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www.optometry.co.uk November 2 2012 vol 52:21 ÂŁ4.95

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Journal of the Association of Optometrists

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Welsh eye care changing

live Referral advice

enewsletter

Inspirational NOC Take-home messages for the profession


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CONTENTS

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November 2 2012 vol 52:21

38

News

Advice

The GOC has approved the rules which will underpin the new enhanced CET scheme from January 2013

Clinical adviser to AOP legal services, Trevor Warburton, discusses the GOC’s rules for referring patients

26 Legal update

5 CET changing

6 Caution over anti-VEGFs

Researchers warn that drugs commonly used to treat wet macular degeneration may do more harm than good

7 Practices could be due a tax rebate

Nine out of 10 practices across the UK could be entitled to a tax rebate

8 Comment

30 Completing the journey

Optometrist Sheena Tanna-Shah provides tips on dispensing and concluding the sight test appointment

Events

24 World Sight Day

European Parliament hosts the World Sight Day event with ECOO

AOP chairman David Shannon reflects on the AOP Awards and the NOC, and OT’s new managing editor John White discusses new beginnings

38 AOP Awards

10 News Extra

Cover story

The winners announced plus pictures from the glittering ceremony

A new Wales Eye Care Service has been launched which will enable optometrists to deliver even better levels of patient care

Products

12 Industry news

New frames from Stepper, International Eyewear and Menrad, a window display from Rodenstock, plus dry eye drops from an optometrist

An overview of the conference, plus the take-home messages from LOCSU’s Katrina Venerus

Regulars

14 Student news

Apprenticeship scheme offering youngsters their step into optics expands

37 Spectator

32 Instrument review

Optometrist Katy Barnard reviews two new CCTV magnifiers

OT cover picture by Paul Pickard. NOC 2012

Feature is online

16 & 18 NOC 2012

Video is online

Calling for the growing involvement of community-based practitioners in a wider range of eye care services

42 Letters to OT OT readers share their views

www.optometry.co.uk

49 Clinical

44 VRICS: C-19897 O/AS/SP/IP To refer or not to refer

Part 3: Glaucoma detection and management Glaucoma specialist Dr Aachal Kotecha continues our series on therapeutics by looking at the detection, therapeutic management and complications of glaucoma

49 CET 1: C-20076 O/D Anterior eye and oculoplastics

Part 7: Corneal degenerations and keratoconus Consultant ophthalmologists Amit Patel and Sunil Shah discuss the presentation and management of corneal degenerations, concentrating on keratoconus

54 CET 2: C-20101 O/D/CL Are you fitting comfortably?

Optometrist Mark Tomlinson examines the many reasons why patients drop out from contact lens wear and offers advice on how to reduce this

Classified 58 Jobs

The latest optical vacancies

62 Marketplace

Your guide to optical products and services

Company of the Year Association of Optometrists Awards 2012

02/11/12 CONTENTS

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NEWS Robina Moss robinamoss@optometry.co.uk

REGISTRANTS WILL have to obtain at least 50% of their CET points by interactive methods from January. The change is part of the GOC’s enhanced CET scheme for optometrists, contact lens opticians and dispensing opticians from next year. The GOC gave formal approval to the new rules, which will underpin the CET scheme, at its meeting in London last week. Under the enhanced scheme, optometrists and contact lens opticians will have to take part in at least one peer discussion session in each CET cycle. All registrants will have to obtain CET points across each of the

competency units relevant to their registration. Registrants will be encouraged to earn points every year, so that CET is spread out across the three-year cycle. The GOC’s head of education and standards, Linda Ford, updated practitioners on the incoming CET changes at the recent National Optical Conference.

Responding to an OT question this week, she explained: “In developing our proposals to enhance the CET requirements, we commissioned research into risk. While the risks associated with GOC registrants are generally low, the research did identify a key risk associated with professionally isolated practitioners. That is why the new rules are designed to help registrants improve their practice by learning from each other. Registrants will be expected to take part in more interactive forms of CET, with more opportunities to engage with peers and reflect on good practice.” The new requirements are on the GOC website at www.optical. org/en/Education

IN BRIEF

Have your say

Practitioners have just two weeks left to share their views and contribute to the future direction of the UK Vision Strategy. The consultation, which closes on November 16, aims to ensure that the Strategy continues to prioritise the most important eye health and sight loss issues from 2013. Anita Lightstone, UK Vision Strategy programme director and interim chief operating officer for Vision 2020 UK, said: “It is vital that we obtain a wide cross-section of views from the sector to help shape the strategy.” To take part, visit www.vision 2020.org.uk/ukvisionstrategy 



Eye hospital opens

Changes ‘should be embraced’ OT’S CLINICAL editor, Dr Navneet Gupta (pictured), believes the CET changes should be seen as a move in the right direction for all practitioners to be more confident about their skills and knowledge. As part of the professional development team at the AOP, Dr Gupta is responsible for managing CET and the broader education provision in OT. He will also be involved with the facilitation of peer discussion and live educational events through the AOP. “Over the past two years, terms such as ‘peer review’ and ‘revalidation’ have been floating about and have evoked negative responses. However, looking at the new requirements, the enhanced CET scheme is not

hugely different or more onerous to what we all have been doing in the current cycle,” he told OT. “For example, peer discussion should enable practitioners to engage with others to learn ideas that they might not have considered before. Such an activity will carry more CET points value which means that, overall, fewer CET activities will need to be performed during the threeyear cycle, in order to meet the 36 points target. “Practitioners can now be clear on what is expected of them in order to maintain their registration with the GOC, and can begin to plan accordingly. The changes should be embraced as a step in the right direction for all practitioners to be more confident about their skills and knowledge, for the benefit of our patients. At the same time, participation in more interactive learning activities should make life-long learning and development even more enjoyable. “OT and the AOP are currently working hard to put together guidance on the new scheme so that practitioners know exactly

what is required. We are also currently developing strategies to offer a variety of CET points across all competency areas and through a variety of platforms. “Practitioners can expect to see a continued variety of high quality, text-based articles, VRICS tests and online videos, and these will be augmented with interactive events online and inperson live events. Look out for a comprehensive guide to the enhanced CET scheme coming soon in OT.”

Optegra, the private eye hospital group, has announced its entry into London with the opening of a new facility in north west London. It will be managed by Farzam Jafari (pictured), who previously ran Optegra Surrey Eye Hospital, based in Guildford. He is continuing to build on the good relationships with local optometrists and GPs, following Optegra’s well-established professional partnership model.

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02/11/12 NEWS

New CET rules approved


NEWS IN BRIEF

Driving panel chair

02/11/12 NEWS

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A consultant surgeon at Moorfields Eye Hospital has been appointed chair of a Driving and Visual Disorder’s Medical Advisory panel for the Department of Transport. Ananth Viswanathan, who has been on the panel for a decade, takes over from Michael Miller following his retirement on October 11. The panel advises the Secretary of State and the Department of Transport on road safety implications of driving and visual disorders. Its advice assists with the establishment of policy.

Celebrity winners

Su Pollard, of Hi De Hi fame, and Tom Fletcher, from McFly, show off their Celebrity Spectacle Wearer of the Year awards. Specsavers’ star-studded ceremony was held at London’s Battersea Power Station on Tuesday night (October 30), hosted by Gok Wan. Maria Gildea, from the Republic of Ireland, was chosen from 5,000 entries to win the Spectacle Wearer of the Year Award.

Fifth centre opens

Vision Care for Homeless People has opened a new clinic in Brighton. The service, which is the charity’s fifth centre across the UK, will offer free eye tests and spectacles to homeless people on Wednesday mornings between 9am-1pm. The centre is based at the First Base Day Centre in St Stephen’s Hall, Brighton. For information about volunteering, email will.pearce@vchp.org.uk

Caution over anti-VEGF use Nikki Withers nikkiwithers@optometry.co.uk

MANY PEOPLE with wet macular degeneration are prescribed a class of medications known as anti-vascular endothelial growth factor (anti-VEGF). But American researchers have found that reducing VEGF activity may do more harm than good. The blood-vessel growth factor VEGF has previously been implicated in stimulating abnormal blood vessel growth in a range of cancers and eye diseases. VEGF is therefore a major target for drug developers. Several anti-VEGF are already in use such as Lucentis, Macugen, Eylea and Avastin, and many more are in clinical trials against common eye disorders such as wet macular degeneration.

However, to date there have not been extensive studies on the effects of such drugs on the normal role of VEGF. In the new study, published in the Journal of Clinical Investigation, researchers deleted the gene for VEGF from cells in the retinas of adult mice. The team found that without VEGF, a large subset of light-sensing cells lost their main blood supply and shut down, causing severe vision loss.

“It’s becoming clear that VEGF has a critical function in maintaining the health of the retina, and we need to preserve that critical function when we treat VEGF-related conditions,” said professor Martin Friedlander (pictured), from The Scripps Research Institute in California, USA. It is unknown whether the side effects observed in the study are happening with existing anti-VEGF treatments. Mr Friedlander believes studies are needed to investigate the possibility. He plans to conduct such assessments in eyedisorder patients – who typically receive direct injections of antiVEGF drugs to their eyes – to determine whether the drugs are causing any adverse side effects.

LOCSU levy reduced by 20% THE LEVY that LOCs pay to fund the LOCSU will be reduced by 20% next year. From April 2013, the levy will be lower from 0.5% to 0.4%. The levy contribution is calculated by the number of GOS sight tests performed by

contractors in each LOC area. Chairman to the Unit, Alan Tinger, said: “The NHS reforms have meant that more LOCs are seeing the need for LOCSU’s expertise and advice. Now that 80 of the 81 LOCs in England are LOCSU members, with the final one proposing to

join, the finance required to ensure that LOCSU is funded is spread across more committees. Together with focused budgeting, this means that we have been able to reduce the levy payment made by individual LOCs by 20%.”

Public lack knowledge about UV PEOPLE ACROSS Europe lack knowledge about the impact that UV rays have on the eyes, with UK awareness falling behind Poland’s, researchers have claimed. The study investigated people’s views on the implications of chronic UV exposure and discovered a lack of understanding about the benefits of ocular UV protection, such as sunglasses, wide-brimmed hats and contact lenses with UV-blocking properties. Reported at the American Academy of Optometry meeting in Phoenix last month (October 24), the study found that UK consumers were less likely than

those from Poland to recognise the importance of protecting their eyes compared with their skin, with 89% of UK participants and 93% of Polish participants saying that you should protect your eyes

To comment go to www.optometry.co.uk

and skin from UV. Furthermore, two-thirds of participants from Poland were aware that some contact lenses protect against UV rays compared with just 26% of those from the UK.


NEWS

Emily McCormick emilymccormick@optometry.co.uk

NINE OUT of 10 practices across the UK could be entitled to a tax rebate as a result of unclaimed tax relief relating to their premises, according to property tax specialists MoneyBee Tax. Following a review, the company concluded that up to 90% of optical businesses might be able to claim tax relief for capital allowances, which relate to money spent buying, refitting or refurbishing a practice. Capital allowances can be used to reduce the business owner’s tax liability. While some practice owners claim for basic allowances such as shop fittings and computer equipment, many are unaware they can also claim on test room and lab fittings, lighting, heating and specialist ophthalmic equipment. MoneyBee Tax estimates that, on average, for every £100,000

Optometrist helps OGS OPTOMETRIST AND fundraiser Malkit Singh is calling on members of the optical industry to donate just £10 to Optometry Giving Sight. He wants to help the charity raise £60,000 by December 15. This will happen if 6,000 people donate. “I know with everyone’s help we are going to make it. My dream is to raise £60,000; anything more would be a miracle,” said Mr Singh. AOP chairman David Shannon said: “We can all dream. I hope Mr Singh realises his. How inspirational to want to give the gift of sight to so many.” To help Mr Singh and Optometry Giving Sight, donate at www.justgiving.com/ mrsinghsdream

spent on premises, capital allowances could be claimed on around 30% of it. In certain circumstances this could be as high as 90% Andrew Reid, manager of MoneyBee Tax, said: “The value of capital allowances will vary from business to business but we rarely come across a case where a business owner couldn’t save money. “To give an example, if a retail opticians unit was bought and fitted out for £200k, the owner

could be claiming allowances of approximately £60k, potentially giving a tax rebate of £24k. Importantly, even if the business was bought or fitted out years ago, a claim for capital allowances can still be made now.” To find out if you could be due a tax rebate visit www.moneybeetax.co.uk and check out the capital allowances calculator to get an immediate estimate of how much you could be owed.

Eye expert gives evidence at Lords THE HOUSE of Lords Science and Technology Committee heard evidence from a leading expert on eye conditions this week. Professor Peng Tee Khaw, from Moorfields Eye Hospital, spoke to the Committee on Tuesday (October 30) about the future of regenerative medicine and eye health. The session was part of the Committee’s inquiry into regenerative medicine. The aim of the enquiry is to assess the UK’s position and preparedness for the possible health benefits regenerative medicine could provide. Areas the Committee focussed on included UK expertise in the field, the applications of

this research to treatments, the regulatory and financial barriers to translation and commercialisation of the findings of this research, and international comparisons. Lord Krebs (pictured), chair of the Committee, said: “Regenerative medicine has the potential to have a huge impact on health care and provide real benefits for people suffering from a wide range of conditions. “However, it is important to separate the hype and false promises from the real hope regenerative medicine can offer.”

To comment go to www.optometry.co.uk

IN BRIEF

GOC rule change

The GOC last week approved a revision to one of its proposed new Fitness to Practise (FTP) Rules which are being introduced to help make the FTP process faster and more transparent. The revision to Rule 15 means that, when the new Rules come into force, GOC case examiners, rather than the registrar, will review decisions not to refer registrants to the FTP Committee. The Rules will also make clear that this must be on the basis of a unanimous decision by the two case examiners reviewing the decision.

CooperVision courses

Contact lens giant CooperVision has announced a new series of roadshows which will focus on the correction of presbyopia with multifocal lenses. The half-day ‘CooperVision Courses’ will be held at 12 venues across the UK between November 6-29. With up to six CET points available to practitioners attending, the events aim to provide delegates with real-life scenarios and the opportunity to improve their communication skills based on boosting patients’ confidence and understanding about contact lenses.

Council nominations

The College of Optometrists is calling for members to join the College Council. There are 12 positions available across nine regions. “If you are keen to have a say in the work and development of the College, please consider standing for election to Council,” said Bryony Pawinska, chief executive of the College. For further information visit www.college-optometrists.org/ elections

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02/11/12 NEWS

Nine out of 10 practices could be due tax rebate


NEWS ‘Two-thirds fail to train staff’– survey Emily McCormick emilymccormick@optometry.co.uk

02/11/12 NEWS

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SIXTY PER cent of independent practice owners fail to train their staff, with 8% admitting to never offering training, according to new research by in-practice optical training company, Positive Impact (PI). Reporting its findings to coincide with the launch of its first in-practice learning programme, the survey questioned a total of 50 independent opticians across the UK. However, of those quizzed, 66% said they aspire to perform team training every six to eight weeks. “In the current economic

climate, sales growth is increasingly difficult to achieve, with practice teams having to be constantly at the top of their game – often just to stand still. It is, therefore, amazing to find such a lack of regular training in this sector,” said joint managing director of PI, Nick Atkins. Named ‘Gaining and retaining patients by becoming their trusted vision advisors’, the interactive programme contains a series of four modules. They include: Make friends with the sales process; What do patients really want?; Why buy from us?’ and Keeping customers. For more information, email learning@positiveimpactsales. co.uk

Talking of domiciliary care A LARGE gathering of 32 optometrists, dispensing opticians and optometric advisers attended the first open meeting of The Optical Confederation’s Domiciliary Eyecare Committee (DEC) (pictured) last Friday (October 26). They enjoyed a lively debate on topics including the role of the DEC, the Independent Adjudicator Service and the proposed domiciliary information leaflet. The role of domiciliary providers in Local Eye Health Networks and delivering improvements against the Eye Health Indicator were also discussed.

PROUD OF A UNITED PROFESSION THIS ISSUE of OT comes on the back of the second AOP Awards – and what an incredible evening. It was no easy decision for the judges to choose the shortlist for the Awards, which the readers of OT voted on, and all the nominees put forward should be congratulated. What is also important to recognise is the enormous effort from within the sector to support the visual needs of the public. Over the course of the two days at the NOC, there was a tremendous feeling of a profession that was sure of its standing and prepared to adapt to meet the challenges of the NHS. One pharmacy rep said how impressed he was, and felt we ‘spoke as one’. This is truly an accomplishment of which the profession can be proud. It does not seem so long ago that these meetings were not complete without an emergency resolution. Talking of progress, I want to congratulate colleagues in Wales at the achievement of getting the Wales Eye Care Service established. Optometrists throughout the UK are trained, willing and able to take on a greater role in the provision of world-leading, patient-centred care – as the NOC showed us. Rest assured, in England we will be banging on the tables with our Optical Confederation partners, demanding a properly funded eye care service for residents. Perhaps we need a revolution and an emergency resolution, or is that a thought too far? Let me know your thoughts. David Shannon, AOP chairman www.facebook.com\AOPChairman www.twitter.com\AOPChair

NEW BEGINNINGS

“We decided to hold an open meeting to ensure transparency and inclusivity of the committee’s work,” said acting chair, Jayne Rawlinson. “It provided an ideal opportunity for everyone involved in domiciliary eye care to discuss issues with colleagues. I was delighted with the turnout and the productive debate. We agreed that this would be an annual feature in the DEC work programme.”

Warning over illegal Cl sales THE EYECARE Trust has issued a stark warning highlighting the risk that the illegal sale of contact lenses poses to the public’s eye health. It highlights that ‘worryingly, cosmetic and decorative lenses are increasingly available from unregulated Internet

COMMENT

sites as well as market stalls, beauty salons and general retailers’.
 
 In its warning the Trust urges revelers to have an eye examination to discover their suitability for contact lens wear and to contact the GOC to report suspected misselling of cosmetic contact lenses.


FOR A newcomer to any sector, the ebb and flow of an industry-led conference, charged with the energy of delegates and the vision of expert speakers, is an insight not to be missed. Last month’s NOC offered that unique first glimpse in to an optical sector driven by a desire to get to grips with the policies affecting eye care today, and at the same time looking to shape the broader political conversation. In this issue of OT, LOCSU’s new managing director, Katrina Venerus, offers an easy-todigest summary of the presentations from the NHS, Department of Health, and clinical commissioning groups – and sets out the all-important take-home message (see page 18). So, channelling the spirit of openness on display at the NOC, OT would be delighted to hear your thoughts on topics you’d like us to investigate in 2013, receive your letters raising the concerns that keep you awake at night, and read your case studies that reflect the realities of working in a practice today. OT not only seeks to keep you abreast of the latest news; the magazine and associated website, www.optometry.co.uk, are an information gateway that looks to bring together the optical community. And, our platform for debate is widening: for the growing number of twitter fans out there, you can now follow OT around the clock at http://twitter.com/ OptometryToday. Enjoy. John White, OT Managing Editor johnwhite@optometry.co.uk

To comment go to www.optometry.co.uk


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NEWS EXTRA New Wales Eye Care Service set care liveto boost patient CET bookshop

optometrytoday

Journal of the Association of Optometrists

NOVEMBER 2 2012 VOLUME 52:21 ISSN 0268-5485 ABC CERTIFICATE OF CIRCULATION January 1 2011 – December 31 2011 Average Net: 20,038 UK: 19,160 Other Countries: 878 Managing Editor: John White T: 020 7549 2071 E: johnwhite@optometry.co.uk Deputy Editor: Robina Moss T: 020 7549 2072 E: robinamoss@optometry.co.uk

online

Web Editor: Emily McCormick T: 020 7549 2073 E: emilymccormick@optometry.co.uk Multimedia Editor: Laurence Derbyshire T: 020 7549 2075 E: laurencederbyshire@optometry.co.uk Reporter: Nikki Withers T: 020 7549 2074 E: nikkiwithers@optometry.co.uk Clinical Editor: Dr Navneet Gupta E: navneetgupta@optometry.co.uk Multimedia Creative Editor: Ceri Smith-Jaynes E: cerismithjaynes@optometry.co.uk Editorial Office: 2 Woodbridge Street, London, EC1R 0DG Advertising: Vanya Palczewski T: 020 7878 2347 E: vanya.palczewski@tenalps.com Sponsorship: Sunil Singh T: 020 7878 2327 E: sunil.singh@tenalps.com CET and bookshop enquiries: Charlotte Verity T: 020 7549 2076 E: charlotteverity@aop.org.uk Production: Ten Alps Creative T: 020 7878 2323 E: gemma.trevillion@tenalps.com Membership Dept: 2 Woodbridge Street, London, EC1R 0DG T: 020 7549 2010 W: www.aop.org.uk Advertising and Production Office Ten Alps Creative and Ten Alps Media, Commonwealth House, One New Oxford Street, High Holborn, London WC1A 1NU Editorial Advisory Board Vivian Bush, Leon Davies, Cameron Hudson, Polly Dulley, Dan Ehrlich, Navneet Gupta, Andy Hepworth, Olivia Hunt, Niall Hynes, Ceri Smith-Jaynes, Gaumaya Gurung, Vicky O’Connor, Sonal Rughani, David Ruston, David Shannon, Bryony Stather, Gaynor Tromans, David Whitaker, Andy Yorke,

Robina Moss

robinamoss@optometry.co.uk

OPTOMETRY WALES has welcomed the launch of the Wales Eye Care Service, (WECS) which will enable optometrists to deliver even better levels of patient care through a new, national enhanced service. It enewsletter follows the recent commitment from the Minister of Health and Social Services to make eye health a public health priority in Wales. WECS replaces the former Wales Eye Care Initiative (WECI, which was introduced in 2001) with a tiered structure of eye examinations, follow-ups and further investigations. It allows optometrists greater clinical freedom and scope to manage their patients in primary care, thereby reducing the demand on hospital eye services. WECS will be introduced from January 1 and will be fully operational by the end of this financial year. ‘Eye Health Examinations’ will build on WECI and will include new categories, such as dry AMD monitoring and postoperative cataract examinations. ‘Further Investigations’ will enable patients to have additional investigations so that optometrists can further inform their referral, investigate clinical findings, or determine management following a sight test, eg threshold visual field testing and pre-operative

tv VRICS

‘People (in Wales) can expect excellent care provided on their doorstop’ cataract assessment. ‘Follow-up Examinations’ enable patients to be reviewed after they have had an initial appointment for an Eye Health Examination, eg dry eye reassessment following treatment. Chairman of Optometry Wales, Mike George (pictured left), said: “The Welsh Government has shown its deep commitment to eye health and recognised the vital role that community optometrists and dispensing opticians have in the health of the people of Wales. I am thrilled that the success of the Wales Eye Care Initiative has been consolidated in the new Wales Eye Care Service, under which people can expect excellent care provided on their doorstep. “Optometry Wales has worked with our colleagues in Welsh Government, Wales Optometry

W: www.optometry.co.uk Published fortnightly for the Association of Optometrists by Ten Alps Creative Subscriptions Abacus eMedia, Bournehall House, Bournehall Road, Bushey, Herts, WD23 3YG T: 020 8950 9117 E: jenny.hamilton@abacusemedia.com UK £130, OVERSEAS £175 for 24 issues

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Postgraduate Education Centre (WOPEC) and the Welsh Optometric Committee to create a service that will give optometrists the freedom to manage more of their patients themselves. There is a real opportunity for the profession to show the high standard of clinical care we provide and build an evidence base that will support the development of future services. “WECS underpins the nationally agreed Focus on Ophthalmology pathways in Wales and has built in clinical audit so that we can benchmark our performance and demonstrate that we can deliver. “Optometry Wales is a key player in developing the Welsh Government’s first ever eye care plan for Wales. These are exciting and challenging times for the professions in Wales – we must rise to the challenge to meet the expectations of the people of Wales and the Welsh Government. I am confident that we can do so.” Clinical lead for WECS, Dr Nik Sheen (pictured right), WOPEC said: “This new service, funded by Welsh Government, represents a huge stride forward for optometrists, empowering them to be able to manage more patients more effectively in community primary care.”


INDUSTRYNEWS TRADING PLACES

Major changes in contact lenses

02/11/12 INDUSTRY NEWS

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Contact lens manufacturer, CooperVision, has a new president for the European management team to support its ‘considerable investment’ in Europe and other local regions. Mark Harty (pictured) has extensive experience as a general manager, working in numerous international roles and is working from the company’s UK offices at Delta Park, Fareham. “We are very excited to have someone with Mark’s experience and accomplishments joining the CooperVision team and leading our European efforts,” said Dennis Murphy, executive vice president of global sales and marketing. Mr Harty most recently served as the general manager, Medical and Surgical Division of United Drug (UK) Holdings. He also held the positions of vice president and general manager at Boston Scientific, UK, president of Masimo PLC, UK, and vice president and general manager, Global Critical Care, Edwards Lifesciences, in the USA.

Contact lens stalwart Graham Avery (pictured) has joined contact lens manufacturer UltraVision CLPL as its new sales director. He has more than 30 years’ experience in the contact lens industry, from running his own business to sales and marketing director of David Thomas Contact Lenses and, more recently, as global export manager of Menicon. He has a track record of success in introducing speciality contact lens designs, in both the domestic and export markets. “This is an exciting time to be joining UltraVision CLPL with both KeraSoft IC and a stream of new products under development,” he said.

To drive trade in RODENSTOCK UK believes that nothing is more important to aid the sale of high-value spectacles than creating the right impression and so Porsche Design stockists can now highlight the brand’s credentials with a new window display. It strengthens the brand’s presence by showcasing other Porsche Design products, from sportswear and leather luggage to model cars and pens. The white window boxes are available from Rodenstock, which will also supply a range of Porsche Design display items. John Harrup, marketing communications manager, said: “A good, creative window display is a powerful marketing tool that can entice passing customers into your practice.” The growing importance of promoting a practice in today’s challenging times will be reflected at the 2012 Rodenstock Club Awards. For the first time, three marketing categories have been introduced. Practices wishing to enter any of the marketing categories are asked to submit entries by November 23.

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STEPPER UK MD, Richard Crook, challenged the company’s design team last year to ‘make the best even better’. The resulting Stepper Exclusive collection now has six frames, including Ex3006 (pictured). Light titanium styling was used with tumble (part of the manufacture process) for longer than usual for a softer frame. Gold and silver plating was then added plus ‘a little sparkle’. Company founder, Hans Stepper, began his career as a jeweller and his craftsmanship can be seen as the stones are set in jeweller clasp mounts which allows the Zirconium stones to sparkle as light can pass through them. “You can see and feel where the extra time and effort has gone into these extraordinary models,” said Mr Crook.

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Launching an acetate Episode EPISODE 165 is a new and distinctive women’s full rim acetate model from International Eyewear. The Episode collection is designed to be trend aware, yet commercial. The contemporary addition expands the collection, offering a greater choice of acetate frames to compliment the array of existing retro chic, metal models. The new frame encompasses the autumnal season, with an earthy colour palette of brown and olive, which are flattering hues. A distinguishing feature is the graduated mottled patterning on the eye front. The metal grid-like, cross hatch detailing on the lug is textured, complimenting the sculpted temples and tips, which are shaped for added comfort. The deep eye shape is suitable for progressive lenses and is accompanied by a flex hinge.

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Fashion first Robina Moss

robinamoss@optometry.co.uk

MENRAD OPTICS Is launching fashion designer L’Wren Scott’s first eyewear collection. The sunglasses were successfully previewed at the Silmo show in Paris last month. The 21 models of the new eyewear collection are classic with a contemporary twist – oversized butterfly shapes, subtle cats’ eyes and bold squares. The launch marks a new direction for the Menrad group (OT, Industry News 19 October 2012), which has been in the frames business for over 100 years. “We are very excited to be working with such an iconic designer and it’s provided us with the opportunity to step into the high-end designer market,” said Chris Beal, managing director for Menrad Optics in the UK, based at Newbury. “The sunglasses collection, launched to critical acclaim at Silmo, will be available to pre-order from this month, for delivery early 2013, and the ophthalmic range will also be launched in January,” he added. “The collection offers stylish and unique frames to suit all discerning, fashion conscious women.”

www.menrad.com

Natural solution EYESICCAL, A new dry eye product which is 100% natural, has been very successful since its launch earlier this year. The sterile, single-use eye drop contains only herbal active constituents and mineral salts. Ingredients include hydrosols of Euphrasia, Chamomile and Arnica obtained from fresh herbs. The eye drops won the runner up prize in the prestigious Natural Pharmacy Business Awards for best new product. “The drops have been received fantastically well since the launch, particularly in the natural health market,” said independent optometrist, Shockat Adam Patel, who has a special interest in dry eyes, and launched the product earlier this year. “Suitable for contact lens wearers and the only ophthalmic eye drop with the coveted Vegetarian Society approval, Eyesiccal is ideal for those that are preservative reactive and chemical adverse,” he added.

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13

02/11/12 INDUSTRY NEWS

Better by design


STUDENTNEWS

Optics scheme expands

02/11/12 STUDENT NEWS

14

AN APPRENTICESHIP scheme launched in 2011 with the aim to offer youngsters their first step into optics will be expanded this year after proving a success. Having initially enrolled three students on the two-year course, this year the scheme will take on 15 students who will work in practices across the county, including Cheshire, Merseyside and Manchester. The brain-child of optometrist Fred Howard, the Optical Retailing course was established in partnership with Wirral Metropolitan College. Mr Howard took on the first three students himself – Jess Glasson, Lauren Weaver and Lucy Griffiths. All three have passed the first-year with “flying colours” revealed Mr Howard, “having progressed through the course at an

unexpected rate!” He told OT: “I can’t believe the impact that they have had on the practice. Their enthusiasm and solid understanding of all aspects of their roles is immediately apparent to both patients and other staff.” The extensive course, which sees students work in full-time practice, covers a wide range of modules, such as GOC registration, dispensing, patient handling, screening and the freedom of information act.

Student award winner

Sponsored by

Students head to Longleat

WITH JUST under a month until this year’s AOP student conference, undergraduates who are yet to book their place are urged to act fast to avoid disappointment. To date, 235 students have booked their place at the three-day event, with just 50 spaces remaining. Now in its fifth year, the conference will be held at Center Parcs, Longleat on November 30-December 2. It aims to offer students important career advice and tips on how to secure a pre-reg placement. Combining education with the opportunity to network, an AOP student “Eye Ball” will be hosted on the Saturday evening (December 1). Confirmed lectures include: ‘Where will optometry take you’, ‘Ask the employers what it’s really like’, and ‘Planning your pre-reg’. Tickets cost £95. To book your place, visit https://www.eiseverywhere.com/ehome/ index.php?eventid=36482&

THIRD-YEAR optometry undergraduate Jason Searle (pictured second left) was named Student of the Year at the 2012 AOP Awards last month (October 18). The Cardiff University student beat off tough competition for the accolade from shortlisted nominees Jeff Clarke and Mohammed Rizwan. On winning the award, Mr Searle told OT: “All I can say is that I am still shocked to have won, as everything that led to my nomination is just how I live day-to-day. I really enjoy optometry and I think being enthusiastic about what you study keeps you motivated. I feel that the award could have easily gone to either of the shortlisted nominees, or any one of my course mates here at Cardiff, as we all do our own bit in promoting optometry to the world. Finally, I would just like to say thank you to all who voted for me. It was a lovely surprise.” Gary Baker was revealed as winner of the Lecturer Award. Mr Baker, who sadly passed away last November, taught for over a decade in the optometry department at City University.


C-Uni-Optom A4 ad-Oct-12_C-Uni-Optom A4 ad-Oct-12 29/10/2012 10:28 Page 1

Flexible supported learning New modules starting March 2013 - apply now www.cardiff.ac.uk/optom/pgt Studying with Cardiff University offers the flexibility of distance learning with support from experts and practical training in our state of the art building for most modules. Many modules linked with LOCSU distance learning and/or the new College of Optometrists professional qualifications. Study a module at a time (from £550) or work towards a Postgraduate Certificate, Diploma or MSc in Clinical Optometry. Over 20 modules available to study including: ● Glaucoma - A series of modules guiding you from referral refinement to specialist glaucoma optometrist ● Acute Eye Care - Basic and advanced modules relevant to optometrist acute eyecare service providers ● Age-Related Macular Degeneration Targeted for those who work in multidiscplinary teams monitoring AMD ● Low Vision - Basic and advanced levels with contributions from Barbara Ryan, Michael Crossland, Jonathon Jackson, Gillian Ruddock, Chris Dickinson and Marek Karas ● Paediatric Optometry - Led by Maggie Woodhouse with contributions from Bruce Evans and other experts ● Learning Disabilities - Led by Maggie Woodhouse with the opportunity to work in our specialist clinics ● Tear Film Disorders - Bringing the practitioner up to date with the latest evidence based assessment and treatment for dry eye

● Legal Aspects of Optometry - Led by Trevor Warburton. A must for any optometric advisor or LOC member ● Neurology - Contributions from neurologists and a neuro-ophthalmologist. This module includes exciting practical sessions with patient cases ● Evidence and Audit - Supported learning about clinical audit and guidance on how to do it effectively ● Clinical Teaching - A must for any optometrist who teaches, including pre-reg supervisors, University tutors and LOC CET co-ordinators ● Leadership - This module is for anyone who needs and wants to lead, including those in business or LOC chairs ● Diabetes - Clinical teaching with emphasis on holistic patient care

“Great course at WOPEC at the end of last week. Organisation, as usual, superb. Learnt lots, and it was great fun to meet up with the other students as well”. David Woolf

Apply now: www.cardiff.ac.uk/optom/pgt or email: pgoptom@cardiff.ac.uk


REVIEW

NOC-out performance The National Optical Conference (NOC) 2012 arrived in Birmingham for two days of inspirational opinion leadership, debate – and a splash of comedy – writes John White

02/11/12 NOC

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THE OPTICAL community came together for the NOC, organised by the AOP on behalf of LOCSU and the Optical Confederation, last month. Taking the theme of ‘Primary eye care: building on success’, LOCSU delivered a diverse programme, rich in thoughtleadership and debate. With more than 160 LOC members present, LOCSU confirmed that more delegates attended this year’s NOC than ever before.

Looking forward Keynote presentations included speakers from the NHS, Department of Health and local government reflecting on what the NHS reforms will mean for LOC members. There was also an update on the CET requirements from January 2013 from the GOC’s head of education and standards, Linda Ford. Breakout sessions returned to the conference this year, following a positive rating among delegates last year. Attendees could choose between four parallel workshops under the leadership in optics theme, plus four parallel master classes in commissioning. A standout session featured the problems facing the LOC in Oxfordshire, and the turnaround that has taken place using OptoManager IT, as described by optometrist Paul Jewitt and Gian Celion of Webstar Health. The event also featured the presentation of LOCSU’s Annual Report 2011/2012. Entitled ‘The eye of the storm’, LOCSU’s managing director, Katrina Venerus, presented the strategic objectives for the coming year, while confirming that demand from optical

committees is “at an all-time high.” LOCSU remains committed to delivering “excellent support and good quality advice for LOCs,” Ms Venerus added. LOCSU executive chairman, Alan Tinger, was able to announce that, as from the April 1, 2013, the Board has agreed to reduce the levy on LOCs by 20%.

Paralympic inspiration Book-ending the event were two sessions that are sure to live long in the memory of delegates. Keynote speaker, Chris Holmes (above left), a nine-times gold medal winning Paralympian swimmer, opened the conference on Thursday morning. Mr Holmes offered his reflections on the “natural fear of change”, before explaining why change also presents “opportunity.” As a 14-year-old, who awoke one morning to find he had lost his sight, Mr Holmes described his unique Paralympic journey, from finishing 28th in the Moscow Games in 1980, to winning six gold medals in Barcelona’s stunning open-air pool 12 years later. As a member of the London 2012 bid, and later London 2012 director of Paralympic integration, Mr Holmes explained that, early on, the London 2012 team recognised that communicating the message behind the Paralympics was key; a survey before the Games highlighted that 1% could name a Paralympian and less than 1% intended to buy tickets. “We believed that the most effective way to deliver the Olympics and Paralympics was one integrated committee” – a first in Olympics history, and a success that even Mr Holmes was happy to concede was “a massive surprise.”

Vision trivia The NOC turned in to a quiz show for ‘Is it better on the red or the green?’ – a game of trivia based around vision. Rounds including ‘The NHS challenge –

or the challenging NHS’, ‘Name that eye tune’, and the quick-fire finale ‘You’ve been framed’, ensured a raucous end to the conference. Summarising the NOC, Ms Venerus said: “The NHS reforms have created opportunities and challenges for our LOCs. This year’s programme was specifically designed to help support LOCs through this period of change – and a quick scan of initial feedback from delegates reveals that many valued the variety of sessions and speakers on offer.” Reflecting on the event, delegate Deborah Daplyn, from Norfolk and Waveny LOC, commented: “I shall look forward to next year. As a newly elected and somewhat nervous chair, this has given me renewed confidence to go back and have another go.” Paul Cheetham, from Heywood Middleton, Rochdale and Bury LOC, concluded: “An excellent conference, giving much needed reassurance at a time of great changes. I thought we were lagging behind ‘the rest’ but realised we are all in ‘the same boat’ with the same concerns, questions and aspirations. I don’t feel so alone as a result.” NOTE: Video footage of the presentations given at the NOC will be available on www.optometry.co.uk/ multimedia later this month.


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REVIEW

The live sessions One of the highlights of this year’s NOC in Birmingham was the chance to hear from leading voices in the NHS, Department of Health and local government exploring what the latest health reforms mean for LOCs. Katrina Venerus, Managing Director of LOCSU, reports back from the event

02/11/12 NOC

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IN LIGHT of the latest health reforms, the 2012 National Optical Conference (NOC) brought together four leading opinion leaders from the NHS, Department of Health and local government to review and discuss the impact for LOCs in the headline Thursday afternoon session. The speakers were invited to provide different perspectives on the changes in the way services are commissioned across England. The presentations were followed by a lively panel debate on ‘how we can make the new NHS work.’ All the presentations (which are now available online at http://www.locsu.co.uk) provided valuable insights for LOCs, the majority of whom were represented by delegates in the packed main hall at the Hilton Metropole in Birmingham.

Public health developments Denise Vittorino, head of health development for Staffordshire Public Health (pictured left), and colleague Sue Wardle, head of public health and wellbeing intelligence, Staffordshire County Council and Staffordshire NHS kicked off the session. Ms Vittorino explained the role of health and wellbeing boards and how they are being developed. She also outlined the overlap between public health, adult social care and the NHS – an area that the health and wellbeing boards will manage. Ms Vittorino told the audience that board members will collaborate to understand their local community’s needs, agree priorities and encourage commissioners to work in a more joined up way. As a result, patients and the public should experience more integrated services from the NHS and local councils in the future. The presentation from Ms Wardle highlighted the importance of joint strategic needs assessments. She

reminded delegates that from April 2013, local authorities and clinical commissioning groups (CCGs) will have for the first time equal and explicit obligations to perform a joint strategic needs assessment – which is a duty discharged through health and wellbeing boards. In response to this demand, Ms Wardle highlighted the work being done in Staffordshire which brought together all the evidence to develop an eye care profile for the county which linked to other health conditions and demographics, such as age, ethnicity, diabetes, learning disabilities, obesity, smoking and children. This work was a useful reminder to LOCs on the value of drawing together evidence which links eye health to other conditions.


Local eye health networks The second speaker in the session was Jim Barlow, optical lead, NHS Commissioning Board, who detailed how the new local eye health networks will work in terms of linking into CCGs. Mr Barlow began by giving an update on the structure of the NHS commissioning board. He then went on to describe the single operating model for the management of general ophthalmic services contracts, which will be delivered through the NHS commissioning board’s local area teams (LATs). The LATs will be responsible for contract monitoring and performance management, leading to overall quality improvement in line with centrally agreed strategies and frameworks. The LATs will also be responsible for local eye health networks.

“The LATs will be responsible for contract monitoring and performance management” Mr Barlow moved on to talk about some of the lessons revealed by the 20 or so areas in England, which had piloted local eye health networks. These lessons included: • The need to communicate in different ways when working across large geographic areas • The importance of recognising the value of the eye health needs assessment in providing a focus for the work of local eye health networks (emphasising the points made in the previous presentation from Ms Wardle).

Clinical commissioning in Sheffield Dr Richard Oliver, clinical director at Sheffield NHS CCG, addressed why CCGs are so important in the new NHS, and highlighted the achievements made by his own CCG in developing links with other health professionals including

Continued on page 20

02/11/12 NOC

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REVIEW

02/11/12 NOC

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the LOC. Particularly helpful to other LOCs, looking to develop relationships with their own CCGs, was the example he gave of how his invitation from Sheffield LOC to their regular LOC meetings had helped the relationship and meant that Dr Oliver had learnt a huge deal about the work of optometrists and dispensing opticians in the region – much of which he had previously been unaware. Surely it is not a coincidence that Sheffield LOC has a large number of enhanced services in place!

“It is vital that LOCs have strong representation within their local eye health network” Get networked The final presentation in the session was from Edna Robinson, national lead for NHS Networks, who is an innovator and set up NHS Networks when the Internet was in its infancy, 10 years ago. Ms Robinson asked delegates to challenge both existing and new structures and bureaucracies which impede their ability to develop their own networks in their area. Ms Robinson applauded the fact that many leaders of CCGs are not of the ‘old guard’ of the NHS. She suggested that this is a really positive aspect of the NHS changes and means genuine opportunities for LOCs. Ms Robinson referred back to the successful work in Sheffield cited by Dr Oliver in his presentation as a powerful example of what effective networking can achieve.

The bigger picture Overall, there were a number of key themes amongst the presentations. Firstly, Ms Vittorino, Ms Wardle and Mr Barlow highlighted the importance of joint strategic needs assessments. Only by ensuring eye health is considered in the assessment of local needs will we be able to influence health priorities for the region. Secondly, the value of sharing information across traditional boundaries was recognised by Dr Oliver and emphasised by Ms Robinson. Dr Oliver clearly demonstrated the change that they were able to achieve in Sheffield thanks to the dialogue between the LOC, GPs, secondary care and others. The final theme was around the need to establish close links between health and wellbeing boards, CCGs and local eye health networks in setting health priorities for local regions. The local eye health network will be tasked with connecting with both of these structures and ensuring that eye health is firmly on the agenda. It is vital that LOCs have strong representation within their local eye health network, and that they are ready to connect with the new NHS in their area. The afternoon session was a true highlight of the conference and we are very grateful for the speakers who gave up their time, and travelled great distances to speak – real recognition of the growing profile of the NOC. NOTE: As always, I would remind LOCs who need advice or support, to contact LOCSU at info@locsu.co.uk


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REVIEW

MEPs educated about eye health 02/11/12 EUROPEAN EVENT

22 28

The European Parliament was home to an eye health event for EU policy-makers in October. Julie-Anne Little, AOP councillor and ECOO president elect, shares the event’s success TO MARK World Sight Day, an event was held on the October 18 at the European Parliament, with the European Council of Optometry and Optics (ECOO) taking part in an ‘European Forum Against Blindness’ dinner debate and undertaking retinal photography in the Parliament buildings over a period of two days.

photographs were taken from a large number of Members of the European Parliament (MEPs), advisors and staff, with each attendee given an explanation of their retinal image. The stand was busy throughout and there was a real hunger amongst European policy-makers for additional information about eye health and what they could do to help.

A stand in the European Parliament provided an opportunity for optometrists Mark Nevin, Bob Chappell (from the ECOO Executive Committee) and myself to discuss eye health, the importance of regular eye examinations and provide information about avoidable sight loss from a range of international vision charities. To illustrate the health benefits of eye examinations, retinal

Evening debate The evening debate was hosted by Marian Harkin (Ireland), Richard Howitt (UK) and professor Ioannis Tsoukalas (Greece), who are all senior MEPs. The president of the European Men’s Health Forum, professor Ian Banks, expertly facilitated the speakers and debate. He highlighted that in the context of men’s health, the late presentation of men

with visual problems, as well as health problems generally, is a significant barrier to prevention and early detection of disease. Richard Howitt, MEP, welcomed participants to the event and discussed visual impairment in the context of disability. He contended that not only should preventable blindness be an unacceptable health problem in Europe, “reasonable accommodation” for visual impairment as occurs in adjustments for disability generally, should be commonplace and makes good economic sense. Participants then had the opportunity to hear from Peter Ackland, chief executive of the International Agency for the Prevention of Blindness

Continued on page 24


“My New Eyes”

The Diploma in

by Demelza Whitbread B.Optom - (Aged 32)

Practice

Up to 60% of children are predisposed to dyslexia1 At school I had considerable literacy and spelling difficulties, and a slow writing speed, with poor handwriting. I was statemented as dyslexic in Primary School (1990). There is a strong history of dyslexia and myopia in my family. I also suffered from poor short term visual and auditory memory. When I was 11, I had the reading age of a 7 year old, and at 16 ½ , my reading and spelling age were both about 11. Throughout my school years, I really struggled, as my spelling, grammar and writing were so poor. I found it hard to read my notes, often got words in the wrong order when reading, I couldn’t always tell right from left, and I had mild rivers in the text. I decided to take the Schoolvision Diploma course in late 2011 which is where I first began to realise the potential of what was being taught. I was very interested to see what a difference it could make to me at this late stage, so had a Schoolvision Assessment myself with Geraint Griffiths. The results were astonishing. It took me about 8 weeks to get used to my new glasses, however, once I’d gone through the period of adaptation, I found: • Near vision felt good – happy to wear reading glasses for all reading.

• No eye strain any more.

• Could adapt more easily to both with or without glasses.

• Happy with glasses at work, particularly after a bad night’s sleep.

• I couldn’t believe the change in the depth of focus that I had.

• I could read later into the evening than before, and found it easier to do course work.

It still makes me feel a bit sick that a simple pair of glasses may have made so much of a difference to my education! 2006, The Moreton Study, Published The Association of Sport and Schoolvision Practitioners (ASvP), download available www.schoolvision.org.uk

1

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“I have really be nefited from w hat The School vision di ploma course ha s taught me – I have had loads of interest from patients” - Mic helle Beach to g new way is an excitin n io ed is g lv n o a o its ch “Sch lar vision... ... revisit binocu - Suzanne Dennis ” my thinking

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ADVICE (IAPB), presented statistics regarding preventable blindness as a European problem. He discussed European demographic data and described the different healthcare systems and workforce issues within Europe. Mr Ackland also outlined the major causes of visual impairment in Europe and the fact that uncorrected refractive error and a lack of access to eye care means that a significant proportion of sight loss in Europe is preventable.

02/11/12 EUROPEAN EVENT

24 28

Julie-Anne Little discusses anatomical elements of the fundus image for Anna Rosbach, MEP, Denmark

European priority Nick Astbury, past president of the Royal College of Ophthalmologists and chair of Vision 2020, spoke about how eye health needs to be a public health priority in Europe and how the UK Vision strategy has developed, with successes such as preventable sight loss now being one of the UK Government’s public health indicators. He also discussed the UK’s National Eye Health Week and the key messages from this initiative: regular sight tests, the importance of early detection of disease, smoking cessation and promoting good lifestyle habits. He called for better data to be captured regarding sight loss and emphasised the importance of screening for ocular disease, highlighting the fact that only nine EU member countries have blind/ partially sighted registers. Participants also heard a personal experience of visual impairment from Dennis Lewis of the AMD Alliance International. This powerful speech reminded all of us how not only the visual but emotional outcomes are also important to patients, and that even when vision is lost, strategies and support are still fundamental to maintain the best quality of life possible. Finally, participants received a presentation about the importance of a cross-disciplinary approach with other agencies from professor Sehnaz Karadeniz, ophthalmologist and president elect of the International Diabetes Federation. She highlighted the fact that many of those with diabetes do not present until after 10 years of having the condition,

“There was a real hunger amongst European policy-makers for additional information about eye health and what they could do to help” Ms Little and Ms Rosbach, at the World Sight Day fundus photography stand

and underlined the importance of optometrists in primary eye care commonly being the profession detecting diabetes and prompting referral to a GP for further investigation for diabetes. Marian Harkin, MEP, closed the event stating how she was delighted to be able to support the meeting. The MEp told delegates she had learnt so much from the speakers, who convinced her of the strong human and economic argument against visual impairment in European society.

Special thanks The event would not have been possible without the support of Novartis and Alcon, representatives from the company and a range of other eye care bodies, including the International Glaucoma Association who also attended to voice its support. It is hoped that in partnership we can build on the momentum from this event to increase awareness and the goals of the Vision 2020 right to sight initiative in Europe.


REVIEW Book review: Glaucoma Surgery Professor Emeritus Robert Fletcher reviews Glaucoma Surgery (Developments in Ophthalmology Volume 50) reserved for patients who are unresponsive to even surgical methods of glaucoma management. All details are expertly presented and are highly informative. OCT is helpful for monitoring changes in the ocular surface tissues following surgical treatment; such changes as fibrosis may impair drainage of aqueous from the anterior chamber, which can be particularly exacerbated if patients have been on long-term medical management with topical hypotensive drops – the effects of preservatives in some drugs can induce necrosis and thinning of tissues. Indeed, benzalkonium chloride is frequently mentioned here due to implications in allergic reactions. Such considerations are discussed very well in this text and in this manner, the authors have done well to provide succinct yet relevant details. Although readers may need to compile a list to define a wide use of acronyms as they enjoy this text, common ones used being MMC, BAK and FBCE, overall this text is beautifully written and arranged. Indeed, the editors have done really well to put together the contributions of several authors, arranging the chapters marvellously so that they flow and link very well. Each chapter begins with a highly informative abstract, which summarises the content to come in that chapter, while the text is accompanied with a variety of high quality and helpful coloured illustrations. Despite being an ophthalmology resource, this handy reference text deserves early attention from specialist optometric practitioners and students alike.

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02/11/12 BOOK REVIEW

GLAUCOMA IS a leading cause of irreversible blindness across the world and although medical therapy with ocular hypotensives is the treatment of choice in the vast majority of cases, there are select patients for whom surgical treatment must be considered. As with all medical walks of life, technology and treatment continually evolves and therefore this text is a timely update of important surgical techniques and developments. Although largely aimed at ophthalmology, those eye care practitioners dealing with patients following such surgery can benefit greatly from this lucid, fully illustrated and varied account. The text describes older and newer surgical anterior chamber drainage filtering approaches for glaucoma management, including drainage implants, fornix conjunctival flaps and deep sclerectomy. Of particular note is the recent Moorfields Safer Surgery System, which is a variation of trabeculectomy aimed at reducing surgical risks, and which is described in the first chapter. Trabeculectomy is still the most popular surgical technique for glaucoma filtration surgery and while surgical risks will always exist, in this chapter the authors describe how these can be reduced through pre-, intra-, and post-operative surgical strategies. For example, drainage blebs, naturally, have prominent placement in the globe and so consideration of the position is important, especially to avoid diplopia (hence high positions, shielded under the lid are the most ideal). While descriptions of surgical management in this text are centred on more common types of glaucoma, such as paediatric, angle closure and laser approaches to management, not to mention how to deal with concurrent cataract extraction in glaucoma filtration surgery, the text does not shy away from discussing more modern techniques such as the minute stent procedure, which aims to increase aqueous outflow at Schlemm’s canal in order to reduce intraocular pressure, to cyclodestructive approaches which are


ADVICE

Referrals: Are you aware of the GOC’s rules?

Trevor Warburton, clinical adviser to AOP legal services, discusses the GOC’s rules for referring

02/11/12 REFERRALS

26 28

DO YOU know everything you are supposed to do in relation to referrals? We all know (or should do) the obligation to look for signs of injury, disease or abnormality during a sight test. This is achieved by performing internal and external examinations and any other procedures that appear necessary to detect signs. But then what? The GOC rules require you to refer that patient, except in certain circumstances, but there are rules about how to deal with referrals.

Written reports Legislation1 requires you to give the patient a statement immediately following the sight test that you are referring them, together with the reasons. GOC rules require you to advise the patient to consult a medical practitioner, to provide a written report to the medical practitioner wherever practicable and, where the referral is urgent, to take such steps as are open to you to inform a medical practitioner immediately.

Urgent referrals Generally speaking, if you send an urgent referral to a GP there is a distinct chance that it will be dealt with as routine and you will find yourself liable for having used an inappropriate referral pathway. Do ensure that you know the urgent referral pathways for the likes of wet AMD and retinal detachments for any location where you work. It is

a contractual requirement that GOS contractors know their local referral pathways and pass this information to their performers. LOCs can help here by providing details of all local referral pathways on their websites. Ideally these would be capable of being viewed on a smart phone, as well as being printed for reference in the practice.

Informing the patient As mentioned above, you must provide the patient with a written statement of the reason for referral immediately after the sight test. Of course, many of us don’t write the actual referral letter until after the patient has left the premises, so the simplest way to comply with this requirement is to add a short comment in the notes space on the prescription, for example “cataract” or “suspect glaucoma.” All of these requirements are echoed in the GOS contract. It is considered good practice within the NHS to copy letters to the patient and should probably be done as a matter of course when referring patients, in addition to the short comment on their prescription. Apart from anything else, when the surgery (or HES) loses your referral letter, the patient is less likely to complain that you didn’t send it if they have received their own copy. You should also advise them to take the copy to their appointment at the surgery or hospital in case the original has gone astray.

Continued on page 28


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ADVICE Referring to non-medical practitioners

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You can refer to someone other than a medical practitioner. This could be another optometrist, an orthoptist or, quite commonly, a referral centre. In these cases the GOC requires you to record the date and the fact of the referral, a sufficient description of the condition, the advice given, and that a written report is provided along with the urgency and instructions as to where the patient should go next. This is the only occasion where a statement of urgency is mandatory2. Whether urgency is stated or not, your actual referral must always be of appropriate urgency and directed on an appropriate pathway.

02/11/12 COVER REFERRALS 08/04/11 STORY

Internal referrals Part-time optometrists can often have a problem when they wish to repeat a procedure on another day in order to help them reach a decision, eg visual fields. If the outcome of the sight test hinges on this then, in the case of GOS, the form should not be submitted until the additional procedure has been performed. If the part-time optometrist is not returning to the practice for some time this can be a problem. It is advisable for part-time optometrists to keep a log of such occasions and to follow up and ensure the test was performed with an appropriate outcome. An alternative is to formally refer the patient to another practitioner in the practice. This allows completion of the sight test. The referral should be made in writing, separate to the record but with a note on the record, and with advice to the receiving practitioner as to what you expect to be done with the patient dependent on the result. This could be handed to the receiving optometrist or to the practice manager. Just ensure it doesn’t simply get filed with the record.

“Your referral must always be of appropriate urgency and directed on an appropriate pathway” Not referring There are three situations in which you need not refer. One is when you are acting under the direction of a medical practitioner, but the GOC rules2 then impose an obligation to inform the medical practitioner of any condition of which they may be unaware. Secondly, the GOC rules allow you discretion not to refer where there is no justification or it is impractical to do so. In this case you must record a description of the injury or disease, the reason for not referring, the advice given and, if appropriate and with consent, inform the patient’s GP. Thirdly is if the patient refuses referral, in which case you should record that fact and the reasons given by the patient. AOP advice in this situation is to send a referral letter (recorded delivery) to the patient with a covering letter asking them to take it to their GP if they change their mind. In a nutshell, if referring: • Record a description, who you referred to (or the reason why not) and the advice given

Website containing local referral pathways • Make any referral in writing including following up urgent phone referrals with a written report • Inform the patient of the reason for referral in writing immediately following the sight test and consider giving/ sending them a copy of your referral letter • Note the urgency when it’s to a referral centre or nonmedical practitioner and say where it should go next • You have discretion on referral.

What about the referral itself? Make sure you know the local pathways. Ignorance will not be treated as an excuse. Write legibly or, preferably, type. Many referrals are scanned and faxed, so use a dark pen. Be clear, concise and to the point; include necessary, relevant clinical information. Say what you think the problem is and what you think should be done (this is particularly important if the patient has multiple pathologies – eg cataract and suspect glaucoma). If it’s urgent, say so (but don’t necessarily expect a GP to act). If it’s a referral to the GP that is not for onward referral to the eye clinic, eg for suspect blood pressure, then make that fact clear and tell the GP whether the patient will contact them, or whether you would like the GP to contact the patient (ideally the former). Include all relevant information. On a GOS18, if there isn’t enough space, consider whether you are writing too much. This all sounds obvious, yet audits suggest we aren’t as good at this as we might like to think. In an audit of referrals to ophthalmology (OT August 17, 2012), Susan Parker found that optometry referrals could only be considered complete in 62% of cases. On the bright side, the same audit concluded that “optometrist referrals were usually appropriate and some were excellent.” For all optometry legislation and rules see the GOC website, http://www.optical.org/en/about_us/legislation/rules_and_ regulations.cfm

References 1. Sight Testing (Examination and Prescription)(No 2) Regulations 1989 2. Rules Relating to Injury or Disease of the Eye 1999


Moorfields Eye Hospital NHS Foundation Trust

Moorfields Gonioscopy and Therapeutics Course for Optometrists Sunday 9th December 2012- Tuesday 11th December 2012

Moorfields Eye Hospital is happy to present a three day clinical course designed for Optometrists who are interested in gonioscopy and the therapeutic management of ocular conditions including those working towards or possessing higher therapeutics qualifications. The course will include didactic lectures, case discussions and workshops and will be given by leading ophthalmologists in the field. Lectures include: Sunday: The normal angle, pathological angle and angle closure • Gonioscopy; the procedure, structures and angle grading • Gonioscopy: interactive case studies Monday: Recurrent corneal erosion syndrome • Atopic keratoconjunctivits • Nasolacrimal duct obstructions - investigations and management • Acute and recurrent anterior uveitis – investigations and management • Herpetic eye disease • Choroidal neovascular membranes – diagnosis, treatment and prognosis • Diabetic macular oedema – review of therapeutic treatment options • Tuesday: Medical management of high IOP • Management of secondary glaucomas – uveitic and traumatic • Glaucoma treatment –elderly patients and pregnancy • Post-operative endophthalmitis – diagnosis and management • Management of cellulitis – pre-septal and orbital • Scope of independent prescribing in hospital and practice • Workshops include: • Gonioscopy (Sunday) • Speakers include: • Frank Larkin • Romesh Angunawela • Claire Daniel • Vincenzo Maurino • Steve Tuft • Robin Hamilton • Gus Gazzard • Winnie Nolan • Keith Barton • Seema Verma • Scott Hau • Sue Lightman • Badrul Hussain CET points: approx. 8 General points on Sunday and 12 SP/AS/IP/ General points (6 per day) on Monday and Tuesday Course Fee includes course materials, lunch and refreshments: Gonioscopy (Sunday 9th December 2012) and Therapeutics (Monday 10th and Tuesday 11th December 2012) £250 per day registration by Friday 23.11.2012. £290 per day thereafter Please contact: Emma Cunningham at optometrycourses@moorfields.nhs.uk for further information and registration details.


BUSINESS

Completing the journey In the second of a two-part series on the patient journey, optometrist and personal performance coach Sheena Tanna-Shah offers advice on dispensing and concluding the appointment

02/11/12 THE PATIENT JOURNEY

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IT IS important to understand that a sight test appointment does not conclude when the patient leaves the testing room. In fact, to a certain extent, it is just the beginning; it is the time when optometrists have the opportunity to develop a strong rapport with the patient and increase the practice’s chances of patient retention.

The three-way handover When the sight test is complete, the famous three-way handover between the optometrist, patient and dispensing optician is what should be aimed for. It offers practice employees the perfect opportunity to provide the patient with the personal touch and an increased level of care. The patient will value what is recommended in the consulting room if they hear the optometrist pass this information on to their dispensing colleague in their presence – in turn reassuring the patient that the products which are consequently recommended will be right for their needs. There is considerable pressure on the optometrist to ‘sell in the consulting room.’ Practice managers are known to question optometrists on how they ‘sell’ and some are even monitored on the products they sell. In many cases, selling doesn’t come easily to an optometrist; they can find it uncomfortable and may feel it over shadows their clinical role. Put bluntly, many optometrists worry about sending out a message that they care more about what patients spend rather than their health. However, the key is to not think in terms of ‘selling’ products, but rather providing for patients’ needs. Practitioners should consider the patient’s history, symptoms, hobbies and occupation in the eye exam. For example, if they list hobbies where spectacles are not always suitable, why not suggest that they might benefit from contact lenses.

At the end of the consultation, optometrists should summarise the needs that the patient has explained and recommend products based on the feedback.

The optical assistant One of the biggest dilemmas for the optical assistant or dispenser is where to take the patient next? For a field test, if required? Straight to the frames? Or to sit down and have a discussion with the patient? There is no right or wrong answer. However, from experience I have found that the patient is reassured about what they are purchasing when the dispenser takes time to discuss the patient’s requirements. Research has shown that some patients display anxiety in the consulting room and that they often don’t understand some of the information given to them by the optometrist. Therefore, having the opportunity to talk to the dispenser means that the patient is more likely to relax, ask questions and to be given a summary of the optometrists’ findings. Products can then be recommended accordingly.

The end of the line Every step of the journey should be stress-free for the patient and, most

importantly, enjoyable. Staff should be confident when sharing their knowledge and helping patients select frames. Discuss what frame shapes and colours suit different colourings and face shapes. Don’t be afraid to inject some fun into the process; encourage the patient to try frames that are bold and different. When using promotions, such as the famous BOGOF, try describing the offer in different ways to make the patient feel the offer is unique. For instance, instead of the usual ‘anything from this particular range is buy one, get one free’, why not show the patient a frame that suits them from a range and let the patient admire it before informing them that ‘with this particular frame you get a second pair completely free.’ Explain to the patient everything that is included in the frame price, such as coatings, so that they feel they are getting value for money. For any offers that the practice has, it is vital to explain to patients what saving they are making. Finally, when the dispense is complete, confirm the order and complete any outstanding routine. Remember to complete the journey with a polite goodbye. It can be as simple as ‘We look forward to seeing you again soon.’


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REVIEW

CCTV magnifiers 02/11/12 VIDEO MAGNIFIERS

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Video magnifiers can have a significant impact on the lives of patients with vision loss. Senior optometrist Katy Barnard reviews two new products which may be of interest to patients IN RECENT years there has been an increase in the availability of smaller and more affordable video magnifiers (CCTVs). These offer more options for low vision patients who may be on a budget and/or have limited space. Bierley has been manufacturing and supplying such products since 2002 and has launched two new products: the Maggie MD and the Colourmouse Zoom.

Maggie MD The Maggie MD has external LED lights that are very helpful for improving the illumination of a task. It has four levels of magnification, from 4-11x, which would be useful to many low vision patients. It is easy to use as it has three main control buttons, which are white against the dark background on the device itself so are easily visible. There is also a less visible button that operates the freeze frame; however it is in quite an instinctive place as it is like a camera button. It also has the benefit of providing negative contrast images, which is very useful to help reduce glare for a lot of patients. However, it is a shame that the Maggie MD is missing an enhanced positive contrast function, which is as useful to patients as the negative contrast option. This is one of the smallest portable electronic magnifiers I have seen. It is only 55x88x12mm in size, and weighs 70g. This is obviously very advantageous as it is easy to carry around and works well with elderly patients who do not have good hand mobility (eg due to arthritis). The downside of this device, however, is that the screen is smaller than on many portable CCTVs, which restricts the field of view, and yet it is the larger field of view that attracts most patients to using a CCTV above a conventional magnifier. As with all portable CCTVs, it takes a little practise to be able to hold it steady at the appropriate distance from the page. The small size can be both a help and a hindrance here, since its lightweight design makes it easy to hold but the small size, and the fact the screen covers almost the whole area, means it needs to be held carefully with your fingers at the edge, which can be tricky. An acrylic stand is available if handling is difficult, though that then makes it more bulky and less portable. At ÂŁ130 (excluding VAT) it is at the cheaper end of the market for portable CCTVs. If you were going to demonstrate portable CCTVs to patients, it is a great addition to have. However, due to its size limitations it should perhaps be used in conjunction with a larger portable CCTV.


This is the latest edition to the Monomouse portfolio. Like the rest of the range, it is simple to install and use. It connects to any TV SCART port, and once it is plugged in and turned on you’re away. With only four buttons, it is very easy to use; there is a power switch, two buttons either side for magnification and a final button which scrolls through different colour modes. The Monomouse is designed in a similar way to a large computer mouse; it is quite easy to hold and move, especially if you are familiar with using a computer mouse. At first some patients do have difficulties with keeping the mouse moving in a straight line and getting the speed of movement right. Therefore, as with any magnifier, it takes a little practice. The Colourmouse is similar but has the option of either viewing things in full colour, which is great for photographs, high contrast positive (black text on white) or high contrast negative (white text on black). These enhanced contrast modes are very useful as they

can improve the reading of items of poorer contrast such as a newspaper. Patients who suffer from glare often do better on the reverse contrast, as the majority of the screen is then black. The Colourmouse (and Monomouse) Zoom versions of this device have variable magnification, but this is still dependent on the size of the TV screen; the larger the screen the more magnification. On a 20” screen, for example, the range of magnification is 16-57x – a good range for a large proportion of low vision patients. The advantages of using a video magnifier over conventional magnifiers are well known, providing patients with a larger field of view for the level of magnification required, a larger range of magnification and the ability to enhance the contrast. At £129 (excluding VAT) this is an affordable way for patients to access these benefits. We have a Colourmouse in our low vision clinic and demonstrate it frequently to our low vision patients, and the majority are very positive about it. It is a useful tool to have in the clinic; the primary downside is that a TV is needed as well. This means it takes up more room than just the Colourmouse device itself. Furthermore, it means patients have to move to the device and TV as opposed to being able to carry it around as a portable device.

About the Author Katy Barnard is a Senior Optometrist at Moorfields Eye Hospital, specialising in low vision. She has worked in hospital optometry and low vision for 12 years.

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ADVICE

02/11/12 MEMBER BENEFITS

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Keeping the taxman happy Thinking about becoming self-employed? TWD Accountants provides a guide to the basics of starting your own business STARTING OUT in business is a daunting prospect but the initial thrill of going it alone, the financial rewards and the freedom of being your own boss are all very attractive, especially if you are working in a field you love such as optometry. TWD Accountants has been providing tax return and accountancy services to AOP members for over 15 years. Here it highlights a few tax-related essentials that should not be forgotten when starting up your own business.

Register with HMRC Even if you will be only working parttime, you must register as self-employed with HM Revenue & Customs (HMRC), no matter how small your income may be in the early days. The first step is to contact your tax office or the self-employment helpline on 0845 915 4515. Alternatively, you can register online at https://online. hmrc.gov.uk/registration/options You may also need to inform the tax credits office. This is essential if you already claim tax credits as all changes in circumstances need to be reported to HMRC as soon as possible.

Keeping records Good record keeping is one of the bedrocks of running your own business and something you should get used to right from the start. This comes in two forms: a written record of what you do

and paper records such as receipts and bills. If you don’t keep good records you could end up paying too much tax. In addition, preparing your year-end accounts and tax return becomes quicker and easier if you have kept good records, which can reduce your accountancy fees. Good financial information also helps in matters such as obtaining a business loan. You do not need a professional bookkeeper or expensive software. An accounts ledger or simple spreadsheet can be sufficient to record your income and expenditure. Alternatively, you can use one of the many online accounting packages. However you record your transactions, all invoices, receipts and other business records must be kept for a minimum of five years and nine months after the relevant return deadline.

Save money to pay tax Putting money aside means it is easier to pay your tax and national insurance when it is due. If you do not have money to pay your liability on time, you could be charged interest or need to take out a loan to pay the bill. The basic rate of income tax is 20%, and you may need to pay 9% Class 4 national insurance, but there are no hard and fast rules about how much to put aside. If you are unsure, it is a good idea to ask an accountant. In addition, you may have to

pay Class 2 national insurance, which is sometimes known as your ‘stamp���. It is a flat weekly contribution rate paid regardless of how much you earn (there are some exemptions available). The current weekly rate is £2.65. It is usually paid six monthly.

Meet tax deadlines and pay your tax on time All self-employed individuals are required to submit a tax return before the set deadlines. Failure to meet a deadline can be costly; an initial £100 fine, followed by daily fines of £10, means a tax return filed 12 months late will incur penalties of at least £1,600. You will also have to pay a penalty of 5% of the tax you owe, plus interest. For the current tax return (declaring income up to April 5, 2012) the deadlines are: • To file a paper return – no later than October 31, 2012 • To file via the Internet – no later than January 31, 2013 For this tax return, you have to pay all the tax and national insurance by January 31, 2013.


SPECTATOR

Get involved in wider services or fall behind

ON THE same day that LOCSU and the Optical Confederation were co-hosting the National Optical Conference (NOC), the Department of Health launched a short consultation exercise on the proposal to introduce one national list of ophthalmic performers, to replace the current patchwork of lists held by PCTs across England. This process began back in 2007 when the department tasked a working group to review the current structure and draw up proposals for how the system could be improved. That it has taken so long for these proposals to reach the stage of consultation is more indicative of the pace of legislative change rather than the complexity of the recommendations themselves – which appear largely to be common sense. Achieving consistency and ‘one version of the truth’ when it comes to interpreting and applying the performers’ list regulations will come not a moment too soon for anyone who has ever had to suffer the frustration of what can sometimes prove to be a very frustrating progress (for example when comparing the variability over the time taken for newly qualified practitioners to obtain a list number in different PCT areas). Of course, if we can achieve uniformity across the listing process, then the next logical step must surely be to achieve consistency of application across the range of NHS contractual issues which impact on GOS providers. Until then, we will continue to have to tolerate the similarly erratic approach which sometimes appears to be applied by local NHS administrators (often under the

37

02/11/12 SPECTATOR

LAST MONTH’S annual meeting of the LOC clans offered a number of examples of the growing involvement of community-based practitioners in a wider range of eye care services. The interested observer would have found it difficult to come to any conclusion other than that we would be mad not to embrace any, and all, of these opportunities. Among other examples, the business case for an optometrist referral refinement programme in Humber and East Yorkshire was articulated well, and shown to be both cost effective for the NHS and reasonably profitable for the practices involved. It was good news to hear that two-thirds of practices in the area had signed up to provide the scheme, but regrettable that a third had not. It may be tempting to assume that the flag bearers for such involvement are all from one section of our sector, and likewise that the laggards are from another, yet there was ample evidence on offer from Hereford, Huddersfield and Leek, that dispensing opticians, independent optometrists and multiples alike, are all actively involved. While the enthusiasts, through their engagement with the current process of change the NHS is undergoing, will doubtless be well placed to achieve the greatest benefit (and most advantage) from what is on offer, those that are disengaged are likely to fall further behind.

guidance of their optometric colleagues) when managing GOS contractors. Unfortunately, it is the variability experienced here that undermines the logic of the argument for local control and if we are now seeing momentum in the move towards greater centralisation, then maybe that is recognition enough that localism is not the solution to every challenge. LAST WEEK’S GOC council meeting gave formal approval to the widely anticipated changes to the CET scheme from next January. The main impact on practitioners will be the removal of the option to achieve all CET points from simply reading journal articles, the need to include a broad range of competencies rather than concentrating on areas of narrow professional interest and the introduction of peer discussion. The last point is the one that has probably generated most debate, but as the changes will soon be upon us, there are indications that what had initially been greeted with some trepidation, is now being recognised as a positive move for the profession. The recent DOCET Optometric Quarterly and a presentation by the GOC at the NOC both served to highlight the benefits that the introduction of peer discussion will bring. In the past, there will have been many optometrists who practised for an entire career with limited peer interaction. This does not make sense for a modern healthcare profession and the changes to be introduced next year should be embraced as a welcome step in the right direction.


REVIEW

Night to remember NOC attendees let their hair down at the AOP’s prestigious Awards ceremony at the Hilton Metropole Hotel in Birmingham THE EAGERLY awaited AOP Awards took place last month (October 18) and proved, once again, why the event is now a highlight in the optical calendar. The ceremony saw over 400 practitioners, students and industry representatives enjoy a three-course black-tie dinner, followed by the Awards presentation.

02/11/12 AOP AWARDS

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The 16 accolades acknowledged those who have stood out from their peers and deserve to be recognised for their excellence and contribution to optics. They are the only awards that are decided by OT readers, and therefore the profession itself. Once the winners had been announced, many attendees took to the dance floor, swaying along to the live band until the early hours.


REVIEW “It was an absolutely fabulous evening and provided the Association with the opportunity to acknowledge and celebrate with the best in class across all sectors of eye care provision” Chris Hunt, AOP president

The winners of this year’s awards were: Community Achievement Award – Eglinton Eyecare LOC/AOC/ROC of the Year – Bexley, Bromley and Greenwich (BBG) LOC Specialist Practice of the Year (non-CL) – McPherson Optometry Best Educational Video – University of Bradford Digital Media Working Academy Supplier Award – Barry Dibble Charity of the Year – Vision Care for Homeless People Company of the Year – The Outside Clinic Practice of the Year – McPherson Optometry

39

Dispensing Optician of the Year – Jon Sames Contact Lens Practitioner of the Year – Brian Thompkins Optometrist of the Year – Peter Bainbridge Optical Assistant of the Year – Cheryl McDermott Student of the Year – Jason Searle Lecturer Award – Gary Baker Lifetime Achievement Award – Professor David Thomson Optical Bravery Award – John Courtney

Optometry Giving Sight held a raffle at the Awards, with prizes donated by CooperVision. The charity raised a grand total of £1,179.

02/11/12 AOP AWARDS

“The nominees and winners should be justifiably proud because being nominated by one’s peers is just about the greatest compliment that can be paid. I think the magic of the evening was just the tonic we all needed in these tough economic times and I cannot wait for next year and judging from the positive feed back we have received, neither can the attendees,” commented AOP president Chris Hunt. OT announced the Award winners live on Twitter. Following this, the winners were interviewed by the OT news team. Interviews with the winners will be appearing on the OT website later this month.


REVIEW

This is the second year that Louise Walpole, head of support services at the AOP, has organised the event. She said: “Being involved in launching the AOP Awards has been a true honour. I have been humbled by the inspirational work individuals are undertaking in their communities, which is driving and influencing the shape of the profession in the future. “This year we have received over 11,000 votes from OT readers, they are the ones who have decided the winners; to have the recognition from one’s peers is the ultimate honour and all who won and who were shortlisted should be very proud.” Ms Walpole added: “I must at this point thank CooperVision, the 2012 AOP Awards headline sponsor, as well as all the category sponsors. Without their financial support, we wouldn’t be able to hold the event. Last of all I must thank the readers of OT who recognise the work of their colleagues and have nominated and voted for them. Please continue to support this initiative, these are your Awards and your chance to be recognised for the work you do.”

02/11/12 AOP AWARDS

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Celebrating the practitioners who volunteered as Games Makers at London 2012

Continued on page 20


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© Alcon Eye Care UK Ltd, 2012. DAILIES AquaComfort Plus, the DAILIES AquaComfort Plus logo, Focus DAILIES All Day Comfort, the CIBA VISION logo and the Alcon logo are trademarks of Novartis AG. CIBA VISION is now part of the Vision Care business of Novartis AG. References: 1. Alcon data on file 2010 Among leading daily disposable lenses. 2 Alcon data on file 2010 In a randomised, parallel group clinical study at 26 sites with 291 neophyte contact lens wearers; significance demonstrated at the 0.05 level. 3. Wolffsohn J, Hunt O, Chowdhury A (2010) Objective performance of ‘comfort enhanced’ daily disposable soft contact lenses. 4. The Eye in Contact Lens Wear 2nd Edition Larke JR 1997 Butterworth-Heineman Oxford. 5. Steigmeier MJ Fahmy M, Thomas M Beating back SAC Optometric Management 2008;43(9):84-85. 6. Lemp M Contact lenses and allergy Current Opinion in Allergy and Immunology 2008;8:457-460. 7. Alcon data on file 2007. * Of those with a preference. # Statistically different.

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LETTERS

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02/11/12 LETTERS

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THE STATUTORY function of the GOC is very clearly stated on its website (www. optical.org): ‘to protect, promote and maintain the health and safety’ of members of the public. We interpret this in our Mission as ‘Assuring the health and protection of those who use the services of optometrists and dispensing opticians’. This is a powerful statement that specifies real responsibility. In this column, I want to ask if the GOC is fulfilling its role. Surely part of the answer must be to examine if the GOC is ensuring that the professionals involved – optometrists – are given the right environment to work in. This is all the more important considering a large proportion of the GOC’s funding comes from optometrists. In a commercial, sales-driven environment, can both the public be protected, and an academically gifted optometrist deliver good community eye care? The answer is possibly, but the odds are against it. The reality is that an optometrist will have a mere 20 minutes to take history, symptoms, visions, visual acuity, refract and binocularity; perform thorough checks on the external and interior eye; and check the results of prescreening – for which the optometrist is solely responsible. Next, the patient must be given suitable feedback and a report written for the GP. Last, but not least, the optometrist must write a prescription, followed by the handover with the eagerly awaiting dispenser – only to tell him or her that new glasses are not required because the potential prescription difference is so small. The dispenser will then be berated by the manager; the manager by the regional manager… and so on up the commercial (not clinical) chain of command. Unless the optometrist is superhuman and can withstand great pressure, the chances

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are that somewhere along the line our unsuspecting member of public will not receive the clinically independent eye care promised by their protectors, and a complaint may be lodged. This is a real shame, given reasonable conditions, the average optometrist can deliver magnificent eye care. Instead, however, they find themselves thrown into an over-commercialised system managed by those lacking relevant academic knowledge. Not surprisingly, the result is disillusioned and frustrated optometrists, who in a final ironic twist may find themselves in front of a fitness to practice committee, which they are funding. This committee will decide if the individual is fit to practice and may tarnish their reputation by publicising the case. Does the committee care? No, they revel in the glory of ‘protecting the public’. Not having enough time to do a test and being severely pressured is not an excuse for negligence. Optometrists must not err clinically, whatever the external surroundings. Until the system is changed, this unfairness will continue to happen. A normal optometrist in the wrong place at the wrong time may make a mistake, just like any normal human under great pressure. The GOC can clearly see this, but has done nothing about it, despite the extra money provided for them by optometrists. Given this, it should come as no surprise that relationships between the GOC and optometrists are hardly flourishing. Throw in falling salaries and increased bureaucracy from the PCTs and newly formed trusts, and it’s no wonder the profession is descending into chaos. To summarise; the GOC has not

delivered what it promises, ‘to protect, promote and maintain the health and safety’ of members of the public… Add to this the fact that the public can still order lenses online without a prescription and can order spectacles online without professional dispensing, and it is clear that are optometrists not playing on a level playing field. An answer from the GOC and feedback from readers would be most welcome.

Mr Anonymous, optometrist

Have your say, email louisewalpole@aop.org.uk

Mr Anonymous’ inbox Dear editor Regarding My Anonymous – I completely agree! We are so devalued in the UK. The profession has gone downhill over the past few years and it continues to go that way. No wonder so many optometrists are moving to Australia to practise.

Optometrist, London Dear editor I am in total agreement with the sentiments of Mr Anonymous, optometrist (July 13, 2012). I registered as an optometrist in 1978, but four months ago I decided that enough was enough. I am fortunate, my financial situation means I can retire early, not as a wealthy person, but with some degree of self-respect and sanity – which is especially important after what has happened to the ‘profession’ over the past decade. More and more optometrists are laying themselves open to criticism from the public and GOC, to the point where we have a virtual witch hunt – what other profession would tolerate this? No wonder there is so much paranoia. We have seen the rise of ‘the great god of KPIs’ among employers, who have managed to choose a spurious system which has been widely discredited by many other businesses. Even the most inexperienced of ‘managers’ now regards an optometrist as a tool to be used and made to conform to business plans handed down from their ‘superiors’ , with little or no knowledge of the real world of optics. I see nothing but a depressing future for optometry. I regret voting for the formation of ‘the College’, as do many of my peers. It is an institution that is detached from reality and become a harbour for self-serving academics. My plea to anyone contemplating a career in optometry – ‘Don’t do it!’

Optometrist, Monmouthshire Dear editor On your OT letters page Mr Anonymous stated (OT, July 27 2012, Vol 52:15): “The problem now is if optometrists don’t convert sight tests into sales, then they are seen to be hurting the business and they can be performance managed out of the company”. I am no HR consultant, but I do have many years experience as an optical practice manager. I disagree that any manager would performance manage an optometrist because of sales figures alone. I cannot think of an optometrist who has been “performance managed out of a company” based on sales. Perhaps I am naive or just lucky to have a good employer! Surely they would be on dangerous ground in terms of winning employment tribunal hearings for unfair dismissal. If the practice is registered as a business with the GOC, then their registration is possibly in danger. As we all know, the dispensing staff are responsible for closing a sale, it is very much a team effort. If an optometrist was performance managed, then this would be relating to overall performance, as outlined by the GOC Code of Conduct and College of Optometrists Guidelines (are poor 23/07/2012 17:05

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sales because of poor clinical ability, or communication and lost confidence from the patient?). The good manager would look at the whole patient experience in the practice. Is there anything that other staff are neglecting? Do all dispensers in the practice approach a nochange scenario with the same zest and drive as a new prescription scenario? Indeed, I would argue poor sales performance says more about management’s ability to train and motivate staff. A bright welcome from a helpful and organised receptionist, a competent optometrist giving an involved and well explained sight test with relevant recommendations, backed up by further explanations from an enthusiastic dispenser should lead to a good sale (of course, not everyone attending a sight test wants to buy new glasses). Poor sales show one part in the process is not working well. I cannot agree with the suggestion that poor sales means the optometrist alone is hurting the business. I would be interested to hear the opinions of any HR-trained individuals who may have read this.

Multiple Practice Manager

Your cheque is in the post The Government may claim the NHS is “safe in their hands”, but GOS payments are not – heaven help those reliant on Stephenson House. Only 50% of our May account was settled, the remaining forms were returned after three weeks because we had not stated the correct floor. Surely someone could have opened the parcel and redirected it to the ophthalmic payment floor? Another consignment of three packages, sent at some expense and electronically tracked by the Post Office has resulted in no payment at all for June. We are now £10,000 down, but still with suppliers to pay. Parcel Force has an impressive system, a consignment can be tracked all the way on the Internet; unfortunately, all this online sophistication is negated by the humans at Stephenson House.

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17/08/12 LETTERS

LETTERS Optometrists, the GOC and the public

17/08/12 LETTERS

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DEAR MULTIPLE practice manager (see Letters, OT August 17 2012), I read your letter concerning your disbelief at performance management based on sales. Perhaps you need to come and see the practice I work in. I have been placed on a capability performance management procedure based “solely on sales”. I have struggled through two grievance appeal meetings to argue my case with the powers that be – to no avail. They tell me I should see the performance management procedure as a positive step not a negative one. Any observations of my work were only started after the performance management procedure. There was no direct evidence to explain why I was being performance managed at the time other than sales reports based on my sight tests (I do not dispense the specs after my own sight tests). Eighty per cent of my patients who need a change buy specs the same day, as do 30-50% of no changes – is this poor performance? You commented that an employer might well be breaching the GOC Code of Conduct. The codes relating to this situation are under the Code for Business Registrants. The practice I work in is not registered with the GOC as a business. I am in no doubt that members of the public would be quite shocked to discover my employer sees sales ability as the main reason for employing an optometrist; I am sure this would lead to a loss of confidence in the profession, however, my employer is not advertising its actions to the public. I am very angry and feel humiliated to be employed on a capability based solely on sales – especially as I am told there is nothing wrong with my ability as an

MD COOPER, Enfield

Your chance to have your say OT wants to hear your point of view. Whether you agree, disagree or have a personal experience related to anything we have published in the magazine or relating to optics, OT wants to hear from you. You can opt to remain anonymous if you would prefer, just let us know. Contacting us is easy, either send a letter via email to louisewalpole@aop. org.uk or by post to The AOP, OT Letters, 2 Woodbridge Street, London, EC1R 0DG.

The editor reserves the right to edit letters and points out that the views expressed may not be those of the journal and the AOP

Write to: OT Letters, Optometry Today, AOP, 2 Woodbridge Street, London, EC1R 0DG

I have been placed on a capability performance management procedure based “solely on sales” optometrist (ie performance). I have not gone shouting my mouth off to family and friends or posted any of my woes on Facebook – that would be bringing the profession into disrepute and I would then be the one in front of the GOC. Instead, I am expected to quietly go about my work, in the knowledge that if sales don’t improve my employer may well serve a second improvement note (effectively a final written warning). My opinion is that in order to protect the public’s perception of the profession, there should be clearer boundaries for individual registrants. The GOC needs to address the fact that individual registrants may well be managers or business owners. The fact that registration as a business is not compulsory shows this part of the code serves little purpose. The GOC code is open to interpretation and as such is rather

ambiguous – this makes it very difficult to raise a genuine complaint. Is the GOC putting the best interests of the public first by making it so easy for individual optometrists to be performance managed in this way? I could save my job by giving out specs to children who don’t need them and telling every spectacle-wearing patient they need to change their prescription, but in doing so would put my registration at risk (I have not been asked to do this of course – simply to use my abilities to sell more specs). It appears that by following the GOC code and College of Optometrists’ advice I am making myself unemployable in community practice. Perhaps I could apply for a position at multiple practice manager’s store?

Anonymous

Have your say. Email johnwhite@optometry.co.uk

23/07/2012 17:05


LETTERS

Proactivity pays I HAVE been following the ‘state of optics’ debate with interest and on the whole agree that the current model of 15-20-minute testing, coupled with high conversion rates, is unsustainable. Clearly an awful lot of us feel something needs to change. So who is putting their money where their mouth is? Who is taking 40 minutes to test and charging appropriately for their time? If every optometrist refused to do 20-minute tests, but instead took their time and gave appropriate advice based on clinical findings rather than potential bonus, employers, managers and those at the top would have no choice but to charge more for the sight test. I daresay the extra care and attention given to each patient would result in greater loyalty and customer satisfaction, and a reduction in complaints and legal action. I am fortunate enough to be self-employed and I test in 25 minutes (a time which I am very comfortable with in the practice I work in) and do not go back to work anywhere I feel unnecessary pressure to sell. So, come on folks, be brave enough to make that change yourself rather than waiting for ‘them’ to make that change for you.

Anonymous, Wiltshire

Fairness on sight test fee claim IT IS interesting to note the comments on the GOS sight test fee claim with respect to the private charge (OT September 21 2012). In my view, the NHS should set the rate of the sight test fee according to the nominal private fee charged by individual opticians/optometrists or any High Street retailers. There is no reason why they should pay £20 to someone who only charges £5 for a sight test privately for supposedly the same job. On the other hand, it would be unfair to pay this amount to those who normally charge £30 for a private exam either; in which case a top-up fee should be paid by either the NHS or the patient to make up the difference.

Optometrist, London

Pioneers for change THE REAL problems facing optometry are: an obsolete business model, a change in the channels of distribution of its core products by the disruptive technology of the Internet, and the current recession. Optometrists dreaming of a golden age of high status, high salaries and a comfortable existence don’t live in the real world. Blaming the GOC for being intransigent, the AOP for being incompetent and the NHS for not financing our lifestyle won’t solve the problem.

We should recognise that we no longer live in a knowledge economy, nowadays almost everyone’s got a degree, but in the new wisdom economy where the wise application of knowledge is the key to success. Many optometrists fear change and don’t see it as an opportunity to expand and grow their skills. Those skills may be in commerce, independent practice, the Internet, hospital optometry, as an independent prescriber or in a new and unexpected role in the future. All are equally valid and worthy of our respect. Rather than snootily deriding optometrists whose chosen mode of practice is different from our own, we should accept that optometrists are not a coherent group of people seeking the same goal, but of individuals working towards a vision of their own future and in doing so opening up new opportunities for the rest of us. So please, don’t despair. There is a great future ahead for optometrists with open minds.

Archie Toppin, Glasgow

Over supply concerns in Australia I NOTE with interest that a large multiple is advertising for optometrists and dispensers to move to their franchises in Australia. It is worth restressing that optometry is already on the government restricted list for emigration into Australia, as numbers are considered adequate to a slight over-supply. International companies can only get round this by sponsoring individuals, regardless of actual need or demand. It is also worth re-stressing that two new university departments, again, largely commercially sponsored, will be churning out new graduates within the next two years, producing a further over-supply. Undoubtedly this will produce the same salary drop here as has occurred in the UK.

A J Phillips, optometrist , Adelaide Eyecare

Your chance to have your say OT wants to hear your point of view. Whether you agree, disagree or have a personal experience related to anything we have published in the magazine or relating to optics, OT wants to hear from you. You can opt to remain anonymous if you would prefer – just let us know. Contacting us is easy: either send a letter via email to johnwhite@ optometry.co.uk or by post to The AOP, Optometry Today, OT Letters, 2 Woodbridge Street, London, EC1R 0DG.

OT reserves the right to edit letters and points out that the views expressed may not be those of the magazine or the AOP

Write to: Optometry Today, OT Letters, AOP, 2 Woodbridge Street, London, EC1R 0DG

43 02/11/12 READERS’ LETTERS

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Readers are encouraged to discuss the cases in this FREE VRICS with their colleagues, conduct simple Internet searches, and use the references provided to complete the Multiple Choice Questions (MCQs). Please note that there is only one correct answer for each MCQ. Complete the VRICS test online at www.optometry.co.uk/cet/exams

TO REFER OR NOT TO REFER? PART 3: GLAUCOMA DETECTION AND MANAGEMENT Dr Aachal Kotecha, BSc (Hons), PhD About the authors Dr Aachal Kotecha is a Senior Research Associate at the NIHR Biomedical C-19897 O/AS/SP/IP Research Centre for Ophthalmology, Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of

02/11/12 VRICS

44

LARGER SCALE IMAGES ARE AVAILABLE ON THE OT WEBSITE (simply click on the image when completing the exam online)

Ophthalmology. She has been in the glaucoma research field for over 10 years, investigating the effects of corneal biomechanics on the accuracy of IOP measurements and quality of life in glaucoma. She is also a Specialist Optometrist in the Glaucoma Service at Moorfields Eye Hospital and at St. George’s hospital in Tooting.

A 50-year-old Caucasian male attends for a routine sight test. He is asymptomatic and generally fit and well. His clinical data is shown in Image A.

A

B

1. What is the MOST appropriate description of the findings shown in Image A?

a) Van Herrick angle 0% open b) Van Herrick angle 5% open c) Van Herrick angle 20% open d) Van Herrick angle 50% open 2. Which of the following is the LEAST appropriate course of action for the patient described in Image A?

a) Perform dilation with caution due to the risk of angle closure b) Perform gonioscopy to evaluate the risk of angle closure c) Refer to the HES for emergency (same day) treatment d) Refer to the HES on a ‘soon’ basis (to be seen within 1 month) 3. Which of the following is the MOST likely first-line treatment that might be performed on the patient described in Image A?

a) Argon laser iridoplasty b) Prophylactic selective laser trabeculoplasty c) Prophylactic YAG peripheral iridotomy d) Cataract extraction with implantation of an intraocular lens

The results at the bottom of Image B were measured 6 months after those at the top of Image B in a 48-year-old Caucasian female with glaucoma. She has been using guttae Dorzolamide 2% twice daily, Brimonidine tartrate 0.1% twice daily, and Latanoprost 0.005% nocte in both eyes during this time.

4. Which of the following BEST describes the results shown in Image B?

a) Long-term fluctuation is exhibited; the visual field is likely to be stable b) The results are completely unreliable so no accurate judgements can be made c) The patient is “trigger-happy” and no further visual field tests should be performed d) The results are likely to be a genuine representation of the visual field, with evidence of progression 5. What is the MOST appropriate management of the patient described and with the results shown in Image B?

a) Review routinely in practice in 4 months, including repeat visual fields b) Advise use of Latanoprost twice daily and review in 6 months, including visual fields c) Inform the treating consultant ophthalmologist of unreliable visual field test results and recommend follow-up with optic disc imaging d) Refer back to the treating consultant ophthalmologist for a ‘soon’ review of the treatment options 6. If there is evidence of progression of the visual field defect shown in Image B, how is the patient MOST likely to be managed at HES?

a) Continued observation on a 6 monthly basis as there is good IOP control b) Addition of further topical hypotensive eye drops to lower the IOP c) Consideration of laser peripheral iridotomy to reduce the IOP d) Consideration of trabeculectomy filtration surgery to reduce the IOP

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Sponsored by CONFUSED ABOUT CET REQUIREMENTS? www.cetoptics.com/cetusers/faqs/ IMPORTANT INFORMATION: Under the new Vantage rules, all OT CET points awarded will be uploaded to its website by us. All participants must confirm these results on www.cetoptics.com so that they can move their points from the “Pending Points record” into their “Final CET points record”. Full instructions on how to do this are available on their website. The closing date for this examination is December 28 2012. CET points for this exam will be uploaded to Vantage on January 7 2013.

Approved for Optometrists

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AS Points

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SP Points

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References to aid completion of the exam: Q1, Q2 & Q3: McDonnell C (2010) Assessment of the anterior chamber angle and depth. OT October 15th, 42-44, & http://www.tricountyeye.com/ glaucoma/lasertreatmentiridotomy.shtml Q4, Q5, & Q6: Barton K (2002) Ocular therapeutic case studies Glaucoma – when to operate? OT June 28th, 28-32, & Bracewell RM (2007) Neurology for optometrists: Part 3: Pupils and visual fields. OT March 23rd, 30-37

The clinical data of a 47-year-old male Caucasian who has previously undergone corneal laser refractive surgery to correct myopia, and who has no family history of glaucoma, is shown in Image C.

C

7. What is the likely risk of the patient with the clinical data shown in Image C developing glaucoma?

a) No risk: IOP is unreliable due to previous history of laser refractive surgery b) No risk: IOP is likely to be significantly overestimated due to laser refractive surgery c) Low risk: IOP is significantly underestimated due to laser refractive surgery d) High risk: IOP is significantly underestimated due to laser refractive surgery 8. Which of the following is the MOST appropriate course of action for the patient described and with the clinical information shown in Image C?

a) No further action is required as yet, review routinely in practice in 1 year b) Re-measure IOP with Goldmann applanation tonometry and refer to HES if the readings are lower than the NCT readings c) Prescribe, or refer to the patient’s GP for, Latanoprost 0.005% eye drops to be used nocte d) Refer the patient to HES with a view to a consultant performing peripheral iridotomy due to narrow angles

4

Bryan S (2010) Medical management of glaucoma. OT March 12th, 34-40 Q7, Q8, & Q9: Hirani S et al. (2012) Risk Factors for Open Angle Glaucoma. OT January 13th, 48-52, & Cowan L & Sidiki S (2011) Optimising glaucoma referral: Referral Refinement Part 5. OT June 3rd, 40-44 Q10, Q11& Q12: http://eyewiki.aao.org/Medical_Management_for_Primary_ Open_Angle_Glaucoma

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D

A 48-year-old Caucasian female is currently taking Brimonidine tartrate 0.1% twice daily and Latanoprost 0.005% nocte to treat her glaucoma. Her general health is normal and she reports good compliance. She has recently started to experience red and itchy eyes, accompanied with watering.

10. What sign(s) can be observed in the image shown in Image D?

a) Pigmentation of the skin b) Meibomian gland dysfunction c) Tarsal conjunctival follicles d) Eye lash growth 11. What is the MOST likely cause of the sign(s) shown in Image D and the symptoms reported?

a) Allergy to PolyQuad preservative b) Exposure to grass pollen allergen c) Allergic sensitivity to Brimonidine eye drops d) Trichiasis caused by eye lash growth 12. What is the MOST appropriate course of action to manage the patient described and with the sign(s) shown in Image D?

a) Prescribe olopatidine 2% eye drops twice daily for 4 weeks b) Advise cessation of Brimonidine eye drops and review in 1 week c) Advise cessation of Latanoprost eye drops and review in 1 week d) Refer her back to the treating consultant for ‘soon’ review of her treatment

9. Which of the following findings would MOST likely increase the suspicion of glaucoma development, for the patient described and with the clinical information shown in Image C?

a) If the CD ratios at the next visit are RE 0.70 LE 0.60 b) If the IOPs at the next visit are RE 21mmHg LE 18mmHg c) If there is a nasal step visual field defect in the right eye at the next visit d) If Van Herrick’s measures 90% in both eyes at the next visit

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DIARYDATES NEW…13 CooperVision, Audi Quattro Rooms, 22 BCLA, Royal Society of Medicine, London, West London, CET course Pioneers evening lecture ‘Understanding how (www.coopervision-courses.co.uk) to eliminate contact lens related microbial keratitis’ (events@bcla.org.uk) NEW…13 Surrey and South West London AOP, Bourne Hall, Ewell, CET lecture ‘Advances NEW… 22 CooperVision, Murrayfield, in the treatment of kerataconus’ Edinburgh, CET course (01883 380289) (www.coopervision-courses.co.uk)

02/11/12 DIARY DATES

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Annual lecture to look at BV The annual optometry lecture of Bradford School of Optometry and Vision Science at the University of Bradford is on Tuesday, November 6 and will focus on binocular vision problems. It will be given by Professor Bruce Evans, director of research at the Institute of Optometry, London, and will examine how the diagnosis and management of binocular vision problems, such as lazy eye, has changed since Professor Pickwell’s first textbook in 1984. Lecturer, Dr Catherine Chisholm, said: “It was Pickwell’s work at the university that laid the foundation for the success of the School of Optometry and Vision Science that exists today. He led the way in the optometric teaching of binocular vision, producing a seminal textbook that is still used today. Professor Evans’ lecture will demonstrate just how much this area has developed, particularly since the development of 3D screen technology.” The lecture is in the Richmond Building at 6.30pm. To register, contact Kate Daley on 01274 236030, or email k.daley@bradford.ac.uk.

NEW…13 No7 Contact Lenses, Royal London

25 Eyecare 3000, The Queen Elizabeth II

College of Physicians, ‘An evening with Patrick J. Caroline’ (www.no7contactlenses.com)

Conference Centre, Westminster, London SW1P, London conference (www.eyecare3000london.com)

14 University of Warwick, Coventry,

26 Mid Thames AOP, Wycombe General Hospital Education Centre, ‘Presbyopia is the compromise, not multifocals’ (Satish Sinhal, 07900 184567)

Diabetic retinopathy course begins (www.warwick.ac.uk)

NEW…14 CooperVision, Celtic Manor, Cardiff, CET course (www.coopervision-courses.co.uk) NEW…14 No7 Contact Lenses, Birmingham Marriott Hotel, ‘An evening with Patrick J. Caroline’ (www.no7contactlenses.com) NEW…15 CooperVision, M Shed, Bristol, CET course (www.coopervision-courses.co.uk) NEW…15 No7 Contact Lenses, Manchester Midland Hotel, ‘An evening with Patrick J. Caroline’ (www.no7contactlenses.com)

NOVEMBER 3 Haag-Streit UK, Arora Hotel, Heathrow, Ellex European Eye Cubed training course (www.ultrasound.ellex.com)

6 North East Optical Society, Holiday Inn Express, Newcastle upon Tyne, ‘Updates from the eye emergency department and lid clinic’ (simonraw44@hotmail.com)

18 Identity Optical Training, ABDO Office,

5 Spectrum Thea, Latimer, Chesham, Buckinghamshire, ‘Dry-Eye Project 2012’ (www.spectrum-thea.co.uk)

7 CooperVision, Imperial War Museum, Manchester, CET course (www.coopervision-courses.co.uk)

18-20 Sportvision, Hilton East Midlands

5 Northern Optometric Society, Manchester Conference Centre, ‘OCT in optometric practice’ (www.northernoptom.com)

NEW…8 East Sussex LOC, Pilgrim Hall, Easons Green, Uckfield, East Sussex, CET study day (Jackie.oxley@googlemail.com)

19 Northern Optometric Society, Manchester

NEW…8 CooperVision, National Space Centre, Leicester, CET course (www.coopervision-courses.co.uk)

20 The College of Optometrists, Aston University, West Midlands regional CET lectures (020 7766 4347)

NEW…11-12 Ocuco, Ocuco Ireland Head Office, Blanchardstown, Dublin, Ocuco User Group Meeting (usergroup@ocuco.com)

NEW… 20 CooperVision, Oulton Hall, Leeds, CET course (www.coopervision-courses.co.uk)

12 Lancashire Optical Society, Swallow

NEW…21 CooperVision, Durham Cricket

Hotel, Preston Road, Preston, ‘Driving in the fast lane’ lecture (janelbarker@yahoo.co.uk)

Club, Newcastle, CET course (www.coopervision-courses.co.uk)

6 CooperVision, National Motorcycle Museum, Birmingham, CET course (www.coopervision-courses.co.uk)

6 Bradford School of Optometry and Vision Science, D floor, Richmond Building, University of Bradford, David Pickwell Lecture ‘Orthoptics and the Pickwell Legacy’ by professor Bruce Evans (www.bradford.ac.uk)

NEW…27 CooperVision Imperial War Museum, Duxford, Cambridge, CET course (www.coopervision-courses.co.uk) NEW…28 The College of Optometrists, The Nottingham Belfy Hotel, East Midlands regional CET lectures (020 7766 4347) 28 ABDO graduation ceremony and prize giving ceremony, Canterbury Cathedral (www.abdo.org.uk) NEW… 28 CooperVision, The Montcalm at The Brewery, central London, CET course (www.coopervision-courses.co.uk)

199 Gloucester Terrace, London W2, FQE Optical NEW… 29 CooperVision, Ageas Bowl, Southampton, CET course Management Programme (www.coopervision-courses.co.uk) (sal_bates@hotmail.com)

Airport, Derby, Sportvision diploma course (www.schoolvision.org.uk)

Conference Centre, ‘Optic Disc Assessment’ (www.northernoptom.com)

30 AOP Student ‘Eye-Opener’ Conference, Center Parcs, Longleat, Wiltshire (www.studentaop.org.uk) NEW…30 The Medical Contact Lens and Ocular Surface Association, One Great George Street, Westminster, London, annual scientific meeting and regional meeting (secretary@mclosa.org.uk) DECEMBER 3 Northern Optometric Society, Manchester Conference Centre, ‘Modern corneal transplant surgery’ (www.northernoptom.com) 4 North East Optical Society, Holiday Inn Express, Newcastle upon Tyne, ‘Neuroophthalmology update’ (simonraw44@hotmail.com)

Publicise your event for free through OT. Simply send FULL details before November 6 by emailing robinamoss@optometry.co.uk or write to Robina Moss, OT Deputy Editor, 2 Woodbridge Street, London EC1R 0DG. Please check you have included where and when the event is being held plus who it is organised by and the booking information. Please let us know if anything changes with your event.

See more events at www.optometry.co.uk/events


UPDATE

AOP fees unchanged The AOP continues to protect practitioners without passing on higher membership costs in 2013 FOR THE third year running, the AOP has decided that membership fees will remain at the same level in 2013, having undertaken a restructuring which is focused on providing greater value for members. The AOP will be sending out renewal letters to all members in November.

02/11/12 AOP MEMBERSHIP

Legal defence As part of the package, members receive medical malpractice insurance. A prerequisite in order to practise, it is vital that members renew their membership before the year-end. Practising without insurance can result in the GOC removing a practitioner from the Register. Some practitioners choose to rely on their employer’s insurance policy. David Craig, AOP director of marketing and business development, has identified two pitfalls to this approach. “First, an employer’s insurance will only cover them while working for that employer; should they undertake locum work elsewhere, they need additional insurance for that work. AOP insurance covers them wherever they work. “Second, while relying on your employer’s insurance may seem attractive and cheaper, you should bear in mind that an insurance policy is designed to look after the policy holder. That policy holder is the employer and not the employee. The AOP has no corporate members. All members are individual and we give them all the benefit of the experience and skills of a legal team which deals with optometric and dispensing cases exclusively. Their experience is without equal; no other body or insurer can come close to matching it.” Mr Craig adds: “I was delighted to read, in a discussion on an Internet optometric discussion forum, a member writing about

47

the AOP legal team: “AOP lawyers seem to really enjoy ripping apart anyone who looks sideways at their members... I can’t recommend them highly enough”. That sums us up pretty well.” Easier ways to pay The AOP is encouraging members to set up a Direct Debit or to pay online. Direct Debits ensure that membership fees continue to be paid without interruption. Online payments do require action, but ensure that the data entered are accurate. Both methods offer increased reliability, are more efficient, plus they help the Association keep its membership costs down. Categories of membership Different membership categories to the AOP are available to suit the varying circumstances of practitioners. Part-time practitioners can take advantage of the concessionary grade – provided they work for fewer than 100 days per year. The 100-day allowance includes work in all modes of practice, including work as an optometric adviser. Newly qualified practitioners are offered

a substantial discount on membership for the year in which they qualify. “ Most students enter their working life carrying significant debt and also have new expenses to cover, such as work clothes and often relocation costs”, says Mr Craig. “The AOP is doing what it can to help make life easier for those who are the future of the profession. Of course, students and pre-regs are entitled to free membership.” Those practitioners thinking of leaving the AOP, either in order to retire from practice or because they wish to rely on alternative insurers, are asked to contact the AOP directly so that the Association can offer insurance cover into retirement or a policy which insures non-members in perpetuity for work carried out while they were an AOP member. How to renew a membership Members can set up Direct Debits using the form enclosed with their renewal letters or make online payments via the ‘Members area’ on the AOP website, www. aop.org.uk. Contact the membership team at membership@aop.org.uk or call 020 7549 2010 for more information.


optometrytoday

live

CET Video

2C

poinET ts

OCT in Optometric Practice: a hands-on guideenewsletter online C-19965

Publication date September 28, 2012, closing date November 28, 2012 Optical coherence tomography (OCT) is a new imaging technology that allows the layer-by-layer assessment of the retina and optic nerve. The instrument’s excellent resolution allows features to be recognised that previously were not visible. This lecture will discuss the clinical use of the OCT for both optic disc and retinal conditions

For more information, log on to

www.optometry.co.uk You must be logged into the CET section of the OT website before you can watch this video and take the exam. A hint button is now available for each question and will take you to the section of the video that relates to the question. The closing date for MCQ submissions is November 28, 2012. Points will be uploaded to CET Optics up to 10 days later.


1 FREE CET POINT Approved for: Optometrists

4

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Dispensing Opticians

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Corneal degenerations and keratoconus ANTERIOR EYE & OCULOPLASTICS PART 7 C-20076 O/D Amit Patel, MB BCh, FRCOphth Sunil Shah MBBS, FRCOphth, FRCS(Ed), FBCLA Corneal degenerations are defined as deterioration of tissue in which its vitality is diminished or its structure impaired. Specialised cells may be replaced by less specialised cells (eg in fibrosis) or cells may be functionally impaired (eg by deposition of abnormal material in the tissue). In contrast to dystrophies, degenerations may be unilateral or bilateral and are often asymmetric, eccentric or peripheral. They may be associated with local or systemic disease and there is usually no inheritance pattern. This article discusses the presentation and management of such degenerations, beginning with an in-depth look at the common corneal degeneration keratoconus.

Keratoconus Keratoconus is a progressive condition where there is corneal thinning and protrusion (ectasia). It affects the central two-thirds of the cornea and results in a conical corneal shape. There are various theories regarding the aetiology of keratoconus, although the exact cause remains unknown. Its association with systemic diseases, eg atopic conditions such as asthma, hayfever and eczema, suggest an ectodermal origin, however association with connective tissue disorders, eg Ehlers-Danlos syndrome and osteogenesis imperfecta, suggest a mesodermal origin. Several reports have also indicated microtrauma, eg from rubbing eyes, as a causative factor in inducing keratoconus. This theory is supported by the fact that patients with keratoconus frequently have itchy eyes and ocular irritation. An autosomal dominant inheritance is reported in approximately 10% of cases.

Figure 1

Conical protrusion and thinning of the cornea in advanced keratoconus

The prevalence of keratoconus varies widely, but is estimated to be between 50 and 230 per 100,000.1 The onset is around puberty and there is gradual progression until the third or fourth decades of life when it usually ceases to progress. There is no gender predominance and it almost always presents bilaterally, although clinical features are frequently asymmetrical. The rate of progression varies between individuals and also between the two eyes. The severity at the time progression stops is also highly variable and ranges from mild irregular astigmatism to severe thinning, scarring and protrusion.

Presentation and clinical signs The majority of patients present early in the course of disease complaining of decreased or distorted vision. In cases where keratoconus is suspected and VA remains relatively normal, a significant decrease in contrast sensitivity may be noted. The

Figure 2

Fine vertical striae (Vogt’s) and faint anterior stromal scarring from breaks in Bowmans layer

hallmark of keratoconus is central or paracentral thinning, irregular astigmatism and apical protrusion; clinical examination and topography aid in the diagnosis. Key clinical signs include: • Scissoring reflex on retinoscopy •O  il droplet sign on direct ophthalmoscopy from a distance •A  ngulation of the lower lid on down gaze (Munson’s sign) • S lit lamp biomicroscopy reveals corneal thinning and protrusion (Figure 1), deep, vertical striae (Vogt’s) that disappear on application of pressure (Figure 2), prominent corneal nerves, iron deposit line surrounding the base of the cone (Fleischer ring) and scarring (in advanced disease from breaks in Bowman’s layer or after hydrops). Acute corneal hydrops is a stromal oedema caused by aqueous penetration through breaks in Descemet’s membrane. The onset of corneal hydrops is classically associated with a sudden decrease in both uncorrected and corrected vision as well as redness, pain and photophobia. The corneal oedema may persist unpredictably for weeks or months, with gradual resolution as the posterior break is replaced with a collagenous scar. Topical osmotic agents such as hypertonic saline may accelerate the recovery of vision; however, this treatment is mostly helpful to alleviate oedema within the epithelium and anterior stroma. Prophylactic topical antibiotics are frequently prescribed and steroids may reduce the risk of corneal neovascularisation. Corneal topography is invaluable in detecting the presence of keratoconus, especially in patients with little or no signs on slit lamp examination. Furthermore, it allows detection and monitoring of disease progression and treatment response. Various different types of corneal imaging systems are available, eg Placido discs, slit-scan, Schiempflug imaging, and ocular coherence tomography (OCT). In early keratoconus there is a characteristic steepening of the posterior corneal surface, initially occurring mid-peripherally below the midline. This is demonstrated by the close proximity of the keratoscopy (placido) rings to one another. Above the midline, the superior cornea remains relatively normal in curvature. As the condition progresses, individual corneae can take on a wide range of topographical shapes and three types of cones have been described: nipple, oval and globus (Figure 3). Topographic indices are used to screen

49

02/11/12 CET

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CONTINUING EDUCATION & TRAINING


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CONTINUING EDUCATION & TRAINING

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4 Having trouble signing in to take an exam? View CET FAQ Go to www.optometry.co.uk

to quiet activities (eg, puzzles and

with special needs, may be nervous.

colouring) rather than allowing children

Consider allowing children to visit the

to become excited by playing with

practice before their first appointment,

active items. Remember that children

to meet the staff and see the room

may resent being dragged away from a

where the examination will take place.

toy corner to have an eye examination.

There are children’s books about eye

Think about the equipment on display in

tests available so consider loaning a

your examination room. Is it unfamiliar

book at the time the parent makes the

and scary? Is it computerised and highly

appointment. Some practitioners create

20/04/12 CET CET 02/11/12

attractive Figure 3to inquisitive fingers? Can you their own leaflets especially for children. Staff seen training may bea) Nipple needed as b)not Cornealunnecessary topography depicting the three typesaof cones in keratoconus: cone; place equipment behind Oval cone; c) Globus cone everyone has a natural rapport with screen? Can you replace your information

of with keratoconus. type of contact Inpatients this case leave theThe door open or lenses used varies depending on the stage of have another member of staff join you. keratoconus. Early in the disease, soft toric lenses may be adequate to correct myopia and regular Conclusion astigmatism. As the disease progresses, rigid gas In order to successfully test children, permeable (RGP) lenses are used. Tolerability it may be necessary and advanced protrusion to of purchase the cornea tests may specificallythe designed the age group. necessitate use offor hybrid/piggyback or lenses. Itisis the imperative to Of scleral equalcontact importance attitude understand that many patients with keratoconus of all staff, the practice environment depend on their contact lens correction for most and the approaches taken to make of their daily activities. Appropriate selection the entire experience child-friendly. and fitting of contact lenses may delay the requirement of surgical treatments (see later). About the author On the other hand, a proportion of patients who elect to undergo surgicalistreatment to Maggie Woodhouse senior return lecturer contact in order to achieve their VA. at the lenses School of Optometry and best Vision

posters and with children’s pictures? patients distinguish keratoconus from Arrange your appointment book to normal corneae. The indices proposed include avoid unnecessary and to give central corneal powerwaiting of >47.2D, inferiorflexibility. Some practitioners like>1.2, to superior dioptric asymmetry (I-S value) astigmatism andsession skewed radial axes >21° reserve one>1.5D whole per week for (Figure 4). While inbuilt children, software may indicate children. For older reserving the likelihoodappointments of ectasia, normal after-school can bevariation useful. and a poor ocular surface (eg dry eyes) may When the appointment is made, it may be lead to erroneous results. The scans must helpful to discuss parental concerns and therefore be interpreted in conjunction with determine whether an extended or second clinical examination and use of artificial tears appointment might be needed. Remember prior to scanning may improve image quality.

children. Ensure that all members of staff

irregular astigmatism and so contact lenses provide a better option in such cases. Contact that a parent or guardian comes into lenses represent the treatment of choice in 90%

Shecornea runs the progression Special ofAssessment the and halts the disease. The treatment the corneal Clinic, whichinvolves caters soaking for patients of all stroma with riboflavin (vitamin B2) followed by ages with disabilities. Her particular irradiation with ultraviolet (UV) light. Riboflavin interests are visual development in acts as a photosensitiser that causes formation children with Down’s syndrome and the of bonds between the collagen fibrils and impact of visual defects on education. extracellular matrix, thus strengthening the

explain what is going to happen and after

This may not always be possible eg, a

References

the examination to discussisthetooutcome The aim of management prevent with both the child and the parent(s). further progression of corneal changes and Some children, those simultaneously provideparticularly visual rehabilitation. Various options are available, the choice depending on the severity of the condition.

parent may need to take a distracting

See www.optometry.co.uk/

sibling outside, or an older child may

clinical. Click on the article title and

not want the parent to accompany them.

then on ‘references’ to download.

to allow time during the examination to

Keratoconus management

These patients must also be strongly advised

are familiar child protection issues to refrain fromwith rubbing their eyes as there is

and localthat protocols (see the College of evidence this may exacerbate the ectasia. Optometrists’ guidelines on examining the younger child and consider studying Contact Lenses the e-learning module In the very early stagesonof safeguarding keratoconus, children provided DOCET).of vision, It is spectacles are an option by for correction especially for patients who achieve of 6/12 good practice to ensure that aVAchild is or better. However, do not never alone withspectacles a member of correct staff.

This extends to the examination; ensure the examination room with the child.

Sciences,cross-linking Cardiff University, where she Collagen (CXL) specialises in paediatric optometry. CXL is a relatively recent treatment that stiffens

Module questions Course code: C-18705 O/D

PLEASE NOTE There is only one correct answer. All CET is now FREE. Enter online. Please complete online by midnight on May 18, 2012 – You will be unable to submit Ocular surface exams after this date. Answers to the module will be published on www.optometry.co.uk/cet/exam-archive. CET points for these exams will be uploaded to Vantage

As onmany patients may suffer from atopic May 28, 2012. Find out when CET points will be uploaded to Vantage at www.optometry.co.uk/cet/vantage-dates conditions, the eyelids and ocular surface c) Uses a flashing colourful target 1. Diagnosing a congenital vision defect must be examined carefully.colour Any allergic eye in early childhood d) Uses a large target has the following benefits EXCEPT: disease and can ocular surface inflammation a) The defect be treated 3. Success in eye health examination of a young child may be improved if b) Teachers can understand a child’s with colourtopical choice in artwork must be appropriately treated c) Inappropriate career plans can be avoided the practitioner: antihistamines/mast cell stabilisers and a) Asks the child to sit as still as possible for as long as it takes d) Alternatives to colour coding can be used lubricants to improve ocular comfort. Where b) Asks the child to keep looking at an interesting picture on the wall, no matter what 2. Measuring eye movements in children isare likely to be more appropriate, preservative free preparations c) Uses a slit-lamp and a Volk lens successful if the practitioner: preferable. Occasionally topical or subtarsal d) Examines sections of the eyes in separate intervals a) Moves the target very slowly steroids or other immunomodulatory treatments, Figure 4 4. Practice preparation may include all of the following EXCEPT: b) Avoids distracting the child by speaking eg tacrolimus ointment, may be required. Corneal topography in advanced keratoconus with adjacent Placido ring reflections

a Novartis company

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Sponsored by

a Novartis company

Ana, California, USA) for the duration of the study. They were instructed to maintain their regular correct cleaning

cornea may be treated with CXL in order to prevent any further deterioration. not validated at the Therebeen are statistically various reports of combination treatments that publication, show promisingtheoutcomes. time of this results5

are preliminary but not conclusive. Corneal transplantation

Blink’n’Clean and 14 days initially approvedeye by thedrops, US FDA for management

vertically below the temporal limbus. Combination treatments A subjective questionnaire (Table 1) Once patients achieve a good visual outcome

of myopia and astigmatism. However, have after first use of Blink’n’Clean eyethey drops.

was to wearers minutesor eg also after given intracorneal ring five implants

patients which have extensive corneal scarring and/or are Subject’s gender is not a parameter to contact lens intolerant. Over the last few be included in the analysis since the years there has been a move away from full distribution of valueskeratoplasty is not balanced thickness (penetrating – PKP) sufficiently (nine men and women). The to partial thickness (deep 42 anterior lamellar age distribution in the was normal keratoplasty – DALK) for sample keratoconus, in cases (Kolmogorov-Smirnov test, or p=0.66). without significant corneal scarring corneal hydrops. The DALK technique aims to remove The distribution of NIBUT values all, or nearly all, of the corneal stroma down was normal (Kolmogorov-Smirnov to Descemet’s membrane. DALK is a more test, p>0.05 on all occasions), and challenging procedure compared to PKP and therefore parametric tests were applied may result in a slightly reduced visual outcome. (ANOVA with post hoc analysis and It does, however, offer significant advantages Pearson’s correlation coefficient). The over PKP including reduced risk of ‘open sky’ remaining parameters follow categorical surgery. Also, since the patient’s endothelium is scaling preserved,and there therefore is no risk ofnon-parametric graft failure from tests were applied (Chi-square, endothelial rejection. Figure 5 shows the preFriedman ANOVA, Wilcoxon and post-operative clinical and appearance of a patient with keratoconus who underwenttests). DALK. matched-pairs signed-ranks Figure 6 shows the corresponding topography.

been authors shown to used be effective for the treatment of The the modified Rudko 10,11 keratoconus and ectasia 1) resulting validated scaleto stabilise (Figure for

reduction irregular astigmatism following after first ofinstillation of Blink’n’Clean

Non-invasive break-up time

topography surface the and again guided after 14 days ablation, of twice

assessment of deposits on contact lenses.

daily use. It is necessary to point

Results showed Degenerations significantly higher Other Corneal

Heaviness, extent and type of deposits

out that, since the questionnaire has

regime Figure(rub 5 and rinse) as well as a) Pre-operative showing corneal their normal appearance replacement schedule. scarring and protrusion; b) flattening of the in Types of contact lenses used corneal curvature following deep anterior this investigation were Biofinity lamellar keratoplasty (CooperVision, Fairport, New York,

cornea and reducing progression of ectasia.

USA), Acuvue Oasys, Acuvue Oasys for Most patients only require a single treatment.

Presbyopia, Advance (all Johnson It is indicatedAcuvue in patients that have evidence

calculation

of

the

NIBUT

without

thickness (at least Air 450µm). This revolutionary Florida, USA) Optix, Air Optix

interfering with lenses tear film stability. Phakic intraocular Several studies have reported theanalysed successful Corneal staining, which was

treatment may(both prevent patients from Duluth, requiring Night & Day CIBA Vision,

use ofthe toric as well as phakic intraocular dye, lenses with application of fluorescein

a corneal transplant if applied early in the Georgia, USA) andand PureVision (Bausch

and hyperaemia were assessed according

&ofJohnson Visioncare Inc., Jacksonville, progressive disease and adequate corneal

course of disease, it may allow them to maintain good vision with spectacles or contact lenses. Subjects were wearing lenses for at least It is therefore imperative to refer patients with five hours per day and were examined suspected keratoconus for an early evaluation.

& Lomb, Rochester, New York, USA).

at

the

following

intervals:

before

administration of segments Blink’n’Clean eye drops, Intracorneal ring five minutes after first instillation of Intracorneal rings are the PMMA segments that were

(IOLs) in patients with keratoconus.3-5 Stable keratoconus or high ametropia/astigmatism to the Cornea and Contact Lens Research following corneal transplantation may be Unit (CCLRU) grading scale (School treated with IOLs. Various types exists, eg of Optometry and Vision The anterior chamber lenses, Science, iris-clip lenses University of New South Wales, Sydney, (Artisan) and intraocular collamer lenses (ICLs).

Australia). LIPCOF were also counted,

This is usually reserved for Analysis and results

NIBUT valueschanges after 14 days Degenerative may be (13.4±6.7 classified seconds) of (primarily twice-daily of as involutional related use to age)

or non-involutional (related to local or systemic conditions). Generalised 1. During a normal day within the last week, how often was the wearing comfort of your contact lenses unpleasant? involutional degeneration of the cornea includes decreased thickness, Never Rarely Sometimes Often Always corneal increased rigidity, thickening of Descemet’s 2.When exactly did you note this unpleasant wearing comfort? membrane, and reduction of endothelial cells. Table 1 lists some of the common corneal Never Early morning Noon Evening All day degenerations and these are discussed below.

3. If you felt Figure 6 this unpleasant wearing comfort, how unpleasant was this feeling at the end of the contact lens wearing time? a) Topography showing a nipple cone with high degree of astigmatism pre-operatively; b) flattening of the cornea and reduction of astigmatism one-year post-corneal transplantation No problem Slightly unpleasant Unpleasant Annoying

Corneal arcus (Arcus Senilis) Extremely annoying

This common degeneration is characterised by a yellow/grey peripheral arc, which has a sharp 4.Involutional During a normal day within the last week - Non-involutional how often did you have the feeling that your contact lenses are dirty? outer edge and a more diffuse inner edge. Never Rarely Sometimes Often Alwayszone between the outer There is a translucent Band keratopathy Corneal arcus edge and the limbus (Figure 7). The prevalence 5. How was the wearing comfort after using Blink’n’Clean? Salzmann’s nodular degeneration Farinata increases with age and it is more common in men Much worse Worse Same Better Much better than women. It represents deposition of lipids at Spheroidal degeneration Furrow degeneration Descemet’s membrane and Bowman’s layer with 6. How was your vision after using Blink’n’Clean? extensions into the stroma. The lipids are thought Terrien’s marginal degeneration Crocodile Shagreen to permeate through the capillaries at the Much worse Worse Same Better Much better Table 1 limbus. Corneal arcus is not visually significant, Classification of corneal degenerations but young patients (under 40 years of age) may

Table 1 latest CETeyevisit Subjective questionnaire used to evaluate theFor effectthe of Blink’n’Clean drop www.optometry.co.uk/cet use on contact lens comfort and vision

For the latest CET visit www.optometry.co.uk/cet

51 49

02/11/12 23/03/12 CET CET

(Abbott Medical Optics Inc., Santa

from corneal refractive surgery.2 These rings are inserted into channels within the corneal stroma. were compared The channels may before be madeinstillation mechanicallyofor Blink’n’Clean drops, five laser. minutes with the use ofeye a femtosecond Once inserted, cause flattening the cornea in after thethey first eye drop ofinstillation, the corresponding area twice of insertion may and 14 days after dailyanduse. allow better contact lens fitting and reduction Pre-lens non-invasive tear break-upof myopia. Treatment with intrastromal rings does time (NIBUT) was evaluated without not eliminate the progression of keratoconus, but application of fluorescein dye with it may delay the need for corneal transplantation. different types of mires, such as placido This treatment may also be combined with CXL disc of the videokeratograph or mires in patients that achieve a good visual outcome of the to keratometer. This allowed in order prevent a corneal transplant.


CET

CONTINUING CONTINUING EDUCATION EDUCATION TRAINING &&TRAINING

1 FREE FREE CET CET POINT POINT

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Approved for: Optometrists 4 Dispensing Opticians 4 Approved for: Optometrists 4 Dispensing Opticians

48 52

Having trouble signing in to take an exam? View CET FAQ Go to www.optometry.co.uk

to quiet activities (eg, puzzles and

with special needs, may be nervous.

In this case leave the door open or

colouring) rather than allowing children

Consider allowing children to visit the

have another member of staff join you.

to become excited by playing with

practice before their first appointment,

active items. Remember that children

to meet the staff and see the room

Conclusion

may resent being dragged away from a

where the examination will take place.

In order to successfully test children,

toy corner to have an eye examination.

There are children’s books about eye

it may be necessary to purchase tests

Think about the equipment on display in

tests available so consider loaning a

specifically designed for the age group.

your examination room. Is it unfamiliar

book at the time the parent makes the

Of equal importance is the attitude

and scary? Is it computerised and highly

appointment. Some practitioners create

of all staff, the practice environment

attractive to inquisitive fingers? Can you

their own leaflets especially for children.

and the approaches taken to make

Figure 7 place unnecessary equipment behind a Corneal arcus (arcus senilis) screen? Can you replace your information posters

with

children’s

Figure 8 Staff training may be needed as not Crocodile shagreen everyone has a natural rapport with

pictures?

children. Ensure that all members of staff

book

to

are familiar with child protection issues

avoid unnecessary waiting and to give

and local protocols (see the College of

flexibility. Some practitioners like to

Optometrists’ guidelines on examining

reserve one whole session per week for

the younger child and consider studying

children. For older children, reserving

the e-learning module on safeguarding

after-school appointments can be useful.

children provided by DOCET). It is

When the appointment is made, it may be

good practice to ensure that a child is

helpful to discuss parental concerns and

never alone with a member of staff.

to allow time during the examination to

the examination room with the child.

explain what is going to happen and after

This may not always be possible eg, a

Arrange

02/11/12 20/04/12 CET CET

4

your

appointment

Figure 10 determine whether an extended or second Salzmann’s nodular corneal degeneration appointment might be needed. Remember have underlying hyperlipoproteinemia and a higher risk of coronary artery disease. Unilateral the discussabnormality the outcome arcusexamination may representtovascular (eg with both the child and the carotid stenosis) on the contralateralparent(s). side. Thus young patients and those with unilateralthose arcus Some children, particularly must be referred for further investigations.

This extends Figure 11 to the examination; ensure Terrien’s that a marginal parent degeneration or guardian comes into be in the anterior or posterior stroma and are most often bilateral and central. The posterior parent may need to take a distracting form appears similar to central cloudy dystrophy sibling outside, or an older child may of François. They may occasionally be found not want the parent to accompany them. in the peripheral cornea mimicking corneal arcus. Crocodile shagreen does not generally affect vision and no treatment is necessary.

the entire Figure 9

experience Band keratopathy

child-friendly.

About the author

edge is sharply demarcated, while the central Maggie Woodhouse is senior lecturer edge is diffuse and blends into the normal at the Lucent Schoolholes of Optometry cornea. are frequentlyand seenVision within Sciences, Cardiff University, she the band and represent areas ofwhere penetrating corneal nerves (Figure 9). Band keratopathy can specialises in paediatric optometry. occur a variety local and systemic causes She from runs the ofSpecial Assessment (Table 2) but is commonly seenpatients in chronicof uveitis Clinic, which caters for all and hypercalcaemic states. It is believed that ages with disabilities. Her particular alteration of the pH of tears and evaporation interests are visual development in (on the exposed interpalpebral area) leads to children with Down’s syndrome and the precipitation of calcium. Early band keratopathy impact visual on education. does not of require anydefects intervention. Later stages may cause irritation, grittiness or intense pain (from sharp exposed edges of calcium plaques) References and/or reduction of vision as it encroaches See www.optometry.co.uk/ the visual axis. Inonsuch removal clinical. Click the cases, articlesurgical title and with application of ethylenediaminetetracetic then on ‘references’ to download. acid (EDTA) may be performed. Alternatively, excimer laser phototherapeutic keratectomy may be used to clear the visual axis.

Module questions Course code: C-18705 O/D

Farinata

Corneal farinata appears as tiny grey-white PLEASE NOTE There is only one correct answer. All CET isFurrow now FREE. Enter online. Please complete online by midnight on May 18, 2012 – You will be unable to submit degeneration Salzmann’s nodular degeneration ‘flour’ like opacities the deep stroma,will just exams after this date.in Answers to the module be published on www.optometry.co.uk/cet/exam-archive. CET points for these exams will be uploaded to Vantage This toisVantage represented by peripheral corneal This is characterised by white-blue elevated anterior to 2012. Descemet’s membrane. These on May 28, Find out when CET points will be uploaded at www.optometry.co.uk/cet/vantage-dates opacities do not interfere with vision and thinning (between corneal arcus and the lesions on the corneal surface. The lesions may c) Uses a flashing colourful target 1. Diagnosing a congenital colour vision defect in early childhood is usually shallow be singular or multiple and are often found in the arehas best visualised by retroillumination. limbal vessels). The thinning d) Uses a large target the following benefits EXCEPT: They an incidental finding. and the patients are asymptomatic. There is mid-periphery (Figure 10). They are more common a) Theare defectusually can be treated 3. Success eye health examination of a young childand maymay be improved if b) Teachers can understand a child’s colour choice in artwork in women than men be unilateral or absence of inflammation and invascularisation. c) Inappropriate career plans can be avoided the practitioner: bilateral. It appears in eyes with inflammatory Crocodile shagreen a) Asks the child to sit as still as possible for as long as it takes d) Alternatives to colour coding can be used disease e.g. vernal keratoconjunctivitis, phlycten, This is characterised by a mosaic polygonal Band keratopathy b) Asks the child to keep looking at an interesting picture on the wall, no matter 2. Measuring eye movements in children is likely A togrey-white be more opacity what pattern that resembles crocodile skin (Figure results from deposition of trauma, and trachoma, or may be idiopathic. c) Uses a slit-lamp and a Volk lens if the practitioner: 8).successful This appearance results from irregular calcium at Bowman’s layer. It typically begins in The lesions are generally asymptomatic, but d) Examines sections of the eyes in separate intervals a) Moves the target very slowly may cause irritation or EXCEPT: decrease in vision if arrangement of collagen due relaxation of the periphery at the 34. and 9 o’clock positions and Practice preparation may include all of the following b) Avoids distracting the child by to speaking tension within the cornea. The opacities may gradually progresses centrally. The peripheral involving the visual axis. Topical lubrication

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regime (rub and rinse) as well as

their normal Terrien’s marginalreplacement degeneration schedule. This is a rare Types of condition contactof unknown lenses aetiology. used Itinis most commonly seen between the ages of 20-40 this investigation were Biofinity years and is three times more common males (CooperVision, Fairport, New inYork,

than females. It Oasys, is a peripheral USA), Acuvue Acuvueinflammatory Oasys for condition that begins as an area of superonasal corneal thinning. The central edge is steep and & Johnson Visioncare Inc., Jacksonville, a yellow-white zone of lipid may be seen. The Florida, USA) Air Optix, Air Optix peripheral edge gently slopes towards the Night Day CIBAepithelium Vision, Duluth, limbus &and the(both overlying is intact Georgia, USA) and PureVision (Figure 11). The lesion may progress(Bausch centrally & Lomb, Rochester, New York, USA). or circumferentially. It is frequently bilateral and Subjects wearing lenses for at least symmetricwere but may be asymmetric. Younger patients mayper getday episodes of inflammation, five hours and were examined episcleritis or scleritis and may be treated with at the following intervals: before topical steroids. The superior locationeye frequently administration of Blink’n’Clean drops, leads to against-the-rule astigmatism, which five minutes after the first instillation of may be managed with spectacles or contact Blink’n’Clean eye drops, and 14 days lenses. Progressive disease may cause corneal after first use of Blink’n’Clean eye drops. perforation (usually precipitated by trauma) The authors used the modified Rudko and necessitates corneal transplantation.

Presbyopia, Acuvue Advance (all Johnson

validated

scale

10,11

(Figure

1)

for

assessment of deposits on contact lenses. Spheroidal degeneration Heaviness, extent and type of deposits (Climatic droplet keratopathy) Yellow-gold

spherules

form

within

the

interpalpebral aperture, usually at the limbus,

Local were compared before instillation of Chronic uveitis eye drops, five minutes Blink’n’Clean after the silicone first eye Intraocular oil drop instillation, and 14 days after twice daily use. Interstitial keratitis Pre-lens non-invasive tear break-up Topical medications containing) time (NIBUT) was(phosphate evaluated without

Systemic not been statistically validated at the Hyperparathyroidism time of this publication, the results Renal are failure preliminary but not conclusive. Excessive vitamin D intake

Analysis and results

Sarcoidosis Subject’s gender is not a parameter to

application of fluorescein dye with Juvenile idiopathic arthritis with uveitis different types of mires, such as placido Phthisis bulbi disc of the videokeratograph or mires

be included in the analysis since the Milk-alkali syndrome distribution of values is not balanced Hypophosphatasia sufficiently (nine men and 42 women). The

of the Table 2

allowed

age distribution in the sample was normal Midland Eye Institute in Birmingham. He

calculation of causes the NIBUT without Local and systemic of band keratopathy interfering with tear film stability.

(Kolmogorov-Smirnov has a special interest in test, corneal,p=0.66). cataract

keratometer.

This

and refractive surgery. of He NIBUT is a treasurer of The distribution values but may start centrally.which They may alsoanalysed form on the was the British Society for Refractive Surgery Corneal staining, was normal (Kolmogorov-Smirnov conjunctiva and are frequently found in association (BSRS) p>0.05 and a council member of the Medical with the application of fluorescein dye, test, on all occasions), and with pingueculae. The spherules darken with age Contact Lens and Ocular Surface Association. and hyperaemia were assessed according therefore parametric tests were applied and may become elevated, leading to irritation Prof Sunil Shah is a consultant ophthalmologist to the Cornea and Contact Lens Research

(ANOVA with post hoc analysis and

and reduced vision. Risk factors include UV light at the Midland Eye Institute, Birmingham and Unit (CCLRU) grading scale (School Pearson’s correlation coefficient). The and microtrauma (from dust, wind, or drying). It Midland Eye Centre, and honorary consultant

of Optometry and Vision Science, The

remaining parameters follow categorical

Australia). LIPCOF were also counted,

tests

is thus more common in dry and warm climates at Birmingham Children’s Hospital. He is also an University of New South Wales, Sydney, scaling and therefore non-parametric with a higher incidence in men. Spheroidal honorary professor at the University of Ulster and

were

applied

(Chi-square,

degeneration may also occur secondary to local visiting professor at Aston University, Birmingham. vertically below the temporal limbus. ANOVA, and and Wilcoxon disease e.g. herpetic keratopathy and glaucoma. Friedman He specialises in complex corneal refractive

A subjective questionnaire (Table 1) signed-ranks Protection from UV light and irritants and the use matched-pairs surgery. Professor Shah is past presidenttests). of the was also given wearers fiveofminutes of lubricants formstothe mainstay treatment. British Society for Refractive Surgery (BSRS) and

break-up after firstcases instillation Blink’n’Clean is a specialist advisor to thetime National Institute for Advanced may requireof excision (conjunctival Non-invasive showed significantly higher and again aftertransplant 14 days of twice Clinical Excellence and British Standards Institute. lesions) or corneal (corneal lesions). Results daily use. It is necessary to point

NIBUT values after 14 days (13.4±6.7

out that,the since the questionnaire has About Authors

seconds) of References

twice-daily

use

Mr Amit Patel is a consultant ophthalmologist See www.optometry.co.uk/clinical. Click on the at the Heart of England NHS Trust and article title and then on ‘references’ to download.

1. During a normal day within the last week, how often was the wearing comfort of your contact lenses unpleasant? Rarely Sometimes Often Module questions Course code: C-20076 O/D

Never

Always

2.When exactly did you note this unpleasant wearing comfort? PLEASE NOTE There is only one correct answer. All CET is now FREE. Enter online. Please complete online by midnight on November 30, 2012 – you will be unable to submit exams after this date. Answers to the module will be published on www.optometry.co.uk/cet/exam-archive. CET points for these exams will be uploaded to

Never morning Evening All day Vantage on December 10, 2012.Early Find out when CET points will be Noon uploaded to Vantage at www.optometry.co.uk/cet/vantage-dates

Which of theatfollowing aboutlens collagen cross-linking of the statements regarding thehow diagnosis of 3. 1. If Which you felt thisfollowing unpleasant wearing comfort, unpleasant was4. this feeling the endstatements of the contact wearing time?

is TRUE? keratoconus is TRUE? a) It is indicated for advanced keratoconus a) Unaided and best corrected VA may be good in the early stages of disease Nob)problem Slightly Unpleasant Annoying Extremely annoying b) It aims to prevent further progression of keratoconus Vogt’s striae are always present on slit unpleasant lamp examination c) It results in flattening of the cornea back to the normal shape c) Diagnosis can be made solely on corneal topography d) Most severalcontact treatments for fullare effect It neveramanifests age ofthe 30 years 4. d) During normalafter daythe within last week - how often did you have the patients feelingrequire that your lenses dirty? 2. Which of the following statements about keratoconus is FALSE?

Never Rarely a) There is thinning of the peripheral cornea

Sometimes

b) Multiple breaks can be seen in Bowman’s membrane

5. c) How wasresults the wearing comfort after using Blink’n’Clean? Hydrops from a break in the Descemet’s membrane d) Iron deposition can be seen at the base of the cone

Much worse

Worse

of

Same

3. Which of the following is the LEAST appropriate management option patients suspected having keratoconus? 6. for How was your visionofafter using Blink’n’Clean? a) Advise them against rubbing their eyes b) Vision correction through RGP contact lenses Much worse Worse Same c) Referral to ophthalmology for collagen cross-linking d) Referral to ophthalmology for penetrating keratoplasty

5. Which of the following statements regarding corneal arcus is TRUE? Often Always a) It often encroaches the central cornea b) It is uncommon in the elderly c) Occurrence in young people requires further investigation d) It consists of protein deposits

Better

Much better

6. Which of the following statements regarding band keratopathy is FALSE? a) It is only associated with systemic disease b) It usually originates Betterat the 3 and 9 o’clock positions Much better c) It can be removed by chelation with EDTA d) It consists of calcium deposits in Bowman’s layer

Table 1 Subjective questionnaire used to evaluate the effect of Blink’n’Clean eye drop use on contact lens comfort and vision

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53 49

02/11/12 23/03/12 CETCET

is usually effective in controlling the mild irritation. A superficial keratectomy or excimer (Abbott Medical Optics Inc., Santa laser ablation may be performed to remove Ana, California, USA) for the duration the lesions. Deep stromal lesions may rarely of the study. They were instructed to require a lamellar or penetrating keratoplasty. maintain correct treatment. cleaning The lesionstheir may regular recur following


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Are you fitting comfortably?

54 48

to quiet activities (eg, puzzles and

with special needs, may be nervous.

colouring) rather than allowing children

Consider allowing children to visit the

to become excited by playing with

practice before their first appointment,

active items. Remember that children

to meet the staff and see the room

may resent being dragged away from a

where the examination will take place.

toy corner to have an eye examination.

There are children’s books about eye

C-20101 Think aboutO/D/CL the equipment on display in your examination room. Is it unfamiliar

tests available so consider loaning a book at the time the parent makes the

20/04/12 02/11/12CET CET

Mark Tomlinson, BSc (Hons), MCOptom

and scary? Is it computerised and highly appointment. Some practitioners create Concern about comfort is the main reason why patients are reluctant to try contact lenses attractive to inquisitive fingers? Can you their own leaflets especially for children. initially and poor comfort is instrumental in patients dropping out from contact lens wear. place unnecessary equipment behind a Staff training may be needed as not This “drop out” effect is counter-productive for patients, practitioners and manufacturers. screen? Can you replace your information everyone has a natural rapport with This article examines the multi-factorial reasons why this continues to be one of the main posters with children’s pictures? children. Ensure that all members of staff challenges that practitioners face in everyday practice. Arrange your appointment book to are familiar with child protection issues avoid andlenses to give Patientsunnecessary wanting to waiting try contact for flexibility. Some practitioners like to the first time have to perceive some benefit reserve one whole week for from wearing them iesession cosmeticper improvement children. older children, or practicalFor enhancement for sportreserving etc. This after-school appointments desire for improved quality can of be life useful. is the When the appointment is made, it mayand, be motivating factor for trying contact lenses

helpful to eye discuss parental concerns and if satisfied, care practitioners have gained determine whether an extended or second a new, and hopefully loyal, patient for many appointment needed. Remember years. The flip might side tobe this, however, is that if to allow time during the examination to a contact lens wearer becomes disillusioned

explain what is going happen and after and de-motivated withtotheir regime, they the to significantly discuss thereduce outcome are examination likely to stop or the with both the child andwear the them. parent(s). amount of time that they This Some those “drop outchildren, factor” has particularly plagued the contact lens industry for many years. Contact lens

and local protocols (see the College of practitioners is that they could potentially Optometrists’ on examining lose 12.5% to 25%guidelines of their patients every year. the child and consider studying Theyounger most significant contributory factor the e-learning module on safeguarding for patients becoming dissatisfied with their

children provided by DOCET). It is contact lenses is poor comfort, with cost coming good practice to ensure that a child is well down the list. Recent studies show that

never with of lies staff. the dropalone out rate duea tomember discomfort at This extends to the examination; ensure 1 somewhere between 41.9% and 52.9%, while that out a due parent ororguardian comes vision into drop to cost no longer needing the examination with respectively. the child.2 correction is at 11%room and 12%

This may not always be possible eg, a

parent may need to take a distracting Factors influencing comfort

wear, 66% are still concerned about the comfort In this case leave the door open or of their lenses and of these, 23% had major have another member of staff join you. comfort concerns.2 Perhaps of greatest surprise is that 56% of the patients that dropped out from

Conclusion

contact lens wear had not sought any further In order to successfully test children, advice from their eye care practitioner before it may be necessary to purchase tests ceasing wear. Naroo et al.3 concluded that many specifically designed for the age group. contact lens wearers self-diagnose problems Of equal importance is the attitude rather than seeking the clinical judgement of of all staff, the practice environment their practitioner. This strongly suggests that and the approaches taken to make practitioners need to be more proactive in the entire experience child-friendly. encouraging wearers to attend for aftercare appointments and to discuss their concerns.

About the author Appropriate questioning and communication

Maggie Woodhouse is senior lecturera techniques are paramount in separating at the School of Optometry and Vision happy patient with no concerns from those

Sciences, Cardiff University, where she who have issues. Asking closed questions such specialises in paediatric optometry. as “Are your contact lenses ok?” or “Are they She runs the Assessment comfortable?” resultsSpecial in a “yes/no” answer, Clinic,does which patients of all which not caters providefor enough information

ages withas disabilities. especially “comfort” and Her “ok” particular are relative interests are visual development terms. Even asking an open question suchinas

children with Down’s syndrome the “How comfortable do you find yourand lenses?” impact of visual defects on education. to receive a more complete answer from the wearer still may not give the information

References you need to make an accurate judgement. See www.optometry.co.uk/

sibling outside, or an olderis child may Comfort of contact lenses influenced not want the parent to accompany them. by many different factors including:

clinical. Click on the article title and What’s the score? on ‘references’ Athen better approach totodownload. elicit significant

• Contact lens material properties: lubricity,

symptoms is to ask your patient to subjectively

score out of 10 the following key areas: wettability, and oxygen transmission Module questions Course code: C-18705 O/D (i) How happy are you with the vision from your • Contact lens care products

manufacturers and eye care professionals have been bemoaning a flat and static market

PLEASE NOTE There is only one correct answer. All CET is now FREE. Enter online. Please complete online by midnight on May 18, 2012 – You will be unable to submit

contact lenses? in exams whichafter we this fastidiously channel energies • Patientoncompliance with replacement and CET points date. Answers to theour module will be published www.optometry.co.uk/cet/exam-archive. for these exams will be uploaded to Vantage on May 28, 2012. Find out when CET points will be uploaded to Vantage at www.optometry.co.uk/cet/vantage-dates (ii) What grade would you give to the overall into gaining new contact lens wearers, only wearing schedules and care of lenses to1.be disappointed at the end of vision each defect year in • Eearly nvironmental air conditioning, Uses as a flashing colourful target Diagnosing a congenital colour childhoodissuesc)such

comfort of your contact lenses?

d) Uses a large target has the benefits EXCEPT: (iii) What grade would you give to the comfort when we following learn that the net gain in patient climate control and airborne allergens a) The defect can be treated of your contact lenses the end of the numbers is small or, even worse, showing a loss. • W  orkplace factors such as dust, computers and 3. Success in eye health examination of a young child mayatbe improved if day? b) Teachers can understand a child’s colour choice in artwork c) Inappropriate career plans can be avoided the practitioner: By asking these three questions in this Recent research has estimated the ducted air heating systems a) Asks the child to sit as still as possible for as long as it takes d) Alternatives to colour coding can be used “score” format,picture you onare likely to dropout rates to be 15.9% in the USA, 31% • Tear film and eyelid disease. b) Asks the child to keep looking at an interesting the far wall, more no matter what Measuring eye movements children is likely to be more identify the patients who are at a higher risk of in 2.Asia and 30.4% in Europe.1 in Even the most c) Uses a slit-lamp and a Volk lens successful if the practitioner: becoming dissatisfied. Using a pre-appointment conservative puts the drop out rate in Are our wearers reallysections happy? d) Examines of the eyes in separate intervals a) Moves the figure target very slowly 2 4. continue Practice preparation may include all of the may following EXCEPT: Avoids the child by speaking questionnaire be more reliable, as people UKb)at 12%.distracting Therefore, the stark reality facing Of all the patients that in contact lens

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a Novartis company simplicity in use; maintain or even enhance

their individual and instillation wants matched were comparedneeds before of to

not been statistically validated at the

comfort for the complete length of wearing

of the study. They were instructed to

a lens material eye and drops, replacement modality; a time; be effective in the suppression of ocular Blink’n’Clean five minutes time of this publication, the results “one size fits all” approach is too simplistic. pathogens; remain non-toxic to the ocular after the first eye drop instillation, are preliminary but not conclusive.

maintain their regular correct cleaning

and 14 days after twice daily use.

On average, contact lenses are only worn

surface; remove deposits from the lens surface;

regime (rub and rinse) as well as

for 3.5 days per week, with an average daily

Pre-lens non-invasive tear break-up

and be affordable. The use of silicone hydrogel Analysis and results

their

schedule.

time (NIBUT) was evaluated without

used

in

application of fluorescein dye with

Biofinity

different types of mires, such as placido

Ana, California, USA) for the duration

normal

Types this

of

replacement

contact

lenses

investigation

were

wearing time of 6.5 hours.2 It is reasonable

to suggest that for part-time wear and short wearing hours, comfort is more important than ultra-high oxygen supply to the cornea.

9

lenses however has is changed challenge for Subject’s gender not athe parameter to solution manufacturers. Hydrogelsince materials be included in the analysis the

attract protein silicone distribution of deposits, values iswhereas not balanced

disc of the videokeratograph or mires

hydrogel materials attract lipid sufficiently (nine men and 42deposits, women).which The

USA), Acuvue Oasys, Acuvue Oasys for

of

Presbyopia, Acuvue Advance (all Johnson

calculation

&

(CooperVision,

Fairport,

New

York,

This is recognised by the number of “comfort

This

allowed

candistribution make wettability an issue for some wearers. age in the sample was normal

NIBUT

without

Recently-introduced lens care products have (Kolmogorov-Smirnov test, p=0.66).

Inc., Jacksonville, Corneal staining caused by toxicity from a Florida, USA) Optix, Air Optix contact lens careAir solution Night & Day (both CIBA Vision, Duluth,

interfering with tear film stability.

been to work of withNIBUT silicone hydrogel Theoptimised distribution values

Corneal staining, which was analysed

materials. These more advanced features was normal (Kolmogorov-Smirnov

with the application of fluorescein dye,

include the ability reduce lipid deposition, test, p>0.05 on to all occasions), and

Georgia, USA) and PureVision (Bausch

and hyperaemia were assessed according 8

which keeps the lens tests surfaces cleaner and therefore parametric were applied

& Lomb, Rochester, New York, USA).

to the Cornea and Contact Lens Research

Figure 1 Johnson Visioncare

are more likely to answer truthfully about negative responses on paper, rather than when face to face with their practitioner.

Subjects were wearing lenses for at least

five hours per day and were examined

Are silicone hydrogel lenses the following intervals: before the answer? administration of Blink’n’Clean eye drops, at

Silicone hydrogel contact lenses are now the

five minutes after the first instillation of

preferred lens choice for many practitioners

Blink’n’Clean eye drops, and 14 days

and as a result the signs of hypoxic stress

after first use of Blink’n’Clean eye drops.

and compromise to corneal health are now

the

keratometer.

enhanced” daily disposable contact lenses that

of

the

are available on the market.6 Comfort enhanced daily disposable lenses play a significant role in delivering comfort to wearers by maintaining a better quality tear film over the lens surface.7 Wolffsohn and Emberlin have also reported

healthier. Wetting agents such as hyaluronate that daily disposable contact lenses offer a (ANOVA with post hoc analysis and (used in Biotrue by Bausch & Lomb) and Unit (CCLRU) grading scale (School barrier to airborne antigens to reduce ocular Pearson’s correlation coefficient). The ethyloxylene-butyloxylene, also known as of Optometry and Vision Science, The allergic reactions, an effect that appeared remaining parameters follow categorical HydraGlyde (used in Optifree PureMoist by University of New South Wales, Sydney, to be enhanced by use of Alcon Dailies scaling and therefore non-parametric Alcon) arewere added toapplied provide a lens(Chi-square, surface that is Australia). LIPCOF were alsolenses. counted, Aqua ComfortPlus contact They tests

vertically below temporal wetter and more lubricious,and creatingWilcoxon enhanced ANOVA, proposed that thisthe effect may belimbus. linked to Friedman Athesubjective (Table comfort over time. Hydraglyde embedstests). in the signed-ranks release of questionnaire lubricating agents from 1)the matched-pairs was given during to wearers five minutes lens also poylmer the wearing period.

surface of the lens matrix, providing a highly

ultimately leading to drop out. Fitting the correct

impact of a lens care product and material on

break-up first instillation Blink’n’Clean The authors used 4the modified Rudko after hydrophilic layer on thetime lens surface. This is Concentrating solely onofoxygen transmission Non-invasive much less common. It has been reported that 10,11 Results showed significantly higher again after 14 days of twice validated scale (Figure 1) for 5 and claimed to provide moisture on the surface of 42% of patients sleep or nap in their lenses , when selecting a contact lens may mean a patient NIBUT values after 14 days (13.4±6.7 use. It is necessary to point assessment of deposits on contact lenses. daily the contact lens independently of the tear film. so selecting a silicone hydrogel lens that is being fitted with a lens that gives less comfort, seconds) of should twice-daily use the of that, since the questionnaire has Heaviness, extent and type of deposits out Practitioners consider carefully and a less enjoyable wearing experience, licensed for overnight wear may be erudite. Not all silicone hydrogel materials are equal

contact lens to the match a patient’s lifestyle comfort, cleaning and antimicrobial efficacy. 1.however. During a Silicone normal day within the last week, how often was wearing comfort of would your contact lenses unpleasant? is naturally hydrophobic and attracts lipid. Therefore, manufacturers appear to provide greater patient comfort and Indeed, many practitioners seem blasé Never Rarely Sometimes Often Always employ different technologies to overcome satisfaction. Indeed, asking specific questions about lens care and pay little attention to the about patient lifestyle, healthcare concerns 2.When exactly&did you note unpleasant wearing comfort? this. Johnson Johnson andthis Coopervision, for example, use wetting agents incorporated

Never

Early morning

(including allergies), exploring requirements

Noon

Evening

in the lens polymer to improve the lubricity

and expectations and discussing past wearing

plasma treatment on their lenses to provide

on individual needs. Explaining the reason for

combination of lens and lens care solution they are ‘prescribing’ for their patients.10

All day

However, solution-induced corneal staining

allowswas forthis lensfeeling selection based 3.and If you felt thisof unpleasant wearing how unpleasant at the end of the contact lens wearing time? wettability the lens, while Alconcomfort, use a experiences

No problem a

smooth,

uniform,

Slightly unpleasant the recommendation Unpleasant of a particular lens Annoying raises surface.

hydrophilic

(SICS) or preservative associated transient hyperfluoresence (PATH) are common events Extremely annoying that can be observed with contact lens wear and

wearer knowledge and isthe more likelythat to lead When selecting best lens for particular 4. During a normalthe day within thealast week - how often did you have feeling your contact lenses are dirty? possibly represent a reaction to the disinfecting wearer, it is necessary to take into account all

Never

Rarely

of the factors described above, in addition

to a lens that meets wearer comfort needs.

Sometimes

Often

Does the choice of lens care thewas patient’s intended wearing 5.toHow the wearing comfort after habits using Blink’n’Clean?

agents added toAlways lens care products (Figure 1). The exact aetiology is not well known, but it is evident that certain combinations of lens care

in order to achieve a comfortable wearing

product matter?

experience. Simply to say “I have fitted my

The challenges faced by solution manufacturers

Much better are more likely to solutions and lens materials

6.patient How was your using lens Blink’n’Clean? with a vision siliconeafter hydrogel so I over recent years have been both varied and

lead to this type of event. Practitioners seeing

am meeting not be true if Much worse their needs” may Worse

complex in order to keep pace with modern

wearers demonstrating either SICS or PATH

that lens does not allow them a comfortable

technology and the demands of a modern

may wish to change the lens care regime either

wearing experience throughout the day for

lifestyle. Lens care products should ideally

to one containing a different preservative

Much worse

Worse

Same

Same

Better

Better

Much better

Table 1 all of their work and social activities. Patients provide patients the following benefits: or to Subjective questionnaire used to evaluate the effect of Blink’n’Clean eye drop use on contact lens comfort and vision

For the latest CET visit www.optometry.co.uk/cet For the latest CET visit www.optometry.co.uk/cet

a hydrogen peroxide based system.

55 49

02/11/12CET CET 23/03/12

(Abbott Medical Optics Inc., Santa

need to be managed as individuals, with


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Month

special needs, may be nervous. Patients fittedwith to date Income (£)

January

16

to quiet activities (eg, puzzles and

56 48

Income year to date (£)

to become excited by playing with

308 appointment, practice before their first

have another member of staff join you.

February 32 children active items. Remember that

to meet the staff and 616see the room

Conclusion 924

may resent being dragged away March 48 from a toy corner to have an eye examination.

where the examination will take place. 924

In order to successfully test children,

There are children’s books about eye

it may be necessary to purchase tests

Think about the equipment on display in

tests available so consider loaning a

specifically designed for the age group.

April

64

May 80 your examination room. Is it unfamiliar June and scary? Is it computerised96and highly

1,232

1,540 book at the time the parent makes the 1,848 appointment. Some practitioners create

attractive to inquisitive fingers? July 112 Can you

their own leaflets especially 2,156 for children.

place unnecessary equipment August 128behind a

Staff training may be2,464 needed as not

screen? Can you replace your144 information September

everyone has a natural 2,772rapport with

posters

with

children’s

Arrange

your

appointment

October

20/04/12 02/11/12CET CET

In this case leave the door open or

Consider allowing children to visit the

colouring) rather than allowing children

pictures?

160

book

to

November avoid unnecessary waiting 176 and to give December 192 flexibility. Some practitioners like to

reserve Table 1one whole session per week for

308

1,848 3,080

Of equal 4,620 importance is the attitude

6,468 of all staff, the practice environment and the 8,624 approaches taken to make the entire11,088 experience child-friendly.

13,860

children. Ensure that all members of staff

About the author

are familiar with child protection issues

Maggie Woodhouse is senior lecturer

3,080

3,388 and local protocols (see the College of 3,696 Optometrists’ guidelines on examining the younger child and consider studying

children. For ofolder children,effect reserving Demonstration the cumulative of contactthe lense-learning growth on amodule practice on safeguarding after-school appointments can be useful. children provided by DOCET). It is complying better (64%) than those who wear Patient compliance When the appointment is made, it may be good practice to ensure that a child is When patients wear contact lenses as directed two-weekly disposable lenses (57%). This helpful to discuss parental concerns and never alone with a member of staff. by their practitioner, complication rates lack of conformity may also be down to not determine whether an extended or second This extends to the examination; ensure are extremely low. That said, practitioners remembering on which date to change the appointment might be needed. Remember that a parent or guardian comes into should never assume that all of their lenses. Nevertheless, payment plans, direct to allow time during the examination to the examination room with the child. patients are fully compliant with lens care debit schemes with regular supplies of lenses explain what is going to happen and after This may not always be possible eg, a procedures. A recent study has shown that will help to eliminate this. Similarly, if the parent may need to take a distracting the examination to discuss the outcome non-compliance is often far too prevalent.11 payment plan includes solutions, for reusable with both the child and the parent(s). sibling outside, or an older child may Key areas highlighted by the study include: lenses, then this should help to encourage want the parent to accompany them. Some children, particularly those not patients to change their lens case regularly.

‘Topping up’ of lens solutions

16,940

20,328 at the School of Optometry and Vision

24,024 University, where she Sciences, Cardiff specialises

in

She

the

runs

paediatric

optometry.

Special

Assessment

Clinic, which caters for patients of all little confused or uncertain of what is expected ages with disabilities. Her particular if practitioners themselves are unclear. interests are visual development in Practitioners may need to spend extra time children with Down’s syndrome and the with patients to reiterate the correct method. impact of visual defects on education. During the application and removal training, it is important that practitioners start in the way

References

that you want your patients to continue. Clear See www.optometry.co.uk/ concise instructions and guidance should be clinical. Click on article andwith given to patients andthe issuing thetitle patient

then on ‘references’ to download. written instructions to take away with them will back this up. Practitioners should ensure that

support staff understands the importance of percent of patients are non-Course code: C-18705 O/D Module questions Perhaps the area of greatest concern, and

Fifty-four

Inappropriate cleaning of lenses

their role when instructing patients during this

compliant with this task, which may be

PLEASE NOTE There is only one correct answer. All CET is now FREE. Enter online. Please complete online by midnight on May 18, 2012 – You will be unable to submit

certainly that needs the greatest diligence training. It is also important that alltomembers examsto after this date. Answers the module will be published on one www.optometry.co.uk/cet/exam-archive. CET points for these exams will be uploaded Vantage of down ineptitude or a todeliberate coston May 28, 2012. Find out when CET points will be uploaded toprofession, Vantage at www.optometry.co.uk/cet/vantage-dates in the is the inappropriate cleaning the practice team conform to each other when cutting exercise. In either case, correct contact lenses, particularly the failure to ‘rub c) Uses a flashing colourful target giving advice and instructions to patients, so 1. Diagnosingshould a congenital vision defect inofearly childhood procedures be colour re-established d) Uses a large target has the following benefits EXCEPT: and rinse’. Failed compliance in this regard is that if a patient returns for clarification, they when this is suspected by the practitioner. a) The defect can be treated as high as 77%. In recent yearsin there has been are notofthen given conflicting advice. This 3. Success eye health examination a young child may be improved if can b) Teachers can understand a child’s colour choice in artwork c) Inappropriatereplacement career plans canof belenses avoided Inappropriate d) Alternatives to colour coding can be used

Cost cutting may also influence patients when

practitioner: contradictory advicetheand recommendations

lead to confusion or, even worse, an implication a) Asks the child to sit as still as possible for as long as it takes given by manufacturers and on at that it “doesn’t really matter b) Asks thepractitioners child to keep looking an interesting picture on the wall, nothat mattermuch”.

what 2. Measuring eye movements in children is likely rub to be more and rinse. It is now acknowledged that this it comes to replacing lenses at the correct time. successful if the practitioner:

There is a the difference between a) Moves target very slowly modalities, with b) Avoidswearing distracting the child disposable by speaking lenses patients monthly

c) Uses a slit-lamp and a Volk lens

is the procedure of choice for lens cleaning, but Contact lens value d) Examines sections of the eyes in separate intervals

Practice preparation all of the following EXCEPT: it is hardly surprising4. that patients may bemay a include The true value of a contact lens patient usually

a Novartis company

Find out when CET points will bebe uploaded to to Vantage at at www.optometry.co.uk/cet/vantage-dates Find out when CET points will uploaded Vantage www.optometry.co.uk/cet/vantage-dates


Sponsored by

Sponsored by

a Novartis company

comes after the first year of wear. The investment

from the same practice where they buy their

lenses, so that they can see and feel the difference

compared before of (Abbott Medical contact lenses.12 This needed in time, andOptics therefore Inc., money,Santa is often were statisticinstillation is very reassuring not been Practitioners statisticallychannel validated at the themselves. huge resources eye drops, five lens minutes Ana, forfitting the duration quiteCalifornia, considerable,USA) so when patients it is Blink’n’Clean for practices with satisfied contact patients, time of this the results into gaining newpublication, wearers; introspectively can the represent first eye drop significant instillation, regard each instructed one as long-term, but may a further loss of are of good the practice study. to They were to after we say that a similar but level is usedconclusive. in retaining preliminary not requiring their dynamically evolving techniques and and income their after contacttwice lens business is lost. 14 ifdays daily use. maintain regular correct cleaning products. Monetary on the of contact regime (rub and data rinse) ascost well as Pre-lens non-invasive tear break-up lens normal dropouts isreplacement significantly lacking. Some time Conclusion (NIBUT) was evaluated without their schedule.

them? Finally, be wary of the old adage “if it isn’t broken… don’t fix results it” because Analysis and

it may be that

it is alreadygender broken is butnot we don’t realise it yet. Subject’s a parameter to estimates lost sales lenses to the industry The ‘thorny’ issue of contact lens of fluorescein dyecomfort with is be included in the analysis since the Types of putcontact used ininthe application regioninvestigation of £27.9m.12 Table widely regarded as an enigma of successful long- distribution 1 demonstrates About theofauthor types of mires, such as placido this were Biofinitythe different values is not balanced

57 49

termof patient yet we do or have various sufficiently cumulative effect of registering New four newYork, contact disc Mark Tomlinson in women). optics forThe 33 the satisfaction, videokeratograph mires (CooperVision, Fairport, (ninehas menbeen and 42 options and patient management techniques lens patients per week in optometric practice (it years as a Dispensing Optician, Contact Lens USA), Acuvue Oasys, Acuvue Oasys for of the keratometer. This allowed age distribution in the sample was normal He currently works test, p=0.66). and is a Practice NIBUT values

of contactstaining, lens and care products our disposal, was amount USA) earned at end of Air the year is an Corneal Academy Consultant(Kolmogorov-Smirnov for Alcon, where he which wasatanalysed Florida, AirtheOptix, Optix normal and even though we may our firstdye, choice lectures on various CET topics including impressive in this example the application of favour fluorescein Night & Day£24,024. (both However, CIBA Vision, Duluth,an with test, p>0.05 on all occasions), and

products, practitioners should remain aware of contact lenses. He has previously lectured average practice wouldPureVision lose a minimum of 12% of and hyperaemia were assessed according Georgia, USA) and (Bausch therefore parametric tests were applied individual needs and requirements. Practitioners patients from dropout, which equates to £2,883. widely to optometric audiences, including pre& Lomb, Rochester, New York, USA). to the Cornea and Contact Lens Research (ANOVA with post hoc analysis and should(CCLRU) not assume that patients not pay registration students and peers on a local level. Taking the European average of 30.4% grading scale will (School Subjects were wearing lenses for athowever, least Unit Pearson’s correlation coefficient). The this equates to a staggering loss of £7,303. more for a superior product and instead should five hours per day and were examined of Optometry and Vision Science, The remaining parameters follow categorical Recent market research showed that in the

assume that patients want what is best for them,

References

before

University of New South Wales, Sydney,

scaling and therefore non-parametric

administration of Blink’n’Clean eye drops,

Australia). LIPCOF were also counted,

tests

five minutes after the first instillation of

vertically below the temporal limbus.

Friedman

Blink’n’Clean eye drops, and 14 days

A subjective questionnaire (Table 1)

matched-pairs

after first use of Blink’n’Clean eye drops.

was also given to wearers five minutes

at

the

following

intervals:

UK, 86% of contact lens wearers were “always or highly likely” to purchase their spectacles

and should make a recommendation in a manner that allows the patient to compare different

See www.optometry.co.uk/clinical. Click on the

were

applied

(Chi-square,

article title and then on ‘references’ to download.

ANOVA,

and

Wilcoxon

signed-ranks

Non-invasive break-up time after first instillation Blink’n’Clean O/D/CL Module questions Course code:of C-20101 Results showed significantly

tests).

The authors used the modified Rudko validated

scale10,11

(Figure

1)

for

and again after 14 days of twice

higher

NIBUT values 30, after PLEASE NOTE There is only correct answer. is now use. FREE. Enter Please complete on November 2012 14 – youdays will be (13.4±6.7 daily It online. is necessary to online pointby midnight assessment of deposits onone contact lenses.All CET unable to submit exams after this date. Answers to the module will be published on www.optometry.co.uk/cet/exam-archive. CET points for these exams will be seconds) of twice-daily use of out that, since the questionnaire has Heaviness, extent and type of deposits uploaded to Vantage on December 10, 2012. Find out when CET points will be uploaded to Vantage at www.optometry.co.uk/cet/vantage-dates 1. Which of the following factors is likely to reduce contact lens comfort? a) Air conditioned environment Never Rarely Sometimes b) Cleaning lenses with rub and rinse c) Replacement of lenses on schedule 2.When exactly did you note this unpleasant wearing comfort? d) Plasma treatments on contact lens surfaces

4. What is the BEST strategy to keep a contact lens wearer in the long-term? a) Always fit silicone hydrogel lens materials for all patients Oftenpriced contact lenses Always b) Always fit the lowest c) Select a lens that meets the wearer’s lifestyle and wearing habits d) Let the wearer use which ever lens care product is on offer at the supermarket

1. During a normal day within the last week, how often was the wearing comfort of your contact lenses unpleasant?

Never

Early morning

Noon

Evening

All day

2. Which is the LEAST effective method of ascertaining true 5. Which lens type is associated with the greatest level of compliance forthis replacement 3. If patient you feltsymptoms? this unpleasant wearing comfort, how unpleasant was feeling atfrequency? the end of the contact lens wearing time? a) Asking patients to complete a questionnaire prior to the appointment a) Monthly disposables b) Asking patients to score their symptoms on a scale of 1 to 10 No problem Slightly unpleasant Unpleasant b) Two-weekly disposables Annoying Extremely annoying c) Asking open questions about how patients feel when wearing their c) Long-term replacement soft lenses contact lenses day within the last week - how often did you have d) There no difference modalities 4. During a normal theisfeeling that between your contact lenses are dirty? d) Asking closed questions such as “Is the vision with your lenses good?” who has hayfever, works Never Rarely Sometimes 6. Which is the MOST Oftenappropriate for a patientAlways 3. Which statement about lens care products is FALSE? in an air conditioned office, and wishes to wear contact lenses for four days per week, for seven hours per day? a) They be simple comfort to use andafter effectively remove pathogens from 5. How wasshould the wearing using Blink’n’Clean? lens surfaces a) Silicone hydrogel monthly disposable lenses with hydrogen peroxide Much Worseprotein deposits from silicone Same Much better b)worse They should effectively remove cleaning systemBetter hydrogel lenses b) Hydrogel daily disposable lenses incorporated with enhanced wetting agents 6. How was your vision after using Blink’n’Clean? c) Combination with certain lens materials may lead to SICS c) Silicone hydrogel daily disposable contact lenses d) Hydrogen peroxide systems can be used if patients are intolerant to d) Hydrogel monthly disposable lenses with ‘no rub/no rinse’ cleaning regime Much worse Worse Same Better Much better multi-purpose solutions

Table 1 Subjective questionnaire used to evaluate the effect of Blink’n’Clean eye drop use on contact lens comfort and vision For the latest CET visit www.optometry.co.uk/cet

02/11/12 23/03/12 CET CET

available to us help to keep our (Kolmogorov-Smirnov has been assumed that a variety(all of products Optician and Optometrist. of that theshould NIBUT without Presbyopia, Acuvue Advance Johnsonare calculation contact lens patients longer. There are a variety prescribed totalling £77 per week). The cumulative asThe a Locum Optometrist & Johnson Visioncare Inc., Jacksonville, interfering with tear film stability. distribution of


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Designed Interiors and Bespoke Furniture To discuss your options with one of our designers or for a copy of our “Directory of Practice Design� phone: 01594 546385

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5430 Aon Optomotrist ad 59 x 60mm_Layout 1 02/11/

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Finance made simple For a comprehensive range of competitive finance products including Practice Loans, Equipment Leasing, Motor Finance and Personal Loans contact us on 01635 876624 or e-mail info@premlease.co.uk

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Optometrist and Locum PracticeShield Insurance

Aon Limited is authorised and regulated by the Financial Services Authority in respect of insurance mediation FP6537.11.11

We’re behind you

To find out more and get a competitive quote: Visit endsleigh.co.uk/aop Or call us on 0800 028 3571 Endsleigh Insurance Services Limited is authorised and regulated by the Financial Services Authority. This can be checked on the FSA Register by visiting its website at www.fsa.gov.uk Endsleigh Insurance Services Limited. Company No: 856706 registered in England at Shurdington Road, Cheltenham Spa, Gloucestershire GL51 4UE.

BUY ONE GET ONE FREE Who needs them? NOT AN EYEPLAN ASSOCIATE OPTICIAN! For more information please contact: Tel: 01761 414142 Fax: 01761 414161 e-mail: info@eyeplan.co.uk care – quality - value

Optometry in North India 7 - 20 April 2013

R A Valuation Services Limited

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FOR AOP MEMBERS* Visit

INDEPENDENT PRACTICE VALUATIONS Essential guide when selling; buying; incorporating; legal/matrimonial separation; management or internal buyouts; probate; disputes; tax etc In celebrating 20 years of success with the AOP, RA is now offering a new Market Appraisal Mini Report for practices with a turnover of less than £100k.

Income Protection

www.pgmutual.co.uk/Quotation and enter ‘AOP11’ for your personal quote. *20% off first three years’ subscriptions. www.jonbainestours.co.uk/optometry For full details please contact: JON BAINES TOURS LIMITED info@jonbainestours.co.uk 020 7223 9485

call 0800 146 307 PG Mutual is the trading name of Pharmaceutical & General Provident Society Ltd. Incorporated in the United Kingdom under the Friendly Societies Act 1992, Registered Number 462F. Authorised and regulated by the Financial Services Authority, Firm Reference Number 110023.


EP165 C2

Telephone: 0121 585 6565 www.internationaleyewear.co.uk


Optometry Today November 2 2012