk.

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INNOVATION |

VISION TEST

Visual Check

The importance of charting visual acuity in low vision patients by Joanna Lee

of the minimum angle of resolution).

Beyond that point, counting fingers (CF), reading hand movements (HM), and the test of light perception are used. These methods, however, often result in inaccuracies and fluctuating measures and are highly dependent on the individual clinician making judgments on estimations.

To counter the lack of standardized results at each reading, as well as limitations presented beyond quantifying by letter charts for low vision cases, some new tests have been developed.

Thanks to a blind cricket game organized by the World Blind Cricket Council, Dr. Ian Bailey and his colleagues created Precision Vision’s Berkeley Rudimentary Vision Test (BRVT).4 At the game, he observed and heard complaints of perceived irregularities in player selection criteria.

The cricket players in each team must consist of members categorized into three levels of low vision. Therein lies the challenge — beyond what the ETDRS could measure, how does one quantify with true accuracy the degree and extent of each member’s low vision, besides counting fingers and using hand motions?5

A

n estimated 295 million people suffer from moderate to severe vision impairment, with 43.3 million living with blindness.1 Although mild cases of vision impairment are estimated to be 258 million, how do optometrists and ophthalmologists measure the subtle changes toward severity when it occurs?

Low vision is defined by the World Health Organization as impairment of visual functioning even after treatment and/or standard refractive correction, a visual acuity (VA) of less than 6/18 to light perception or a visual field of less than 10 degrees from the point of fixation, but who uses (or is potentially able to use) vision for planning and/or execution of a task.2

34

Measuring VA changes in low vision patients A crossover study3 brings to light the advances of testing to help further measure VA changes in low vision patients. However, besides revealing the need for tests that can be more easily reproduced, a look behind the tests in this study highlights an urgency to bridge gaps in awareness and accessibility for low vision rehabilitation.

The current practice in many countries finds the common use of the Early Treatment Diabetic Retinopathy Study (ETDRS) charts, which have been the gold standard in measuring VA with a low cut-off of 1.6 logMAR (logarithm

August 2022

In the same vein, the idea for the crossover study which compares BRVT and the Freiburg Acuity Test (FrACT)6 was mooted when Associate Professor Dr. Jasleen Jolly at The Vision and Eye Research Institute, Anglia Ruskin University, realized there were not many options for measuring very low vision. At that time, she was working on a range of clinical trials for new treatments for inherited retinal diseases covering a range of vision.

“As a low vision practitioner, we often hear from patients that they feel their vision has deteriorated, but we are unable to measure that with current methods,” Dr. Jolly said.

“This study shows easy-to-use, cheap methods that can be implemented in clinical settings as well as research settings that allow us to better assess very low vision to make changes for improvements in quality of life,” she further said.

The research concluded that both tests were appropriate for low vision patients with the BRVT being easier to use but reported poorer vision, while the FrACT shows “numerical results in more eyes.”3 Unfortunately, the two tests are not interchangeable, as they discovered, due to “poor inter-test repeatability.”

What experts have to say The key reason could be found in the difference in lighting while measuring, as FrACT is computer-based which gives a more uniform contrast at various distances when viewing, while the BRVT is card-based (requiring higher luminance to achieve a vision that is on par with traditional screens), rendering them non-interchangeable. Further investigations based on luminance while testing may shed further light on the interchangeability of the tests.

“I think the applicability of the FrACT test, in that it is a digital screen test, will likely make it more useful in the long run. Yes, it may take slightly longer to administer, but its increased accuracy, numerical values, and contrast consistency make it better suited for research,” commented Dr. Joseph Allen, Founder of Doctor Eye Health in Minnesota, USA. “In addition, our world is also continuing to progress with more usage of digital screens, including in low vision devices, and it may translate well to understanding and aiding the needs of our low vision patients, as the reading media will remain more consistent,” he added.

However, this study seemed to serve to highlight several barriers and gaps that could be further bridged when it comes to caring for low vision patients in other parts of the world.

Consultant optometrist, low vision specialist, educator and founder of Learn Beyond Vision (Gurgaon, Haryana, India) Dr. Monica Chaudhry said tests like BRVT and FrACT are not as commonly used in routine practices in India as frequently as the ETDRS. “There are hardly any low vision centers that would have access to these newer charts. Practitioners here are aware of the BRVT chart, but not so much the

FrACT,” she shared.

“The second barrier is the cost of these charts, as low vision divisions here are mostly run as charities. Being noncommercial, charts like these might not be on the priority list,” Prof. Chaudhry added.

“We have yet to move beyond Snellen charts here,” she continued. “Besides costs, chair time and awareness of better ways to measure low vision remain a challenge,” she added.

“Indian practitioners look forward to advancements, but poor accessibility and information about these products are a challenge as there is a need for more efforts to reach out to optometrists to have better tests for the low vision population.”

Mr. Zubair Suhaimi, an optometrist at the National University of Malaysia, was slightly more optimistic.

“While visual acuity tests are important, it is equally important that we figure out the best approaches to help them to rehabilitate their vision and improve their quality of life,” Mr. Suhaimi said.

“Besides electronic retinal implants and retinal gene therapy, there are a lot of ways to help them.”

According to Ms. Vinodhini Munikrishnayya, low vision specialist and visiting optometrist at OasisEye Specialists Centre in Kuala Lumpur, Malaysia, as well as founder and optometrist at EYE2U Consultancy, optometrists usually use the ETDRS chart in Malaysia. “The chart is generally a comprehensive tool, but it also depends on the room lighting and chart contrast. Some charts may be old and yellowish, and that could affect the vision,” she shared.

Better co-management between optometrists and ophthalmologists: A crucial task Another important gap that needs to be addressed, according to Ms. Munikrishnayya, is that many ophthalmologists may not be aware of low vision rehabilitation services being offered.

Her sentiments follow studies that highlighted a need for educating more ophthalmologists about referring low vision patients to rehabilitation services.7,8 That said, improving the entire ecosystem of care and awareness among both optometrists and ophthalmologists to expand the means available to help low vision eye patients remains a crucial task.

Dr. Jolly sees her comparison study playing a role in improving care for this cohort of patients. “Often, a small increase in vision at this end can mean a significant improvement in quality of life,” she enthused.

In a follow-up to this study, Dr. Jolly has since been involved with a consortium of experts who have developed the HOVER Consensus Document9 to provide formalized guidance for the measurement and reporting of very low vision and ultra-low vision.

“The ability to discern these vision changes can help us to validate the patient experience and support this quality of life improvement, hence improving low vision care, as well as improving outcomes in trials,” she concluded.

Like Dr. Chaudhry, Ms. Munikrishnayya also cited costs as a barrier to gaining better treatment access for low vision patients. “The devices (used in treatments) are very expensive.

Those who have low vision are usually from poor financial backgrounds,” she continued. “There are many devices now with more current technology which can improve their quality of life but they are expensive.”

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INNOVATION |

VISION TEST

Photo credit: UODO John Cairns

Dr. Jasleen K. Jolly is a clinical academic taking a multidisciplinary approach and keeping all research centered on the patient.

Dr. Jolly qualified from Cardiff University in Optometry, completed an MSc in Investigative Ophthalmology and Vision Science from the University of Manchester, and completed a D.Phil. in Clinical Neuroscience from Oxford University with a prestigious NIHR clinical doctoral fellowship. Dr. Jolly has spent the last 10 years as a clinical academic in Oxford, working between the University, NHS and BRC in the field of retinal genetics and gene therapy, working on first-in-man trials of novel therapies for inherited retinal degenerations. She is now associate professor at The Vision and Eye Research Institute, Anglia Ruskin University. Dr. Jolly was also awarded the NIHR Thames Valley and South Midlands Health Research Award 2016 for Outstanding Research Practitioner, and the College of Optometrists Philip Cole Prize for Practice-Based Research in 2018 for her work in retinal genetics, phenotyping, and outcome measures. She is also leading work on investigating the neuroscience of Charles Bonnet Syndrome. She is passionate about promoting clinical academia, including through the use of supervising student projects in medicine and optometry, stressing the importance of multidisciplinary research, as well as raising awareness about equality, diversity and inclusion.

eye2u.optom@gmail.com Dr. Monica Chaudhry is a consultant optometrist and educator who have more than three decades of experience as an academic and a clinician.

With her extraordinary skills in optometry education, she has recently ventured to be a freelancer educator, strategy advisor and practitioner. She is the founder of an online optometry up-skilling education platform – Learn Beyond Vision. Also, she has instituted some centers of excellence and vision centers, which aim to be a unique referral, academic and research units.

Her name is well-known as a contact lens and low vision specialist and has a far and wide patient referral in India. Dr. Chaudhry has served at the All India Institute of Medical Sciences (AIIMS) in New Delhi, had academic experience with various universities, including the Indira Gandhi National Open University (IGNOU) and Amity University (India), and has recently retired as director of School of Health Sciences at Ansal University (Gurgaon, India). She has been associated with leading eye care companies such as Menicon, Johnson&Johnson , Baush +Lomb , Alcon, Essilor, among others, as a key opinion leader, faculty, consultant or advisor. In recognition of her contribution to the field of academic medical service, she has been awarded the Shreshtshree Award by the Delhi Citizen Forum, the Australian Leadership Fellowship award in 2012 and the IACLE Contact Lens Educator of the Year (Asia Pacific) award in 2015. Dr. Chaudhry was chairman of the Optometry Council of India. She has been actively involved in organizing conferences, seminars, national and international workshops, faculty development programs and many corporate training programs.

She has chaired many scientific

jasleen.jolly@aru.ac.uk Ms. Vinodhini Munikrishnayya is the founder and optometrist at EYE2U Consultancy. She is also a low vision specialist and visiting optometrist at OasisEye Specialists Centre in Kuala Lumpur, Malaysia. In 2014, she completed her undergraduate training at the Tun Hussein Onn National Eye Hospital (THONEH) in collaboration with the prestigious Birla Institute of Technology and Science (BITS) in Pilani, India. In addition, she also completed her fellowship in Binocular Vision and Vision Therapy at Sankara Nethralaya Eye Hospital in Chennai, India. While there, Ms. Munikrishnayya took the opportunity of being posted to the Low Vision and Contact Lens clinics, thus gaining much experience from this world-renowned eye hospital.

In January 2019, she completed her master’s degree in Optometry and Vision Therapy from the School of Advanced Education, Research and Accreditation (SAERA) in Spain. She has completed a certification course on Low Vision and Vision Rehabilitation in

36

sessions and presented many papers in national and international optometry and ophthalmology conferences. She has travelled abroad extensively and attended many international trainings and conferences. She has written chapters in books and has published three books.

2021. Currently, Ms. Munikrishnayya offers clinical eye care, support, and training for low vision patients to optimize their functional vision.

Contributing Doctors

monica.rchaudhry@gmail.com Mr. Zubair Suhaimi’s field of interest is in rehabilitating and restoring vision in persons with blindness and visual impairment. Upon graduating from Universiti Teknologi of MARA (UiTM) in Optometry, Mr. Zubair Suhaimi joined a private practice in Senawang for almost a year before joining Universiti Kebangsaan Malaysia (UKM). During his years in UKM, he has helped extensively in teaching and training students in ophthalmology in their clinical skills and knowledge while actively assisting students to conduct their studies in the area of clinical data collection.

Currently, he is an exco member of the Association of Malaysian Optometry and also the treasurer and head of Sector in I-Medik. zubai.ace@gmail.com Dr. Joseph J. Allen is a practicing optometrist in Minnesota (USA) and the founder of Doctor Eye Health – an educational YouTube channel with more than 640K subscribers. In that channel he provides information about eye health, ocular disease and vision products. His videos cover a range of topics that his subscribers frequently ask about: eye floaters, glaucoma, dry eye syndrome, contact lenses, eyeglasses, and more. Dr. Allen has been featured in Ask Men and Oprah Daily and was awarded the Media Advocacy Award from the American Optometric Association in 2021. In his free time, he enjoys rock climbing, running, playing video games, hiking, and biking. hello@doctoreyehealth.com

References 1.

Latest statistics on prevalence of blindness and low vision worldwide. Prevent Blindness. Published on March 7, 2021. Available at: https://lowvision. preventblindness.org/2021/03/07/latest-statistics-onprevalence-of-blindness-and-low-vision-worldwide/.

Accessed on July 21, 2022.

2.

Dandona L, Dandona R. Revision of visual impairment definitions in the International Statistical Classification of Diseases. BMC Med. 2006;4:7.

3.

Jolly JK, Gray JM, Salvetti AP, Han RF, MacLaren RE. A Randomized Crossover Study to Assess the Usability of Two New Vision Tests in Patients with Low Vision.

Optom Vis Sci. 2019;96(6):443-452.

4.

Bailey IL, Jackson AJ, Minto H, Greer RB, Chu MA. The Berkeley Rudimentary Vision Test. Optom Vis Sci. 2012;89(9):1257-1264.

5.

Precision Vision Introduces the BRVT Testing Chart – Precision Vision. Available at: https://www.precision-

August 2022

vision.com/newsletters/precision-vision-introduces-thebrvt-testing-chart-precision-vision/. Accessed on July 21, 2022.

6.

Bach M. The Freiburg Visual Acuity test--automatic measurement of visual acuity. Optom Vis Sci. 1996;73(1):49-53.

7.

Coker MA, Huisingh CE, McGwin G, et al. Rehabilitation Referral for Patients With Irreversible Vision Impairment Seen in a Public Safety-Net Eye Clinic. JAMA Ophthalmol. 2018;136(4):400-408.

8.

Khimani KS, Battle CR, Malaya L, et al. Barriers to Low-Vision Rehabilitation Services for Visually Impaired Patients in a Multidisciplinary Ophthalmology Outpatient Practice. J Ophthalmol.

2021;2021:6122246.

9.

Ayton LA, Rizzo JF, Bailey IL, et al. Harmonization of Outcomes and Vision Endpoints in Vision Restoration Trials: Recommendations from the International HOVER Taskforce. Transl Vis Sci Technol. 2020;9(8):25.

ENLIGHTENMENT | EYE CARE

problems with vision, but may not identify the cause. If there are problems detected, the patient will likely be referred for a full eye exam, which is performed by the optometrist.

Optometrist vs.

Ophthalmologist Which doctor does your patient need? by Ben Collins

I

t’s a question as old as time: “Which doctor, in particular, should I go to for eye health concerns — an optometrist or an ophthalmologist?”

Optometry or ophthalmology — they both start with an “O” and end in a “Y.” But “oh why” and “oh when” does your patient need an ophthalmologist, as opposed to an optometrist (or vice versa)?

Let the COOKIE crew cut through the confusion, clarify the differences, and correlate the crossover, so patients can easily understand which practitioner they should see and when!

When should patients see an optometrist?

While both professions are integral to maintaining eye health, an optometrist is going to be your first port of call when it comes to eye care. How often patients will need to see an optometrist depends on a number of factors, including age, pre-existing conditions and hereditary predispositions to eye disease, among others. But, in general, we should all see an optometrist regularly to prevent, treat, monitor and maintain our vision.

So what services does an optometrist provide?

An optometrist can examine patients’ eyes and assess their vision. They can provide a diagnosis of conditions and prescribe medications, eyeglasses or contact lenses if needed.

A typical visit to your friendly local optometrist will generally involve a basic vision screening procedure. This consists of a series of simple tests, often performed by an optician. This quick assessment should pick up any

A comprehensive eye examination involves a range of tests, from visual acuity checks to screening for color blindness and ocular motility.

An optometrist will also perform some form of eye pressure test, generally using a tonometer, which measures intraocular pressure and can help detect glaucoma, as well as a slit lamp examination, a high magnification analysis of the eye structure. Slit lamp examinations can help detect a number of eye conditions — from cataracts and macular degeneration, to corneal ulcers and diabetic retinopathy.

Furthermore, some optometrists can perform minor surgeries, such as removing a foreign body from the eye, giving laser treatment, or providing post-surgical care. But for more complex vision problems and in-depth surgical procedures, patients need to see an ophthalmologist.

An ophthalmologist can treat the following, among others: •

retinal problems (swelling/bleeding, or detachment)

•

corneal diseases (diseases affecting the cornea)

•

cataracts (a cloudy patch on the lens of the eye)

•

amblyopia (also known as lazy eye, occurring when sight in one eye does not develop properly)

•

glaucoma (which can damage the optic nerve and lead to a build-up of fluid in the eye)

•

strabismus/squint (misalignment of the eyes)

•

intraocular inflammation (swelling within the eye)

•

eye injuries (minor or major)

•

infectious eye diseases

•

macular degeneration (a disease that affects the retina and can result in central visual field loss)

•

diabetic retinopathy (a complication of diabetes which can result in vision loss)

•

and other rare diseases of the eye (e.g., hemolacria or bloody tears).

So, it’s ophthalmology time!

If your patient has ongoing or more serious eye health problems (such as cataracts, glaucoma or macular degeneration), needs visioncorrecting surgery (like laser-assisted in situ keratomileusis [LASIK] or photorefractive keratectomy [PRK]), or has been referred by an optometrist — then it’s time for them to see an ophthalmologist.

What services does an ophthalmologist provide?

An ophthalmologist can perform eye exams and test for vision problems like an optometrist, but they are also medical doctors who are qualified to provide treatment and perform surgeries for all eye diseases or disorders.

Although this is by no means a comprehensive list, this will give patients a good idea. If it’s eye-related, an ophthalmologist will have the skills and know-how to deal with it.

Still confused?

If patients still can’t decide whether they need an optometrist or an ophthalmologist, don't fret! Truth is, a visit to either is going to put them on the right path to eye health.

Optometrists and ophthalmologists are both experts in their fields and often work closely together to ensure successful patient outcomes.

Just be sure to ask them to see one or the other regularly for best chance of maintaining vision.

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ENLIGHTENMENT | EDUCATION

from a wide range of backgrounds on a daily basis.

How to Upgrade Your Practice Wise words from our experts

by Andrew Sweeney

"G

entlemen (and ladies), we can rebuild this clinic. We have the technology. We have the capability to make the world's first bionic optometry clinic. It will be your clinic. Better than it was before. Better, stronger, faster.”

It might have taken six million dollars to upgrade the character of Steve Austin from the 1970s television show The Six Million Dollar Man, but it probably won’t cost that much to upgrade your own optometry clinic.

Times are, indeed, a-changin’ — and when it comes to boosting the performance of your practice for patients and staff alike, there are a lot of ways you can upgrade an optometry clinic.

Yet in an industry characterized by rapid technological advancement and sweeping changes that can come out of nowhere (if you have been trying to forget about the COVID-19 pandemic, apologies), it can be difficult to determine the necessary questions you need to ask yourself when it comes to upgrading your practice.

when should you start, why should you upgrade (we’ll get to that), and finally, how will you go about it?

Keep up with technology These questions and more were put to our own six-million-dollar optometry experts when we asked them how optometrists can upgrade their practices. How to tell if you need an upgrade, what are the things you need to consider, and what is the importance of education and technology?

“Every field evolves and optometric practices are no different. Twenty years ago there was much less equipment needed for an eye exam. Now with widefield imaging, optical coherence tomography (OCT), intense pulsed light (IPL) therapy, and radiofrequency (RF) treatment, optometry has a lot of infrastructure requirements,” shared Dr. Mark Eltis, one of our optometry upgrading ultras. “Clinics can easily run out of space or look dated. If that happens, they need to evolve.”

Who should be responsible for overseeing such changes, what should you start with, and where would these changes best be implemented? Exactly

Dr. Eltis is an accomplished optometrist with particular interests in glaucoma, dry eye, laser vision correction, multifocal contact lenses and myopia control. Based in one of Toronto’s more well-heeled suburbs, he sees patients

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He emphasized the importance of creating a custom eye care experience for your client’s specific needs, an upgrade step that’s within reach of most clinics. Our Canadian colleague pointed out that while a more individualized experience is more expensive and timeconsuming, it’s well worth it.

“We don’t only see affluent patients.

I often see second, third or tenth opinions,” Dr. Eltis added. “They’re regular people who are frustrated with the impersonal care they have received in the past, or have a problem that hasn’t been addressed to their satisfaction.”

“It’s so rewarding to see patients impressed with our new facilities and equipment. Ultimately, it comes down to having the right people and attitude in a practice. Patients can sense if the employees are happy and if the doctors take pride in their work,” he enthused.

Understand that continuing education is key Now, to adopt this more individualized approach, it’s likely that education and training are required. And this is something that Dr. Eltis and our other optimal optometrist, Dr. Monica Chaudhry, emphasized.

Whenever an upgrade is to take place, technological or otherwise, educational programs are going to be rather useful.

This applies to clinical staff as well as optometrists, too!

Dr. Chaudhry is a leading optometrist and specialist consultant in contact lenses, irregular cornea, orthokeratology and low vision optometry. When she consults fellow clinicians, one of her most emphasized points is the importance of ongoing education and early adoption of new technologies.

Both, she said, are part of the same process, and clinicians that fail to keep up run the risk of dropping out.

“The staff of every optometry clinic should undergo a process of continuing medical education and upgrading their knowledge,” continued Dr. Chaudhry.

“I strongly believe in training sessions, and that seminars and symposiums constitute an important part of upskilling.”

founder of an upskilling online platform Learn Beyond Vision, which has many optometry courses for practitioners to understand useful and recent skills.”

Further, she said: “Individuals must invest time and money to learn. And for every patient, the outcomes must be introspected. A happy patient gives the best indication that the right care is done, and every unhappy patient highlights how much has to be improved. Evidence-based practice learning is one of the best ways to upgrade here.”

Dr. Eltis said he sees a lot of young optometrists rushing to buy all the latest toys, thinking this will set them apart. “The truth is with experience, you realize most practices will eventually get the same equipment and that’s not what generally retains patients. Having

Ensure that your cutting edge stays sharp In optometry, ophthalmology, or any other medical field, it seems like there’s new technology or a new toy coming out every week. And that’s naturally important for optometry clinics looking to keep their cutting edge sharp.

Whether it be the latest development in OCT or a novel way to screen a disease that’s not even related to optometry, such as Alzheimer's, there’s something new to keep us engaged. However, both Dr. Eltis and Dr. Chaudhry cautioned that technology isn’t entirely the name of the game.

They both conclude that the most proven way to upgrade your clinic, to create actionable benefits for your staff, is adhering to the fundamentals of practice as much as ensuring continuous education or acquiring the latest equipment and new tech toys.

For Dr. Chaudhry, this means focusing on the basics of optometry and not trying to branch too much into different directions. For Dr. Eltis, it is important that optometrists remember that new tech is not some wonder-tool and that experience and empathy are more important.

“Those working in optometry should only focus on their domain. That’s how I’ve worked, and I feel that it enhances my practice,” Dr. Chaudhry advised. “For myself, the exchange of case studies and patient care in professional forums is one of the best ways to achieve this focus. I’m the

Contributing Doctors With almost twenty years of experience, Dr. Mark Eltis has practiced Optometry in New York, California, and Toronto. He is a graduate of the University of Waterloo School of Optometry and has taught there for over a decade.

Dr. Eltis is a fellow of the American Academy of Optometry and a diplomate of the American Board of Optometry.

He is also a faculty member of the Academy of Ophthalmic Education and has completed his California Glaucoma Certification at UC Berkeley.

Dr. Eltis has served as an examiner for national licensing assessment in both Canada and the United States.

He has presented and published internationally and has been sought as an expert on optometric issues for national television and print.

In 2013, Dr. Eltis was honored as a member of the Optometric Glaucoma Society (OGS) having “demonstrated excellence in the care of patients with glaucoma through professional education and scientific investigation.”

Dr. Eltis is a reviewer for over a dozen publications including Journal of Glaucoma and Canadian Journal of Optometry. In 2017, he was recognized for his “outstanding contribution in reviewing” by the editors of Journal of Optometry and Elsevier. He is also on the editorial board of scholarly publications and is a US optometric residency program evaluator.

Dr. Eltis has been a consultant for academic institutions overseas, contact lens/pharmaceutical companies, law firms, and a subject matter expert for competency evaluations. He serves on the board of directors of the Council for Healthy Eyes Canada and was elected to council at the College of Optometrists of Ontario. Dr. Eltis is currently focusing his practice on dry eye patients employing the latest diagnostic and therapeutic options.

He loves connecting with optometry students and the public by sharing his eye care tips on social media. drmarkeltis@vieweyecare.com

the latest model of phoropter or OCT is not what gets patients in the door,” he shared.

“Ultimately, it still comes down to your chair side manner and diagnostic abilities, and results are what drives positive word of mouth and a loyal patient base. Reputation and integrity always trump short-term revenue,” Dr. Eltis concluded.

Dr. Monica Chaudhry is a consultant optometrist and educator who have more than three decades of experience as an academic and a clinician. With her extraordinary skills in optometry education, she has recently ventured to be a freelancer educator, strategy advisor and practitioner. She is the founder of an online optometry up-skilling education platform – Learn Beyond Vision. Also, she has instituted some centers of excellence and vision centers, which aim to be a unique referral, academic and research units.

Her name is well-known as a contact lens and low vision specialist and has a far and wide patient referral in India. Dr. Chaudhry has served at the All India Institute of Medical Sciences (AIIMS) in New Delhi, had academic experience with various universities, including the Indira Gandhi National Open University (IGNOU) and Amity University (India), and has recently retired as director of School of Health Sciences at Ansal University (Gurgaon, India). She has been associated with leading eye care companies such as Menicon, Johnson&Johnson , Baush +Lomb , Alcon, Essilor, among others, as a key opinion leader, faculty, consultant or advisor. In recognition of her contribution to the field of academic medical service, she has been awarded the Shreshtshree Award by the Delhi Citizen Forum, the Australian Leadership Fellowship award in 2012 and the IACLE Contact Lens Educator of the Year (Asia Pacific) award in 2015. Dr. Chaudhry was chairman of the Optometry Council of India. She has been actively involved in organizing conferences, seminars, national and international workshops, faculty development programs and many corporate training programs.

She has chaired many scientific sessions and presented many papers in national and international optometry and ophthalmology conferences. She has travelled abroad extensively and attended many international trainings and conferences. She has written chapters in books and has published three books. monica.rchaudhry@gmail.com

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