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www.optometry.co.uk May 3 2013 vol 53:9 ÂŁ4.95

optometrytoday

Journal of the Association of Optometrists

Wet AMD referrals audit

online

CET on clinical live decision-making Optrafair news and reviews

enewsletter

Practice potential Ideas to increase CL patients at BCLA’s Business Day


JANET REGER 4096


CONTENTS

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May 3 2013 vol 53:9

News/Comment

5 Lucentis warning

Eye care charities and professional bodies have warned Clinical Commissioning Groups about the rise in demand for the drug Lucentis to treat retinal diseases

6 Wet AMD breakthrough

Oraya Therapeutics’ study shows that a single dose of Oraya Therapy significantly reduces the need for anti-VEGF injections

Optrafair: news and reviews 18 Launching pad

New products on show at Optrafair 2013

21 Legal support

The AOP’s new employment counsel, Heidi Blakey, answers some of the legal queries raised by Association members

24 Eye spy

OT’s multimedia creative editor and optometrist Ceri Smith Jaynes names her top four ‘tried and tested’ instruments

7 Liver transplant link

People who have undergone a liver transplant are at increased risk of developing AMD, according to research

8 National Eye Week

A new guide has been launched to help the profession support the annual eye health campaign

Advice/Profiles 32 App update

OT speaks to optometrist David Crystal two years on from developing a dispensing App

53 Clinical

44 VRICS: C-31552 Clinical decision-making

Part 1. Optometrist Stanley Keys presents scenarios in practice which touch on four areas of clinical investigation and findings, with how optometrists might respond in practice

49 CET 1: 30971 Acquired brain injury

Part 3. Optometrist Mark Menezes describes how a patient with ABI can be managed in order to minimise the visual symptoms and problems they might experience

53 CET 2: C-31558 Shared care and referral pathways

38 Wet AMD audit

Part 3. Chris Steele provides an overview of cataract referral pathways and considers the implications of the new NHS changes for eye care practitioners

Events

Classified

30 NOC preview

59 Jobs

Optometrists Trevor Warburton and Susan Parker conduct a practice audit of wet AMD

10 News Extra

A census on the profession has been announced by the event company behind next year’s 100% Optical tradeshow in London

12 Comment

AOP chairman, David Shannon, reports on his Optometry Study Tour to India and reflects on the disparate approaches adopted by practitioners providing vision care to a poor population

Cover stories

26 BCLA means business

A one-day business seminar on driving practice growth and profitability through contact lenses will be held at the BCLA’s clinical conference next month OT Cover picture from Thinkstock

Feature is online

The National Optical Conference will be the profession’s chance to examine the impact of the NHS reforms

36 SECO review

The AOP’s head of professional development, Karen Sparrow, reviews the Atlanta event

Regulars

13 Letters to OT

Practitioners’ views on topical subjects including DO refraction and a GOS campaign

16 Student news

Applications are being sought for an annual summer research scholarship plus celebrations at Cardiff

www.optometry.co.uk

The latest optical vacancies

62 Marketplace Your guide to optical products and services

Company of the Year Association of Optometrists Awards 2012

03/05/13 CONTENTS

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12

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NEWS Emily McCormick emilymccormick@optometry.co.uk

A GROUP of eye care charities and professional bodies have joined forces to warn that people will lose sight needlessly unless the new-look NHS prioritises eye care. As part of Vision 2020 UK, the Macular Interest Group has written to senior officers in Clinical Commissioning Groups (CCGs) across England to highlight the rise in demand for the drug Lucentis, which is used to treat a number of retinal diseases, including macular oedema. Until recently, the sight-saving drug was solely approved on the NHS to treat wet AMD. However, in the past few months, the National Institute for Health and Care Excellence (NICE) has approved it for patients with macular oedema as a result of diabetic retinopathy. On April 11, it also approved Lucentis for those with macular oedema

caused by retinal vein occlusion. It is estimated that these subsequent approvals will increase demand for Lucentis by at least 50%, with this rising to 70% to 80% in some areas. NICE is also evaluating the use of a new drug called Eylea, which has been developed as an injection into the eye to treat the same range of diseases. The Macular Interest Group fears that ‘unless CCGs commission enough services from hospital trusts, they will not be able to meet demand and patients will lose their sight unnecessarily.’ Urging CCGs to review their plans for intravitreal injection services to ensure they purchase enough supplies for their areas, the letter reads: “Failure to commission, or deliver the

appropriate level of care will mean that people will lose their sight and place additional burden on other health and social care services.” Chairman of the Macular Interest Group, Winfried Amoaku, said: “We understand how stretched the NHS is, but giving Lucentis less often than required is a waste of money and causes unnecessary sight loss.” The recommendations from the Royal College of Ophthalmologists state that patients with wet AMD should wait no longer than two weeks for their first treatment, and be monitored every four weeks to determine if further treatment is required. Chief executive of the Macular Society, Helen Jackman (pictured), added: “Eye clinics around the country are under enormous pressure. The Government has made preventable sight loss a priority and we ask CCGs to do the same.”

Blind people have better memories, research finds PEOPLE WHO are congenitally blind have more accurate memories than those who are sighted, according to researchers from the University of Bath. Led by Dr Michael Proulx (pictured), the researchers ran memory tests on groups of congenitally blind people, people with late onset blindness and those who are sighted. Each participant was asked to listen to a series of word lists and then recall the words that they heard. Reporting the findings in the journal Behavioural Brain Research, the team found that congenitally blind participants remembered more words than the other two groups. Moreover, they were also less likely to

create false memories of the related words. In contrast, the sighted and late blind people remembered fewer words and were much more likely to falsely remember related words. Commenting on the findings, Dr Proulx said: “Our results show that visual experience has a

significant negative impact on both the number of items remembered and the accuracy of semantic memory, and also demonstrate the importance of adaptive neural plasticity in the congenitally blind brain for enhanced memory retrieval mechanisms. “There is an old Hebrew proverb that believes the blind were the most trustworthy sources for quotations, and that certainly seems true in this case. It will be interesting to see whether congenitally blind individuals would also be better witnesses in forensic studies.” The picture of Dr Proulx was supplied by Nic DelvesBroughton from the University of Bath.

To comment go to www.optometry.co.uk

IN BRIEF

AREDS2 findings to be revealed The Age-Related Eye Disease Study 2 (AREDS2) research team will present the results of its study during a special session at ARVO 2013 in the US. The findings of the randomised, controlled clinical trial of lutein/ zeaxanthin and omega-3 fatty acids for the treatment of AMD and cataract will be presented on Sunday (May 5) at the Washington State Convention Centre in Seattle. The study, which was conducted in 82 clinical sites in the USA, included over 4,000 participants aged between 50 and 85 years. These nutritional supplements were added to the original AREDS formula, which consisted of vitamins C, E, betacarotene, zinc and copper.

Survey appeal

A researcher at Nottingham Trent University is seeking practitioners to complete a quick and simple online survey exploring whether more can be done to aid the recycling, reusing and redistribution of equipment which optometrists use on a daily basis. To take part in the survey, visit www.surveymonkey. com/s/BV9LXB6

Independent expands Leeds-based Bayfields Opticians has confirmed its fifth acquisition, buying Patterson Opticians in Wakefield for an undisclosed sum. The acquisition puts Bayfields on target to meet its ambitious plan to have 50 outlets by 2025. The company was launched in 2004 by optometrist and managing director Royston Bayfield.

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03/05/13 NEWS

Lucentis demand warning


NEWS IN BRIEF

Focus on nutrition

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The latest information on the role of nutrition for vision will be presented at a conference at Downing College, Cambridge University, on July 9. The Vision for Optoms Conference will discuss ‘the role of macular pigment in terms of optimising the visual experience’ and will attract eight CET points. For full details and to book visit www.visionforoptoms.org

03/05/13 NEWS

GOC recruiting DO

The GOC has launched a campaign to recruit a new dispensing optician to its Investigation Committee. The Committee analyses allegations about registrants and decides whether further action is required. “The role is extremely important in protecting the public and upholding confidence in the profession,” said the GOC director of regulation, Mandie Lavin (pictured). “I’d encourage any dispensing optician who thinks they have the right skills and experience to consider applying.” The closing date for applications is 5pm on May 20.

WCO winners The World Council of Optometry (WCO) announced the winners of its international optometry awards at a ceremony in Malaga last month. Professor Brien Holden from Australia was named winner of the Distinguished Service award, while Dr Jillia Bird from Antigua was awarded the International Optometrist accolade. Dr Bird said: “I am deeply humbled to be chosen by the WCO for this prestigious award. Sight is by far our most precious sense. Each of us holds the potential to raise the world’s awareness of avoidable blindness, and in doing so, reduce the current unacceptable global blindness burden.”

Oraya Therapy reduces need for anti-VEGF Nikki Withers nikkiwithers@optometry.co.uk

RESULTS OF Oraya Therapeutics’ INTREPID study show that a single dose of Oraya Therapy significantly reduces the need for anti-VEGF injections for patients with wet AMD. The study, which was published online in the journal Ophthalmology last month, enrolled a total of 230 patients from 21 sites across five European countries. The investigators evaluated the effectiveness and safety of Oraya Therapy – a onetime radiation therapy – in conjunction with as-needed anti-VEGF injections.

The researchers reported that patients who had previously been treated with anti-VEGF for up to three years experienced a 32% reduction of injections and substantially drier retinas with Oraya Therapy compared with the control group. Moreover, 25% of Oraya Therapy patients needed no further injections. Among the best responders to Oraya therapy, there was a 52%

decrease in injections. “The results of the INTREPID study reported to date are encouraging for clinicians and individuals with wet AMD,” said lead investigator, Timothy Jackson, from King’s College Hospital in London. “The prospect of maintaining vision while needing fewer eye injections will appeal to any patient receiving anti-VEGF therapy, and for certain subsets in the trial there is the added advantage of an improved visual outcome.” Oraya Therapeutics’ CEO, Jim Taylor, added: “It is rare for a new therapy to demonstrate improved patient outcomes while simultaneously offering the potential to significantly reduce treatment burden and costs.”

New DME drug released in UK A DRUG developed to treat chronic diabetic macular edema (DME) was made available in the UK on Monday (April 29). Announced by the biopharmaceutical company Alimera Sciences, Iluvien is the first sustained release pharmaceutical product to be designed for the treatment of the sight-threatening condition. Iluvien is administered as an implant and works for up to 36 months. Injected into

the patient’s eye, it delivers sustained sub-microgram levels of fluocinolone acetonide. Alimera Sciences has submitted a Patient Access Scheme (PAS) to the National Institute for Health and Care Excellence (NICE), with its Appraisal Committee expected to meet on May 15 to discuss the submission. A 30-day review period is likely to follow. If accepted, Iluvien would be funded for NHS use with chronic DME patients in England and

Wales. Dan Myers, president and chief executive officer at Alimera Sciences, said: “We are pleased that Iluvien is now available in the UK. We continue to work with NICE and are hopeful that our simple PAS will make Iluvien available to a larger group of chronic DME patients in England and Wales, who are considered insufficiently responsive to available therapies.”

Education Destination seminar IN LIGHT of the success of the inaugural Education Destination event in 2012, the AOP, in partnership with SECO International, is once again hosting a two-day CET seminar focusing on therapeutics and

optometrist prescribing on October 6-7, 2013. The meeting, London 2013 Education Destination, will be held at the AOP offices and will explore optometry as a specialist area, with sessions targeted at

To comment go to www.optometry.co.uk

therapeutics, prescribing rights and the contrasts between UK and US patient care pathways. For more information and to book for the seminar and social programme, visit www.etouches.com/ London2013EducationDestination


m/

NEWS

Emily McCormick emilymccormick@optometry.co.uk

PEOPLE WHO have undergone a liver transplant are at increased risk of developing AMD, according to research published in the journal Ophthalmology last month. Led by ophthalmologist, professor Andrew Lotery, researchers at Southampton General Hospital discovered that almost two-thirds (65%) of liver transplant patients had developed some form of the sight-threatening condition. As a result, professor Lotery has called for more emphasis to be placed on the eye health of liver transplant patients, with regular monitoring recommended and the prompt referral to ophthalmologists if AMD is detected.

Cycling for the homeless OPTOMETRIST ELAINE Styles (pictured) will tackle the Trans Pyrenean Raid to raise funds for Vision Care for Homeless People in July. The seven-day cycle challenge will see Ms Styles cover 742km, climb 14,353m and raise £1,435 for the charity. She said: “Knowing what I am raising money for adds to the incentive to get up those long steep mountain climbs. For every £5 raised a homeless person will have a free eye examination and a pair of spectacles. To sponsor Ms Styles, visit http://uk.virginmoneygiving. com/ElaineMcKnight

During the three-year study, which aimed to explore the relationship between the eye disease and transplantation, the team of experts monitored 223 Western European patients aged 55 years and over who had received a liver transplant at least five years previously. Prior to the study, a mutation which causes the complement factor H (CFH) gene in the liver to produce abnormal proteins had been pinpointed as more common to AMD sufferers, possibly causing inflammation in the eye. Professor Lotery said: “This study has provided us with some invaluable insights into this complex eye disease and the intriguing science behind CFH. As a result of this project, we have discovered liver transplant patients have a high

incidence of AMD and that was unexpected.” The specialists were keen to discover if receiving a new liver, without the mutation, had an effect on the development of AMD and inflammation in the eye. They reported that levels of inflammation in the eye remained unchanged in patients with AMD after a liver transplant, concluding that the liver is not responsible for the development of AMD and therefore AMD treatment directly into the eye was likely to be most successful.

Growth in the UK CL market THE CONTACT lens market in the UK was worth £234.4m in 2012, the ACLM has reported, up 1% compared to 2011 figures. The statistics, which derive from 12 contributing members of the Association, found that over 606 million contact lens sales occurred in 2012. Over half of the market’s value comprised of daily disposables (59%), while soft frequent replacement lenses made up 35%, traditional soft lenses 1% and rigid lenses 5%. A total of 3.7 million contact lenses wearers in the UK were identified, which accounts for 9% of adults aged between 15-64 years. Of this total, 1.61 million people wore daily disposables

and 1.74 million used frequent replacement lenses, with 1.32 million of frequent replacement lens wearers opting for silicone hydrogels. Statistics show that the number of contact lens wearers has more than doubled in the UK over the last 10 years, from 1.6 million in 1992, to 2012’s 3.713 million figure. However, this is down on last year’s 3.772 million. Despite wearer figures reporting a 2% year-on-year fall, market value has risen from £231,064m in 2011 to £234,386m in 2012. In addition, the market value has risen dramatically since 1992, when its worth was reported at £33,373m.

To comment go to www.optometry.co.uk

IN BRIEF

Guilty DO A dispensing optician who was suspended from practising last year has been found guilty of assault occasioning actual bodily harm and making a threat to kill. Shashi Obhrai, from Moor Park in London, was part of a group of three people convicted at Croydon Crown Court for abusing an Indian woman who was treated like a servant. The court heard that with little food provided by her employers, Ms Obhari would beat the victim when she was too dizzy to cook. She was paid around £2,300 from 2003 to 2006. Her employers also took her passport away from her, and one sexually abused her.

AIO conference

The Association for Independent Optometrists and Dispensing Opticians (AIO), which sees itself as ‘a pressure group for the independent sector,’ is holding a conference at Eastwell Manor in Ashford, Kent, from October 11-14. A CET programme will be held on Sunday, October 13 featuring 11 speakers and a group discussion. The topics will be ophthalmology and the optometrist, dispensing matters, contact lens matters and instrumentation. For details, visit www.afio. co.uk. To book, email nigelhodd @nfburnetthodd.com

India proposal Optometrist Helen Kershaw received a romantic, surprise proposal from boyfriend John Attrill outside the Taj Mahal during a recent Jon Baines Study Tour to North India. The newly engaged pair were travelling with a group of practitioners around India from April 7-20. The tour group, which was led by AOP chairman David Shannon, made stops in Delhi, Jodphur, Pushkar, Jaipur and Agra (read more on p12). The optometrist duo first met on a Jon Baines Study Tour to South India in 2011.

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03/05/13 NEWS

Liver transplant link to AMD discovered


NEWS

COMMENT

Guide is launched for National Eye Week Robina Moss robinamoss@optometry.co.uk

03/05/13 NEWS

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A FREE guide has been launched to encourage support for National Eye Week, the ‘UK’s biggest celebration of eyes and eye health’. The campaign (from September 16-22) provides a unique opportunity for the eye care sector to raise awareness of the importance of good eye health and the need for regular sight tests for all. The booklet on this year’s campaign, ‘Your Guide to Getting Involved’ , was distributed at Optrafair. It has the slogan ‘Your vision matters’ and can be downloaded from the website www.visionmatters.org.uk. “This free guide is a fantastic toolkit to inspire everyone to get involved in this year’s National Eye Health Week,” chair of the National Eye Health Week steering group, Francesca Marchetti (pictured), told OT. “It includes ideas about innovative events that can be organised and details of the free resources which will be available later this summer to help make the event as successful as possible. Register events and download the guide today,” she urged. The support resources will be launched next month at the Vision UK Conference at the Queen Elizabeth II Conference Centre,

London, on June 11. Last year, more than 500 organisations participated in the campaign week. The new guide gives ideas on how to get started on raising awareness of the importance of good eye health, including using the Internet and social media. Practitioners or organisations can get involved in a number of ways. There are sponsorship opportunities for organisations to partner with National Eye Week campaigns which promote the link between smoking and poor eye health, strategies for preventing falls caused by poor vision, as well as NHS entitlements to sight testing and domiciliary care. ‘Unofficial partners’ can create their own mini-campaign, or event, promoting good eye health. Supporting organisations will have the opportunity to download the campaign logo when they register their activity on the visionmatters website. The campaign team can be contacted on 0845 2268 063.

Tetris ‘could help lazy eye’ PLAYING THE popular video game Tetris has been found to be an effective way of treating lazy eye, Canadian researchers have reported. The study, performed by a team of scientists at McGill University in Montreal, discovered that the puzzle game was able to train both eyes to work together. Consisting of 18 adults, the study found that using Tetris was more effective at treating the condition than the conventional patching method, which sees the good eye covered to make the weak eye work harder. Published in Current Biology, researchers will trial the treatment on children across North America later this year. Dr Robert Hess and colleagues used a special pair of video goggles in the study which ensured that both eyes would work together. Nine amblyopic volunteers wore

them for an hour a day over the two-week period when playing Tetris. As a comparison, a second group of nine volunteers with amblyopia wore similar goggles, but with their good eye covered, they watched the game through their lazy eye only. At the end of the study, researchers found that those who used both eyes showed more vision improvement than the patched group. They also showed improvement in 3D depth perception. The comparison ‘patched’ group then played the game with both eyes uncovered, showing ‘dramatically’ improved vision as a result. Dr Hess believes that the treatment could be a suitable alternative to patching those with lazy eye, especially for adults whom patching tends not to be beneficial.

MAKING CONTACT Over the last fortnight, at OT HQ we have seen a flurry – mercifully not of snow – but of statistics on the state of the contact lens market in the UK. The Association of Contact Lens Manufacturers (ACLM), working alongside 12 contributing members, has been reviewing studiously the facts and figures for 2012 (see page 7). Examining current consumer trends, the report re-confirmed the strength of support for daily disposables, which represented 59% of the market’s value, while soft frequent replacement lenses covered 35%. A bellwether, certainly for CL practitioners and service-providers, is the actual number of CL wearers in the UK, and, critically, what percentage growth that represents year-on-year. In the latest ACLM study, 3.713 million wearers were identified in 2012 – a slight drop from 2011’s estimate of 3.772 million. While far from calamitous, the lack of growth will help to focus minds, none more so than at the BCLA Business Day, on Sunday, June 9, at Manchester Central (see page 26 for OT ’s preview). A standalone, one-day event, the programme has been designed for practitioners ranging from support staff to practice manager. During the day, the MD of independent group Eyesite, David Samuel, a DO, will speak on ‘Retaining patients and reducing dropout.’ Drawing on research and personal experiences, he will reflect on: the state of the contact lens market; why patients stop wearing contact lenses; why they continue, but attend a different practice; and strategies which could help reduce drop out and how they can assist business growth. The results of the ACLM’s survey on Internet sales will also be shared on the day, billed by optometrist and business guru Peter Ivins, as a “wake-up call” to contact lens practitioners. He notes: “The Internet as a supply channel is here to stay and will get bigger. My view is that it is an opportunity if you know how to harness it.” The BCLA Business Day is the smart option for practitioners to understand the way to really improve their contact lens dispense – be it their business approach or their own performance in practice. John White, OT managing editor johnwhite@optometry.co.uk

To comment go to www.optometry.co.uk


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NEWS EXTRA optometrytoday

Journal of the Association of Optometrists

MAY 3 2013 VOLUME 53:9 ISSN 0268-5485 ABC CERTIFICATE OF CIRCULATION January 1 2012 – December 31 2012 Average Net: 20, 575 UK: 19, 726 Other Countries: 849

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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

03/05/13 NEWS EXTRA

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 Multimedia Creative Editor: Ceri Smith-Jaynes E: cerismithjaynes@optometry.co.uk Editorial Office: 2 Woodbridge Street, London, EC1R 0DG Advertising and sponsorship: Oliver Todd T: 020 7657 1810 E: oliver.todd@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 AOP Membership Dept: AOP, 2 Woodbridge Street, London, EC1R 0DG T: 020 7549 2010 W: www.aop.org.uk Advertising Office: Ten Alps Media, 40 Bowling Green Lane, London EC1R 0NE Production Office: Ten Alps Creative, Commonwealth House, One New Oxford Street, High Holborn, London WC1A 1NU

live Census on the profession is announced

bookshop

enewsletter

CET

tv

VRICS

Emily McCormick emilymccormick@optometry.co.uk

THE EVENT company behind next year’s 100% Optical tradeshow in London will commission one of the UK’s largest research companies to investigate the market conditions, views and trends of the optics industry. Through the research, which will be carried out by MarketMakers, Media 10 seeks to reach every optical trade professional and find out what they want from a tradeshow. Entitled Optical Census, the independent survey will see practitioners interviewed to provide a greater insight into the number of optometrists and opticians practising in the UK, as well as the company they work for, the practice location and size. Scheduled to begin on Monday (May 6), practitioners

who wish to take part in the survey should visit www.100percentoptical.com and complete the brief survey. They will then be contacted via telephone for a short interview. Show manager, Nathan Garnett, said: “This industry-wide initiative will provide us with the vital insight necessary to deliver an exhibition and education programme that not only meets, but also exceeds, the needs and expectations of all sectors of the optical industry, both here in the UK and overseas.” MarketMakers has specialised in telemarketing for over 25 years and has appeared in the Times’ ‘ Top 100 companies to work for’, for the last four years. Previous clients include Microsoft and HSBC. Business director at MarketMakers, Graham Gillett,

Editorial Advisory Board: Mohammed Abid, Vivian Bush, Leon Davies, Cameron Hudson, Polly Dulley, Dan Ehrlich, Andy Hepworth, Olivia Hunt, Niall Hynes, Ceri Smith-Jaynes, Vicky O’Connor, Sonal Rughani, David Ruston, David Shannon, Bryony Stather, Gaynor Tromans, David Whitaker, Andy Yorke. 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

To comment go to www.optometry.co.uk

commented: “We are looking forward to working on this project. To run any successful business, it is vital that databases are accurate and current. Media 10’s audit of the optical market is incredibly exciting and something the industry should do annually.” The show, 100% Optical, will be held at the ExCel exhibition centre in London on February 16-18, 2014. The three-day event will comprise of four key areas, which organisers have described as being like four different shows. They include, 100% Eyewear, 100% Lenses, 100% Equipment and Machinery, and 100% Business Services. Companies already confirmed as exhibitors are: William Morris London, ic!Berlin, Lindburg, gotti Switzerland, Jono Hennessy (pictured above), Carter Bond and Zuma Eyewear. Confirmed in February this year, the show will also feature live seminars on topics such as business development, research and education. It is predicted that the inaugural event will attract around 8,000 visitors from across the globe, ranging from buyers, designers, dispensers and optometrists, to orthoptists, laboratory managers, technicians, ophthalmologists and students. For more information on the census and the show, visit www.100percentoptical.com


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COMMENT

03/05/13 COMMENT

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Land of contrasts

Following an Optometry Study Tour across North India, AOP chairman David Shannon reflects on the disparate approaches adopted by practitioners to tackle the challenges of providing vision care there THE TOUR bus serenely pulls out of the hotel on to the right-hand side of the road. This strikes me as odd; in India, like the UK, people drive on the left. Cars and rickshaws come hurtling towards us, horns blaring. One member of our group, who has had his head buried in a book, looks up, mutters something, and quickly retreats to his reading matter. Luv, our tour guide, with an infectious laugh announces: “In England you drive on the left. In India we drive where the road is left.” So began our Optometry Study Tour across North India on what affectionately became known as the ‘Luv Bus.’ Explaining the rules to frequent gasps from inside the bus, Luv tells us that “we have only one rule: there are no rules.” In truth, the signs by the roadside say otherwise – not that you would notice. There are only three things required to drive in India he continues: “Good horn, good brakes, good luck.” Nipping round a roundabout to the right – “because it is quicker” – rather than the left, could be seen either as wonderfully liberating or downright

scary, depending on your perspective. This dichotomy struck me as epitomising India: a land of contrasts among vibrant colours; rapidly developing, but still with significant problems; an incredible sense of history and a deservedly proud people keen to learn as much from us as we were from them. Despite the wonderful sights and history to explore, the primary purpose of our trip was to learn about optometry and eye care. At Dr Shroff’s Charity Eye Hospital, in Delhi and The Tarabai Desai Eye Hospital, in Jodphur, we learned about the huge cost to their society of uncorrected refractive error and the challenges of dealing with what is often avoidable blindness. Both continued to look for innovative solutions to deal with their problems, including training optometrists and moving towards a cross-subsidy financial model. At the other extreme at Eye Destination Jaipur, we met a young optometrist with a modern practice equipped with the latest OCT and frames imported directly from Europe. He proudly told

us of his colleagues’ astonishment when he decided to charge for an eye examination, explaining that: “If it is free, it has no value.” What really impressed us though was the determination of all those we met in India. In Delhi, representatives of the India Optometry Federation outlined their aspirations for the future of the profession. For them, optometry should be recognised by the Government, optometric education should be appropriately regulated, and there should be a national council for the profession similar to the UK’s General Optical Council. They were passionate in making their case. Having no official regulation for optometry brings me back to that roundabout: wonderfully liberating or downright scary? David Shannon travelled to North India with Jon Baines Tours, an AOP member benefit provider. For more information, visit www.jonbainestours.co.uk www.facebook.com/AOPChairman www.twitter.com/AOPChair


DO refraction ‘betrayal’ Dear OT, DO refraction is ‘on the agenda’ says the new ABDO president. I hope not. The AOP and the College, collectively and individually, should immediately become proactive to ensure that the aspirations of the new ABDO president are not realised. I became involved in optical politics in the late 1950s and early 1960s. This period saw the fruition of decades of endeavour against governments and the medical profession, led by the redoubtable George Giles with the passing of the Opticians Act and the establishment of the GOC. The role of the ophthalmic optician (optometrist) and the protection of the public were now enshrined in statute and law. If our present leaders allow, by default, the creation of two standards of eye examination, they will betray the legacy of generations of members of the BOA (British Optical Association) and SMC (Spectacle Makers Company)who worked so hard to achieve recognition. Recognition of DO refractions would be a major retrograde step for the profession and a disservice to the health care of the nation.

Stuart H Macpherson, chairman of the AOP 1964/65

ABI CET clarification Dear OT, The article on ‘Acquired brain injury: part 2’ (April 19, p58-62) suggests that Cardiff Acuity Cards can be used for acuity measurement in patients. Please note that the test is called the Cardiff Acuity Test and has never been called ‘Cards’. The illustration (figure 2) in that article is of the Cardiff Contrast Test and has as the caption ‘The Cardiff (Contrast) Acuity Cards Test.’ Readers should be made aware that there are two separate tests; the Cardiff Acuity Test whichmeasures acuity and the Cardiff Contrast Test which measures contrast sensitivity. Both might be useful in the assessment of a patient with brain injury, but each measures a very different aspect of vision and the two should NOT be confused.

J Margaret Woodhouse, senior lecturer and optometrist, Cardiff

AIO GOS campaign Dear OT, One of the issues that the Association for Independent Optometrists and Dispensing Opticians (AIO) is campaigning for is that any practice providing a ‘free’ eye test or charging less than the GOS fee should be unable to claim a full GOS fee from the local payment authority. This is for the following reasons:

LETTERS •It is immoral to claim a fee from the state for something that is otherwise being provided for less, or even given away for nothing

• It amounts to discrimination against those who are entitled to an NHS test by making the state pay when everyone else going to that practice gets it either for less or for ‘free’ • It forces the practices performing free or discounted eye tests to have to sell more spectacles per client. This leads to overprescribing which can create in the public a mistrust of the profession as a whole • There is little chance of a realistic fee ever being paid by the state for a service that is commonly used merely as a loss leader to obtain a sale • It demeans the whole optical profession by making the service we provide appear worthless Most independent practitioners would agree with this logic. So, it appears, would multiple-employed practitioners, many of whom expressed, when visiting the AIO stand at Optrafair, their concerns. We heard many stories of professional judgement being overruled by commercial pressures, for example the reduction of ‘testing’ times to an unacceptable degree and the enforcement of high per cent conversion rates. Failure to comply in either of these by an employee would result in a manager’s reprimand at the least, even for graduates in their preregistration year. Such exploitation of a professionally qualified person, registered or unregistered, should not be allowed to continue. For the future of the profession, we urge those who find themselves in contentious circumstances to make a formal complaint to the GOC – their employer is unlikely to be complying with the Code of Conduct as stipulated for Body Corporates. If in any doubt about this course of action, informally contact the GOC beforehand for advice.

David Beaumont, AIO chairman; Peter Warren, AIO vice chairman; and Patricia Davies, AIO secretary

Fluorets attention Dear OT, Why this hue and cry over the discontinuation of fluorets by Bausch + Lomb when the company doesn’t find it economical to continue with its production? There are other brands available, and one of these may well be tested and licensed for use by British practitioners. Like the majority of other practitioners in India, I have been using FluoStrips with absolutely no complaints... and eye care practices in India are fortunately on par with the best available elsewhere.

Dr Narendra Kumar, Ophthacare Eye Centre, India

Do you agree, or disagree, with our readers views? Write, or email johnwhite@optometry.co.uk and share your opinions. 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, EC1R23/07/2012 0DG

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03/05/13 LETTERS

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INDUSTRYNEWS TRADING PLACES

Contact lens developments

New styles are blooming

03/05/13 INDUSTRY NEWS

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JOHNSON & JOHNSON Vision Care has expanded its professional affairs consultant team to support the roll-out of practice-based education and product support programmes. Optometrist Dimple Zala and contact lens optician Karen Chambers have recently been appointed, and will be covering London and the south respectively. Director of professional affairs, Marcella McParland, said: “Their experience will offer a fresh perspective and build on the current team’s knowledge, as the group works to offer education and support to practitioners across the UK and Ireland. In 2013 we will be offering new in-practice Acuvue training programmes for practitioners, as well as facilitating Peer Review discussion groups.” Pictured is the team with professional affairs manager Ian Pyzer, centre. L-R is Karen Chambers, Robyn Marsden, Preete Kumar, Tony Hibberd, Liya Ali, Dimple Zala, Robin Reid and Pam Ernest. SAUFLON HAS appointed optometrist Sue Cockayne to the board of directors as professional services director. She joined the contact lens company in September 2011, bringing Sauflon her wealth of experience in retail optics. Since joining she has been instrumental in the successful launch of two ‘world first products’ – clariti 1day toric and clariti 1day multifocal, providing professional services support in all markets across the globe. As Sauflon’s business continues to grow, she will support the development, and launch, of new products, co-ordinating Sauflon’s professional services input in all markets.

LUXOTTICA’S NEW frames and sunglasses collections will be available to order from midMay onwards. A high profile press day was held in London last week, attended by OT’s Robina Moss, which showed 17 collections and previewed the autumn/winter 2013/14 collections. The event was attended by 200 representatives of the national and fashion press, with consumer coverage expected to follow. A distinctive high fashion trend from Prada was the use of floral details in its special ‘Poeme Sunglasses’ capsule collection which was presented in the spring/summer 2013 shows. The Poeme Deluxe model SPR 25P (pictured in medium tortoiseshell) has handpainted flowers in black and white combinations. A less flamboyant option could be seen in the optical version VPR 07Q (pictured) which has the flowers on the arms and also has them available in black and red combinations. Stella McCartney is presenting a new sun collection and her second optical range. There are also new high fashion lines in Miu Miu as well as Dolce & Gabbana, Burberry, Ralph Lauren, DKNY, and interesting jewellery details from Tiffany & Co inspired by necklaces and bracelets.

www.luxottica.com

Invention on the radio THE MANAGING director of Anglo Italian Optical, Bob Forgan, made a guest appearance on BBC Radio 2’s Simon Mayo show recently, when he was invited into the studio to talk about his latest innovation, Aquaviz, which featured in OT industry news earlier this year. Show producer Rebecca Pike (pictured) was intrigued to know more about Aquaviz, the world’s first prescription watersports mask. It has a unique ‘snap in’ lens insert, which can be interchanged between swim, snorkel and ski masks, and is designed to sit the same distance away from the eyes as glasses, to maintain normal vision. “I’ve always been a fan of Mayo’s weekly innovations slot and was surprised, but delighted, of course, to be invited on the show,” Mr Forgan told OT. “The reaction from listeners has been astonishing and I’ve spent at least two full days replying to hundreds of emails, and the team has been busy processing orders. “Also as a result of my appearance, Jason Bradbury from The Gadget Show tweeted about Aquaviz and we’re in the process of sending him it too.”

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26/04/2013 15:35


STUDENTNEWS

Summer scholarship opens

03/05/13 STUDENT NEWS

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APPLICATIONS ARE being sought for contact lens giant CooperVision’s annual Summer Research Scholarship. Open to all second-year optometry students across the UK, the programme provides undergraduates with a unique insight into contact lens research. The applicant of the winning project at each institution will receive a £2,000 prize, which will allow them to conduct their study, with the chance to attend the National Student Summit at CooperVision’s headquarters near Southampton in September. The six- to eight-week research project should be based on a contact lens topic of the student’s choice, and will be undertaken this summer. The nine selected finalists will present their findings to a panel of judges at CooperVision’s headquarters on September 16-17, where they will compete to be selected as ‘Student of the Year.’ Last year’s winner from Glasgow Caledonian University, Michelle Snowball (pictured), said: “The summer scholarship was great fun and provided a chance for me to not only expand my

own anterior eye knowledge, but also make a contribution to this field. I was very fortunate to have a good supervisor who was always on hand with ideas, support and a good sense of humour when things went wrong.” Ms Snowball’s project was entitled ‘Devices to investigate the anterior eye.’ She added: “Winning the scholarship has meant that I can start my preregistration year with a good grounding in cutting edge research. I would thoroughly recommend the scholarship to optometry students with an interest in research. It’s an eye-opening opportunity and provides invaluable career experience.” Students interested in applying for the scheme are advised to contact their head of department.

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AOP student reps are named THE AOP has announced the names of eight of the nine optometry undergraduates selected as student representatives for the Association for the 2013/14 academic year. They are: Sonam Ruparelia for Anglia Ruskin University; Aston University’s Malcolm Maclver; the University of Bradford’s Melissa Ramsey; Manish Patel for Cardiff University; City University’s Tulsi Parekh; Gemma Hill for Glasgow Caledonian University; Henal Patel for the University of Manchester; and Ulster University’s Nina Richardson. All students, alongside new OT student representative Mohammed Abid, met at an annual student forum during Optrafair last month. Head of professional development at the AOP, Karen Sparrow, said: “It has been incredibly difficult to choose one representative per university from the large number of applications which were all of an excellent standard.” A representative for Plymouth University is yet to be confirmed.

UltraVision hosts Eye Ball celebrations at Cardiff school visit OVER 250 undergraduates, postgraduates and staff from Cardiff University’s optometry department have attended the School’s annual celebratory Eye Ball. Hosted at The Coal Exchange in Cardiff Bay, the James Bond themed evening was organised by the University’s Optometry Society (OPSOC) and raised more than £300 for Vision4Africa. A three-course meal and jazz band was followed by a charity raffle and awards

ceremony. Vision4Africa sees a group of second-year Cardiff optometry students attend a summer project. Pictured left to right are OPSOC organisers: Angharad Hobby, Elizabeth Ainsworth, Shaimil Shah, Zarna Dasani, Nicholas Campbell, Nicole King, Jasmeet Bahra, Lowi Rooke and Eimear Fitzgerald.

A GROUP of Science A-Level students from Vandyke Upper School and Community College in Bedfordshire recently visited the headquarters of UltraVision to learn about the science behind the manufacturing of contact lenses. Clinical and customer services advisor manager, Josie Barlow, and export executive, Wendy Churchill, led the students’ visit, while answering any questions they had. Ms Barlow said: “The students were always engaged and asked some fantastic questions that will enhance their applied science studies.”


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26/04/2013 15:20


OPTRAFAIR

Launching pad Exhibitors pulled out all the stops at Optrafair 2013 with new products and services launching across all sectors. OT ’s Robina Moss reports on some of the highlights

03/05/13 OPTRAFAIR LAUNCHES

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ONE OF the joys of this year’s show was the feeling of optimism and confidence in the profession inspired by the exhibitors. It was clear that more thought than ever had been put into the stands and staff were proud to demonstrate their wares to show visitors. It created an electric atmosphere, especially on the Sunday. The event saw attendees looking to the future, with companies actively seeking to help practitioners build their businesses with innovative products and new services.

Frames and sunglasses Dunelm Optical said it was one of the busiest Optrafairs in the 32 years that it has been attending the show. The family firm was ‘inundated with orders’ for its new frames, which included fashionable styles from Paul Costelloe, with the female optical collection attracting a lot of attention (pictured above is PC5089 which boasts the ‘finest quality Mazzucchelli Italian acetate’ with a quilted pattern running down the sides). There were also new additions previewed from the Janet Reger and Celine Dion collections, as well as Dunelm’s own Julian Beaumont, Retro and Whiz Kids ranges.

“The mood at the show was buoyant, and a sure sign that the optical market has weathered the worst of the storm” “The reaction to the 150 new styles we previewed, across the ranges was fantastic and we secured a good number of quality leads,” said Dunelm Optical director, Peter Beaumont. “The mood at the show was buoyant, and a sure sign that the optical market has weathered the worst of the storm.” Continental Eyewear launched 47 new styles, with 600 frames on display on its colourful stand – the well-known show stalwarts even had special ties to match the distinctive pink with blue spots. The most popular frames were the colourful X-eyes, with Lazer Junior in the TR90 material also attracting a lot of interest. The children’s frames are very flexible and are offered in two designs, Lazer Junior 2102 and 2104. Another six styles will be launched later in the year. Viva International Group exhibited its frames and sunglasses at this year’s Optrafair for the first time in over 10 years. Over 500 practitioners visited the stand which featured a Guessthemed lounge area. CECOP, Europe’s largest international optical buying group, exhibited its new frame ranges, and launched The Fab Glasses, designed for a ‘cosmopolitan’ audience. OWP, celebrating its 66th anniversary and exhibiting in its own right, launched 12 new styles in OWP and 14 in the Mexx range. As well as the big players in the optical market, small, unique businesses made the most of the opportunity. Fan Frames, based in Hull, had 60 styles on display in the


Lenses During a briefing at the show, PPG Industries announced the UK launch of Tribrid lenses made of a new material that has taken 10 years to develop. The lenses will be available through Norville, Seiko and Shamir. To introduce them to the UK, executives from all four companies presented their perspectives on what the lenses mean for practitioners and patients. The main benefit is that they are suited to patients with higher prescriptions within the +/-3.00 to +/-7.00 diopters range but are designed to be thinner and more comfortable. “Tribrid material represents the next evolution in lens material technology,” said Frédéric Lefranc, PPG director of prescription sales, EMEA and Southeast Asia. “It expands upon the foundation of the Trivex material that the industry has come to trust – clarity, lightweight, strength and UV protection – and it makes those desirable attributes available in a thinner lens to meet the everyday visual needs of patients with higher prescription requirements.” Carl Zeiss Vision showcased its new portfolio of lenses, its latest dispensing technology equipment such as the i.Terminal

19 03/05/13 OPTRAFAIR LAUNCHES

Fashion Quarter across 10 football teams. “We might be the smallest company here but we have the largest brands such as Manchester United and Liverpool FC,” said director, optometrist Paul Gibson with a smile. Orange Eyewear launched a small capsule collection of five CC sunglass styles which will be “exclusive to independent opticians until 2014,” according to the MD, Hanna Nussbaum. DO Chintu Bhatt, the sales manager of Feb31st (named after a nonexistent date to show its uniqueness), was on a mission to “make wood frames more apparent in the UK.” The 2013 collection of optical and sunglass models features new styles (pictured bottom left on page 18) and a wider choice of colour combinations. Among these is a “capsule collection” in Kauri wood from New Zealand, carbon dated as being 48,000 years old. Another DO, Jayshree Vasani, launched her new venture with a stand at Optrafair. She is the UK distributor of Erin’s World frames (pictured right), designed for people with Down’s syndrome and those with low bridges. They were developed by a US optician whose daughter, Erin, has the genetic condition. The range consists of 14 models and 20 colours. “Patients with Down’s syndrome have difficulty with their specs constantly slipping and are consequently looking over the top of their glasses,” she explained. “This is because of their unique features. However, my hope is to change this.” The California-based Shauns Shades has the slogan, ‘Every time you buy a pair of sunglasses, we give a pair to someone in need.’ The company was founded by Shaun Paterson, 33, from Edinburgh whose early struggles with vision inspired him to provide eyewear to the visually impaired in developing countries. The sunglasses are named after areas of Scotland and feature three dots in braille, which spell out the ‘give sight’ message.

2 and its new black and white brand identity, focusing on capturing special moments in people’s lives.

Software Software for independents proved a big draw. York-based Optix Software had a particularly busy show. “Optrafair for us was simply astonishing, especially on the Sunday when, despite having 15 staff on our stand, we still struggled to cope with the demand for information and demonstrations,” said managing director, Trevor Rowley. “We saw many people for the first time and took confirmed orders for Optix installations at over 90 new sites. The feature that has created the most excitement this year is our new next-generation MySight online patient portal which attracted interest from some very major industry names.” Optrafair 2013 saw the preview launch of ‘Flex,’ the new practice management software package from Optinet which ‘will be making life better for practice staff,’ when it is released this summer, it is claimed. “Flex is not just another upgrade; it is a complete re-write from the ground up,” said Optinet sales manager, Chris Smith. Optometrist Andy Clark’s Practice Building company launched The Cashflow Wizard, a mentored programme ‘designed to put more money into an independent’s bank account.’ The company works one-to-one with the practice owner and tackles projects one at a time, giving coaching, support and tools as necessary.


OPTRAFAIR

A little something extra at Optrafair 2013 OT ’s Nikki Withers reviews the attractions that made Optrafair 2013 ‘not just a tradeshow’

03/05/13 OPTRAFAIR EVENTS

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AFTER ELOQUENTLY being labelled an ‘Optrafair virgin,’ I arrived in Birmingham last month not knowing what to expect. Once I had collected my pass, I was one of the 6,600 people to pass through the doors of the NEC halls and enter into the world of Optrafair. I was blown away by the variety of frames, lenses, and technology on display, but I was also impressed by the ‘added extras’ that the show had to offer. FMO chief executive and show organiser Malcolm Polley told OT that he wanted the show to be even more attractive than before. “The unique thing about Optrafair is that it’s not just about frames, it’s not just about lenses, it’s not just about instrumentation and software,” he said.

Window dressing creatively Prominently positioned at the event’s entrance, the three regional finalists of the window dressing competition were on display for all to see. The winning design was the Emporio Armani window (pictured), sponsored by Luxottica and dressed by Jilly Southworth, an optical advisor at Broadhurst Optometrists. Her romantic beach-inspired design was chosen as the unanimous winner. After judging the competition, managing director of Green Room Retail, Richard Ash, offered some advice on window dressing. “It is important to keep in mind the fact that the audience for a High Street window is normally passing at quite a pace, and the window has just three or four seconds to stop them in their tracks,” he said. “The window is not normally viewed straight on, but at a 30 degree acute angle and this is important to remember when the design is created.”

Educating the profession Replay Learning offered a three-day CET programme to practitioners in a purposebuilt educational arena. During the event the provider’s managing director, Peter Charlesworth told OT that he was really pleased with how the programme was going. “It’s great, all of the sessions are fully booked and attendance is high. We’re very pleased.”

Optical runway

A dog is for life

High-end fashion could be seen three times a day on the Optrafair catwalk. Located in the Fashion Quarter, which was 33% larger than the 2011 event, the runway saw an array of models strutting their stuff while wearing the latest fashion frames. Conveniently, Orange Eyewear was giving away popcorn nearby, while the Champagne bar certainly saw its fair share of customers. Also strutting around the show floor were two scantily clad promoters for Butterflies Healthcare – a woman in a bikini and a muscle man in silver swim shorts is certainly one way to get people to notice your stand.

In the charities area, the Guide Dogs display brought in the crowds, young and old. Talking to OT, Jackie Potts, who works for the charity, explained that the full lifetime cost of a guide dog from, birth to retirement, is around £50,000. “We’re privileged to be here at Optrafair, and we’ve had lots of people showing interest in what we do. It’s all about raising awareness,” she said. Mr Polley explained to OT that the charities are all given free stands. “They all give so much to the industry, we want to give something back,” he explained.

The best in design By popular demand, the OptraAwards returned this year. Celebrating the very best of frame design, exhibitors at the show were invited to send in their submissions. The ProDesign model 7624 won best male ophthalmic, the best female ophthalmic was won by J.F. Rey 2498 7080 and Tiny Tots Tomato by Tots Specs was awarded for best junior ophthalmic. Dunhill 1027 and J.F. Rey Bloody Lys from Caseco won the accolade for best male and female sunglasses, respectively.

A little extra You would be hard-pressed to miss the double decker bus which was located in the centre of the hall and was promoting Optrafair London in 2014. Other notable features were a piano player, a caricaturist (who even drew AOP interim chief executive, Richard Carswell, see p12 of the April 19 edition of OT), classic cars, massages and lots of free pens. An event catering for everyone, the enthusiasm that could be seen and felt at the show left me feeling optimistic about the state of the High Street. I’ll be eagerly awaiting Optrafair London next year.


OPTRAFAIR

‘Legal lounge’ case file The AOP’s new employment counsel, Heidi Blakey, who attended Optrafair last month to discuss any legal queries from the Association’s members, shares her advice. its members, whether business owners/ employers, employees, pre-reg students or locums. The main benefit of this service is that it is focused wholly on the AOP member. Moreover, it is completely independent and impartial and is entirely

Returning from maternity leave An AOP member recently returned to the same job after maternity leave and her employer is now trying to change her shifts and make her work longer and later hours Heidi says… • Workers have the right not to be treated less favourably on account of their sex, pregnancy or maternity. The requirement to change shifts/work longer hours could have a disproportionate impact on women with childcare responsibilities and could constitute sex discrimination •This may also constitute a breach of contract, particularly if carried out without consultation, or a clear business need • I n the first instance, the member could send a formal letter to her employer or raise a grievance about this treatment •S  he could also make a flexible working request if she wants to change her working pattern to fit in with her childcare needs

separate from any legal advice available to their employer. Having provided members with advice on a wide variety of matters, here are some common queries which were discussed, along with summary points for practitioners to note.

Gross misconduct A member is facing allegations of gross misconduct and has been warned that dismissal may follow Heidi says… • Employers must have a fair reason for dismissal, follow a fair procedure, and act fairly and reasonably in all the circumstances. Dismissal must be in the range of reasonable responses open to the employer • I n order to dismiss for misconduct, the employer needs to be able to show it had genuine belief in misconduct based on reasonable grounds and following a reasonable

The threat of redundancy

An AOP member is at risk of losing their current role Heidi says… •T  he employer needs to demonstrate that there is a genuine redundancy situation (business closure, workplace closure or reduced requirement for employees to do work of a particular kind) • The employee needs to be fairly selected for redundancy – this means that the employer must apply its mind to an appropriate selection pool of employees and when conducting a selection process and scoring employees, it must try to use objective and non-discriminatory selection criteria • The employer should conduct a genuine and meaningful consultation process where alternatives to redundancy are properly considered and the decision is not pre-determined • The employer should consider alternative employment for employees at risk • The employer needs to ensure appropriate payments are issued if redundancies are made, taking account of both statutory rights and any enhanced contractual entitlements

investigation • I f the dismissal may be careeraffecting, this can impose a higher standard for an investigation • Employees facing these allegations have the right to: have the full details of the allegations against them and copies of all evidence against them prior to any disciplinary hearing; be accompanied to a disciplinary hearing; be given proper notice of the hearing and appeal any disciplinary sanction

AOP members who have any employment law queries, can contact Heidi on 020 7549 2018 or heidiblakey@aop.org.uk. Please see the next issue of OT for pre-reg queries raised from Optrafair.

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03/05/13 AOP LEGAL

OPTRAFAIR 2013’s ‘legal lounge’ provided a key opportunity for AOP members to meet me, and discuss any queries relating to their employment. The AOP is unique in providing an employment law advice service to all


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OPTRAFAIR

What did I spy? OT ’s multimedia creative editor, optometrist Ceri Smith Jaynes, names her top four tried and tested instruments at this year’s event

03/05/13 INSTRUMENTS

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OPTRAFAIR IS always worth a visit and this year was no exception. There seemed a less gimmicky and more practical approach from the exhibitors, with more resources directed towards staff to speak to rather than freebies and PR. The buzzwords were OCT and fundus autofluorescence. So, what were my top test-room finds from the show?

1. Optomap Daytona from Optos This is a slick-looking, compact instrument with perhaps a soupçon of Apple-influence in its trendy design (pictured). What impresses me is how Optos has managed to reduce the footprint compared to its forerunner, the Optomap 200DX. The Daytona will fit into anyone’s practice and wonderfully practitioners receive peace of mind from an ultra wide-field fundus image (up to 200 degrees) and the appreciation patients express when they see it for themselves. In addition to a composite digital image, the Daytona also incorporates fundus autofluorescence – a non-invasive technique, developed over the last decade to study the fluorescent properties of lipofuscin, which is a mixture of autofluorescent pigments that accumulate in the RPE as a by-product from the incomplete degradation of photoreceptor outer segments.

“The buzz-words were OCT and fundus autofluorescence” This means you can see areas of retina in which the RPE is under stress (bright, hyperfluorescent patches) or where the cells have dropped out completely (dark hypofluorescent patches). It can explain why that patient can’t see even though their macula doesn’t look so bad. It can show patches of atrophy, oedema or toxic effects from drugs such as hydroxychloroquine.

2. 3D OCT-1 Maestro from Topcon This is another new, compact, and easy-to-use instrument which incorporates the quality I have come to expect from Topcon. The Maestro can manage a wide 12mm x 9mm OCT scan, allowing you to see the macula and disc topography in one go and can produce a high definition B-scan composed from 50,000 A-scans per second. The capture process is quick, incredibly automated and operated through a rotatable touch screen. With a single touch to the pupil on the capture screen, the Maestro automatically scans the left and right eye, and produces simultaneously an OCT scan and a true colour

fundus image. Then, of course, you have to interpret what you see. You do need a separate PC and screen for this, but the software is intuitive to use and Topcon is happy to help you out in person with full training in capturing and clinical interpretation.

3. Medmont E300 topographer from No7 Contact Lenses This neat Placido-based videokeratographer’s new software version 5.3.0 can seamlessly stitch together five corneal topography images to give a 11.7mm composite map, so you can now see the entire corneal surface. Because it averages multiple maps, this also increases the accuracy. Great for orthokeratology and fitting those post-grafts and keratoconics with specialised lenses. Being able to measure corneal height is great when you’re trying to fit lenses based on their sag rather than base curve. It will even simulate the fluorescein patterns of many types of contact lenses, including Paragon’s 16.5mm ICD lens.

4. Test Chart 2000 Xpert 3Di from Thomson Software Solutions The developers of the world’s first computer-based test chart continue to modify its product led by professor David Thomson. You can now control your chart remotely from an iPad, iPhone or Android device and hand the device to the patient to perform near tests, including fixation disparity. Thomson also provides software for controlling a Nidek phoropter, screening and prescribing tinted lenses for MilesIrlen syndrome, performing a Hess Screen test and patient education animations.


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PREVIEW

Doing business the BCLA way 03/05/13 BCLA BUSINESS DAY

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The BCLA will host a one-day business seminar on the Sunday of its annual clinical conference and exhibition. OT ’s Emily McCormick previews the inaugural event

A BUSINESS day designed to offer advice on driving practice growth and profitability through contact lenses will close this year’s BCLA clinical conference and exhibition next month (Manchester Central, June 6-9). Developed for practice managers, owners and contact lens practitioners alike, the Sunday event will see a variety of industry experts offer delegates tips on maximising contact

lens conversion opportunities, as well as how to ensure a patient remains loyal to the practice after the initial consultation and fitting. The day, entitled, ‘Understanding the business of contact lenses,’ will be chaired by well-known optometrist and business guru Peter Ivins (pictured top right), director of Purple Ivy, a company which offers advice on business and clinical skills to practitioners across the

independent and multiple sectors. Highlighting the ‘great line up of speakers’ from outside of the profession, including digital and retail experts, Mr Ivins told OT: “Contact lenses provide practitioners with a huge tool to grow their business and the day will explore consumers’ attitudes, including a move towards the Internet.” Promising the delivery of ‘some good data,’ Mr Ivins added: “It’s a tough market out there, but the contact lens sector is a growing category, and it is an area which produces increased profit and patient loyalty.” In addition to chairing the event, Mr Ivins will present the day’s keynote address on, ‘Defining success in contact lens practice.’ Offering delegates a general overview of contact lenses and business, the optometrist will explore the current and future market trends, as well as who is actually fitting and supplying contact lenses. With more than 30 years’ experience in the optical industry, Mr Ivins will also address the ‘common’ needs and concerns of professionals in the eye care sector, and discuss the threats and opportunities of the Internet. Interestingly, research shows that 65% of people who buy online, do so for convenience rather than price.

Continued on page 28


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PREVIEW

03/05/13 BCLA BUSINESS DAY

28

Mr Ivins, who admits that there are some ‘scary’ contact lens myths about, will go through what he calls ‘the simple process’ of how to acquire contact lens patients and retain them. “It’s about recognising the opportunity that contact lenses as a category offers. It’s not rocket science,” he added. Dispensing optician and MD of independent group Eyesite, David Samuel, will speak on ‘Retaining patients and reducing dropout.’ During his presentation, the past chair of Sight Care will draw on a combination of new and existing research, alongside his experiences, to help delegates understand four key reasons for retention and drop out: the state of the contact lens market; why patients stop wearing lenses; why they continue wearing lenses but attend a different practice; and strategies which could help reduce contact lens drop out and how they can assist business growth. Talking to OT, Mr Samuel said: “One of the things that Eyesite finds beneficial is selling contact lenses online. If we didn’t have an online facility, a lot of our customers would buy online from someone else. “We find that those people shopping online are not necessarily looking to find something a bit cheaper, but because they want to buy the lenses at nine o’clock at night.” Sharing a handful of tips on how

to maintain customers ahead of his presentation, Mr Samuel revealed that focusing on a patient’s needs and environment, rather than what you want to sell, ensuring customers can access your services 24/7, 365 days of the year, and charging appropriately for your professional time and remaining competitive on contact lens prices were key. He also expressed the importance of a friendly service which leaves the patient satisfied. “Like anything, people buy people, and if a patient likes you then they are more likely to buy from you,” he added.

independents. On hand to demystify delegates on, ‘Maximising the opportunity online and in practice’ will be Alenka Ward and Mike Brotherston, customer marketing director and associate director at Johnson & Johnson Vision Care, respectively. They will reveal how shopper behaviours are changing across Europe as a result of pressure from the recession and a surge to online alternatives. With statistics confirming that over 50% of the UK population use their mobile phones to access information, Mr Brotherston and Ms Ward’s presentation promises to offer practical and simple tips to aid business. Also speaking as a pair will be Amanda Bogers and David Boxall. While Ms Bogers is professional marketing manager for Alcon, Mr Boxall is cofounder and creative director of the digital agency 301 Design. Together they will present on ‘Contact lens customer excellence.’ The session aims to demonstrate how retail excellence aligns with the High Street practice, as well as focusing on the patient journey. Encouraging practitioners to attend the day, David Samuel told OT: “These days, if you want to be a good eye care practitioner, if you don’t have some sense of what is involved in the business side of things, it’s tough.”

“Contact lenses provide practitioners with a huge tool to grow their business” Reflecting on how contact lenses can boost business, the independent, who owns practices in Brighton, Reading, Oxford and Winchester, said: “You have to take contact lenses seriously. I don’t think a business can win in contact lenses by dabbling in it. You either have to do it properly or not at all; to do it properly, you need the right kind of tools to offer the patients and the customers the right systems and services and methods of payment that are convenient in today’s world.” As the population becomes more tech savvy, the importance of an effective website has been heightened for

He added: “This is a chance to learn from industry specialists and other people in practice. It’s also a great networking opportunity to speak to people who are also looking to improve their business.” The BCLA is offering a Sunday-only rate for delegates who wish to solely attend the business day. It also includes entry to the exhibition and the closing ceremony, where Andy Yorke will be named the new president of the BCLA. The business day fee is £195 for members and £210 for non-members. For full details, and to book, visit www.bcla.org.uk


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PREVIEW

Coming soon:

NOC 2013

03/05/13 NOC 2013

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The National Optical Conference in 2013 will be the optical profession’s chance to examine the impact of the NHS reforms on the development of community eye care in England. Gill Brabner, training and development associate for LOCSU, explains why practitioners should attend THE NATIONAL Optical Conference (NOC) is the only conference in the optical calendar which brings together Local Optical Committee (LOC) members and professionals with an interest in local eye health to share best practice and debate current national and local issues and concerns.

What can you expect from NOC 2013? • To hear the latest news about the national picture affecting LOCs •To be informed about the latest commissioning developments affecting eye health in your region •To hear from expert speakers from

health, public health and optics, and join the debate • To have the opportunity to learn from LOC colleagues and share expertise and knowledge, build contacts and your support network across England – with peers all sharing an interest in community eye care

Don’t just take our word for it… Delegates who attended the NOC in 2012 shared their views: “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.”

“You hit the mark with the topics you chose and the speakers came up with the goods. Well worthwhile giving up two days to attend. Thank you.“

Cara Burns, Manchester LOC

Wendy Newsom, Bedford LOC and Moorfields Hospital optometrist

“Brilliant event, great presentations.” Nayha Patel Hophins, Shropshire LOC

“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.” Paul Cheetham, Heywood Middleton, Rochdale and Bury LOC

“A very well organised NOC. Great speakers with very useful information to all LOCs.” Sanjeev Patel, Leicestershire and Rutland LOC

“Great venue, great networking event. Well done.” Emer Kirwan, Leicestershire and Rutland LOC


This year’s event is again being organised by the AOP on behalf of LOCSU and the Optical Confederation. It will be focused around ‘the new NHS – six months in’ and will bring together a full review, analysis and debate on the impact of the new NHS on the optical sector. By the time of the conference, the reforms will be fully felt by LOCs across England, with many success stories arising from the way different LOCs have been able to respond to the changes in commissioning arrangements. What can we learn from this success? What challenges are still to be overcome in terms of developing eye care? Following the success of last year, NOC 2013 will also feature masterclasses led by peers, and this will include specific sessions on the lessons learned from the LOCs who have been able to overcome any challenge and make this happen.

One place available for every LOC In common with previous NOCs, each LOC will be able to book one place without charge. This is to encourage every LOC to make sure that the members in their area are represented at the conference, and that there is someone there who can update the rest of their committee on the discussion, activities and issues raised this year.

AOP Awards Now in its third year, the AOP

Awards 2013, sponsored by CooperVision, has quickly become a highlight of the optical calendar. Popular categories such as ‘Optometrist of the Year’ and ‘Contact Lens Practitioner of the Year’ are returning for the 2013 Awards, alongside a new category which highlights an exceptional marketing initiative. The new ‘Marketing Innovation of the Year’ Award is one of 12 Awards that was open for nominations. Any delegate booking a residential place will be able to go the AOP Awards dinner – a black-tie event which will be held on the Thursday evening. This awards ceremony celebrates the success of the whole profession with a specific award (hotly contested) for LOC of the Year.

The venue The Hilton Birmingham Metropole is one of the largest conference hotels in the country. Conveniently located next to the NEC, with excellent air, rail and road links, this hotel is ideally placed for delegates arriving from across the country. After working hard in the day, the hotel offers a range of leisure facilities including an indoor swimming pool, the a complimentary fitness centre and an aqua-aerobics class in the LivingWell Health Club. Delegates can also choose to have a relaxing massage in the Ocean Rooms Spa or unwind in the spa pool and sauna.

Exhibition The conference offers practitioners the chance to visit the exhibition area,

where some of the leading suppliers of equipment and services are available to keep delegates abreast of the latest developments in the sector. Any company interested in exhibiting at the conference should contact stevegrice@ redactive.co.uk

How to book Places for this year’s NOC can be booked by visiting www.locsu. co.uk and clicking on the NOC box on the homepage

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Costs Residential places: £558 (including VAT). This rate includes: • O vernight stay for two nights (Wednesday, November 6 and Thursday, November 7) • Breakfast on Thursday and Friday • Evening meal on arrival on Wednesday • Lunch on Thursday and Friday • A ticket to the AOP Awards black tie dinner on the Thursday night • Access to the NOC 2013 and exhibition area Non-residential place: £342 (including VAT). This rate includes: • Lunch on Thursday and Friday • A ticket to the AOP Awards black tie dinner on the Thursday night • Access and entrance to the NOC 2013 and exhibition area.

The gold sponsores for NOC 2013 are Topcon and Moorfields Pharmaceuticals

03/05/13 NOC 2013

NOC 2013


INTERVIEW

Dispensing the Crystal clear way “When I go through it with patients, the whole dispensing process is a lot slicker and speedier. It’s not that I’m seeing more patients, but the time I have is more quality driven and, without a doubt, it’s resulted in increased patient retention.”

03/05/13 EYE DISPENSE

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David Crystal developed an App to aid the dispensing process in his independent practice almost two years ago. OT ‘s Emily McCormick speaks to the optometrist about the latest developments

The optometrist

EYE DISPENSE is the brainchild of tech savvy optometrist David Crystal. Launched in July 2011, with additional updates and a HD version to follow, the App is designed to help patients choose their new eyewear with ease. “It’s very difficult to picture yourself in frames when you can not see – and that is what we ask people who require vision correct to do when they try on frames with blank lenses in,” Mr Crystal told OT. Explained simply, the portable dispensing tool works by holding up the iPad, pressing ‘record’ and panning around a patient from side to side, capturing video and images of them wearing up to four different frames from every angle. Each video can then be played and paused, while pictures can be emailed or uploaded to Facebook for friends’ approval. The split screen functionality of the iPad also allows the patient to view their appearance in the different frames side by side. Having been commercially available through iTunes for almost two years, Mr Crystal reflects on the business benefits that the App has brought to his practice: “It’s eliminated our ‘think about it response,’ and that’s key.

Having graduated from Glasgow Caledonian in 1984, this optometrist’s route into optics was not a straight road. “Before ophthalmics, I completed a year of physics with computing at the University of Bradford – that’s where my interest in computing comes from,” he told OT. Explaining how he ended up in Glasgow studying optometry, the Northampton-born independent was candid: “I had to walk past the optometry department to get to the physics department and the students there looked like they were having a lot more fun than I was.” Unable to transfer onto optometry at Bradford, a move to Glasgow was the result. Based in Edinburgh, Mr Crystal’s pre-registration year consisted of one third splits between hospital, Donald Cameron’s contact lens practice (now known as Cameron Optometry) and Trotters Opticians. With a grounding which many practitioners can only dream of, it wasn’t long before this modest man went into practice ownership, buyingout a retiring colleague 12 months after qualifying. Based in Edinburgh’s Rodney Street, it is at Eyecare Plus Optometrists that Mr Crystal has remained for around 25 years. The setup is unusual, with Mr Crystal practising with his wife, Dorothy. “We share a single clinic; she sees the paediatric patients and I see the adults,” he explained. The optometrist duo, who met at university, then complete the patient journey themselves, dispensing for their patients when required. “That’s where Eye Dispense comes in,” he added.

“Without a doubt, it’s resulted in increased patient retention”


A multiple move

Since its launch, with downloads now in triple figures, the App has made it as far afield as New Zealand – http://stratfordoptometrists.co.nz – and late last year, it caught the eye of a large High Street multiple. Out of the blue, Mr Crystal received a telephone call from Specsavers. A non-exclusive agreement was reached in January, which provides Specsavers with unlimited worldwide rights to distribute Eye Dispense across its 600-plus stores.

An App business Eye Dispense is not the only App that Mr Crystal has developed. In fact, he has two more.

w ne

The future Revealing what he labels a ‘pipe dream’ at present, the profession could certainly see a new App arrive on the market from Mr Crystal in the future. “I have an idea for a visual stress app that I want to develop which is about colour overlays.” He explained: “There are various ways to currently test a person’s visual stress at the moment, but to me they all seem long winded.” Proving details about the App to this journalist, who is hesitant to share the idea with the profession as yet, what I will say is, watch this space.

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03/05/13 EYE DISPENSE

Sister App to Eye Dispense is ‘Just Reading Test Types,’ an App that Mr Crystal says he is ‘most proud of.’ Alongside Eye Interested in technology and having purchased an iPad, Dispense, the independent uses it in practice “every single day, businessman Mr Crystal’s next thought was ‘how can I utilise the with every single patient.” iPad professionally?’ Launched in July 2012, ‘Just Reading Test Types’ offers “I came up with the idea [of Eye Dispense] because in practice practitioners an alternative to the reading text chart cards which we had a cumbersome unit which you had to pull over to the patient when it was required to take a picture of their eyes, and it are routinely used when patients come in to collect their new spectacles to check that they are reading to the same scale as was just backwards and forwards all the time.” they did when they were tested. Within a week of the ‘eureka’ moment, Mr Crystal was in the The optometrist explained that the idea for the App came offices of a development company signing a non-disclosure after he encountered problems using the printed cards, which agreement. And the rest, as they say, is history. Eye Dispense took 12 weeks to build, with lots of to-ing and fro- “get bacterially contaminated, soiled and grubby.” The App took Mr Crystal some time to get right because, ing between himself and developers to create something which as practitioners will know, the font type and size used is very was simple and easy to use. Mr Crystal said: “I wanted Eye Dispense to be very intuitive and easy to use; I wanted it to be a tool which carefully regulated, with the spacing of the letters and the font both medically standardised. didn’t need instructions.”


INTERVIEW

Non-GM ‘super’ broccoli Molecular geneticist Dr Allan Brown (pictured) wants to increase lutein levels in broccoli and, in the long-term, improve human health. OT ’s Nikki Withers speaks to him about his research

crop have been produced we select for ones that have higher levels of the compounds that we are looking for, in this case lutein.

03/05/13 SUPER BROCCOLI

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That sounds pretty simple [Laughs] That’s not the full story. What we really want to do is combine these higher levels of lutein from the wildtype with all of the other characteristics that people want from broccoli such as a nice big head. It doesn’t take just one generation to produce what we want, it takes quite a while.

What made you look at this area of research?

I hear you work closely with broccoli; can you tell me a bit about your research?

IF ASKED to describe my working environment here in the OT office, I would say that I am predominantly surrounded by technology; computers, telephones, dictaphones, and printers. By contrast, Dr Allan Brown has, for the past 17 years, been surrounded by broccoli. Working at North Carolina State University in the USA, the molecular geneticist is developing broccoli lines which he hopes will help protect against diseases such as cancer, diabetes and AMD. I spoke with Dr Brown to find out more.

We had begun to look at some of the wild relatives of broccoli when we noticed that some had higher levels of lutein than the broccoli that is purchased in the grocery store. We decided to make some hybridisations between the wild broccoli and conventional broccoli, and through this it seems that we have been able to increase the level of lutein in broccoli two-fold compared with what is conventionally found in store today.

So this is not genetic modification? No, there is no transfer of genetic material. This is just conventional plant breeding; it’s just like the birds and the bees. We take the pollen off of one plant and place it onto the flowers of the other. Once ‘children’ of that particular

When it comes to any kind of chronic disease, whether it is AMD, diabetes, cancer or heart disease, there are two approaches that we can take: the therapeutic approach or the preventative approach. Drug companies spend billions of dollars on the therapeutic side – developing new drugs to treat these chronic disorders once they


If you eat lots of greens, such as broccoli, why did you show early signs of AMD? I’m a former smoker, and nothing could be worse for AMD.

cancer people would be throwing money at me, but if I say that I’m improving broccoli because I want to prevent cancer it’s a little harder to get funding for.

What do you hope to achieve in the long-term? The long-term goal would be to sell the product in store. At this point we are working with some of the food and seed companies. I would love to licence this material to them so that they could market it through their existing chains.

What other research are you involved in? I am also involved in sequencing the blueberry genome. We hope that this will enable us to identify some of the products of blueberries that could

“This is just conventional plant breeding; it’s just like the birds and the bees” Has your project been successful? We have some material that we will be evaluating this year at multiple locations in North Carolina. We have just received some funding to move this material along, and we think that within a few years we will have results that we can release to the general public.

Is anyone else doing similar work? The UK actually has a product on the market called Beneforté broccoli. You can find it in most upscale chain stores and it is labelled as having high levels of anticarcinogenic compounds. We are working with the people who developed Beneforté and we hope that, if we can enhance this product, then we can reach out to those people who are suffering from AMD and cataracts.

Have you encountered any problems? Funding is always an issue. If I were to say I had a drug that could cure

prevent various health disorders such as diabetes. If we manage to identify these genes, we could enhance them through conventional plant breeding, just like with broccoli. We also work with cabbage, but this is harder to sell than broccoli. I had one person tell me that cabbage is just not as sexy as broccoli.

I’ve got one final question for you… What is the best way to prepare broccoli? [Laughs] People often ask me this. The fresher the broccoli is, you tend to have higher levels of lutein. I would probably not recommend microwaving it. If you can lightly steam it, that’s the way I prefer it, with a bit of ranch dressing. My take-home message is to eat blueberries with breakfast, have broccoli at lunch or dinner, and you will be in great health.

Dr Brown is an applied molecular geneticist and assistant professor in the Department of Horticultural Science at North Carolina State University.

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03/05/13 SUPER BROCCOLI

have developed. But we don’t spend nearly as much on the preventative side, which is a shame because it is certainly a more cost effective way to approach the problem. It’s funny though, a few years ago I went to the optometrist and was diagnosed as having early stages of AMD. One thing that the optometrist told me was to go to the store and buy some lutein supplements and eat lots of leafy green vegetables. I said ‘do you mean something like broccoli’ to which he responded ‘yes.’ I had to laugh and tell him I had plenty of that.


REVIEW

19/04/13SECO EYECARE 03/05/13 2013 IN DUBAI

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Celebrating 90 years of optical education SECO 2013 was held in Atlanta, Georgia, USA. The AOP’s head of professional development, Karen Sparrow, reports on what the event had to offer THERE AREN’T many optometry meetings which can claim nine decades of history, but SECO has been providing optometry education since 1924 and, from those small beginnings, when a handful of enthusiastic clinicians came together, it has grown to a congress of over 8,000 optometrists and allied optometric professionals participating in nearly 400 hours of continuing education. SECO 2013 attracted delegates from across all 50 States, as well as internationally. President of the Trinidad & Tobago Optometrists Association, Niall Farnon, is a new SECO fan: “I was lucky enough to attend the three major American conferences during the last two years – the American Academy of Optometry in Boston, SECO in Atlanta and Vision Expo East in New York. Overall, in terms of education, location and social events, SECO wins hands down. So much so, I booked my trip for this year’s conference as soon as registration opened. The Southern hospitality is present in all aspects of this conference. “It’s always great to hear the giants of American optometry give their presentations. I also love the workshop options. Last year, I participated in a workshop on subconjunctival, subcutaneous and intra-muscular injections. This year I did a workshop on skin lesions and how to remove them using scalpels and radio-surgical ablation. Both areas are very different from my everyday work but something that, for some optometrists in the US, is everyday practice. I would highly

recommend SECO to any optometrist.” For Dr David Shannon (pictured top left), AOP chairman and a regular at SECO, the highlight was signing a new business agreement between the AOP and SECO to continue and strengthen the ongoing 15-year partnership to produce joint education events for optometrists. SECO president, Dr Ron Foreman, is also positive about the new arrangements. “We are very excited to be hosting London 2013 with our long-time partners at the AOP. This collaboration has been beneficial for both of our organisations and has allowed optometrists from both the US and the UK to share best practices for the good of the profession,” said Dr Foreman. “We see tremendous growth potential for this meeting in London and envision it expanding to become the SECO of Europe.” Away from business, Dr Shannon’s highlights included the ‘Lou and Jimmy Show.’ Dr Lou Catania and Dr Jimmy Bartlett hosted one of the Special Sessions in the 1,700-seater auditorium and Dr Catania opened with a deprecatory, “The only thing worse than an old man reminiscing is two old men reminiscing.” Dr Catania then proceeded, along with Dr Bartlett, to entertain the packed audience for two hours, taking them on a journey from the 1970’s to the present day, with a call to action for American ODs in their therapeutic work: “Don’t be timid about using steroids.” Dr Shannon also remarked on another key moment for him: “Optometrist of the Year, Senator David Heitmeier, from


The Diploma in Practice

37

What every optician should know “Highly in fo provoking rmative and thou ght course... ...Its open mind to a ed my different d imension that I ma / le y adopt in carrying o vel optometr ut my ic duties” - Harsh S h ah

ose e can help th n on how w ” n re “A revelatio ild ged ch disadvanta as - Andy Lom

“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 ng new way n is an exciti “Schoolvisio r vision... ... its changed la revisit binocu - Suzanne Dennis ” my thinking

26 CET Points Topics include: Dyslexia Symptoms Eye tracking Prisms Binocularity Therapy, orthoptics The Business model

Reading Speed Fixation Disparity Light sensitivity/Tints Ametropia Refractive correction Schoolvision Dispensing

16th - 18th June 2013 Hilton East Midlands Airport Hotel Diploma Cost £2,250.00 + VAT (payment options available)

Book on the website, or call 0116 2363113

www.schoolvision.org.uk

03/05/13 SECO 2013

Louisiana, spoke at the House of Delegates Meeting (AGM), of his experiences in State Government and showed a depth of political know-how that enabled him to respond to the ophthalmologists’ stand that there was no more money to finance an element of a health bill by promptly writing out physicians rather than optometrists.” Another new SECO attendee who enjoyed the ‘Lou and Jimmy Show’ was Glasgow optometrist and AOP board member, Alison McClune. “The lecture given by Dr Bartlett and Dr Catania was so interesting – it gave the history of how optometry in the USA developed over the past 30 years. The UK is treading a similar path, but is a few years behind, and our funding model will make it more difficult to get there. It is, however, heartening to hear how the various issues were dealt with in the USA, and to have this delivered by two of the pioneers of the time was an honour.” Ms McClune also appreciated the variety of CET on offer: “It was my first experience of SECO Education Destination and I would hate for it to be my last. What an amazing education event, with every lecture of a high standard. Coming from the UK it is good to hear about a different way to practise, as well as brush up on ‘the basics.’ The range of subjects meant that there was something for everyone: nutrition; children’s eye care; contact lenses; case studies… the list goes on. And with enough time off from the lecture programme to enjoy the tradeshow, there was no feeling of compromising one for the other.” The trade and exhibition element of SECO is ‘Optometry’s Marketplace,’ which is one of the largest in the world and hosts nearly 300 leading companies, offering everything from the trendiest new frames to the latest pharmaceutical products and practice management solutions. A fun addition to the exhibition is SECO’s ‘Money Pit,’ a Crystal Maze style, wind-generated money booth where attendees can grab as much cash as they can. Unfortunately, none of the UK delegates managed to secure a chance in the booth and so didn’t come home with a suitcase of dollars. A particular feature of SECO, alongside a comprehensive education programme, are the social events and 2013 was no exception with a new ‘Downtown Dine Around’ which gave delegates the opportunity to sample some of Atlanta’s best restaurants at a reduced rate. The Saturday night extravaganza is always a great event and ‘The President’s Celebration’ welcomed ‘Better than Ezra,’ an alternative rock trio straight from New Orleans in president Darby Chiasson’s home state of Louisiana, for an evening of raise the roof music that got everyone on their feet. And for those not danced out upstairs, the entertainment continued in the basement with ‘dueling pianos’ playing jazz and pop requests to a packed bar late into the night. SECO 2014 will be held in Atlanta March 12-16. Visit www.secointernational.com for more information. To book for London 2013 Education Destination (October 6-7, 2013) visit www.etouches.com/ London2013EducationDestination


ADVICE

Practice audit of wet AMD referrals 03/05/13 CLINICAL AUDIT

38

Optometrists Trevor Warburton and Susan Parker, alongside student Anthony Bryan, explore wet AMD referrals in Stockport Background WET AMD is one of the few urgent referrals which optometrists encounter and, in our experience, is probably the most common. It requires direct referral to a treatment centre – referral via the GP can be a risk. In common with many areas, Stockport has a dedicated wet AMD pathway, and most of the service is commissioned from a local private provider. The majority of patients are treated by the private provider, although it refers a minority on to an NHS provider. This pathway was functioning from early 2007 with a dedicated referral form (Stockport LOC 2013). In the practice, one of the optometrists (Susan Parker) is the optometric adviser for the area and is made aware of any referrals which follow an inappropriate pathway with potential delay. This set us wondering about our own referrals to the service and the decision was taken to audit them. At the time, the practice had an A-level student on work experience who provided valuable help for data entry.

Standards The obvious first standard is whether the referrals were correct – was it wet AMD? Evidence of a diagnosis

of wet AMD would be taken as correct. A diagnosis of some other condition causing macular oedema would be taken as nearly correct if it presented with the specified wet AMD symptoms of recent visual loss, distortion or a blurred patch in the vision, or with findings of macular haemorrhage, fluid or exudate. Another question is whether we are detecting the expected level of wet AMD within the practice population. This requires knowledge of the incidence of wet AMD and the likely numbers given the practice size and demographics. Owen et al (2012) estimated the incidence of wet AMD in women aged over 50 as 0.23% and in men as 0.14%. In 2009, Stockport’s population stood at 282,975 (Stockport MBC 2010), with 104,623 of those over the age of 50. Using an average 0.185% as the figure gives an annual incidence of 194. NICE (2008) gives incidence figures as ranging from 0.088% to 0.2%, this time applied to the population of both genders aged over 55. For Stockport this is 86,034 (2009), giving a range of incidence from 76 to 172. Stockport PCT worked on the assumption that 200 new patients would need treatment per year, while the actual figures are shown below in Table 1

Year

Referrals

Treated

2007-08

135

113

2008-09

197

145

2009-10

209

151

2010-11

185

143

2011-12

236

192

Table 1 Wet AMD referral and treatment numbers in Stockport from 2007-2012

(Stockport CCG Board 2012). In the most recent full year for which data is available (2011-12), 192 patients were treated, while 236 were referred. The service that is commissioned from the private provider is for an initial assessment, and treatment if required. We understand that most of the referrals come from optometry, although there are a few exceptions. A small number are sent direct by a GP, and a few are re-directed after being sent to the local NHS eye department, which does not provide the wet AMD service. The number of GOS sight tests carried out in Stockport in the same 2011-12 period was 66,210, of which 29,062 were aged over 60 (data.gov.uk). The population of Stockport is not changing a great deal and data shows that the 192 patients treated for wet AMD is very close to the 194 estimated by Owen et al. It is also slightly above the NICE estimate of 172. Although Owen et al use the age of 50, and NICE the age of 55, the majority of patients are older than that and, therefore, the practical age to use for sight test counting purposes is the GOS eligibility age of 60. For the purposes of this audit, we will assume that there are few cases of wet AMD in those aged between 50 and 60 years. Using the actual figure of 192 results, in 6.6 cases of wet AMD per 1,000 GOS sight tests on those over the age of 60. Thus our second standard is whether we are detecting this expected level of wet AMD cases within the practice. The third standard we established was to judge whether the referral forms had been fully completed. In the practice we have a protocol which states the support staff should always follow up a faxed referral for wet AMD with a phone call


Data collection

Referrals per year 9 8 7

Incorrect Unknown Confounding macular problem

6 We make all referrals Wet AMD for wet AMD by 5 completing a Word template which is 4 printed, faxed and then filed in a folder 3 on the computer, as well as on paper with 2 the record. Thus all wet AMD referrals since the introduction 1 of the electronic form, which coincided with 0 2011 2012 2008 2009 2010 the introduction of the fast track anti-VEGF Figure 1 The outcome of wet AMD referrals for each of the five years is shown pathway, are readily available. We looked at the last five complete years. For each patient, their record was reviewed and the outcome determined either from a return letter sent by the treatment centre, or by information the patient provided seen. As outlined previously, we might and pigmentary changes. Definite at a subsequent visit to the practice. macular haemorrhage in image (absent expect 6.6 cases of wet AMD per 1,000 Information from both the record and sight tests on those aged over 60. In our 12 months later) and a new symptom the referral was entered onto an Excel 591 patients there should, therefore, be of missing patches in vision. So a worksheet by Anthony Bryan, who was 3.9 patients with wet AMD. With such correct referral on symptoms in the practice for work experience at the small numbers, there is bound to be 2. Dry AMD. A faint area of pigment time. fluctuation away from the average in any appeared red in the fundus images. The practice system was scrutinised to single year. Rather than look at one year, This can happen and normally we establish the number of patients over the we will use the average over five years, would take additional images to try age of 60 who had a sight test in the year which is 3.4 true cases per year. and establish whether it is blood or 2011-12. The referral forms had been completed pigment, but in this case it did not fully in all bar five cases and there were help Results eight cases identified out of the total 28 In the last complete five years, there have 3. Diagnosis of possible diabetic where there was no record of confirmation been 28 referrals from the practice for maculopathy that the faxed referral had been received. suspected wet AMD (Figure 1). 4. Referred by wet AMD service to a

“Wet AMD is one of the few urgent referrals which optometrists encounter”

From 2008 to 2012, the average number of referrals for the condition annually has been 5.6. Of the total 28 referrals, 17 were wet AMD, six were other macular pathology, while three have unknown outcomes and two were incorrect – both of which were dry AMD. Details of the eight referrals that were not wet AMD are as follows: 1. Dry AMD. Extensive calcified drusen

tertiary centre with unspecified nonwet AMD pathology 5. Diagnosis of macular hole 6. Diagnosis of retinal telangiectasia with localised oedema 7. Diagnosis of myopic maculopathy 8. Diagnosis of post-operative cystoid macula oedema. In the year April 2011 to March 2012, 591 patients over the age of 60 were

Discussion We could expect to find an average of 3.9 cases per year from the practice’s 591 sight tests on those aged over 60. We had 17 true cases over five years, which is an average of 3.4 referrals per year. This detection rate is less than the area average by half a patient per year. Therefore, for the second standard, we are case finding

39

03/05/13 CLINICAL AUDIT

to confirm receipt, and then note this on the record. Our fourth standard was to determine whether this had always been recorded.


UPDATE

03/05/13 CLINICAL AUDIT

40

slightly under the expected number for the practice population. For standard three, the referral forms were not complete in five cases and the error was the same each time; the name and address of the practice had been omitted. For some reason we had not created a personalised template of the dedicated referral form which is a Word document. This has now been rectified. In fact, a letter was received back in each of those cases, so it would appear that the practice was identified from the name of the practitioner. Standard four reviewed whether practice protocol was followed by the support staff in all cases. This requires a ‘phone call to confirm receipt of the faxed referral, followed by making a note on the record. The call is usually made about half an hour after the fax is sent. Eight out of the 28 cases (29%) had no written confirmation on record. All those in the practice – practitioners and support staff – are now aware of this and the need to confirm with each other that the call has been made and noted on the record. There were no cases of lost referrals. We believe it is likely that the calls were made, but simply not recorded. However, as with all record keeping, the practice has no evidence to support that belief. In fact, recent changes mean that referrals have now moved to NHS mail where possible, and receipt is confirmed by a return email without specific request. This audit has been a useful exercise in reviewing practice procedures and clinical decisions on urgent referral, and has enabled some improvements in procedures to be actioned. With the small numbers involved, it is impossible to say whether the practice is really detecting the correct amount, but it suggests that it is close to expected. Practice systems too were appropriate and will be improved with a few minor changes. In the overall figures for the area, some patients not treated may have wet AMD but have vision too good or too poor for treatment within NICE guidelines. In addition, patients who are diagnosed too late for treatment should be investigated by commissioners to see if lessons can

be learned to promote timely access for diagnosis and treatment. One further interesting statistic is that three (13%) patients who required referral had no relevant symptoms at all; in other words the pathology was an opportunistic finding. This has been a useful learning point for us in the practice. Health and Wellbeing Boards and commissioners should consider the importance of promoting regular sight tests in Health Promotion and Ageing Well agendas.

About the authors Trevor Warburton and Susan Parker are community optometrists. Mr Warburton is chair of Stockport LOC, clinical adviser to AOP legal services and leads Cardiff University’s postgraduate module on clinical audit. Ms Parker is optometric adviser for Stockport and is a member of the Stockport CCG Quality and Provider Management Committee. Anthony Bryan is hoping to study optometry in the future.

Work experience in optometry A-LEVEL student Anthony Bryan reflects on his work placement with Warburton Optometrists I developed an interest for a career in optometry a year ago; opting to study A-level biology, chemistry and maths with the aim of studying optometry at University. Despite this, before my time at Warburton Optometrists, I had little experience of what a practice, and the examinations performed inside one, were like. As a non-spectacles wearer, I hadn’t anticipated the amount of time that would be spent by the optometrists ensuring that the eyewear being dispensed was comfortable and aesthetically pleasing to the patient. However, I was given anecdotal information about other practices in which optometrists carry out roles less involved in the alteration of eyewear. During my experience, every patient that was asked was happy for me to observe their examination and therefore I had the opportunity to see a wide range of different methods of exam being performed by three different optometrists. For each exam I observed, the importance of good communication skills in this profession became clearer. The sensitivity required to keep patients at ease, while simultaneously ensuring that all required procedures were carried out, was a challenge I hadn’t anticipated, but was second nature to those I observed. In addition to observing eye exams and spectacles fittings, I was shown how lenses are altered to meet the requirements of the patient, in this case by an auxiliary member of staff. Such a career has since become a consideration of mine having seen the importance to the patient of the role they play. During days three and four, I helped with an audit on the referrals of patients with wet AMD made in to Stockport’s dedicated ‘wet AMD pathway.’ My role was transferring data from patient records and referrals into an Excel spreadsheet. This data included relevant symptoms that patients displayed and whether a fax acknowledging the referral had been received from the treatment centre, whether or not the patient who had been referred suffered from wet AMD or not (and if not, then what the outcome was). While inputting data, it seemed impractical to search through records for forms, which could be out of place, or left incomplete. A recurring thought was that this process may be improved if all records and required documents were digital. I am grateful to all those who helped to make my time at Warburton Optometrists as informative and pleasant as it was, and I have gained a large amount of knowledge from the experience. Accordingly, I would like to thank


Brien Holden Vision Institute is one of the largest and most successful social enterprises in the history of eye care. By applying commercial strategies to vision research and product development the Institute has generated income for research and public health programs that provide quality eye care solutions and sustainable services for the most disadvantaged people in our world. The concern for the devastating shortfall in eye care education in developing communities, especially for correction of refractive error, became action in 1998 for those at the Institute. The lack of training institutes and educational opportunities was creating a human resource gap and a critical eye care shortage for hundreds of millions of people in need of services. The concern and willingness to address the issue gave rise to the International Centre for Eyecare Education (ICEE). Almost 15 years later, and acknowledging that 640 million people are still without access to permanent eye care, concern has galvanised

into action again. To advance the process of addressing the challenge, both ICEE and Brien Holden Vision Institute will more closely align, share one common purpose and one name. Together, we believe if we harness our efforts and broaden our scope we can achieve much more. Together, we aim to drive, innovate, educate, collaborate, advocate and negotiate what is needed so that hundreds of millions of people worldwide can enjoy the right to sight. Whether it’s research to develop the technology to slow the progress of myopia, investment in new systems for diagnosis of disease, delivery of sustainable access to services or provision of eye care education in the most marginalised and remote communities in the world, the Institute will focus on the quality of vision people experience and equity in eye care access worldwide.

vision

for everyone... everywhere

Share the vision

brienholdenvision.org

We believe in vision for everyone...everywhere.

The Durban community in South Africa arrives in hundreds to support the Brien Holden Vision Institutes initiative Drive for Sight, part of the World Sight Day celebrations in October 2012. All attendees were offered free eye examinations, access to free or affordable low cost spectacles and referrals for further eye care where necessary. Photo by Graeme Wyllie.

Education Research Technology Public Health Brien Holden Vision Institute Foundation (formerly ICEE) is a Public Health Division of Brien Holden Vision Institute

BHVI2013_May_Optometry Today UK_RH.indd 1

10/04/2013 2:27:21 PM


DIARY MAY 7 Spectrum Thea, London Heathrow Marriott Hotel, Bath Road, Harlington, Hayes UB3 5AN. The Dry Eye Project. All day workshop (emily.jones@spectrum-thea.co.uk)

7-8 Johnson & Johnson, The Vision Care Institute, Wokingham. Practice made perfect – bringing it all together (0845 310 5347)

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NEW… 8 The College of Optometrists, The Kings Manor, University of York. Moving on in supervision roadshow (www.college-optometrists.org)

03/05/13 DIARY DATES

9 College of Optometrists, Peninsula Allied Health Centre, Plymouth University. South West regional CET event evening (Sammi Kwok 020 7766 4377)

NEW… 14 The AOP, Hotel Pullman, London St Pancras, 100-110 Euston Road, London NW1 2AJ. AGM (www.aop.org.uk)

NEW… 15 Institute of Optometry, London. Opening date for applications to Institute of Optometry and London South Bank University Dr Optometry programme (www.ioo.org.uk)

NEW… 30 ABDO Area 4 (East Anglia),

11 UK Vision Strategy, Queen Elizabeth

Hilton Hotel, Round Coppice Road, London, Standsted, Essex CM24 1SF. CET evening on DO’s and children’s vision care (abdoarea4@gmail.com)

II Conference Centre, London. Vision UK 2013 conference (www.vision2020uk/ ukvisionstrategy.org.uk)

NEW… 19 ABDO Area 2 (North East),

JUNE

Bradford College. Student day meeting (lyndamatthias@yahoo.co.uk)

NEW… 2-3 Vision Aid Overseas, The

NEW… 20 The College of Optometrists, Aston University Business School. Moving on in supervision roadshow (www.college-optometrists.org)

NEW… 21 The College of Optometrists, Holiday Inn, Filton, Bristol. Moving on in supervision roadshow (www.college-optometrists.org) NEW… 22 ABDO, Macdonald Manchester Hotel, London Road, Manchester M1 2PG. President’s consultation day (jburnand@abdolondon.org.uk)

AOP, 2 Woodbridge Street, London EC1R 0DG. Volunteer development programme (www.visionaidoverseas.org)

NEW… 5 ABDO Golf Society, Moseley Golf Club, Birmingham. ABDO Challenge Cup (m.stokes67@ntlworld.com) 6 BCLA, Manchester Central. Clinical conference and exhibition (www.bcla.org.uk) NEW… 10 Practice Building, Aztec Hotel and Spa, Aztec West, Almondsbury, Bristol BS32 4TS. Dispensing project day (www.practicebuilding.co.uk)

NEW… 13 The College of Optometrists, The Forum, Norwich. Eastern regional event (www.college-optometrists.org) NEW… 14 Board Evaluation, Yorkshire Bank Business Centre, Temple Point, 1 Temple Row, Birmingham B2 5PG. ‘Duties and liabilities of being a director’. One-day workshop (joanne.ellingworth@boardevaluation.co.uk) NEW… 14 International Institute of Colorimetry, Institute of Optometry, London. One-day colorimetry training seminar (www.colorimetryinstitute.org) NEW… 17 Hoya Lens UK, Industrial Estate, Wrexham LL13 9UA. Hoya factory tour (enquiries@hoya.co.uk)

Publicise your event for free through OT magazine and online. Simply send FULL details before May 9, 2013 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.

October 6 & 7

The Association of Optometrists, in partnership with SECO International, are proud to be hosting a 2-day program featuring 12 hours of CET** and COPE** approved education.

Featuring:

Saturday, October 5

Sunday, October 6

Monday, October 7

Paul Ajamian, OD, FAAO

6:00 pm

Jane Bell, FCOptom DipTP(IP)

Meet & Greet Event

8:30 am – 4:45 pm Continuing Education

8:30 am – 5:00 pm Continuing Education

Gus Gazzard, MA, MD, MBBChir, FRCOphth

Guest Programme

Exhibition

Exhibition

Guest Programme

IP Peer Review

7:30 pm Networking event

Afternoon Guest Programme/Tours

Teifi James, FRCP, FRCOph

Registration Fees

Early Bird Registration: April 15 - August 1 Member (AOP/SECO) £270.00 $410 USD* Non-Member                               £300.00         $450 USD*   * Exchange rates may vary/Registration will be charged in GBP ** Applied for

For more information visit www.etouches.com/London2013EducationDestination

Registration August 2 - October 5 Member (AOP/SECO)                               £300.00    $450 USD* Non-Member           ��                               £350.00      $530 USD*  


Colorimetry

Training

Seminars

Colorimetry in

Clinical Optometry and Education Colorimetry Science lecture based seminar With the Institute of Optometry Institute of Optometry

14th June 2013

Following on from the successful previous courses, and the significant demand for further such events, we are delighted to announce that we will be hosting the next course jointly with The Institute of Optometry at their South London venue.

Speakers include:

“The Intuitive Colorimeter and Precision Tints have become a key instrument for optometrists who care for people with learning difficulties.” Professor Bruce Evans BSc PhDFC Optom DCPL FAAO

Professor Arnold Wilkins The University of Essex Professor Bruce Evans Dr Peter Allen

City University and the Institute of Optometry

Ian Abbott

Swindon Education Authority

Dr Ian Beasley

Aston University

Dr Amanda Ludlow

University of Birmingham

The seminars welcome members of the vision, education and medical professions to hear the above speakers present on the topic of Visual Stress and its affects on reading, migraine, autism and other medical conditions. Full day rate: £175 CET points in relevant core competencies applied for

THE INSTITUTE OF OPTOMETRY

Patrons

International Institute of Colorimetry Garrick House | 26-27 Southampton Street | London WC2E 7RS T: +44 (0)20 7717 8486 F: +44 (0)20 7717 8401 E: info@colorimetryinstitute.org www.colorimetryinstitute.org


VRICS

VISUAL RECOGNITION AND IDENTIFICATION OF CLINICAL SIGNS

1 CET POINT Visit www.optical.org for all the information about Enhanced CET requirements

Clinical decision-making Part 1

03/05/13 VRICS

44

Stanley Keys, BSc (Hons), FCOptom, Dip Glauc, Dip Tp (IP) Optometrists are confronted with a wide range of clinical scenarios and situations on a daily basis which requires a good understanding of ocular examination techniques and ocular conditions. In practice different parts of our knowledge and skills get tested almost at random, depending on the patients who present, and in doing so forcing us to make the best clinical decisions we can. This latest set of scenarios touches on four areas of clinical investigation and findings and how we might respond to these in practice.

Course code C-31552 | Deadline: June 28, 2013 Learning objectives Be able to investigate visual fields and analyse and interpret the results (Group 3.1.5.) Be able to access pupil reactions and differential from normal and abnormal (Group 3.1.9.) Be able to identify external pathology and offer appropriate advice to patients not requiring referral (Group 6.1.4.)

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 Image C, page 46

About the author Stanley Keys is principal optometrist and clinical teacher at Ninewells Hospital in Dundee. He also works in private optometric practice. He has gained independent prescribing status as well as the College Diploma in Glaucoma. He is also active in optometric education, having authored CET and through his work with NHS Education Scotland and as vice-chair of Acuity Scotland. He is a fellow of the College of Optometrists.


MORE INFORMATION

• EXAM QUESTIONS Under the new enhanced CET rules of the GOC, answers to MCQs for this exam must be submitted online. Please visit www.optometry.co.uk/cet/exams and complete by midnight on June 28, 2013. You will be unable to submit exams after this date. Answers will be published on www.optometry.co.uk/cet/exam-archive and CET points will be uploaded to the GOC on July 8, 2013. You will then need to log into your CET portfolio by clicking on “MyGOC” on the GOC website (www.optical.org) to confirm your points.

• R EFLECTIVE LEARNING Having completed this CET exam, consider whether you feel more confident in your clinical skills – how will you change the way you practice? How will you use this information to improve your work for patient benefit?

A

03

01

What is the MOST accurate description of the clinical finding shown in Image A? a Marked anterior blepharitis b Moderate lower lid entropian c Inferior corneal staining and moderate posterior blepharitis d Lower lid chalazion

Which of the following does NOT make up part of the treatment strategy for the condition shown in Image A? a L id and lash cleaning through hot compresses and lid cleaning regime b Referral for the prescription of an oral steroid to reduce inflammation in severe cases c Artificial tears and ocular lubricants to maintain comfort and aid corneal epithelium regeneration d Referral for prescription of oral doxycycline in severe cases which are unresponsive to first line treatments

Reference to aid completion of the case a) College of Optometrists Clinical Management Guidelines – Blepharitis. http://www.college-optometrists.org/en/professional-standards/clinical_ management_guidelines/index.cfm b) http://dro.hs.columbia.edu/blepharitis.htm b) http://dro.hs.columbia.edu/blepharitis.htm

B 05 Which of the following is false in relation to the Image? a High exposure and fair skin type are risk factors for its development b This lesion is completely benign c The majority of these occur on the lower eyelid d This is a malignant tumour with the potential of invading locally adjacent tissues

04 What is the MOST accurate description of the lesion shown in Image B? a Cyst of Zeiss on the left lower lid b Basal cell carcinoma of the left eye c Larger lower lid chalazion d Cyst of Moll on the left lower lid

06 Which of the following statements is TRUE in relation to the treatment of the lesion shown in Image B? a No treatment is required as this tends to resolve spontaneously b Cryotherapy is the most common and successful modality of treatment c Surgical excision of the lesion with Mohs surgery is the treatment of choice d The lesion should be photographed and monitored within optometric practice

Reference to aid completion of the case a) Fong KCS, Malhotra R (2005) Common eyelid malignancies: Clinical features and management options. Optometry Today, 45 (November 18): pp30-34 http://www.optometry.co.uk/uploads/articles/aff9794de0a3c3caead621804b5ff111_Malhora181105.pdf b) College of Optometrists Clinical Management Guidelines – Basal Cell Carcinoma. http://www.college-optometrists.org/en/professional-standards/clinical_management_guidelines/index.cfm

Find out when VRICS CET points will be uploaded to the GOC at www.optometry.co.uk/cet/upload-dates

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03/05/13 VRICS

02 Which of the following is FALSE in relation to the clinical assessment of the condition shown in Image A? a T ear break-up time (TBUT) is not relevant to investigating the severity of this condition b Fluorescein stain should be used to detect and assess the extent of corneal epithelium compromise c Examination of the height and regularity of the tear meniscus provides useful information about the tear film quality d Careful examination of the lids and lashes with a slit lamp is vital in determining the extent and severity of this condition


VRICS

VISUAL RECOGNITION AND IDENTIFICATION OF CLINICAL SIGNS

1 CET POINT Visit www.optical.org for all the information about enhanced CET requirements

C

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08 Which of the following statements in relation to the clinical finding shown in Image C is FALSE? a Prompt referral to an ophthalmologist for investigation of the underlying cause is vital b This can occur in association with a third nerve palsy c The patient does not need to be referred as they can be monitored within practice d This finding might be caused by trauma, tumour or cardiovascular accident 07 Which of the following statements regarding the clinical finding shown in Image C is FALSE? a There is a degree of anisocoria between these two eyes b The right pupil is small in relation to the left pupil c It is impossible to deduce which pupil is affected without examining the reactions to light d There is slight ptosis of the left upper lid

09 If the left pupil is unresponsive to light and appears as shown in Image C, which of the following is TRUE? a There is RAPD due to optic nerve damage in the left eye b There is a right Adie’s pupil due to parasympathetic dysfunction c There is physiological aniscoria present d There is a left Horner’s syndrome due to sympathetic dysfunction

Reference to aid completion of the case a) Kipioti T (2013) Demystifying Pupil Anomalies. Optometry Today, 53 (February 22): pp52-56, http://www.optometry.co.uk/uploads/exams/articles/ cet_22_february_2013_kipioti.pdf

D

10 What is the MOST accurate description of the defect shown in Image D? a Moderate inferior arcuate defect b Marked superor altitudinal defect c Superior nasal step d Inferior paracentral scotoma

11

What is the MOST likely cause of the defect shown in Image D? aA  lesion at a post-chiasmal location in the visual pathway b Marked atrophy of the inferior neuro-retinal rim of the right optic disc c Central retinal vein occlusion in the left eye d Marked atrophy of the superior neuro-retinal rim of the left optic disc

12

In relation to the investigation and management of a patient with the defect shown in Image D, which of the following is FALSE? aP  revention of progressive loss is not important as the patient will be less aware of the defect due to the location b Topical medical treatment is likely to be used to modify the IOP to a level where progression does not continue c Surgery may be required to achieve long-term control, in order to prevent further progression d The anterior segment of the eye requires detailed examination, including gonioscopy, to establish the diagnosis

Reference to aid completion of the case Clinical decision making 1 – ‘visual field interpretation’ www.optometry.co.uk/uploads/articles/CETC8367.pdf


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Acquired brain injury

Part 3: Managing the patient with ABI Mark Menezes, BSc (Hons), FACBO

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In cases of acquired brain injury (ABI), the brain may have been shaken and, as a consequence, the neurology of the brain might not work as well as it did previously. This can result in effects on visual function. The previous article described how to examine the patient with ABI. This final article of the series describes how the patient

Course code C-30971 | Deadline: May 31, 2013 Learning objectives Respect and care for all patients and carers, in a caring, patient and sensitive manner, with particular reference to patients with acquired brain injury (Group 2.2.1.) Be able to recognise which management options is appropriate, dependant on presenting symptoms and history and know about the different types of management including refractive, orthoptic and prismatic (Group 8.1.2.)

About the author Mark Menezes is an optometrist in private practice. He teaches paediatrics and binocular vision clinics at the University of Aston, as well as teaching a module on visual aspects of brain injury rehabilitation as part of the MSc course at the University of Birmingham, since 2010. Previously he was part of a team which set up a binocular vision anomalies clinic, dealing with visual aspects of dyslexia at the University of Manchester. Prior to this, he gained Fellowship of the Australian College of Behavioural Optometrists in 1992. He is a founder member of the British Association of Behavioural Optometrists. He has lectured both nationally and internationally on the subjects of visual aspects of dyslexia and visual aspects of brain injury rehabilitation. He is also a member of NORA, the Neuro Optometric Rehabilitation Association (www.nora.cc) and is in the process of working towards his Fellowship of the Neuro Optometric Rehabilitation Association. The author would like to credit Professor Ken Ciuffreda, Dr Ivan Wood, Maggie Woodhouse, Curt Baxstrom OD, Penelope Suter OD, Bob Edwards OD and Stephen Leslie for their help and guidance.

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with ABI can be managed in order to minimise the visual symptoms and problems a patient might experience.


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1 CET POINT Spectacles prescribing in ABI

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In ABI, the neurology governing the binocular vision system is relatively fragile and, therefore, the ability of the patient to exert, alter and maintain accommodation and vergence function is compromised.1 Consequently, the ability of the patient to adapt to a new spectacles prescription can also be affected. In the author’s experience, often prescribing the full subjective refractive correction is not tolerated. Patients will complain of the spectacles pulling on their eyes, or not being comfortable. In such cases, where appropriate, the full subjective can be reduced, taking the distance retinoscopy and near retinoscopy findings into account, as well the patient’s subjective response to the lenses, that is, always be prepared to modify the prescription in terms of spherical and cylindrical components, as with typical nontolerance cases, while ensuring that the best VA is not compromised. Prescribing spectacles for even small refractive errors can make a big difference to the stability of both distance vision and near vision, as well as the patient’s ability to focus from one distance to another, in ABI. Patients may well report that the correction makes them feel more comfortable. However, the author recommends strongly that if you are going to prescribe such small prescriptions then you should note the distance and near retinoscopy findings as well as the patient’s subjective response to the lenses on the record card in support of your spectacles prescribing. Indeed, it is only appropriate to prescribe refractive corrections for a patient with ABI if it improves their visual function and/or symptomology. Consequently, it is advisable for the patient’s preference for provision of lenses to be ascertained in a trial frame as opposed to a phoropter, since this presents more natural viewing conditions.2 Considering that accommodative function is likely to be compromised, the provision of

separate pairs of spectacles for distance and near might well be useful for patients of all ages.3 Note that in general, patients with ABI of all ages do not tolerate varifocal lenses or bifocal lenses well because of the fragility and reduced flexibility of their binocular vision system.3

Provision of tints Highly specific tints can be beneficial for patients with ABI, particularly if there are presenting symptoms of photophobia or sensitivity to light strobe effects. In the author’s experience, blue tints are particularly beneficial, and the patient’s subjective response to such tints is usually highly specific in terms of easing their symptoms. There are four tinting systems available which might be of use in providing a more specific tint for such patients. These are the Intuitive Colorimeter (Cerium Visual Technologies),4 the Chromagen contact lens system (Cantor-Nissel),5 the Irlen lens system (Irlen Corporation),6 and the Orthoscopics system (Ian Jordan).7 However, the author is not aware of any randomised controlled clinical studies regarding the provision of tints using any of these systems for an ABI population. Ideally, all of the lenses need to be put through a comparison study on the efficacy of prescribed tints for patients with ABI to see if there is a clinically measurable significant improvement, and if a particular system works better than another. As with patients suffering from specific learning difficulties, patients with ABI should be offered (or referred for) assessment with one of the above systems to determine the optimal colour of tint required for the patient’s spectacles lenses. Note that assessment for use of coloured overlays is not necessarily appropriate, as the colour of the overlay does not always correlate to the prescribed spectacle tint.8

Prescribing of prism in ABI Whereas the prescribing of prism is rare in the general population, provision of prismatic correction is more prevalent in the ABI population. Although the traditional orthoptic approach is to not prescribe horizontal prism and instead to encourage the patient to perform orthoptic based eye exercises to improve vergence function,9 often because of cognitive deficits, patients with ABI are not motivated to do such exercises, or do not understand why they have to do such exercises. In these instances, provision of prismatic correction is recommended if this improves patient symptoms. As described in the second article of this series (see OT, April 19, 2013), the most appropriate method is perhaps the Mallett unit, whereby the minimum amount of prism required to neutralise any misalignment of the nonius markers (fixation disparity) and/ or reduce binocular instability is prescribed.10 Where the practitioner does not have access to a Mallett unit, prism can still be prescribed using other diagnostic measures of vergence function.11 In both cases, it is the smallest amount of prism which reduces symptomology that is prescribed.

Prism for visual field loss There are two main prismatic devices: the Peli prism system12 and the Gottleib field awareness system (Figure 1),13 which can be used to aid patients with visual field loss in ABI. The Peli prism system uses a high powered segment (3040Δ) which is placed base out across the upper or lower part of the spectacles lens on the same side as the location of visual field loss, at the level of the limbus. The prism is placed across the upper part of the lens for upper field loss and across the lower part of the lens for lower field loss. Via this arrangement, an area of the field of vision equal to the height of the prism is moved laterally by 15-20° relative to the field of view of the other eye. Objects which are in the area of field loss in the affected eye can be

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recommended that you ensure that they have understood the instructions you have given them for any particular exercise, since patients with ABI have cognitive deficits. The author strongly suggests that you give the patient written instructions for the exercises, as this is likely to result in better compliance. Other orthoptic exercises which can be prescribed for patients with ABI have been described in Optometry Today already (see OT, April 5, 2013).

Management of dry eye Dry eye symptoms can be managed by use of topical ocular lubricants and punctal plugs. The patient ought to be advised as to the frequency of instillation of such drops and perhaps a support worker or family member can be taught how to instil the drops and at what frequency. The cognitive deficits present in such patients often mean that, unless helped, they might not be able to comply with the treatment regimen on their own. There are a range of products which can be used, and patients should be re-assured that they can use the drops frequently and that they will most likely be on long-term therapy.

Dispensing considerations From a dispensing perspective, practitioners should remember that patients with ABI are no longer in control of many aspects of their life and, therefore, they tend to be very particular about their choice of spectacles frame and type of lenses. Be aware that they may require more time than other patients when choosing a frame, and they may also need further advice regarding lens coatings. Note that patients might have issues with

Orthoptic exercises and vision training Where appropriate, patients with ABI can be given orthoptic exercises or vision training in order to improve their symptoms. Whereas most patients comply relatively well with orthoptic exercises, patients with ABI often fatigue very easily as the neurology which governs their visual system and their cognitive capacity are both compromised. What might be a simple exercise for most patients might be too challenging for a

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Figure 2 Stick-on Fresnel lenses

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patient with ABI. It is, therefore, very important that patients are selected appropriately, based on capability and willingness to do the exercises. Before prescribing Figure 1 Gottlieb visual field awareness system fitted to the right orthoptic exercise or eye of a patient to treat a right homonymous hemianopia vision training activities of any description, seen through the prism in the other eye. The practitioners should ensure that the patient patient can look into the Peli prism and so gain simultaneous awareness of details within can comply with the exercise or activity. Also note how long they can comply with the their area of field loss.14 activity. Whereas most patients can comply The Gottlieb field awareness system uses with a pen to nose convergence activity or a prism placed with the base closer to the push up accommodation activity for up to area of field loss. The prism is placed at the one minute, some patients with ABI can only limbus, and looking into the prism brings the lost field into view. One study showed marked comply with the activity for perhaps five to expansion of the visual field with provision of 10 seconds. Remember that such patients prism.15 fatigue easily, so if you have the patient If the patient can cope with making the doing the activity for a longer period of time, necessary saccadic eye movement into the they will fatigue to the point where it will affected field of vision, then both of these take a long time before they can perform the types of optical appliance can allow the activity again. Such patients also have issues patient to achieve much improved function in with paying attention, as well as organising many of their activities of daily living (ADLs). themselves so compliance may not be as good when the activity is carried out for too Fresnel lenses long a period of time. Fresnel prisms (Figure 2) are light and easy to It is better to do the activities little and use for an instant trial of prismatic correction, often – say 15 seconds three times a day – whether it is for improvement of binocular rather than for a longer period of time twice fusion or for expanding the visual field. They a day. Remember that the brain thrives on are easily applied, easily removable, as well novelty, so the more varied the activity, as being cosmetically acceptable. However, the more effective the exercise on the with increasing power, they can cause neurology. In terms of, for example, pen to blurred vision, as well as coloured fringes and nose activities, using different coloured pens reflection issues. If the patient is successful as a fixation target will be more stimulating with a Fresnel trial, a prismatic device can be to the brain and more successful in terms incorporated in their spectacles lenses. of stimulating the neurology. Also, it is


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1 CET POINT their memory and, therefore, it is advisable that all recommendations are written down in detail for the patient, as well as on the clinical record, so that there is no dispute later.

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General management considerations Patients with ABI fundamentally have some element of ‘neuro-developmental delay’. Many of the management strategies outlined in this article also apply to other patient groups with neuro-developmental delay, including dyslexia, dyspraxia and autistic spectrum disorders, Down’s syndrome, Rett’s syndrome and cerebral palsy. The management of patients with ABI is complex, although also rewarding. Some of the signs and symptoms exhibited by such patients as mentioned in this series of articles form part of what is known as ‘post-trauma vision syndrome’.16 Patients frequently present with symptoms of diplopia, blur, asthenopia, headache, photophobia, dry eye, reduced blink rate, visual field loss, nystagmus, as well as difficulties with fixation and tracking. Strabismus, convergence insufficiency, divergence excess and accommodative insufficiency are also common in this population. A high prevalence of reduced VA, reduced accommodation and exophoria and exotropia are also commonly reported.17 Note that, as this is considered a syndrome,

patients may only report some of the symptoms.18 There is some overlap in the management of such patients with other areas of optometric practice. Some patients might have dry eye due to a reduced blink rate and so will require management of their anterior eye condition. Other patients might have retinal or other ocular damage which causes reduced vision which requires provision and training in the use of low vision aids.19 Patients with ABI are often being seen by a number of healthcare professionals such as neurologists, physiotherapists, occupational therapists and speech and language therapists for the management of their

hospital eye care services, as appropriate. It is important that your clinical findings are communicated to other health professionals dealing with the patient via their GP, and that your clinical findings and their implications on ADLs are also explained in great detail to their family, carers and co-workers. The initial management of patients who have had a traumatic brain injury is performed by ophthalmologists who

condition. Whatever the visual difficulties

patient becomes a priority.20 This is where

the patient might have, the most important

the intervention of the optometrist becomes

principle is that the patient is always at

important.

the centre of the care. Depending on any

sometimes have to treat such conditions as orbital fractures, muscle entrapment, retinal tears and detachment, vitrectomy and damaged corneas. However, once the patient is medically stable, the restoration of visual function and the rehabilitation of the

Once the patient’s visual system is working

other co-existing medical conditions being

better through provision of appropriate

treated by other healthcare professionals,

lenses, tints and prisms, in conjunction with

the rehabilitation of their visual system may

vision training where appropriate, the job of

or may not be the first priority. However, as

all other people from occupational therapists to physiotherapists to carers, family and coworkers becomes easier. The patient’s quality of life improves, they can achieve better performance on ADLs, and hopefully in some cases they can return to the workplace. The optometrist is an important part of the team dealing with such patients, working in conjunction with other health professionals as regards overall management strategies.21

an eye care practitioner, you should be able to identify any relevant symptomology and treat these appropriately, and as a minimum meet the patient’s needs so that they are comfortable. Where you feel that the management of the patient is beyond your skills set, the author recommends referral to other colleagues with greater experience in the relevant areas of expertise and/or their GP or

MORE INFORMATION References Visit www.optometry.co.uk/clinical, click on the article title and then on ‘references’ to download. Exam questions Under the new enhanced CET rules of the GOC, MCQs for this exam appear online at www.optometry.co.uk/cet/exams. Please complete online by midnight on May 31, 2013. You will be unable to submit exams after this date. Answers will be published on www.optometry. co.uk/cet/exam-archive and CET points will be uploaded to the GOC on June 10, 2013. You will then need to log into your CET portfolio by clicking on “MyGOC” on the GOC website (www.optical.org) to confirm your points. Reflective learning Having completed this CET exam, consider whether you feel more confident in your clinical skills – how will you change the way you practice? How will you use this information to improve your work for patient benefit?

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Shared care and referral pathways Part 3: See through cataract referral Chris Steele BSc (Hons), FCOptom, DCLP, DipOC, DipTp(IP), FBCLA

Course code C-31558 | Deadline: May 31, 2013 Learning objectives Be able to work within a multidisciplinary team, knowing the roles of other health care professionals, including knowledge of cataract shared schemes (2.2.2.) Be able to manage patients with cataract, including making decisions on referral, understanding referral pathways and HES management (6.1.6.)

Learning objectives Be able to work within a multidisciplinary team, knowing the roles of other health care professionals, including knowledge of cataract shared schemes (2.2.2.)

About the author Chris Steele is consultant optometrist, head of optometry at Sunderland Eye Infirmary. Over the past 19 years he has developed a wide range of extended roles involving hospital optometrists undertaking cataract, anterior segment, diabetes, glaucoma, paediatrics and medical retina case loads. He has authored over 50 publications on topics including glaucoma, diabetes, specialist medical contact lenses, refractive surgery and clinical risk management, and has undertaken many presentations both nationally and internationally. Mr Steele was a member of the NICE Glaucoma Guideline Development Group from 2007 to 2009, which produced the NICE glaucoma guidelines published in 2009.

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Cataract surgery is the most frequently undertaken surgical intervention in the UK, with day case rates of 98%-100% being achieved in most NHS ophthalmic surgical facilities. Cataract surgery in the UK is performed predominantly on elderly patients, with over 90% being 60 years of age or older, and just under 60% being 75 years or older. Serious co-existing eye conditions such as glaucoma, age related macular degeneration (AMD), diabetic retinopathy or amblyopia, are present in 30% of patients having cataract surgery. This article provides an overview of cataract referral pathways and, in light of the new NHS changes which came into effect on April 1 2013, ponders the implications to eye care practitioners.


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The Department of Health’s (DoH) ‘Action on Cataracts’ publication1 and the Royal College of Ophthalmologists’ Cataract Surgery Guidelines2 have greatly assisted ophthalmology units to improve the quality and standards for cataract patients. Large, well conducted observational studies consistently provide evidence for the clinical effectiveness of cataract extraction in routine practice, and demonstrable improvement in reported outcomes in patients with and without additional ocular conditions.3

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‘Action on Cataracts’ The DoH’s ‘Action on Cataracts’ report led to a nationwide revolution in the way in which the patient-pathway for cataract surgery was to be re-organised. Prior to 2000, unacceptably long waiting times for cataract surgery were common, with some waiting up to two years before receiving treatment. However, within five years there had been huge gains in productivity of cataract services and, despite a steady increase in the numbers of elderly people in the population, waiting times for surgery fell dramatically. The gains in productivity were achieved almost entirely by increases in throughput by NHS clinical teams rather than by the provision of additional capacity in independent sector treatment centres. ‘Action on Cataracts’ established best practice guidance and some straightforward eligibility criteria which, when fully implemented, would prevent situations where people experienced a reduction in their quality of life (QoL) owing to treatable cataracts. The guidance also ensured that people did not undergo unnecessary surgery. ‘Action on Cataracts’ did not establish a VA threshold, but instead, employed three basic criteria for cataract surgery eligibility:4 1. The cataract, as the main cause, affects the individual’s sight 2. The reduction in the patient’s sight has a negative impact on their QoL 3. The patient understands the risks and agrees

Figure 1 Posterior subcapsular cataract

Figure 2 Posterior capsular opacification

to have surgery ‘Action on Cataracts’ supported the increased role of the optometrist in cataract care pathways. It recommended the introduction of locally agreed direct referral pathways between ophthalmologists and optometrists, but keeping the GP informed. It was also recommended that the number of hospital visits could be reduced by combining the initial diagnostic visit and pre-operative assessment into one visit, coupled with a reduction in the amount of post-operative follow-up care (see later).

teams to perform elective surgery, such as cataract, within NHS premises (usually at weekends), in mobile operating theatres or fixed treatment centres.6 The use of these independent sector treatment centres proved highly controversial and very expensive because of contracts which were awarded based on fixed fees rather than volume of work completed, which actually turned out to be very low. Many of these centres experienced abnormally high complication rates and continuity of care issues. With this experience in mind, current health policy continues to encourage a plurality of providers for elective surgical care, including non-NHS providers.

The NHS Plan and the role for external healthcare providers The NHS Plan (2000) set out a 10-year strategy aimed at building a more responsive and more patient-centred NHS with uniform standards of care and access.5 Central to the strategy was a staged reduction in the time that patients wait for surgery, for example cataract down to six months in 2005 and eventually a maximum waiting time from referral to definitive treatment of 18 weeks, with a guaranteed choice of providers, including those from the independent sector. Another government paper paved the way for a rapid increase in elective surgical capacity in the UK by awarding contracts to companies employing overseas clinical

DOH ‘hospital episode statistics’ DoH ‘hospital episode statistics’ show that the number of cataract operations peaked in 2010 with a total of 350,602 compared with approximately 201,000 in 1998/9 prior to ‘Action on Cataracts.’ In 2011, this data showed a sudden fall in the number of cataract treatments performed in England to 338,565. The main reason for this has been blamed on crudely applied, ill-thoughtout spending cuts within the NHS.

NHS budgetary challenges and cataract surgery rationing Since 2008, and against this background of enormous budgetary challenges and spending

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provided ophthalmologists with more time to treat greater numbers of patients with day-case cataract surgery. Cataract patients highly rate co-managed care pathways even where there is no or minimal pre- or post-operative contact with ophthalmologists.12

Figure 3 Nuclear sclerosis cataract in a patient with diabetes

Emerging local enhanced cataract referral pathways Throughout the UK, community optometric practices are successfully and safely delivering local enhanced services in primary care with high levels of patient satisfaction, as part of local integrated pathways. Cataract enhanced services, partly as a result of ‘Action on Cataracts,’ are amongst the more straightforward systems to implement. They are well liked by patients and their effectiveness in reducing the number of hospital visits has been clearly demonstrated. The proportion of referrals to the Hospital Eye Service (HES) from optometrists has been increasing in recent years (39% in 1988; 48% in 1999; 72% in 2010) with optometric referrals being mainly for cataract and posterior capsular opacification (PCO – Figure 2) (27%), followed by glaucoma or suspect glaucoma (20%) and diabetic retinopathy (10%).10 In contrast, GPs mainly refer patients with anterior segment disorders, particularly lid lesions, based on direct observation and symptoms. Studies have demonstrated that optometric direct cataract referrals provide better information on objectively measured vision and better delivery of pre-operative counselling. In contrast, traditional GP referrals contain better medical history, drug information, and details of personal circumstances. In one recent study, cataract surgery operative (conversion) rates were higher for the optometric direct referrals relative to GP only referrals (87% compared with 69%).11 For those practitioners working in local direct cataract referral pathways, it is essential that participating optometrists provide all relevant details for every referral to the HES. Consequently, all schemes have devised standardised referral forms, which have led to improved referral quality. Co-managed care in cataract pathways has

The role of LOCSU in the new NHS April 2013 According to the LOCSU website, LOCSU’s main purpose is to “support Local and Regional Optical Committees to increase the role of optometrists and opticians in delivering high quality eye care services in the community and in improving the eye health of the local population.”13 The overall changes currently in progress for healthcare in England are probably the most significant since the inception of the NHS. In order to meet the challenges and maximise opportunities for the optometry profession, it is vital that Local and Regional Optical Committees (LOCs and ROCs) are equipped to cope with this new emerging NHS structure. Increasingly LOCs/ROCs will be expected to provide advice and support to Commissioners, Health and Wellbeing Boards (Health Boards in Wales) and other stakeholders in the redesigning of local eye care pathways. The new NHS will expect improved outcomes and better value from all providers, and LOCSU will play an important role in the shaping of future services with the effective rolling out of existing successful local services to much wider areas.

Pre- and post-operative cataract enhanced service pathway (LOCSU) The aims of any new or re-designed cataract referral pathway should be to: • Reduce unnecessary referrals to the HES • Eliminate unnecessary visits to the GP • Reduce patient anxiety and increase capacity within the overburdened HES • Provide accurate, appropriate referrals, with high conversion rates to surgery • Provide a more cost effective service with a greater number of patients being managed within the primary care setting. Cataract management is a multi-professional process involving ophthalmologists, optometrists, nurses and technicians. Although

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cuts facing the NHS, many of those responsible for commissioning healthcare arbitrarily decided that cataract surgery was being undertaken too readily on people without significant visual disability. Although there are significant variations in the rates of cataract surgery between different areas of the country, as demonstrated by the Atlas of Variation,7 there is very little evidence to support the view that cataract surgery is undertaken unnecessarily. It has been the Government’s stated policy that cuts to frontline services should always be avoided. Controversially cutting access to cataract surgery has, therefore, been reported as a particularly inappropriate course of action owing to the benefits to patients and its proven cost-effectiveness in the longer term.8 In 2011, the RNIB submitted a Freedom of Information request to all Primary Care Trusts (PCTs) in England, asking them to reveal any policies which were in place to control access to cataract services.9 A total of 133 PCTs replied, of which almost two thirds had imposed thresholds for cataract surgery which were partly based on VA, outside which they would not fund the procedure. It is well recognised that certain types of cataract (for example posterior sub-capsular – Figure 1) can leave patients’ vision apparently unaffected according to VA measurement alone, but these can dramatically reduce sight in certain situations, for example glare from sunlight or headlights while driving. Excluding such patients from surgery, because their vision is ‘too good’ according to VA attainment levels, might cause significant danger on the roads and even loss of livelihoods for many patients. A patient whose sight is restricted by a cataract will, at some stage, absolutely need surgery. Introducing such arbitrary VA thresholds, therefore, often only delays cataract surgery anyway, resulting in a false economy. This shortterm saving in delaying cataract surgery could lead to older people having other accidents, and potentially significantly increasing NHS costs in the longer term. Crucially, in terms of outcomes and costs for the NHS, patients who have early access to second eye surgery may experience fewer falls (18% versus 25%) and fewer fractures (3% versus 12%) in the 12 months following surgery, compared to those who had routine second eye surgery after 12 months.10


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cataract surgery is performed by an ophthalmic surgeon, most of the pre- and post-operative care may be undertaken by other suitably trained and supervised healthcare professionals. The decision on whether to proceed with surgery should always be made by the patient in discussion with an ophthalmologist or other practitioner, for example an experienced optometrist to whom the responsibility for the diagnosis and management has been delegated by the ophthalmologist. According to the Royal College of Ophthalmologists’ Cataract Surgery Guidelines, the recommended minimum steps in a direct referral cataract pathway are as discussed below.

be encouraged to consider cataract surgery – particularly those who live alone or act as carers. Cataract referrals should usually be sent routinely, unless there is other co-existing eye disease which may require more urgent attention.

Step 2: Diagnostic and preoperative assessment

Step 1: Referral Usually a routine GOS (or domiciliary for housebound patients) sight test or private sight test will reveal the presence of cataract which can Figure 4 Phacoemulsification cataract surgery then be discussed with the patient. Following this initial consultation, referral for cataract surgery can be initiated be discussed with the patient and relevant either by the optometrist or GP. ‘Action on written information supplied Cataracts’ suggested that direct optometrist • The patient should wish to undergo cataract referral according to locally agreed protocols surgery be followed. The DoH National Eye Care Plan • This information, together with a report from also proposed this as the preferred referral a recent sight test should form the minimum method.14 data on the standardised (locally agreed) Whatever method of referral is used, there direct referral form. are important underlying principles to consider: Patients who do not meet all of the • The patient should have sufficient cataract to above criteria should not be automatically account for the visual symptoms (if not, then disregarded. Patients with co-morbidity, consider other co-morbidity, for example who might appreciate only slight benefit macular disease or corneal scarring) from surgery, may wish to consult with an • The cataract should affect the patient’s ophthalmologist to discuss their case. Patients lifestyle with lifestyle impairment owing to cataract • The risks and benefits of surgery should who do not complain should, if necessary,

Under the recently revised LOCSU pre- and post-operative cataract pathway,15 a diagnostic assessment undertaken by the optometrist in practice is recommended. This would include thorough fundus examination following pupil dilation, time to explain cataract surgery in greater detail with the patient, and also a discussion of treatment provider options. The latest Royal College of Ophthalmologists’ Cataract Surgery Guidelines2 recommend that the diagnostic and preoperative assessment should be combined into one outpatient (HES) appointment once a patient is referred. The purpose of the preoperative assessment is to ensure that the patient is fit for surgery and to instigate a care plan. At Sunderland Eye Infirmary for example, trained hospital optometrists undertake this role in conjunction with nursing staff who undertake the biometry and surgical care planning. Biometry allows the type and power of the intraocular lens (IOL) to be selected, as well as discussion of any refractive surgical procedure. The advantage of this set up is that optometrists at the hospital have direct access to biometry and other clinical investigations,

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Where the fundus view is completely obscured by the cataract, B-scan ultrasonography or electro-diagnostic tests will need to be performed to investigate suspected retinal and visual pathway dysfunction.

Step 3 – Cataract surgery The actual surgery (Figure 4) is usually undertaken as a day case, taking up to half a day. After the procedure, suitably trained practitioners will process the patient’s discharge and will supply instructions for post-operative medication.

Step 4 – The post-operative visit The timing of the follow-up post-operative outpatient visit varies considerably and is, therefore, open to local agreement. In general, around 90% of cataract cases are uncomplicated and therefore the final review is often deferred until four to six weeks after surgery, provided which adequate

patients, but the possibility of total blindness if severe complications should occur must be fully explained to the patient. An experienced cataract surgeon should always perform a one-eyed patient’s cataract operation.

Second eye cataract surgery Over one third of all NHS cataract operations are performed on the second eye.19 Second eye surgery enables significant additional gains in visual function for everyday activities and quality of life, above and beyond those achieved after surgery to the first eye.15 Functional improvement in visual symptoms after second eye surgery has been demonstrated.20,21 Surgery for cataract on the second eye also enables a greater proportion of patients to meet the legal driving standard.21 These benefits of surgery are recognised clinically, and its value should not be overlooked in the management of cataract.

patient counselling has been given and that

Conclusion

there is good access to urgent ophthalmic

Cataract surgery is the most frequent surgical

review, if required. It is not acceptable for

intervention in the UK. The efficiency savings

patients to simply attend their nearest A&E

expected from the NHS has had a negative

department or to just contact their GP if they

impact on the provision of cataract surgery

have problems. The provider must be able to

in England in recent years. Commissioners must

manage any post-operative complications

not abandon evidence-based medicine

in a timely and appropriate way, or have

to achieve the efficiency targets they have

previously agreed arrangements in place for

been set. Instead, they should work with

access to specialist care. It is also essential

clinicians and patients to identify ways of

that all essential data (VA and post-operative

improving productivity so that the growing

refraction) are recorded and reported back

number of people with cataracts can expect to

to the surgeon for the purposes of clinical

access surgery when they and their consultants

audit, governance, quality assurance and

agree that it is necessary, following revised

validation.

and properly thought through, efficient

Only eye cataract surgery Indications for cataract surgery in oneeyed patients are the same as for two-eyed

57

and timely care pathways, maximising the skills of optometrists and other healthcare professionals in a multi-disciplinary team approach.

MORE INFORMATION References Visit www.optometry.co.uk/clinical, click on the article title and then on ‘references’ to download. Exam questions Under the new enhanced CET rules of the GOC, MCQs for this exam appear online at www.optometry.co.uk/cet/exams. Please complete online by midnight on May 31, 2013. You will be unable to submit exams after this date. Answers will be published on www.optometry. co.uk/cet/exam-archive and CET points will be uploaded to the GOC on June 10, 2013. You will then need to log into your CET portfolio by clicking on “MyGOC” on the GOC website (www.optical.org) to confirm your points. Reflective learning Having completed this CET exam, consider whether you feel more confident in your clinical skills – how will you change the way you practice? How will you use this information to improve your work for patient benefit?

Find out when CET points will be uploaded to the GOC at www.optometry.co.uk/cet/upload-dates | For the latest CET visit www.optometry.co.uk/cet

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such as optical coherence tomography (OCT) and ultrasound at this diagnostic stage, to identify any co-existing pathology. Obtaining patient consent is also one of the most important parts of this assessment. A detailed visual history should be affirmed (much of which should be provided by the referring optometrist), including vision and best corrected VA (distance and near), previous personal ocular history and family ocular history, and binocular status and function. Questionnaires, as used successfully in many areas, can be helpful in documenting patient symptoms and extent of visual disability, but should be used in conjunction with history taking and examination when deciding on surgery. A full medical history should be recorded, with particular emphasis on cataract related to systemic disease (for example due to diabetes – Figure 3) and drugs which may increase the risk of surgery; examples are tamsulosin hydrochloride and other alphaantagonists and anticoagulants.16-18 Also consider other medical conditions which may make positioning or lying supine during the procedure difficult. A complete ophthalmic examination at this stage should include: • Measurement of VA (an up-to-date refraction should be available as part of the optometrist’s report) • Pupil examination • External eye examination, including lids and lashes • Measurement of intraocular pressure (IOP) • Full slit lamp examination • Dilated examination of the cataract and fundus • Biometry • If indicated, photokeratometry.


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Optometry Today May 3 2013