Issuu on Google+ October 15 2010 vol 50:20 ÂŁ4.95





Silmo reviewed

The Winter’s sale Fashion frame ideas for the coming months


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04/10/2010 16:21



October 15 2010 vol 50:20

live London 2012




8 Comment




Consensus on primary eye care AOP chief executive Bob Hughes on the responses to the government’s Liberating the NHS White Paper

No ABDO conference in 2011



Robina Moss reports from Bristol

enewsletter 11 Take our latest visual quiz

Events Silmo: vive la difference

A north west hospital is re-examining screenings for diabetic retinopathy after concerns were raised


David Challinor reports from Paris

Eye examinations under scrutiny


Spectator Optics and the spending review Our columnist reflects on George Osbourne’s forthcoming announcement

News Get involved in 2012



Letters CET

When there is no need to screen for rarities


Great escapes on offer New Stars Wars lines, and an opportunity to go on safari


Cover story Legends of the Fall

New looks in fashion frames

tv Visit today


Free CET  General eye irritation and allergic conjunctivitis Part 4 of our management options for UK optometrists series


Vision assessment Assessment of the anterior chamber angle and depth


Contacts at City University can help you volunteer for the 2012 Olympics in London

Your views on OT

Diabetes and the eye 1: Diagnosis and management


Clare McDonnell discusses this assessment


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White Paper offers hope for enhanced services THE GOVERNMENT’S Health Service White Paper Equity and Excellence: Liberating the NHS gives the optical professions opportunities to widen their respective roles, consultation responses from optics have claimed. The Paper proposed that groups of GPs will be given freedom and responsibility for commissioning health care for their local communities, and the Department of Health has now received consultation responses from the Optical Confederation, the UK Vision Strategy and the Royal College of Ophthalmologists amongst others. The Confederation’s response said it was looking forward to working with GP consortia through LOCs, and that it welcomed the possibility of the publication of national quality standards or pathways for a range

of conditions with the help of the new NHS Commissioning Board. AOP chief executive, Bob Hughes, said: “As shown in our response to the White Paper there are key opportunities for the professions in working with GP commissioning consortia and seeking to persuade the new national commissioning board to produce pathways and guidance. And it gives an opportunity like nothing we’ve ever seen before for LOCs to exert professional selfregulation at a local level.” Elsewhere in its submission the Confederation suggests that there needs to be clarification with the DoH over ownership of patient records.

‘Whilst we fully accept the right of patients to access optical records,’ its response states, ‘the records themselves are actually owned by the practice and form part of the practice’s ‘good will’ and resale value in which the practice owners have invested.’ Although the response welcomes many of the points in the White Paper, it opposes any formal role in seeking patients’ views for the new ‘consumer champion’, Health Watch England and states the sector has a ‘rigorous complaints procedure’ system already in place. The Royal College of Ophthalmologists’ response to the White Paper points to NHS Scotland’s national system of eye care as something to aspire to, and the UK Vision Strategy argues for a greater role for commissioning enhanced services.

Question Time to run again HOSTS of optics’ ‘first-ever’ Question Time-style debate were so delighted with it that there are almost immediate plans to stage it again next year. Kamlesh Chauhan, head of Johnson & Johnson’s Vision Care Institute where the debate was held, told OT last week’s

event was ‘a special evening’. “I’m confident that we’ll do this again,” he said. “I’d like it to be an annual event.” Potential plans for a future edition could include a debate on education. Mr Chauhan said anyone wishing to be a panel member should contact him at the

Institute. A review of the event, which included panellists from the professional bodies and academia and was hosted by newscaster John Suchet, will appear on our website.


Enhanced services is launched by LOC

An enhanced services programme has been launched in the Halton and St Helens area by the Central Mersey Local Optical Committee. The scheme, which is a joint initiative between Central Mersey LOC and NHS Halton & St Helens PCT, has been developed in the wake of the NICE guideline on OHT/Glaucoma, with the LOC’s CET coordinator Paul Morgan arranging workshops to refresh the skills of practitioners in the vicinity in time for the launch of the programme.


The programme includes four elements: Cataract referral; acute assessment; Glaucoma LOCSU 1a referral refinement (where the IOP is found to be 21mmHg the measurement can be repeated up to two times using a Goldmann Applanation Tonometer – if the IOP remains over 21mmHg, the patient is referred); and Glaucoma LOCSU 1b referral refinement (if a field is detected after a sight test the field is repeated. If the second field further raises suspicion of glaucoma the patient is referred). Pictured is the LOC’s chair Bob Wilkes explaining the scheme to professionals before its launch. Practitioners are also taking part in an NHS email pilot and it is hoped that referrals will soon be sent by email.

15/10/10 NEWS


optometrytoday OCTOBER 15 2010 Volume 50:20 ISSN 0268-5485 ABC CERTIFICATE OF CIRCULATION January 1 2009 – December 31 2009 Average Net: 20,203 UK: 19,308 Other Countries: 895 Editor-in-Chief: David Challinor T: 020 7202 8164 E: Deputy & Supplements Editor: Robina Moss T: 020 7202 8163 E: Web and Editor: Emily McCormick T: 020 7202 8165 E: Reporter: Chris Donkin T: 020 7202 8162 E: Clinical Editor: Dr Navneet Gupta E: OT Manager: Louise Walpole T: 020 7401 5330 E: Editorial Office: Optometry Today, 61 Southwark Street, London SE1 0HL Advertising: Vanya Palczewski T: 020 7878 2347 E: Sponsorship: Sunil Singh T: 020 7878 2327 E: Recruitment & Classified: Haley Willmott T: 020 7878 2313 E: CET and bookshop enquiries: Denise Williams T: 020 7878 2364 E: Production: Ten Alps Creative T: 020 7878 2343 E: Membership Dept: 61 Southwark Street, London SE1 0HL T: 020 7261 9661 W: Advertising and Production Office Ten Alps Creative and Ten Alps Media, Commonwealth House, One New Oxford Street, High Holborn, London WC1A 1NU Editorial Advisory Board Duncan Counter, Leon Davies, Mark Draper, Polly Dulley, Dan Ehrlich, Andy Hepworth, Niall Hynes, David Ruston, Gill Robinson, David Shannon, David Whitaker, Vincent Yong W: Published fortnightly for the Association of Optometrists by Ten Alps Creative Subscriptions Alliance Media Limited, Bournehall House, Bournehall Road, Bushey, Herts, WD23 3YG T: 020 8950 9117 E: UK £130, OVERSEAS £175 for 24 issues


NEWS Eye examinations under bookshop live CET scrutiny at hospital DOCTORS at a north west hospital are reviewing hundreds of eye examinations after concern was raised about two of its staff. Examinations for diabetic retinopathy screenings at Southport and Formby District Hospital are under the spotlight by the area’s NHS Trust following worries raised about the work of two of its grading team. The review of 536 images is being carried out as a ‘precautionary measure’. Consultant ophthalmologist, Niall O’Donnell, said: “I would like to reassure all our patients that any risk to them is extremely low. “We are reviewing some patient images as a precautionary measure and are confident


VRICS that most, if not all, have been satisfactorily graded. “The Trust has already screened 274 patients again as part of their annual review and who were originally seen by the two staff concerned. None of these patients have shown any significant change.” The Trust voluntarily subscribes to a system of performance monitoring and testing all of its image graders in accordance

with nationally laid down guidelines. This testing takes place at least every two months. It was as part of this process that concern was raised in July about two staff. They were taken off grading duties in the interests of patient safety. The screening examination involves photographing the back of a patient’s eyes and grading the images on a scale of zero to three. Images graded two and three are immediately referred for further investigation. All images graded one are automatically double-checked. A total of 10% of images graded zero (ie, no evidence of diabetic retinopathy) are also double-checked.

Closures warning emerges from OW manifesto launch Optometry Wales launched its manifesto at the Welsh Assembly’s Senedd building last week in advance of elections to the Assembly next June. Sixteen Assembly Members attended the launch along with chief executives from BMA Wales, Community Pharmacy Wales and RNIB Cymru. Chairman of Optometry Wales, Helen Tilley (pictured), warned attendees that optometric practices across Wales were closing down due to no longer being financially viable and urged the Assembly to take notice of the skills within the profession that were

still not fully utilised. David Shannon, chairman of the AOP, who also attended the event commented that that the turnout for the event was impressive and bore testament to the work that Optometry

Wales was doing to promote and develop the profession in Wales. “It was fantastic to see such a wealth of support for optometry in Wales,” he said, “and the manifesto will hopefully raise more awareness of the important contribution that optometry can and does play as part of the primary care support network for patients.” Electronic copies of the manifesto which details the aims and objectives for Optometry Wales are available by email from salidavis@

Volunteer practitioners sought for London 2012

Games) and to apply go to www. where applicants will receive a volunteer code when they complete their form. Games maker applications close at midnight on October 27. For further information contact City University’s Dr Penny D’Ath (p.j.d’ or Professor David Thomson (w.d.thomson@ and for more details on this story visit

Lively education debate THE TEACHING methods used to educate undergraduate optics students and the contents of the final-year syllabus led to a lively debate at the Essilor University and College Symposium. Over 40 university academics from the UK attended the annual oneday event where a new open discussion format allowed them to trade tips on how to better assess students on modules throughout optometry and dispensing optics degrees. This year, for the first time, the symposium was held backto-back with ABDO’s annual conference and exhibition in

the same venue – Bristol City Centre’s Marriott Hotel. Andy Hepworth (pictured), professional relations manager for Essilor, explained to OT that this was for the convenience of the delegates who regularly attend both events. Feedback on the move was positive,

Silmo D’Or nominee Kirk Originals is to open a new flagship store in London’s Conduit Street following the end of its franchise practice in Convent Garden. Managing director Jason Kirk told OT at Silmo the company wanted to take 100% control of the brand and will carry out eye examinations for the first time.

with attendees mirroring Mr Hepworth’s view. During an open discussion hosted by senior lecturer at Aston University, Colin Fowler – ‘Practical Assessment of Ophthalmic Optics, are exams a thing of the past?’ – Bradford University’s Professor David Whitaker revealed that he tests his students in small groups as “they appear to revise more as they don’t want to be embarrassed in front of their peers.” Others, such as Professor Chris Dickinson said that the optometry department at the University of Manchester uses an MCQ format.

Trends in consumer complaints arising from eye care were debated at the King’s Fund in London earlier this week. The Optical Consumer Complaints Service hosted the conference which heard from Earl Howe, Parliamentary under secretary of state for quality at the Department of Health.

1-in-5 put off test

Over 20% of Britons have put off or cancelled an appointment with the optometrist due to concerns about cost, and a further 16% have delayed getting eyewear when a new prescription has been required, a survey has shown. The study, commissioned by health insurance providers, surveyed 1,000 employed adults in the UK about the cost of healthcare. Almost half of those surveyed (43%) thought eye tests were free for all.

Younger wins trio Younger Optics picked up three Optical Laboratories Association (OLA) Awards of Excellence at Vision Expo West in Las Vegas. The company was best in Lens Materials for NuPolar Trilogy Visual Armor and also won in the Marketing category for its NuPolar Glare Wheel Demonstrator. Its Drivewear Owner’s Manual also carried off the Accessory Products category.

Crossword winner The winner of OT’s September crossword competition is JD Friedman from Barnet, London.


15/10/10 NEWS

a minimum of 20 days if volunteering for both, attend three training sessions beforehand, and pass security checks. Although free transport in London and meals will be allocated to volunteers, those applying should note that no accommodation will be provided. Applications are being handled through LOCOG (London Organising Committee of the Olympic Games and Paralympic

Kirk to test eyes

Complaints debated

London 2012

OPTOMETRISTS AND DOs have until a week on Wednesday (October 27) to get involved in a once-in-a-lifetime opportunity – and apply to be part of the 2012 Olympic and Paralympic Games. Practitioners who successfully apply will be known as ‘Games Makers’ and work at the Games’ Optometry Clinic which will be based in the state-of-the-art Polyclinic in the Athletes’ Village. Services at the centre will include eye examinations, minor ocular first aid procedures, contact lens fitting, spectacle dispensing and spectacle repairs. For detailed requirements for both optometrists and dispensing opticians visit our website (see address below). Volunteers will be required to be available for a minimum of 10 days at either the Olympic or Paralympic Games or



NEWS Vision and street lights probe gets £1.2m grant

15/10/10 NEWS


A ‘UNIQUE’ collaboration of UK researchers on vision and lighting has been awarded £1.2m to investigate lighting for pedestrians. The grant follows improvements in the understanding of vision at night time, and researchers at City University London, Sheffield University and UCL propose that lighting in residential streets can be improved and the electricity consumed by the lighting reduced.  Called the Merlin Project (Mesopically Enhanced Road Lighting: Improving Nightvision) the funding award has come from the Engineering and Physical Sciences Research Council (EPSRC) – the main UK government agency for funding research and training in engineering and the physical sciences – for a four-year study. Professor John Barbur (pictured), director of research at the Applied Vision Research Centre at City, said: “Together, the three research teams will identify not only what are the optimum qualities of road lighting for pedestrians, but also why they are the optimum qualities.

“It has been shown that good road lighting can reduce vehicle accidents by 30%. In addition, there are 7.1 million lighting points installed in the UK. It has been estimated that the lighting of one kilometre of UK residential road for one hour generates 1.7kg on CO2.  “The development of optimised lighting which can dynamically adjust in response to changes in natural daylight may have significant functional and environmental benefits.” Lighting is needed to provide a road which is safe for people to use and which is also perceived to be safe. There is, as yet, no definitive evidence-based evaluation of the precise visual tasks of pedestrians. The research team at City, led by Professor Barbur, will investigate how the eye and visual system operates at mesopic light levels.  In parallel, teams at the University of Sheffield, led by Dr Steve Fotios, and at UCL, led by Peter Raynham, will determine the visual needs of pedestrians at night time, and subsequently how these needs are affected by variations in the quality of lighting.

Celebs respond to Sight Day A fifth of people in Britain would choose luxury purchases rather than giving £20 to save someone else’s sight, according to data released to the national press just prior to World Sight Day (WSD), by Sightsavers. The charity released the results of its study, which also showed 85% of the 2,000 people surveyed would miss their sight most of their five senses, to help emphasise its message that £20 could save someone’s sight in some of the world’s poorest countries. Along with the data the charity conducted a variety of celebrity interviews from the likes of Twiggy (pictured), Beverley Knight, Eliza Doolittle, and Rory Bremner. The celebrities were asked: ‘Out of the five senses which would you miss most?’ ‘If you were to lose your sight, what would you miss most?’ and ‘What would you spend your last £20 on?’ Most prioritised sight as their most valuable sense and just one – Twiggy – said she would give her last £20 to charity.

Consensus on primary eye care Consultation on the White Paper Liberating the NHS has closed, and there is wide support for our main objectives. The UK Vision Strategy argues that “There is scope for enhanced services, such as glaucoma referral refinement services, to be commissioned in the same way as POS (Primary Ophthalmic Services) additional services, making it obligatory for local commissioners to commission these services to nationally agreed standards...” This is an important message from an alliance spanning charities, ophthalmologists, ophthalmic nurses, opticians, optometrists, and social services. More significantly, the Royal College of Ophthalmologists (RCO) argues for a replication of Scottish eye care schemes in England. “NHS Scotland has led the way in moving from two, world class, but very separate, services, namely optometry and the hospital eye service, towards a single, integrated, system of eyecare.” The RCO cautions that managing ophthalmic conditions in the primary care setting does not automatically have a beneficial effect on the rate of hospital referral or save on expenditure. This is true but needs to be placed firmly in the context of patients who would otherwise slip through the system until they are untreatable, and the staggering results from the Stockport glaucoma referral refinement scheme with 77% of referrals being deflected from the HES. We look forward to engaging with the RCO to bring quantifiable advantages of Scottish eye care to England. The DoH should sit up and take notice because it is no exaggeration to say that there are people who enjoy sight today in Scotland who, had they been in England, would in all likelihood now be blind. This can no longer be ignored. Bob Hughes, AOP chief executive

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ACUVUE® OASYS® contact lenses give that “no lens feeling”1, even when using a computer. When working at a computer we blink five times less3, leading to dryer eyes and discomfort. ACUVUE® OASYS® delivers a unique combination of smoothness, breathability, flexibility and wettability to ensure patients experience a lens so comfortable they’ll forget they’re wearing them1. Eyes are also shielded by the highest level of UV protection4,5 of any reusable lens. Talk to your patients today about why ACUVUE® OASYS® is the best choice for computer use. 1. JJVC Data on File 2006. 84% of patients using the computer more than 25 hours a week agreed strongly/somewhat that ACUVUE® OASYS® made them forget they were wearing lenses. N=174. 2. Young G, Riley CM, Chalmers RL, Hunt C. Hydrogel lens comfort in challenging environments and the effect of refitting with SiH lenses. OVS 2007; 84; 4: 302-308. 3. Patel S, Henderson R, Bradley L Effect of visual display unit use on blink rate and tear stability. Optom Vis Sci, 1991;68:11 888-92. 4. UV absorbing contact lens are not substitute for UV-blocking sunglasses as they do not completely cover the eye and the surrounding area. 5. JJVC Data on File, 2010. ACUVUE®, ACUVUE® OASYS®, HYDRACLEAR® and SEE WHAT COULD BE™ are trademarks of Johnson & Johnson Medical Ltd. © Johnson & Johnson Medical Ltd. 2010. Johnson & Johnson Vision Care is part of Johnson & Johnson Medical Ltd.

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When there is no need to screen for rarities

15/10/10 LETTERS


The article in September 17’s OT by Garrick and Paul posed the question ‘Visual field assessment (by confrontation): Should it be essential for new car drivers?’ I wonder whether the authors are aware of the consequences of screening for a rare condition? They cite the paper by Johnson and Baloh on Accuracy of Confrontation Visual Field Test in Comparison with Automated Perimetry which showed a sensitivity of 88% (taking the mid-point for serious field defects), a specificity of 93.4%, and a positive predictive value of 72.6%. Thus for every three cases correctly identified, only one false positive would be referred. In fact for serious defects their PPV

was probably better than that. These results are based on a prevalence in their study population of 32%. The positive predictive value of a test falls as the prevalence falls. Think of prevalence as being the likelihood that a person chosen at random from a population has a certain disease. A low prevalence means that a person is unlikely to have a disease, and thus a positive test result is quite likely to be incorrect. However, they also cite the paper by Johnson and Keltner on the Incidence (more accurately prevalence) of Visual Field Loss in 20,000 eyes which showed that only 3% of a real population could be expected to have

significant field loss. If we apply the same figures for sensitivity and specificity to that real population, the positive predictive value of confrontation falls to just 28%. Thus, for every true case of significant field loss, the test would result in three false positives. I am not sure that their ophthalmology departments (or prospective drivers) would thank them for that! The moral to the tale is that unless you have a test with extraordinarily high specificity, you should not screen for rare conditions. David Sculfor, Head of Optometry, Department of Ophthalmology, Stoke Mandeville Hospital, Aylesbury, Bucks

Many thanks, and nice one Topcon May we take the opportunity of your letters page to publicly thank Topcon for providing the latest technology in retinal cameras for the London Vision Care for Homeless People within the Crisis Centre. This brings a new level of screening to this needy group. Abdul Jahangir, London area sales manager for Topcon, presented the Topcon NW100 to the Crisis centre clinic last week. The first patient to be screened on the technology was 47-yearold ex-British Army soldier, Chris Lathan, who served for more than 12 years and is now homeless. After a successful fundus screening he was dispensed reading

glasses which have transformed his daily life. Thanks also to KentOptic for providing the lenses and glazing service for all of our London patients. We are keen to hear from opticians and dispensing opticians who can provide a few hours of care, particularly during the Crisis at Christmas period, when we are especially busy. To find out about volunteering telephone: 020 8356 6532. Elaine Styles, chair VCHP,

Refractive surgery can also be life-changing I read the October contact lens supplement with interest and would wholly agree with Shelley Bansal, David Shannon and others who wax lyrical about the life-changing benefits of contact lenses and the need for a more proactive approach in promoting all vision correction options to patients. From my own experience over the past three years with Ultralase, however, I would add that the life changing benefits

of refractive surgery are potentially even greater both to patients and practitioners. It is disappointing when many prospective refractive surgery patients report that their “optician” has tried to put them off – often with inaccurate or misleading generalisations. Refractive surgery will never be for everyone, but it has certainly moved away from its esoteric and experimental

origins to become firmly established both in business terms and the public consciousness worldwide. Perhaps the time has come for optical professionals to give more fair and balanced information in order to prevent losing credibility in the eyes of the public. Nigel Maycock, optometrist, Ultralase, Elmdon House, Guildford

OT Letters, 61 Southwark Street, London SE1 0HL E: The Editor reserves the right to edit letters and points out that the views expressed may not be those of the journal.


No ABDO conference in 2011

every two years, with the following event taking place in 2014, announced ABDO marketing and communications manager, Michael Potter, at the AGM. From 2013, with the support of the FMO, the ABDO AGM and CET events will be held at that year’s Optrafair. A process has been established to evaluate the viability of also holding the ABDO gala dinner on the Sunday evening of Optrafair. ABDO general secretary, Tony Garrett said: “The bi-annual alignment with

Optrafair will also enable the association to strengthen its resources and work more closely with other optical bodies and partners in the optical profession. “The 25th anniversary event will focus on key figures that have played a vital part in the successful development of ABDO since its instigation in 1986. It will also provide unique sponsorship opportunities and promises to be a truly memorable and fitting celebration of the association’s considerable achievements during the past quarter of a century.” The first female president of the association in 21 years was announced at the AGM. Jennifer Brower (pictured) is a former member of the GOC and a low vision specialist. She took over from Barry Duncan who was the youngest ABDO president. Peter Black of Conlons Opticians, Lancashire, became vice president. For more on the conference see at


15/10/10 EVENTS

ABDO WILL not be holding a conference and exhibition, or its popular annual gala dinner, next year. The surprise announcement was made at its AGM in Bristol on Saturday (October 9) on the eve of 2010’s conference last weekend. The new ‘back to basics’ approach this year attracted more people said organisers, with almost 550 at the exhibition and CET, event on Sunday (up 40% on last year), 176 delegates registered for CET and 356 at the sell-out gala dinner. However, the conference was the last annual event to be held in the autumn. Instead, as next year is the 25th anniversary of the association, a ‘one-off’ formal celebration lunch will be held at Plaisterers’ Hall, the largest livery hall in London, on Friday, May 6, 2011. The following year the conference, AGM, exhibition and gala dinner will return but will be held in the spring. From 2012 onwards the ABDO conference and exhibition will be held


Silmo: vive la différence A new venue and new launches, but with some familiar Gallic travel difficulties – these were some of the characteristics of Paris’s Silmo show this year. David Challinor experienced the event

15/10/10 silmo 2010


Dunelm’s Peter and Tony Beaumont meet Kilmarnock optometrist David Bonellie

SILMO did well to manage its massive change from its previous venue, the homely Porte de Versailles, to its new outof-town site near Charles De Gaulle airport. However, opinions on the new place, the Paris Nord Villepinte, were divided though those less-impressed, who called the new showgrounds ‘sterile’ and lacking in character, wished to take their opinion no further than distain. Nostalgia for the old Silmo apart, the new show successfully fended off a still uncertain global economy and the nowfamiliar transport problems closer to its home. In total 33,065 visitors attended, 4% up on last year’s show, with organised pleased with an increase of overseas visitors by 14%. Nevertheless, the absentees from the home market were noticeable, particularly on the Saturday morning of the show which has traditionally seen more French visitors, some of them bringing their families. The numbers of Gallic visitors did indeed fall 6% this year. Maybe many of them knew about the difficulties getting to the venue that visitors experienced on the opening Thursday of the exhibition (the Métro was closed due to a strike and flights to Paris were also disrupted), and the Saturday and Sunday of the show which were hit by more trouble on the public transport system (engineering works forced those heading towards the Paris Nord Villepinte by rail to endure what was a near-hour long return coach journey to the nearest operating station). However, many exhibitors who attended the show had a profitable time, especially as those visitors present perhaps

valued their time at the event even more, having travelled out of Paris to attend. British exhibitor Jason Kirk, managing director of Silmo D’Or-nominated Kirk Originals, was one of those enthusing about the new showgrounds. “Visitors have travelled out here for a reason,” he said, “to do business, and, in truth, the old place [Porte de Versailles] was looking a bit tired. “We’ve had two brilliant opening days – with the strike on the Metro we thought it would be really quiet. But no, we’ve been happy and seen a lot of contacts.” He launched Kirk’s Kinetic Collection (OT Industry News, September 17), with frames that have animated moving panels. “The frames have a 3D-type effect,” he said. “The range is a tongue-in-cheek, retro look.” Mr Kirk added that the business is opening a flagship store in central London next month after the franchise on the Covent Garden outlet ended (the franchisee of that store, Séamus McClintock, has opened his own store at the Covent Garden site) and has ambitious plans to expand into retailing further (see this week’s news). “We wanted to take more control over our brand image,” Mr Kirk said, revealing that the new store will carry out eye examinations for the first time in a Kirk Originals outlet. “It’s an exciting time for us.” Marchon Eyewear’s senior vice president of global Continued on page 16

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07/10/2010 12:08


15/10/10 silmo 2010


communications and advertising Robert Schienberg revealed that the Lacoste brand of eyewear is to be reintroduced to the worldwide optics market through the massive eyewear manufacturing and distributing company, and the business is selling in the range now with delivery from January. “Lacoste ended its relationship with Charmont and came to us,” he said. “We’re very fashion-led, communicating to fashion retailers, and Lacoste’s brand has grown significantly as a presence in the fashion world.” The stand also highlighted 3D sunglasses from Marchon3D, and the company promised that a range of future items would be developed in 3D, not just for watching TV. “Our 3D eyewear will be there not just for entertainment but for everyday use and to enhance your vision and the information you receive,” said Mr Schienberg, who claimed that a wide range of labelling and products would include 3D technology in future. At Silmo the Californian-based company was finalising plans to show more 3D eyewear at last week’s Vision Expo West show in Las Vegas. Another US company highlighting new technology was Pixel Optics, which displayed its emPower! electronic eyewear at its French distributors stand (Norville is in line to distribute the range when it arrives in the UK in late 2011). Clay Musslewhite, Pixel’s director of marketing said that emPower! is the world’s first electronic focusing eyeglasses. “It will give patients the ability to turn on and off the near power in their lens, enabling the user to have the vision they want,

Brulimar’s Howard Librae (standing) with buyers from Vision Express

when they want it.” An exclusive interview with Mr Musslewhite is available on our web TV channel at www.optometry. The Virginiabased business also highlighted its ‘ultra thin’ lens, Behold! and its composite lens atLast! Fresh from its success at last month’s London Design Week, Continued on page 22

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D’Arienzo P et al. Tear film and Ocular Surface, September 2007, Sicily, Italy. Ousler GW et al. Cornea 2007; 26: 949-952. Lebow K et al. Alcon Research Ltd, Fort Worth,Texas. Torkildsen G et al. Poster, American Academy of Optometry, Denver 2006. Systane® Patient Information Leaflet. Report of the International Dry Eye WorkShop (DEWS). Ocul Surf 2007; 5(2): 65-204. Foster CS et al. Dry Eye Syndrome: Treatment and medication, updated May 2009. article/1210417-treatment. Accessed December 2009.

BAC=benzalkonium chloride. *Optive is a trademark of Allergan Limited. Date of preparation: April 2010



Will the CSR lead to contract holders gaining more duties?

15/10/10 SPECTATOR


With the party conference season now behind us, we can all look forward to the next big event on the political horizon – that is the unveiling of the comprehensive spending review in just a few days time. Both the coalition parties were able to use their respective conferences as warm-up acts for the big event (the CSR) – and although many commentators have poured scorn on chancellor George Osborne’s presentation of his plans for ‘child allowance’, and subsequent handling of responses, it may turn out that this was a deliberate ploy to prepare us for even worse to come. At something less than 0.5% of NHS spending (indeed less than 0.08% of overall government spending) it is to be hoped that the existing GOS budget escapes unscathed as an example of stunningly good value for the taxpayer. All the talk over the next few weeks will be about spending, which means that ‘policy’ will not receive much public airing. However, it is this aspect of government activity and thinking that has the potential for a much greater impact on our sector and profession. Take, for example, the thinking now being articulated by the National Association for Primary Care (NAPC) on the proposed scope of activity for GP consortia. NAPC is

proposing that GPs should be answerable to their consortia leaders, rather than the NHS commissioning board – that it is the consortia that should hold the contract and not the individual GP. Now there’s an interesting proposal – and one that is not a million miles away from that which currently exists in the GOS (where a business will hold the contract and optometrists working within that business are accountable to their employer). If this were to become the preferred model for primary care, then contract holders may find themselves taking on increasing accountability for ‘performance management’ of the practitioners they employ. With increased professional freedom comes increased responsibility. Imminent changes in NHS structures are going to lead to inevitable changes in the delivery of healthcare services. Forward-thinking practitioners will be looking to identify opportunities for delivery of enhanced eye care services – but we should not limit ourselves to thinking simply about ‘eyes’. More ‘food for thought’, is provided courtesy of a report in the Health Service Journal. NHS Bolton has taken an innovative approach to the implementation of ‘NHS health checks’ (introduced in England in 2009) by working with local pharmacists. In order to conduct cardiovascular risk assessments on those aged over 40, the PCT, in conjunction with Pfizer, has enlisted the support of local pharmacists. But this is a service that could be delivered just as easily through the existing network of optometric practices – with the added benefit that the target age group happens to coincide with that for presbyopia and hence ‘healthy’ patients in this age group, who are unlikely to need to visit their GP almost certainly going to be visiting their optician.

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Alcon has updated www.icapsinfo. to celebrate the launch of ICaps new one-a-day formula with 10mg of lutein/zeaxanthin for maintaining healthy eyes. The enhanced website provides consumers with the latest information on nutrition and the eye, the new ICaps formula and also features an ‘ask the expert’ function with advice from research optometrist Dr Frank Eperjesi of Aston University. Alcon business unit manager, Chris Miller, said: “Through this website, we can effectively communicate that ICaps is UK ophthalmologists’ first-choice ocular supplement for maintaining good visual function. The new one-a-day dosage also helps improve patient compliance.”

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Filters for reading The inventor of earlier haploscopically prescribed lenses, Dr David Harris, has released new visual filters to improve the ease of reading for those experiencing reading difficulty. The Harris Dynamically Balanced Visual Filters are prescribed by practitioners of The Harris foundation, a charity, and new practitioners are currently being recruited internationally. “It is terrific to be able to do something really positive to help dyslexics,” said Dr Harris. “The foundation’s diagnostic set now uses 16 trial lenses, double the number of my earlier lenses and the work continues.” The foundation is currently looking at the application of visual filters for the visually impaired and those with colour vision deficiencies. Information can be found at

& 01303 210357

Striking back to celebrate Star Wars eyewear collection from International Eyewear has launched new frames for boys to coincide with the 30th anniversary of The Empire Strikes Back, and the launch of season three of the hugely successful CGI television series, Clone Wars. The new frames have been named after key characters and are composed of metal eye fronts with Star Wars details. Commander Bly (pictured) is a metal, full rim model with striking bilaminate acetate temples. The sides are logo branded with a space age Star Wars metal plate and Kamino (planet of storms) panel cutouts. The colour options are either a green lightsaber inner temple colour glowing through, or the iconic black and white of the Storm/Clone troopers. The tips are in the shape of Clone Trooper helmets. Mace Windu is a tribute frame to the Jedi master. The tips are in the shape of TIE fighters and have been logo branded with both the Jedi and Republic symbols. Both models also feature logo branded nose pads. The Star Wars brand has continued to have a high profile over the past 12 months, with the animated television series bringing it to a new generation. It is currently the number one boys licence in the world and also the highest grossing movie franchise of all time.

& 0121 585 6565

Kenyan safaris, sightseeing trips to Rome and shopping sprees in New York are among the prizes being offered in Hoya’s premium lens sales incentive
programme, Vision Success Experience, or VSE.
 Hoya is preparing to launch its new programme now so that practices are ready to start collecting their VSE points from November 1, with nine months to accumulate them until the end of July 2011. “The concept is to support our customers to dispense more premium products as this then brings very tangible benefits in terms of revenue and patient satisfaction,” said Paul Jones, Hoya Lens UK regional sales manager. 
 The VSE programme has been designed in response to feedback from customers and is open to new customers as well as long established Hoya independent partners. For details, email

New lens era beckons Rodenstock believes it is the first manufacturer to offer an iPad application for lens consulting. It is hoped that the unique application will herald a new era for the profession and provide a new dimension for the modern customer consulting their optician. The program is designed to help sell high-quality products more effectively and in a more professional manner. At the same time, the application can be used in any corner of the practice and in any consulting situation thanks to the wireless iPad. Its new application vividly shows the differences between conventional single-vision lenses or complex progressive lenses and illustrates the benefits of different Rodenstock products. The company’s is simple to use and makes it possible to demonstrate the features of comparative lens products, together with a clear representation of the differences that individual parameters (pupil distance, corneal vertex distance, pantoscopic tilt and face form angle) have on visual fields. The application can also be started in different languages. The Rodenstock Consulting apps will be available in the Apple App Store shortly and Rodenstock will invite customers to participate in a promotion where an iPad, loaded with the new software, can be provided to the practice at no charge.

& 0845 3300 984

& 01474 531103

Dynamics from nature

Award for innovation

Silhouette has launched a 12-model, rimless eyewear line called Titan Dynamics. The new range is designed to accentuate the face rather than the frame. The colour palette is November chestnut, April leaves, August dawn or February breeze. Classics include March dewdrops, July sparkling, December shadows, January frost and also June sunrise, September rainbow, October harvest or May weekend. In the new range, 80% of each model is handcrafted in Austria and the design uses no screws.

& 0208 987 2434

CIBA Vision’s Air Optix Aqua Multifocal contact lenses have been selected as the “most innovative product in the contact lens industry” by almost 800 French opticians. Every two years, the leading French professional magazine, Inform’Optique, invites its readers to vote for the best innovations in the vision correction sector and one prize is awarded for the most innovative product in contact lenses which CIBA Vision has just won. Air Optix Aqua Multifocal contact lenses were launched across Europe last year and have enjoyed success with both eye care professionals and contact lens wearers. CIBA Vision conducted an extensive evaluation of the contact lenses, involving more than 200 eye care professionals and 2,455 contact lens wearers. The study revealed that nearly nine out of 10 eye care professionals agreed that Air Optix Aqua Multifocal contact lenses would be their preferred multifocal contact lens in their business and 96% also stated that they would recommend the contact lenses to other professionals. Since the UK launch, the product is said to have quickly become the number one multifocal contact lens fitted by UK practitioners.

& 0800 336655



Great escapes on offer


15/10/10 silmo 2010


Denmark business Ørgreen presented its special edition København sunglasses range. Ørgreen’s Catherine Lee, PR and communications manager, showed off the company’s new collections at a packed and busy stand in Hall 5. “We’ve had a good show,” she said on Silmo’s second afternoon, “it’s been non-stop.” The business has joined forces with furniture brand Republic of Fritz Hansen to produce a series of chairs designed by the respected Danish architect Arne Jacobsen Swan that feature the same Copenhagen skyline design as the special edition collection of eyewear by the Scandinavian company. Back to the British contingent and Brulimar’s managing director Howard Librae continues to be ‘estatic’ at the reaction his business had received to the Pineapple eyewear brand collection since its launch in August. He was at the show

presenting this and other fashion brands at his stand in Hall 6. “Bench and Lee Cooper are fashion brands we have which are doing very well. We’ve brought Pineapple here to Europe really just to see [the reaction]…we know the Sky TV programme about the dance studio is being sold into many countries in Europe as well as Canada and New Zealand. “Pineapple’s brand is somewhat unique – normally the most successful brands in this sense are clothing-led. Pineapple has more of a cult status following, with its feminine look, and we were interested in taking it on before the television series took off. However, with the interest that the television show has generated we know now that we have ‘a tiger by the tail’ here.” Mr Librae revealed that business in the UK remained tough but opportunities remained – “the public want value for money and the biggest bang they can get for their buck”. Another British exhibitor, Peter Beaumont, director at Dunelm Optical, said at the close of the show: “While this year’s Silmo exhibition was perhaps quieter than in recent years, we have been thrilled to secure two new international accounts based in Hungary and Finland. “Our designer ranges were received with great acclaim, with Paul Costelloe exhibiting 10 new pieces. The European market continues to be challenging, so the spotlight is inevitably on more cost-effective frames. Dunelm is well-placed to meet demand for affordable designer frames, with ranges like Janet Reger, John Rocha and Paul Costelloe.” Next year’s show will take place on September 15-18.

Hospital Optometrists Annual Conference

To be held at Park Inn, Bath Road, Heathrow, Middlesex, UB7 0DU

5th – 7th November 2010 Programme includes • Didactic Short papers • Invited speakers • Interactive lectures • Trade exhibition • Poster Session • Conference Dinner & Dance The conference is organised by the AOP Hospital Optometrists Committee (HOC). All optometrists are eligible to attend. You do not need to work in a hospital. Conference programme and booking forms are available at the hospital section of the AOP web site at or contact: Andrew Tompkin, Optometry Department, St Paul’s Eye Unit, Royal Liverpool University Hospital, Prescot Street, Liverpool, L7 8XP Supported by: Advanced Eye Care


Norville Optical Group

Associated Optical

David Thomas



Grafton Optical

Optima Low Vision


Jack Allen

Optos PLC



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Main-Line Optical

Spectrum Thea

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Tel 0151 706 3900/3901 Fax 0151 706 5846 E-mail


October crossword

This issue we continue our monthly crossword series. So why not enter our competition before the closure date. The winner will receive £50 in Marks & Spencer vouchers.

15/10/10 CROSSWORD




1.The villain of the piece on November fifth (3,6) 8. Doctrine of English law referring to one’s right to an unobstructed view (7,6) 11. Early censorship board for films (4) 12. English county (5) 13. Breed of small horse (4) 16. Stop, prevent from an action (7) 17. Downpours (7) 18. Garden structure (7) 20. Person carrying a taper in a religious ceremony (7) 21. Sand hill (4) 22. Type of energetic dance (5) 23. Render lightly unconscious (4) 26. Concentrate on the task in hand (3,2,8) 27. Explosive devices on November fifth (9)

2. A standard of measurement (4) 3. Ballet dancer, Margot ----- (7) 4. Area featured in ‘Eastenders’ (7) 5. Breakfast food (4) 6. Biblical revenge (2,3,3,2,3) 7. Vehement disagreement (6,7) 9. Care of the feet (9) 10. Look straight ahead (4,5) 14. Large imposing house (5) 15. Gradual decline (5) 19. Very friendly (7) 20. Hot sauce (7) 24. Small needle case (4) 25. Member of the Eskimo race (4)

Name: Address: Send entries to OT, October Crossword, 61 Southwark Street, London SE1 0HL to arrive no later than November 3 2010.




A MUST BUY FOR EYECARE PRACTIONERS IN ALL FIELDS • Which visual problems can be associated with reading difficulties? • What tests should I do for a patient with reading difficulties? • What is dyslexia? • When can eye exercises help? • How do coloured filters work?


08/10/2010 12:15


Legends of the Fall

OT looks at some of the latest fashion frames for autumn/winter.



Larger luxury

Adding impact New Rodenstock metal frame 2120 for women is pictured in classic black and is also available in rose and red. The distinctive design is inspired by fashionable textile prints. Rodenstock ladies frame 4885, pictured in gold turquoise, is also available in three other colour options, rose gold, black and copper brown. It has a titanium front with polyamide sides and comes in two lens shapes. & 01474 531183

Jai Kudo has launched a collection of 14 new affordable luxury styles for autumn/winter. The range incorporates design influences ranging from the world of fine art to retro-inspired models in both plastic and metal. Metal model 556, pictured, and model 557 – the latter featured on our front cover – have a larger eye size to reflect the current retro trend but in a more refined style. Natural elements such as wood and slate are brought to mind by the frames which are available in earth tones, grey, ruby and jet black. The new collection also broadens the spectrum of Jai Kudo’s acetate range, in particular model 1810 for women with its striking giraffe patterning which the company expects to be a best seller. The frame is available in black, grape and lipstick red. Correspondingly, the men’s version, model 1811, features an undulating wave pattern and is offered in classic black, tortoiseshell and metallic silver. & 0208 732 9600

Inspired by lingerie As part of its updated autumn collection, Dunelm Optical is introducing 12 new frames to the Janet Reger range, which continue to be inspired by the designer’s popular lingerie collection. Pictured below are the frames 4056, top, 4053, middle and 4057, bottom. Frame 4056 in brown, rose and black has an intricate diamante dragonfly featured on each temple. Frame 4053 in brown, purple and black, displays a delicate sprinkling of diamantes on each arm, as well as two-tone sides. Frame 4057 in black sees a return to the feminine glamour typical of Reger, with a cut-out flower edged with diamantes on each temple. & 01388 420420

Best seller already Jaeger London model 13 (pictured) was 
launched this year by Continental Eyewear and is already the best selling Jaeger London 
design. It is available in three colours – black, brown and wine. A discreet 
logo is set into a plastic temple which features a distinctive “quilted”
 design. & 0151 426 3907


Optometric Conference Creating Opportunities for Optometry and Optics

4th & 5th November, 2010. The Park Inn Hotel, Heathrow The NOC is the conference for optometrists, optometric advisers and Local/Regional Optical Committees. LOC/ROC officers and members are encouraged to attend the two-day conference, which will provide an unrivalled opportunity to engage first hand with the LOC Support Unit and to share knowledge and network with colleagues from around the country. A variety of companies (contact lens and equipment manufacturers, software suppliers etc) will be exhibiting at the conference. There will be a reception and a formal dinner on Thursday, 4th November. LOCs/ROCs are encouraged to invite their local MP and PCT leaders to the dinner.

Earl Howe, Parliamentary Under Secretary of State for Quality, will speak at the dinner. Parallel sessions will be held on both days to provide delegates with choices of presentations to attend. Delegate fee is ÂŁ525 (inc VAT) including accommodation or ÂŁ315 (inc VAT) excluding accommodation. Accommodation must be booked through the AOP in order to obtain the specially negotiated rate.

LOCSU will fund one representative from each LOC. Download a booking form at or contact Linda Marriott at the AOP Tel. 020 7202 8166 or email


Visual Recognition and Identification of Clinical Signs

The following FREE Visual Recognition and Identification of Clinical Signs (VRICS) test should be completed online by clicking on the VRICS test button at Respondents should use the six images/photos to answer the12 associated Multiple Choice Questions (MCQ). Please note that there is only one correct answer for each MCQ. Successful completion of the VRICS test will result in two CET points. VRICS regularly appears in Optometry Today.

Diabetes and the Eye 1: Diagnosis and Management Course Code: C-14529 O/D. By Professor Rachel North 28

15/10/10 VRICS

1. A 16-year-old patient presents for an eye examination and has been recently diagnosed with Type 1 Diabetes Mellitus. Examination with slit lamp revealed the appearance shown in Image A. Which of the following statements about this finding is FALSE? a) It is commonly associated with Type 1 Diabetes Mellitus b) It can be reversible c) It is associated with hypoglycaemia d) It is due to water clefts


2. For the patient in Question 1 and the appearance shown in Image A, which of the following symptoms is the patient MOST likely to experience? a) Haloes round lights b) Fluctuating vision c) Glare d) No symptoms will be experienced

3. Which of the following techniques has been used to obtain Image B? a) Fundus photography with red-free filter b) Optical coherence tomography c) Scanning laser ophthalmoscopy d) Fluorescein angiography

4. Which of the following statements about the technique used to obtain Image B is FALSE? a) It enhances the ability to see retinal blood vessels b) It improves the ability to detect microaneuryms c) It enhances the ability to detect pigmentary lesions d) It improves the visualisation of retinal neovascularisation


5. Which of the following statements about area X in Image C is TRUE? a) It is seen in pre-proliferative retinopathy b) It is a vitreous haemorrhage c) It is a large cotton wool spot in the nerve fibre layer d) It is a pre-retinal haemorrhage

6. Which of the following statements about area Y in Image C is TRUE? a) It indicates that the retina has been hypoxic b It is caused by dot and blot haemorrhages c) It is more likely to be seen in Type 2 Diabetes Mellitus d) It is an area of choroidal neovascularisation



The author would like to thank Trevor Warburton, the All Wales Diabetic Retinopathy Screening Service, and the University Hospital of Wales for providing images for this VRICS.

2 FREE CET POINTS Approved for Optometrists


Approved for DOs


CONFUSED ABOUT CET REQUIREMENTS? IMPORTANT INFORMATION: Under the new Vantage rules, all OT CET points awarded will be uploaded to its website by us. All participants must confirm these results on so that they can move their points from the “Pending Points record” into their “Final CET points record”. Full instructions on how to do this are available on their website.

About the author Professor Rachel North is an optometrist at the School of Optometry & Vision Sciences, Cardiff University. Areas of research interest include the investigation of functional and structural changes in Diabetes Mellitus and Glaucoma, using psychophysical, electrophysiological and digital imaging techniques.

Associated Reading: 1. 2. Louise O’Toole (2009) Features of diabetic retinopathy and grading protocol. Optometry Today February13 3. Brinda Muthusamy (2009) Diabetes: Indications for

treatment. Optometry Today March 13 4. Rachel North (2009) Monitoring and controlling diabetes. Optometry Today April 10 5. Shaheen Shah (2009) Non-retinal complications of diabetes mellitus. Optometry Today May 8


8. For the patient in Question 7 and with the fundus appearance shown in Image D, which of the following statements is FALSE? a) This occurs more frequently in patients with Type 1 Diabetes Mellitus b) The changes are due to retinal ischaemia c) It affects about 10% of patients with Diabetes Mellitus d) The patient should be reviewed routinely in 1 year

9. The technique shown in Image E was used to investigate the loss of vision in a 52-year-old patient with Type 2 Diabetes Mellitus. What defect is shown to be the cause of the vision loss? a) Lamellar hole b) Ischaemic maculopathy c) Pigment epithelial detachment d) Macular oedema


10. For the patient in Question 9 and Image E, which of the following is NOT an indicated management strategy? a) Improved glycaemic control b) Pan retinal photocoagulation c) Blood pressure control d) Grid/focal laser treatment

11. What is the MOST appropriate grade of retinopathy for a patient with the fundus appearance shown in Image F, according to the National Screening Committee? a) P0 b) P1 c) R3 d) U


12. For the patient in Question 11 and with the fundus appearance in Image F, which of the listed possible side effects of the management technique is FALSE? a) Increased peripheral visual field b) Decreased visual acuity c) Reduced dark adaptation ability d) Poorer contrast sensitivity

15/10/10 VRICS

29 7. A patient with Diabetes Mellitus presents for a routine eye examination and has a visual acuity of 6/6 in each eye. What is the MOST appropriate grade of retinopathy shown in Image D, according to the National Screening Committee? a) R2 b) R3 c) P0 d) M1

DIARYDATES A high-flying venue for NOC conference Tickets are selling fast for the next month’s National Optometric Conference, presented by the Optical Confederation and LOCSU, where the varied lecture programme includes issues including ‘Cost-cutting under the coalition government: threats, opportunities and solutions’ and ‘The LOCSU pathway on low vision.’ Held on November 4 and 5 at the Park Inn, Bath Road, Heathrow, the venue has excellent transport links with flight, coach, road, underground and rail connections to the rest of the UK in easy reach. For further details and to book, email: lindamarriott@

15/10/10 DIARY DATES



NEW… 17 Specsavers PAC, ICC, Birmingham, ‘PAC conference’ (pac@

NEW… 18 Sight Care Group, MWB Business Exchange, Bristol Castlemead, Bristol, ‘Improving dispensing values’ seminar ( NEW… 18 Sight Care Regional, Templeton Hotel, 882 Antrim Road, Templepatrick, Ballyclare, co. Antrim, ‘Building and sustaining reputation’ SEE ABOVE

NEW… 19 Sight Care Regional, Holiday Inn Gatwick, Horley, ‘Building and sustaining reputation’ SEE ABOVE NEW… 19 J&J, The Vision Care Institute, Pinewood, ‘Business Building Programme’ roadshow (www.thevisioncareinstitute. NEW… 19 BCLA, Northampton, ‘How to take the perfect photograph,’ email for venue details ( NEW… 19 Sight Care Group, MWB Business Exchange, branch TBC, London, ‘Improving dispensing values’ seminar SEE ABOVE NEW… 20 South Staffs Optical Society, Cannock Cricket and Hockey Club, Church Lane, Hatherton, Cannock, ‘Multifocal contact lens fitting’ with buffet, 6.30pm ( NEW… 20 Sight Care Regional, Buckerell Lodge Hotel, Topsham Road, Devon ‘Building and sustaining reputation’ SEE ABOVE

CANCELLED 20 BCLA, Monmouth, ‘Fitting RGP lenses,’ email for venue details SEE ABOVE NEW… 20 BCLA, London, ‘How to fit SynergEyes or SoClear lenses,’ email for venue details SEE ABOVE NEW… 20 Mark’ Ennovy, Premier Inn, The Quayside, Newcastle, ‘CET roadshow’, 2 CET points (

NEW… 20 UltraVision, Head Office,

NEW… 24 Glasgow Caledonian University and NHS Education for Scotland, Ninewells Hospital, Dundee, ‘Binocular vision and additional exam techniques’ (Karen.reid@

NEW… 29 Northumbria University Sport Central, Northumbria University, ‘Sight seminar 2010’ (rosemary.reay@

NEW… 24 Glasgow Caledonian University

Exchange, 9-10 Andrew Square, Edinburgh, ‘Improving dispensing values’ seminar SEE ABOVE

and NHS Education for Scotland, Wishaw General Hospital, Lanarkshire, ‘Binocular vision and additional exam techniques’ SEE ABOVE

NEW… 29 Sight Care Group, MWB Business

NEW… 31 Glasgow Caledonian University and NHS Education for Scotland, King James Thistle Hotel, Edinburgh, ‘Communication skills in optometry’ SEE ABOVE

Leighton Buzzard, Bedfordshire, ‘KeraSoft IC Workshop’ workshop and fitting techniques, 9.30am (

NEW… 26 Mark’ Ennovy, Premier Inn, City Centre (Haymarket), Bristol, ‘CET roadshow’, 2 CET points SEE ABOVE

NEW… 20 Sight Care Group, MWB

NEW… 26 Glasgow Caledonian University

Business Exchange, 43 Temple Row, Birmingham ‘Improving dispensing values’ seminar SEE ABOVE

and NHS Education for Scotland, Wishaw General Hospital, Lanarkshire, ‘Binocular vision and additional exam techniques’ SEE ABOVE

NEW… 21 Sight Care Regional, Holiday Inn

NEW… 26 BBGR, Millenium Stadium,

Filton, Filton Road, Hambrook, Bristol, ‘Building and sustaining reputation’ SEE ABOVE

Cardiff, ‘Energeyes your business roadshow’ (

NEW… 21 J&J, Marylebone Hotel, London,

NEW… 26 Sight Care Group, Comfort Inn, 20

‘Business Building Programme’ roadshow SEE ABOVE

Dunsilly Road, Antrim, ‘Improving dispensing values’ seminar SEE ABOVE

South Queensferry, ‘Lectures from Jordan McLeod, Kevin Gutsell and Giles Kenyon’ (

NEW… 21 Mark’ Ennovy, Premier Inn Albert Dock, Liverpool, ‘CET roadshow’, 2 CET points SEE ABOVE

NEW… 26 BBGR, Sussex County Cricket Club, Hove, ‘Energeyes your business road show’ SEE ABOVE

NEW… 2 Mark’ Ennovy, Premier Inn Parkway, Guildford, ‘CET roadshow’ 2CET points SEE ABOVE

NEW… 21 Sight Care Group, MWB Business Exchange, branch TBC, Manchester, ‘Improving

NEW… 27 Bradford University, Richmond Building, Bradford, ‘Those brown eyes turning blue? Can it be true? Heterochromia and other iris abnormalities’ (

NEW… 2 BCLA, 7-8 Market Place, London W1W, ‘Basic soft toric contact lend fitting with Keith Cavaye’ SEE ABOVE

dispensing values’ seminar SEE ABOVE

NEW… 22 Sight Care Group, MWB Business Exchange, Ballitol Business Park East, Newcastle, ‘Improving dispensing values’ seminar SEE ABOVE

NEW… 27 Mark’ Ennovy, Lake View Holiday Inn, Bridge Road, Cambridge, ‘CET roadshow’ 2 CET points (


NEW… 1 BCLA, 7-8 Market Place, London W1W, ‘Multifocal contact lens fitting with Susan Bowers’ SEE ABOVE NEW… 1 Replay Learning, Royal College of Physicians, London, ‘Lifelong eye health conference’ ( NEW… 2 ABDO Scotland, Two Bridges,

NEW… 2 NEOS, The Harvey Suite, Ravensdene Lodge Hotel, 55 Consett Road, Lobley Hill, Gateshead, ‘Cerebal visual impairments’ 7.15pm SEE ABOVE

OTTV 3007.qxd:News



Page 37

2 CET credits available Guide

Diabetes and Diabetic Retinopathy for Optometrists(C 14423/O) From now until the end of October,‘s latest CET video is available to view at Presented by Dr Byki Huntjens (City University), the video provides a refresher for optometrists on the topic of diabetes and diabetic retinopathy (DR). Part 1 details diabetes mellitus, including an overview of the prevalence, systemic chronic complications and medical management of the condition. The symptoms of acute complications, such as hypo and hyperglycaemic episodes, are also discussed. Parts 2 and 3 focus on the effects of diabetes on the retina. The pathogenesis of DR is considered, a reminder of the retinal anatomy is included and the grading of DR is also covered. Each of the retinal signs of DR are examined and the treatment options for DR are briefly reviewed. This video features 12 MCQs that have been accredited with 2 CET points and are GOC approved for Optometrists. SPONSORED BY



2 FREE CET POINTS Approved for: Optometrists


AS Points 4

SP Points

OT CET content supports Optometry Giving Sight


IP Points

Having trouble signing in to take an exam? View CET FAQ Go to


substantially ‘damaged’ (see OT, August

Management Options for UK Optometrists Part 4

General eye irritation and allergic conjunctivitis

13 2010). Such compromise will likely be

Course code: C-14569 O/AS/SP/IP

(fTBUT) values then cause ocular surface

associated with a change in the goblet cells, such that a vicious cycle can result in mucin deficiency that destabilises the tear film; very short fluorescein tear break-up time desiccation and a worsening of the staining. Immediately





are numerous nerve fibre terminals that endow the conjunctiva with sensitivity to mechanical stimuli as well as to sensitivity to tactile stimuli of the bulbar conjunctiva is rather lower than that of the central cornea, but has also indicated that sub-normal sensitivity is associated with a higher than normal eyeblinking.4 This sensitivity is, in some way, linked to the function of the trigeminal nervous

Professor Michael J. Doughty, PhD This article considers the aetiology and demographics of general conjunctival irritation, including seasonal allergic conjunctivitis (SAC) and perennial allergic conjunctivitis (PAC). In terms of patient management, assessment

system that forms organised fibre bundles slightly





connective tissue (Figure 1). Therefore, an acute response to an irritant might

and follow-up, guidelines need to be carefully considered for each type


of condition as does the finer details of legislation relevant to the use of

reflex lacrimation), while a longer-term

different drugs in eye brighteners, decongestants, decongestant / topical

consequence of chronic irritation appears

antihistamines, and oral antihistamines, as well as mast cell stabilisers.

to be a reduction in conjunctival sensitivity

Special consideration will be given to access to topical ocular antihistamines

that also results in increased eyeblinking.

and a topical NSAID by additional supply (AS level) optometrists.

The sub-epithelial connective tissue




(parenchyma) is richly supplied with

Aetiology of ocular irritation and reactions to external allergens

lacrimation and eyeblinking are likely, as


this system attempts to clear the tear film

distinctive smooth muscle surrounding

Patients can report a variety of symptoms

of the cause. There will also be changes in

them and the venules more likely to

associated with tear film deficiencies,

the complex structure of the conjunctival

have a fenestrated endothelial lining

often loosely referred to as ‘dry eye’ (see

epithelium tissue and the connective tissue

(Figure 1). All the blood vessels are likely

OT, July 16 2010). Slightly different

immediately underlying it (Figure 1).

innervated by the autonomic nervous

Most of the healthy conjunctival surface

system (ANS), with the sympathetic









‘itchiness’, can also be experienced in


patients not having dry eye disease (DED);

within the layers of which are goblet cells

arterioles and the parasympathetic nervous

all, however, are sensory responses to

providing mucin that forms the basal


anything abnormal and/or threatening

aspect of the tear film layer.

The surface

venules. It is unknown how the balance

to the conjunctiva. If the exposure to

of the conjunctiva can change such that

of these ANS effects is altered if there

irritants (eg, organic fumes) or allergens

it will ‘stain’ with fluorescein if slightly

is a change in conjunctival sensitivity.


compromised and with rose bengal if more















dominating controlling


the the


15/10/10 CET

irritants. Recent research confirms that the



2 FREE CET POINTS Approved for: Optometrists


AS Points 4

OT CET content supports Optometry Giving Sight

SP Points


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vessels, means that substantial and rapid changes in fluid flow to and from these vessels can occur, which results in changes to the fluid content of the parenchyma. It is such changes that are responsible for the (sometimes) dramatic changes in the


external appearance of the conjunctiva and eyelid marginal skin, when there is an acute response to an irritant or allergen. A progressive impairment of this lymphatic system is also thought to be responsible for the development of conjunctivochalasis,5 perhaps better known by the acronym lid-

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Overall, all of the components outlined here are involved in response of the eye to external irritation as well as to allergens. The





Figure 1 Schematic diagram to illustrate the complexity of the conjunctiva. From Bergmanson JPG, Doughty MJ (2005) in Clinical Contact Lens Practice (Bennett ES, Weissman BA, eds). Lippincott, Williams & Wilkins, Philadephia. Chapter2, pp. 12-39

associated with the innate immune system

inflammatory cells, whether these be

system, the distinguishing symptom often

the natural complement of mast cells

noted is that of ‘itching’. This can often

is also reflected in the use of both non-

or additional white blood cells (eg,

result in the patient wanting to rub (rather

eosinophils) that have migrated from the

than ‘scratch’) their eyes. A patient with

capillaries into the tissue in response to

acute-onset allergic reaction may indeed

irritation;3 both cell types are special in

have an overwhelming desire to rub their

that they generally contain granules which

eyes and, in the process, actually worsen

can release inflammatory mediators such

their condition leading to redness and

as histamine and certain prostaglandins.

puffiness of the eyelid margins and even

Medicines and non-medical products for managing general eye irritation and allergic conjunctivitis

These inflammatory mediators generally

the bulbar conjunctiva. This secondary


cause dilatation of the blood vessels and

response is mediated by the lymphatic

conjunctival system, there is no single

also mediate the sensory responses to

system within the parenchyma. These can

approach to pharmacological management

irritation. Some patients may complain of

be seen as having similar size to blood

of general eye irritation and allergic

general ‘irritation’ or ‘discomfort’ or even

vessels (Figure 1) or, at least at some

conjunctivitis. Furthermore, the legislation

‘smarting’ of the eyes, as opposed to saying

locations under the conjunctiva, as very

relevant to the range of products available

that their eyes are ‘dry’, although some


substantial in size (volume) (Figure 2).

has changed substantially in recent years.

patients experiencing progressive allergy

The electron micrograph (Figure 2)

Eyewashes and eye ‘brighteners’ are general

reactions to eye drop preservatives (eg,

illustrates just how loosely packed the

sales list (GSL), with the latter being an

benzalkonium chloride) may report ‘dry

parenchyma is, especially in the vicinity


eyes’. If the irritant is actually an allergen ie,

of a dilated lymphatic vessel.


containing topical ocular decongestants or

is triggering the specific immune response

attribute, along with the specialised loops

a decongestant and antihistamine. A topical

system rather than the innate non-specific

in the endothelial lining of the lymphatic

mast cell stabiliser has been recently added


and the allergic response with a more specific immunoglobulin E (IgE)-activated system. These distinctions are far from clear by modern-day perspectives and this specific as well as specific pharmacological interventions to manage the wide spectrum of presentations for this group of conditions.








to the GSL category (as well as

(even though the latter can

being available as a P-medicine),

still be efficacious). Older



remedies included use of

ocular antihistamines have been

“true” astringent (eg, very

discontinued, oral antihistamines

hypertonic solutions such as

are available as GSL products and as

5% saline), but modern-day


individuals with a mild-to-



trained optometrists may access all


the above-mentioned products by

are most unlikely to tolerate

way of wholesale trading and then

the use of such products.

may sell and supply them to their patients at the recommended retail price. With





legislation changes in 2005, optometrists with appropriate training may access prescription-only



including mast cell stabilisers, most of the topical ocular antihistamine eye drops and a non-steroidal anti-inflammatory drug of








guideline (CMG) is ‘Seasonal Allergic Conjunctivitis;



Conjunctivitis’ which notes the major role optometrists can play in pharmacological management of these conditions with referral to an ophthalmologist not required.

Figure 2 Very high magnification (electron microscope) image of part of a sub-conjunctival lymphatic vessel with distinctive loops on the very irregular lymphatic lining that appears only loosely attached to the numerous round bundles of collagen fibrils that make up the parenchyma. From Doughty MJ, Bergmanson JPG (2003) Optometry 74: 485-500. a




The external appearance of the eye will indicate that the conjunctiva is reacting slightly to irritants and a very mild ‘red eye’ develops (Figure 3). There should be no discharge of a mucopurulent nature but some lacrimation (or even slight epiphora) may be present perhaps along with little white mucous strands in the lower fornix

Astringent eyewashes and eye drops and topical ocular decongestants

(as the goblet cells can discharge slightly

Once-common causes of ocular irritation

sign of oedema (puffiness) etc. with the

were smoke-filled rooms (now reduced

degree of bulbar conjunctiva hyperaemia

with changes in workplace legislation)

usually being low. In addition, there

but either traffic exhaust fumes or perhaps

will usually be little or no signs of ocular

barbecue smoke or indoor grills are

surface compromise (eg, significant ocular

the likely replacements, in addition to

surface staining with sodium fluorescein)

numerous other indoor airborne micro-

but fTBUT values may be reduced.

particulates causing mucous membrane

Reducing the level of irritants in the tear




such presentations, there will be little


film is a logical first step to management,

sometimes referred to as volatile organics

either by avoidance or with the use of

and associated with conditions such as

eyewashes or lotions. Such remedies have

‘sick building syndrome’. A recreational

mild ‘astringent’ action, a term indicating



that there is a slightly greater cleansing

(eg, swimming pools) can also cause

action than a simple isotonic (0.9%) saline



in response to general irritation). In many





Reduction of tear film irritant levels can therefore be effectively achieved by the use of eyewashes containing plant extracts such as Hamamelis (witch hazel) (eg, GSL Optrex Eye Lotion),6 and are generally most effective if performed with patience and using an eye-cup, at the end of the working day or after the recreational exposure to irritants. Patients can also use eye drops containing the same ingredients or dilute zinc sulphate (0.25%). If simply washing out the irritant is not successful, the next logical step is to use drugs that actually work on the superficial blood vessels to reverse the changes that have been induced ie, reduce hyperaemia and discomfort.7,8 If the cause can be established as essentially a minor irritant, then the use of brighteners or decongestants is appropriate. A number of products are available, which are designed to attenuate these mild reactions regardless of the actual nature of the stimuli; these are labelled as

Figure 3 Very mild ‘red eye’ associated with chronic environmental workplace irritation where some conjunctival blood vessels are notably dilated.

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eye drops) were introduced in the 1950s to

children (ie, those less than 12 years of age),

replace the use of adrenaline (epinephrine)

and the current recommendation is that the

1:1000 eye drops as a vasoconstrictor

combination product Otrivine-Antistin is

(decongestant).9 Eye drops containing

not for use in children at all, or should be

phenylephrine were discontinued in the

half the dose recommended for an adult.

UK in 2003, but may be accessible over the


Internet along with eye drops containing other drugs such as tetrahydrozoline or oxymetazoline. At the concentrations used, the adrenergic drugs act as vasoconstrictors on the smooth muscles of the more superficial vessels of the conjunctiva, to

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whiten the general appearance of the eye.10

the use of topical ocular decongestants is whether there is rebound vasodilation with overuse.14,15 This can be part of a general irritation





that includes a follicular reaction and it may thus be considered as an ophthalmic ‘medicamentosa’. Safety issues are both ocular and systemic. Overuse, in an attempt

last for at least an hour to help relieve

to alleviate all signs and symptoms of any

symptoms such as irritation, mild burning

acute red eye with these products, could

and photophobia,10,11 and reduce reflex

allow a (mild) infectious conjunctivitis to



progress,16 and even dilute solutions may


produce a slight pupillary dilation.10,17 While

to also produce a “calming effect on

only slight pupil dilation has been measured

blepharospasm” associated with ocular

with the use of combination products (with

irritation,11 and this logically applies to the

an antihistamine),18,19 an additive effect

current UK combination of xylometazoline

might be due to mild cholinergic blocking



and antazoline (Otrivin-Antisine). Their combination




astringent such as zinc sulphate,9 or a coloured dye such as brilliant blue,6,13

to minor eye irritations” or to “reduce

below), but a recurrent issue that arises with

rapid in onset (ie, within a minute) and


“for the relief of redness of the eye due

of these products relates to safety (see

The effect of these products should be


Figure 4 Packaging for an ophthalmic brightener product to indicate use and precautions

The primary reason for limiting the use

may provide extra relief and added cosmesis (eg, Eye Dew Dazzling eye drops). The recommended doses for symptomatic relief and cosmesis (ie, whitening of the eye) vary widely. They have been assessed

actions of the antihistamine. Even slight pupil dilation in at-risk individuals could be associated with acute-onset angle closure glaucoma.20 Such an adverse reaction is definitely not wanted, and is the reason for the small print warning on some of these products that they “should not be used in patients with glaucoma” or a far more vague warning about ‘eye disease’ (Figure 4); some small print warnings include the

redness so making the eyes brighter with

and used at anything from one to eight

type “Do not use for more than 72 hours

whiter whites” (Figure 4). These products

drops per day in each eye, but current

except under the advice and supervision

contain low concentrations (sometimes

perspectives are that such products should

of a ‘doctor’ or ‘physician’”. Overall,

not specified) of drugs that primarily act

not be used ‘as needed’ for long periods

therefore, all such decongestant-containing

as alpha-1 adrenergic agonists on the

and that the number of uses per day should

products should be used with caution and

blood vessel smooth muscles. Drugs such

be limited, eg, ‘do not use more than three

should not be recommended for use in

as naphazoline (eg, Murine eye drops,

times per day’ (Figure 4). As can be seen on

patients who are known to have a narrow

or Eye Dew Sparkling eye drops) and

the pack of a contemporary GSL product,

anterior chamber angle. Pupillary dilation


these eye drops are not intended for use in

is more likely to be evident under lower



now deregulated, with the responsibility











sodium cromoglicate




sodium cromoglicate


5 or 10


for safe use being transferred to the user.





the form of the small print on the packing and product inserts (Figure 4).

sodium cromoglicate


30 x 0.3

CATACROM (preservative-free)

sodium cromoglicate




Mast cell stabilisers For





conjunctivitis, part of an appropriate management approach is the use of ‘mast





drugs marketed in the UK (eg, sodium cromoglicate, lodoxamide and nedocromil sodium). There are others with a combined action of being mast cell stabilisers and antihistamines drugs


(H1-receptor ketotifen,



Illustrated in Figure 5 is the corneal surface, at extremely high magnification, to show the presence of extremely small ‘fuzzy balls’ of pollen grains amidst a background of the pre-corneal mucin. The

















be from animal dander, dust mite excreta,





workplace processes, from furniture and





stick to the epithelial surface mucus





coating. Due to the persistent exposure,














density of these very small (circa 1μm in diameter) pollen grains is in excess of 1000,000 per mm2, and these resist washing with saline. Other micro-particulates might

carpeting etc., all of which can tenaciously

it should make sense therefore that the use of a mast cell stabiliser may well be needed, along with twice-daily astringent eye washes, to reduce the allergen load on the ocular surface. Indeed, the idea

Table 1 UK marketed mast cell stabilisers and topical ocular antihistamines. 1 antihistamine in combination with a decongestant, xylometazoline; 2 considered to have dual action as mast cell stabiliser and antihistamines; 3 not on additional supply list

for use of a mast cell stabilizer is to try to

levels of illumination and in blue-eyed

Overall, while some ocular irritation

be achieved, there should be a reduction

individuals and probably is more likely

can develop with overuse, these products

in the tear film levels of inflammatory

when there is significant compromise

have an excellent safety record and this

mediators despite the continued presence


is why some

of the allergen. With repeated contact of







products are


reduce or even prevent the mast cells from discharging histamine and prostaglandins (degranulation)




mediated activation by allergens. If this can

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especially sodium cromoglicate, can be

antihistamines can be used to manage SAC,29-

used to manage a range of types of allergic


conjunctivitis, and have an extraordinary

the faster onset in reduction of symptoms,

good safety record in that local adverse

ie, a patient can start using these at the

effects reports are both unusual and perhaps

first exposure to allergens and can expect

actually due to the benzalkonium chloride

useful effects within minutes to hours (as

preservative. As a broad principle, therefore,

opposed to days with a mast cell stabiliser).


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Figure 5 Pollen grains (the small round balls with irregular surfaces) adhering to pre-corneal mucus layer on the corneal epithelial surface of a cow eye, as viewed at extremely high magnification with the scanning electron microscope

with their principal advantage being

there are no restrictions to the use of sodium

It is unclear, however, whether the overall

cromoglicate eye drops other than known

longer-term tolerance to airborne allergens

allergy to the drug or the preservative

is better when comparing use of topical

benzalkonium chloride, regardless of patient

antihistamines to mast cell stabilisers. The

age. For a named patient, preservative-free

antihistamines all have some restrictions

(unit dose) sodium cromoglicate eye drops

on use, with the various products having

are available through a specialist hospital

warnings that they are not indicated for use

pharmacy, eg, Moorfields Eye Hospital.

on children below the age of three or four

the ocular surface with allergens, the mast

The commoner indications for the use

years, largely because appropriate efficacy

cells (as well as other inflammatory cells)

of sodium cromoglicate eye drops are for

and safety data has not been provided for

can be expected to migrate towards the

chronic conditions such as SAC and PAC.

conjunctival surface.3 These cells can then

such use. Considerable assessments have

The available P-medicines can be used for

respond progressively faster and more

been made on their safety, with particular

most presentations and are designed to

extensively even for the same allergen load.

attention being paid to the ocular surface.

improve tolerance to the external allergens

Certain types of deposits on contact

There is no obvious ‘drying’ effect from

such that symptoms are reduced in severity.


use of these drugs on the corneal and

However, if symptoms are dramatically

allergens.22 These mast cell stabilizers

conjunctival epithelium (eg, as evidenced

reduced in response to sodium cromoglicate

should reduce mast cell degranulation in

by sodium fluorescein staining) but patients

eye drops (or another mast cell stabilizer),26

a dose-dependent fashion,23 and may also

with chronic allergic conjunctivitis are

then substantial activation of the mast cells

reduce migration of white blood cells.24

more likely to have low grade staining and

has not occurred, and such a patient could

lower fTBUT values.32 Patients who already






Sodium cromoglicate eye drops are

likely be managed with occasional use of

have DED may be more likely to show

widely available as P-medicines and

moisturisers, brighteners or an eye wash.

such staining or punctuate epitheliopathy.

even as a GSL product (see Table 1). All

The optometrist with training to AS level

However, it should not be forgotten that

of these cromoglicate products can be

may chose to manage other conditions such

the ocular reaction to allergens could

accessed by optometrists, along with a

as vernal keratoconjunctivitis (VKC)27 or

produce significant morbidity. Lastly, it

P-medicine in the form of lodoxamide. To

adult atopic keratoconjunctivitis (AKC)28

should be noted that patients can prefer

increase tolerance to allergens, these drops

with PoM mast cell stabiliser products.

different antihistamine eye drops despite

need to be used regularly (ie, four times

They can also access the dual acting drugs,

their overall ocular discomfort,30,33 with

per day) and continuously for the entire

ie, ketotifen and olopatadine, as well as


period for which exposure to the allergen

selective antihistamines (eg, azelastine and

to be due to the pH of the eye drops.

is expected. This might be seasonal (eg,

emedastine), all of which can be used in

pollen) or perennial (eg, animal dander,

a similar manner to a mast cell stabilizer

indoor allergens etc.). It may take a week

with certain caveats. The most important of

Oral antihistamines and related products

or so before a reasonable tolerance to

these is that they are not generally indicated

For patients with more substantial SAC,

allergens is achieved, thus the potential

for use in young children (see below).

ocular symptoms are more than likely to

need for eye washes, decongestants or

Another drug, epinastine, is marketed

be accompanied by non-ocular symptoms.

topical ocular antihistamines to initially

as eye drops in the UK but not on the

These may range from sneezing, nasal

manage these conditions. These drugs,

additional supply list. These topical ocular

congestion and rhinitis, to a general irritation





(itching, burning sensations) of the


periocular skin (extending onto


the eyelid skin). The periocular

patient use of anti-depressants (eg,

response to allergens may prompt

monoamine oxidase inhibitors,

a patient to want to rub their eyes,

MAOIs) being a notable contra-

and the nasal symptoms can be

indication. In addition, medicines

rather disconcerting as well. It is


logical, therefore, to use an oral

relevant to the special use of

antihistamine to reduce the non-


ocular symptoms, which may also


reduce the need to repeatedly instill

for use in glaucoma has already

mast cell stabiliser or antihistamine

been described and is of greater


importance in elderly patients



antihistamine-containing products include


acrivastine, cetirizine.


azelastine, Orally






Figure 6 Patient information leaflet accompanying product containing an older oral antihistamine (chlorphenamine)


oral 34




and with

particularly antihistamine,



with a shallow anterior chamber; slight cholinergic blocking effects are notable with some older ‘sedating’ oral antihistamines. There is also a general

antihistamines are used to ‘dry up’

pharmacy chains. The dose used will

warning about limiting alcohol use and

secretions (eg, a runny nose) and therefore,

likely be an important determinant of both

‘Do not drive or operate heavy machinery

for some patients, can actually reduce ocular

the overall efficacy and the likelihood of

if the tablets make you feel drowsy’.

symptoms of watery and itchy eyes too.

adverse reactions / side effects; indeed

Patients’ lifestyles should therefore be

Older drugs such as chlorphenamine have

the use of oral antihistamines can be


been classed as ‘sedating antihistamines’

associated with ‘dry eye’ symptoms.37,38


before oral






for many years,35 with each of the newer

With the reduced regulation of these

Last, but not least, consideration needs to

2nd generation drugs being successively

drugs for the management of common

be given to patient age. Most of these oral

presented as ‘non-sedating’; there is a

conditions such as SAC and PAC, the

antihistamines can be used in children,

further drug that is considered to have

responsibility for safe use has been largely

with a general recommendation that a

even lesser-sedating effects, but it should

transferred to the user, as with the use of

lower dose should be used as compared to

be borne in mind that a condition such as

decongestants. Various precautions apply,

adults. P-medicine and GSL oral solutions

seasonal allergic rhinitis (with congestion)

and while most are relevant to the older

of most of the antihistamines are also

may in itself cause a form of drowsiness

antihistamines (still available in large packs

available to facilitate this low dosing (ie,


(ie, a ‘thick’ or ‘stuffed’ head feeling).

as P-medicines, rather than small GSL

half a spoonful for a child), eg, Allerief

Oral antihistamines are indicated for use

packs), these still need to be considered

(chlorphenamine), Benadryl Allergy Oral

on a QDS basis for older antihistamines

by the optometrist recommending their

Syrup (cetirizine), Benadryl for Children

to once daily for newer antihistamines.

use or even supplying them to their

Allergy Solution, Clarityn Allergy Syrup

Current products include the P-medicines

patients. Some of these precautions are on

(loartidine), Piriteze Allergy Syrup, Zirtek

of Allercalm, Hayleve, Piriton, Pollonase

the packaging, but more typically are in

Allergy Solution and Zirtek Allergy Relief

Antihistamine Tablets (chlorphenamine),

the ‘small print’ on a Patient Information

for Children (cetirizine).

Tavegil (clemastine), Benadryl Allergy

Leaflet inside the packaging (Figure 6).

Beyond considering the use of oral

Relief (acrivastine), Zirtek and Piriteze

As opposed to warnings of substantial

antihistamines as part of management of the

Allergy Tablets (cetirizine), plus the P /

risk of severe side effects, many of these

ocular effects of SAC and PAC, optometrists

GSL drug Clarityn Allergy (loratidine).

precautionary notes relate to possible

should also be aware of numerous over-

There are also a number of small pack

effects of the antihistamines on the

the-counter (OTC) nasally-administered

(seven tablets) products available as GSL

actual bioavailability of the medication.

products for patients for whom the nasal

products manufactured by the major

Optometrists should already be taking

congestion and inflammation is more of

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a problem. These OTC products include

entail instillation of eye drops (either a

stabilizer should be continued until the

nasal decongestants such as phenylephrine

decongestant, mast cell stabilizer or a topical

papillae are greatly reduced, preferably

0.5% (eg, Fenox), xylometazoline 0.1 %

ocular antihistamine) 5 to 10 minutes prior


(Otrivine Adult Nasal), xylometazline 0.05

to morning lens insertion. After lens wear, a

fluorescein (see OT May 21, 2010).49,50

% (Otrivine Child Nasal) or oxymetazoline

patient could then instill further eye drops.

Most resolution should take two to four

0.05 % (Afrazine). OTC nasal products

It would not be unexpected for such a

weeks, after which the dosing could be

containing sodium cromoglicate (Vividrin

patient to instill the eye drops in the middle

reduced to TDS or even BDS for a further



of the day with the lens in place. However,

two to three weeks to ensure complete

as a number of products containing

this is not generally recommended for

resolution of mild-to-moderate CLPC.

corticosteroids (see article 6 in this series).

soft lens wearers because these eye

For contact lens wearers with allergies,

A last option, available to AS-trained

drops are preserved with benzalkonium

the use of oral antihistamines might prove








problematic as a result of the ‘drying’ effect

diclofenac (PoM Voltarol Multi) in eye drop

which could reduce tear secretion,51 and

form, which works to reduce production

it has been reported that shorter-term

would be expected to be greater with the

of prostaglandins (see article 6 in this

BDS use of olopatadine eye drops could

older sedating antihistamines. Therefore,

series). There are only vague guidelines as

reduce symptoms, redness and papillary

it might be beneficial to simply avoid use

to when these eye drops might be used for

reactions,42 while the extended use of

of the older drugs and to recommend a

SAC, but they should reduce inflammation

decongestant (tetrahydrozoline) eye drops

2nd generation drug such as cetirizine.

and redness while having little impact

BDS had no obvious beneficial effects on



superficial punctate keratitis (SPK), follicles,

contact lens wear, could be managed

eye drops, which are preserved with

vasodilation etc.43 Sodium cromoglicate

with the as-needed use of a contact lens

thimerosal, should be considered perhaps

eye drops QDS use has been assessed in

rewetting drop (see OT July 16 2010).

as an adjunct medication to be used

contact lens wearers,44-46 and, especially

alongside mast cell stabilisers as well as oral

for RGP lens wearers, has been reported


or topical antihistamines. Recommended

to be effective and without significant side

Irritation or allergic reactions of the eye

dosing with diclofenac eye drops is QDS.

effects for up to 18 months. For nedocromil

are commonplace, and it is rarely possible

eye drops, the situation is different since

to prevent exposure. Optometrists have

the eye drops have a yellow colour and so

a range of simple options available

As noted earlier, certain deposits on contact

could stain a hydrogel lens matrix;47 the

to them to manage these conditions

lenses may serve as allergens leading to the

product use should also be limited to 12

as part of providing a comprehensive

development of Contact Lens Papillary

weeks. Currently, the various UK marketed


Conjunctivitis (CLPC) or the more severe

products clearly state that they should not

Giant Papillary Conjunctivitis (GPC). In

be used whilst wearing contact lenses.

addition, contact lens wearers may also

The principle of management of CLPC

Professor Doughty has been teaching

suffer from SAC or PAC and individuals

is similar to that for many other ocular

ocular pharmacology, as well as many

with these conditions are perhaps more

allergies, with a period of discontinuation

aspects of ocular physiology and eye

likely to develop CLPC.41 With care,

of contact lens wear recommended as part

disease, for over 25 years and authored

many of the options outlined above can

of the management, and the treatment

books on the subject. He has held the


is usually with a mast cell stabiliser.

post of Research Professor at Glasgow-

contact lens wear in those with ocular

A discontinuation of lens wear should



discomfort reactions to external irritants

result in reduction in the severity of the



or allergens, and for managing CLPC.

condition over several days, often allowing

on symptoms such as itching.


Allergy and contact lens wear












Not withstanding, for contact lens wearers

optometrists, is access to the NSAID

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resumption of contact lens wear within

a conservative approach for daily lens

a few weeks. With contact lens wear

wearers with allergies, which would

discontinued, a QDS regimen of a mast cell












About the Author


Department since


References See and search ‘references’

Course code: C-14569 O/AS/SP/IP

1. Which of the following symptoms is typically experienced by those suffering acute-onset allergic conjunctivitis? (a) Dryness (b) Itching (c) Scratchy feeling (d) All of the above

7. Which of the following is TRUE about eye drops containing antihistamines? (a) They are approved for use by patients of all ages (b) They are not recommended for use in young children (c) They should not be used along with decongestants or brighteners (d) They can be used safely in all elderly patients

2. Which of the following is TRUE about bulbar conjunctival lymphatic vessels? (a) They are very small and are controlled by the corneal nerves (b) They have distinctive sets of smooth muscle cells around them (c) They have a specialised endothelial lining facilitating rapid fluid exchange (d) They are only altered when there are specific IgE-mediated reactions

8. For moderate severity of contact lens-induced papillary conjunctivitis (CLPC) causing lens discomfort, the most appropriate therapy would be: (a) Use of diclofenac eye drops QDS (b) Use of a decongestant eye drops up to 3 times per day (c) Use of a topical antihistamine as-needed whilst continuing lens wear (d) Discontinue lens wear and use lodoxamide eye drops QDS

3. Which of the following is TRUE about Hamamelis extracts? (a) They are included in eye drops as vasoconstrictors (b) They have specific dilation-mediating effects on conjunctival mast cells (c) They have astringent actions equivalent to saline 5% solutions (d) They can be expected to cleanse and sooth the eye

9. Which of the following is TRUE about orally-administered antihistamines? (a) They cannot be legally supplied to patients by optometrists (b) They should not be used concurrently with antihistamine eye drops (c) They are widely available as P-medicines that can be sold by all optometrists (d) They all have the potential to cause substantial drowsiness

4. Which of the following can be found in products labelled as ophthalmic decongestants? (a) naphazoline (b) xylometazoline (c) tetrahydrozoline (d) all of the above 5. Which of the following is TRUE about rebound vasodilation? (a) It is a possible effect of overuse of brightener eye drops (b) It occurs when the conjunctival vessels over-react to environmental allergens (c) It is mediated by IgE effects on the conjunctival lymphatic vessels (d) It is the cause of slight mydriasis associated with use of a decongestant 6. Which of the following is TRUE about topical ocular mast cell stabilisers? (a) They are designed to provide immediate relief in allergic conjunctivitis (b) They can be used effectively on an as-needed basis along with saline eyewashes (c) They should reduce the severity of symptoms in both SAC and PAC (d) They are currently only indicated for use in adults with SAC

10. How does Ketotifen, as PoM Zaditen eye drops, work? (a) Effect on alpha-1 adrenergic receptors in conjunctival arterioles (b) By combined stabilising effects on mast cells, white blood cells and eosinophils (c) Effect on specific histamine H2 receptors on conjunctival venules (d) As a non-steroidal anti-inflammatory drug to reduce prostaglandin synthesis 11. Which of the following is TRUE about airborne pollen grains and other micro-particulates? (a) They can enter the tear film and stick to the ocular surface epithelia (b) They are usually too large to mix with the tear film (c) They are generally inert and will not activate the specific immune system (d) They should usually be easily washed from the ocular surface by the tears 12. Soft contact lens wear can usually be continued with the use of which of the following? (a) Astringent eye drops (b) Topical ocular decongestants (c) Topical ocular mast cell stabilisers (d) None of the above

PLEASE NOTE There is only one correct answer. All CET is now FREE. Enter online. Please complete online by midnight on November 17 2010 - You will be unable to submit exams after this date – answers to the module will be published on


15/10/10 CET

Module questions


Assessment of the anterior chamber angle and depth Claire McDonnell FAOI Assessment of the anterior chamber angle (ACA) and anterior chamber depth (ACD) is necessary for several reasons. Many types of glaucoma


require ACA assessment for a correct diagnosis eg, narrow angle glaucoma, angle closure glaucoma, pigmentary glaucoma and neovascular (or 100day) glaucoma. Visualisation of the angle is also recommended where there is any suspicion of peripheral anterior synechiae, angle recession

15/10/10 CLINICAL

or iridodialysis post-trauma. It is also useful for establishing the patency of peripheral iridotomies and a patient’s suitability for anterior chamber implants. In everyday practice it is useful to know the width of the angle to help determine the potential risk of angle closure prior to carrying out

Figure 2a Measurement of the anterior chamber depth using Smith’s method (see text for details)

pupil dilation on a patient. This article describes the various methods that can be used to assess the ACA and/or ACD in clinical practice.

Pen torch method The simplest method of assessing ACD is by shining a pen torch into the patient’s eye from the temporal canthus such that the pen torch lies in the same plane as the eye. In the case of a deep anterior chamber, the iris lies flat and the whole iris will be illuminated. In the case of a very shallow anterior chamber the iris lies forward, blocking some of the light and very little of the iris is illuminated. Based on the amount of eye illuminated the ACD can be graded (Figure 1).

Smith’s method The Smith method is a quantitative method of measuring the ACD.1 It is carried out using a slit lamp with the observation system directly in front of the patient’s eye and the illumination system at an angle of 60° to the temporal side. If measuring the patient’s right eye,

the right ocular of the slit lamp is used and vice versa for the left eye. A beam of approximately 1.5mm thickness, with its orientation horizontal, is placed across the cornea. The technique is slightly easier if the tear film is stained with fluorescein. A second horizontal beam is then seen in the plane of the crystalline lens (Figure 2a). The length of the beam is adjusted until the beams on the cornea and crystalline lens just appear to meet (Figure 2b). The length of the beam is read directly from the slit lamp and this number is multiplied by 1.34 to calculate the ACD. Eyes with an ACD of less than 2mm should be dilated with caution.

Van Herrick’s technique Van Herrick’s technique2 is perhaps the most commonly used qualitative method of assessing the size of the ACA using a slit lamp biomicroscope. It

Figure 1 Grading of anterior chamber angle/depth using the pen torch method

Figure 2b Measurement of the anterior chamber depth using Smith’s method (see text for details) involves comparing the size of an optic section width on the cornea to the gap between the section and the reflection on the iris when a beam is trained just within the limbus at an angle of 60°. The section must be just within the corneal side of the limbus. The further it is from the limbus the more the angle will be overestimated. An angle of 60° should be used consistently to allow for standardisation of measurements. The AC angle width used to be graded on a scale of grade 0 (closed) to 4 (wide open) but this meant that subtle changes in angle width could easily be missed. Today it is more common to grade the angle on a decimal scale (see Table 1). For example, a grade of 0.2 (Figure 3) indicates a very likely probability of angle closure occurring, whilst a grade of 1.0 (Figure 4) indicates an almost impossible chance of angle closure occurring.

Split limbal technique

Optical coherence tomography Optical coherence tomography (OCT) uses low coherence interferometry to obtain cross-sectional images of the ocular structures. To image the anterior segment, longer wavelength light (1,310nm) is used than that used for the posterior eye. Anterior segment OCT can be used to take measurements of the angle and to visualise, for example the patency of peripheral iridotomies, and blebs in trabeculectomies etc. The Haag-Streit slit lamp OCT is available as an attachment for the slit lamp and the new Cirrus HD-OCT from Carl Zeiss. combines both anterior segment and posterior segment OCT.

Figure 3 Anterior chamber angle graded as Van Herrick’s Grade 0.2

Figure 4 Anterior chamber angle graded as Van Herrick’s Grade 1.0

Scheimpflug imaging

can give a complete representation of the anterior chamber, extending from the endothelium to the posterior surface of the lens. The geometry of the anterior eye chamber is calculated in three dimensions. The chamber angle is also shown in the Scheimpflug image (Figure 6).

The Oculus Pentacam uses Scheimpflug images to create an image of the anterior chamber. The Scheimpflug principle images the anterior eye with a camera at an angle to a slit-beam creating an optic section of the cornea and lens. The image Van Herrick Grade

Limbal Section: Optically dark section ratio

Probability of closure

Grade 0.0

No dark section visible


Grade 0.1


Very likely

Grade 0.2


Grade 0.3


Grade 0.4


Grade 0.5


Grade 0.6


Grade 0.7


Grade 0.8


Grade 0.9


Grade 1.0





Table 1 Grading of the anterior chamber angle using the Van Herrick’s technique Grade

Figure 5 Split Limbal Technique to measure the superior anterior chamber angle

Estimated Angle

Estimated Angle

Grade 0


Grade 1


Very likely

Grade 2



Grade 3



Grade 4



Table 2 Grading of the superior anterior chamber angle using the Split Limbal technique


15/10/10 CLINICAL

The Van Herrick’s technique can be used to measure the width of the angle temporally and nasally but tells us nothing about the superior and inferior angles. The superior angle is the narrowest and the most likely to close. To estimate the superior and inferior angles the split limbal technique can be used. In this technique the slit lamp is used to provide the illumination but observation is with the naked eye. With the illumination in the click position, a vertical slit should be placed across the superior ACA at 12 o’clock. Observe the arc of light falling on the cornea and iris without the aid of the slit lamp eyepieces. The angular separation seen at the limbal corneal junction is an estimation of the anterior chamber angle depth in degrees (Figure 5 and Table 2).


15/10/10 CLINICAL


Structures Visible

Probability of Closure





Only Schwalbe’s line visible

Very likely


Trabecular meshwork visible



Scleral spur visible



Ciliary body visible


Table 3 Grading of the anterior angle with gonioscopy

Figure 6 Anterior chamber image and biometry as obtained using Scheimpflug images from the Oculus Pentacam Gonioscopy The gold standard for ACA assessment is gonioscopy. This is a technique that is commonly performed in a hospital eye department and involves the use of a slit lamp and gonio-lens. The goniolens is a contact lens with mirror(s) and prisms attached to it, which allow direct visualisation into the ACA. To carry out gonioscopy, the cornea is anaesthesised

using topical anaesthetic. A lubricating gel eg, Gel Tears is then added to the gonio-lens before it is placed against the patient’s eye. Lenses with a phlange (or lip) are a little easier to keep on the eye as the phlange stays just under the eyelid making it more difficult for the patient to accidently blink the lens out. Lenses are available in one, two, three and four mirror designs. The advantage

of a four-mirror lens is that less rotation of the lens is required – a part of the procedure that patients tend to find a little unpleasant. With gonioscopy any abnormalities within the angle eg, pigment deposition, neovascular growth etc. can be detected and the width of the angle can be graded depending on which structures are visible (Figure 7 and Table 3). The width of the angle can be underestimated if the patient is not fixating in the direction of the mirror ie, if the mirror is superior, the patient should look up slightly. The structures visible in a wide angle are (from iris to cornea) (a) the ciliary body (CP): this appears slightly darker than the iris itself, (b) the scleral spur (SS): a white band just above the ciliary body, (c) the trabecular meshwork (TM): this can be a whitish-grey or pink colour, and (d) Schwalbe’s line (SL): this is at the edge of Descemet’s membrane. In Figure 7 above Schwalbe’s line, another apparent line can be seen but this is in fact the corneal reflection.

Conclusion A full assessment of the ocular health should include some examination of the ACA and/or ACD. While not all optometrists would have access to OCT or be familiar with the technique of gonioscopy, all optometrists should have access to a slit lamp and could therefore be able to easily carry out some of the procedures outlined above. The depth of the anterior chamber naturally decreases with age due to the increase in size of the crystalline lens and with this decrease comes an increased risk of narrow and closed angle glaucoma.

About the author Claire McDonnell is a lecturer in the Department of Optometry at the Dublin Institute of Technology where she teaches advanced clinical techniques to optometry undergraduates and qualified practitioners.


Figure 7 The visible structures of the anterior chamber angle during gonioscopy. CP = ciliary body; SS = scleral spur; TM = trabecular meshwork; SL = Schwalbe’s line

1. Smith RJ. A new method of estimating the depth of the anterior chamber. Br J Ophthalmol. 1979;63:215-220. 2. Van Herick W, Shaffer RN, Schwartz A. Estimation of width of angle of anterior chamber. Incidence and significance of the narrow angle. Am J Ophthalmol 1969;68:62–9.

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