OUTER COVERS SPREAD
Journal of the Association of Optometrists
NEW Bausch + Lomb ULTRA® Multifocal for Astigmatism VERSION
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* When the ECP followed the fitting guide 1. ULTRA® Comfort Experience™ for Presbyopia Data Analysis Phase 1 + 2. 2017. 2. Bausch + Lomb ULTRA® Multifocal for Astigmatism stabilisation study. 3. Bausch + Lomb, 2013. Perceptions of Bausch + Lomb PureVision® 2 for Presbyopia (#815). Rochester. 4. Bausch + Lomb., 2016. A study to evaluate the product performance of two designs of soft toric lenses (#ROC2-16-016). Rochester. 5. Reindel, W., et al., 2015.Ergonomic Utility of Progressive Multifocal Contact Lenses: A Comparison of Power Profiles Across Near, Intermediate and Distance Zones. AAO Poster Presentation. 6. The 2020 Study of US. Multifocal contact lens market. 7. Hovinga,K.R., 2016. Summary of ULTRA® for Astigmatism Orientation and Axis Markings (#LDR168019). 8. Reindel et al. Use of digital devices and reports of dry eyes: Performance of a novel silicone hydrogel lens among contact lens wearers. Poster presented at the American Optometric Association Annual Meeting, Boston, MA, June 2016. 9. Steffen et al. New technology yields dehydration resistance. Poster presented at the American Academy of Optometry Annual Meeting, Denver, Colorado, November, 2014 11. Millward Brown., 2010. Biotrue® Product Test (#640). 16. Bausch + Lomb, 2013. A study to evaluate the product performance of a new silicone hydrogel contact lens (#817). Rochester. 17. Merchea, M., Wygladacz, K.A., et al., 2014. Comparative Surface Smoothness Durability of a Novel Silicone Hydrogel Material. Association for Research in Vision and Ophthalmology 2014 annual meeting. 18. Hoteling, A., Nichols, W., et al., 2014. PVP content of a silicone hydrogel material with dual phase polymerisation processing. American Optometric Association Annual Meeting; 2014, Philadelphia, PA. 19. Bausch + Lomb, 2013. 16 Hour bilateral dispensing evaluation of methacrylamide lenses as compared to Air Optix® Aqua, Acuvue® Oasys® and Biofinity® lenses (#ROC2-13-002). 20. Schafer, J., Reindel, W., et al. Use of a novel extended blink test to evaluate polyvinylpyrrolidone(PVP) contact lens containing polymer performance. 22. Reindel, W., Mosehauer, G., et al., 2018. Patient comfort, vision and cleanliness over 12-months of Samfilcon A Lens Wear. Poster presented at AAO. 23. Micromass Communications Inc., 2017. Statistical Analysis of Bausch + Lomb ULTRA® for Astigmatism Lenses Challenge Patient Survey. (n=426). 53. Pence, N.,2014. Contact Lens Design and Materials. Contact Lens Spectrum [e-journal]. https://www.clspectrum.com/supplements/2014/october-2014/breaking-the-cycle-of-discomfort/contact-lens-design-amp-materials [Accessed 8/12/2020]. 55. Sulley, A., 2005. Practitioner and patient acceptance of a new silicone hydrogel contact lens. Optician 6017 (230), pp 15-17. 56. Barr, J., 2004. An avalanche of products, compliance and the FCLCA. Contact Lens Spectrum [e-journal]. https://www.clspectrum.com/issues/2010/december-2010/ product-spectrum [Accessed 15/12/20]. 57. Mack, C., 2008. Contact Lenses 2007. Contact Lens Spectrum [e-journal]. https://www.clspectrum.com/issues/2008/january-2008/contact-lenses-2007 [Accessed 8/12/20]
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“One day I’ll be a vlogger” Slow their myopia not their ambition
SLOWS PROGRESSION BY
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1
Rotation, centration and movement at dispensing
-1.0 -2.0
Page 41
THE INDEPENDENT PRESCRIBING EDITION
Power (D)
Intermediate
In practice The IP class of 2009
“ H AV I N G A L O C A L I P O P TO M E T R I S T I M P R OV E S T H E AC C E S S I B I L I T Y A N D Q UA L I T Y O F C A R E ”
Orientation mark helps measure rotational stability and assists patients during insertion7
For illustrative purposes only.
-0.5
2
≤5°on 95% of patients
near, far and in-between1
0.5
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Available in stock and ready to ship so you can reduce your patients’ waiting time and fulfil their vision needs sooner. August/September 2021 / Volume 61:04
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CET Omega-3 and ocular health: what's the deal?
Perspectives Professional boundaries have become less relevent
In practice Reducing the burden on the eye hospital service
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Introducing the Brilliant Futures™ Myopia Management Programme with MiSight® 1 day contact lenses, clinically proven to reduce the rate of myopia progression by 59% and axial length by 52% in children.1 Make a difference to your young myopes’ lives now and you can help protect their vision of the future.2 To find out more and begin your myopia management journey visit coopervision.co.uk/practitioner 1. Chamberlain P et al A 3-year Randomized Clinical Trial of MiSight® Lenses for Myopia Control. Optom Vis Sci 2019;96:556–567. Over a 3 year period, MiSight® 1 day reduced myopia progression on average by 59% compared to a single vision contact lens. 2. Tideman JW, Snabel MC, Tedja MS, et al. Association of axial length with risk of uncorrectable visual impairment for Europeans with myopia. JAMA Ophthalmol. 2016;134:1355-1363.
91OPTAUG21100.pgs 27.07.2021 18:05
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1. Chamberlain P, et al. A 3-year Randomized clinical trial of MiSight® lenses for myopia control. Optom Vis Sci. 2019;96:556–567. 2. Chamberlain P, et al. Further comparisons of myopia progression in new and established myopia control treatment (MiSight® 1 day) groups. BCLA paper presentation 2019. *To access ongoing support materials a minimum of 18 pack must be purchased over a three-month period. †Compared with a standard singlevision one-day lens over a three-year period. ‡Children new to contact lens wear aged 8-12, n= 130 @ 1 month after dispense. §No clinically meaningful change in refractive error -0.25D or less from baseline after 3 years compared to 4% in the control group. II>95% of children were successfully fit with MiSight® 1 day or Proclear® 1 day.
©2021 CooperVision. CooperVision®, ActivControl®, MiSight® and Proclear® are registered trademarks of The Cooper Companies, Inc. and its subsidiaries
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Welcome
SUBS
T
ART PRODUCTION Cover: Grant Pearce
CLIENT
hree years ago, I worked briefly as interim chief executive for the General Optical Council (GOC) before taking up a job running a charity offering care to severely disabled children and adults. The role at the regulator was always a short-term proposition, but as I walked out of the smart offices and off down Old Bailey on my last day, I had a pang of regret – and a sense of unfinished business. To be candid, this pang was not for the GOC itself (nice people though they were). I look back now and I realise that it was the optical profession that had grabbed me. So, when I was offered the chance to come back to optics and work for the leading organisation in the field, of course I jumped at it. I have spent my career in organisations such as Shelter that are valuesdriven, and I could see instantly the importance of the work our members do. As Dr Julie-Anne Little, our new chairman of the AOP Board, puts it in her column for this edition, the profession “does not get the glory, but it does a tremendous job to provide eye care to the nation” (page 35). I am well aware that there is serious work ahead. As a newcomer to the world of optics, I was immediately struck that optometry’s mission was being increasingly threatened by the winds of change whirling around the sector. There is the developing healthcare agenda, with the NHS poised yet again for another of its seemingly endless cycles of reform. There is the rapidly moving commercial market in which eye care is delivered. There is the consumer shift from the High Street to the world of online sales. And there is the inexorable march of technology. At the centre of this whirlwind, are people. That includes the public who need access to proper eye care, and the dedicated and skilled professionals who make up the membership of the AOP and the readership of OT. In this COVID-dominated world, finding innovative ways for me to get to know you and understand your views and aspirations is a key priority. What you do is incredibly important and it is a mission worth protecting. With your help and guidance, I hope I can be part of doing that.
“As a newcomer to the world of optics, I was immediately struck that optometry’s mission was being threatened by the winds of change whirling around the sector”
Adam Sampson, AOP chief executive
August /September 2021
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Welcome
AUGUST/SEPTEMBER 2021
VERSION REPRO OP
Contents
+
Secret life on page 98
56
SUBS ART PRODUCTION
12
CLIENT
Spotlight
AOP MENTORING SCHEME
The news in digest Picture this World Sight Day photo competition OT reports The implications for optics as measures imposed during the pandemic end The edit Optics in 16 stories 100% Optical The biggest line-up to date of speakers, education, and new features Clinical roundup Do plastic screens prevent the spread of COVID-19? Industry profile World Council of Optometry on myopia, with Dr Scott Mundle Supplier insight Options for myopia management AOP roundup A new mentoring scheme, the return of HOAC, and OT’s CET survival pack
4 www.optometry.co.uk
“For mentees, our hope is that this will provide them with a dedicated and unique source of support; someone who has their back” Sarah Melzack, AOP membership benefits officer, PAGE 24
27-33 HIT LIST
The trends, launches and looks OT focuses on... Eyewear for children Me and my glasses Eyewear designer, Patty Perreira Get the look // Anatomy of a frame With Lizzy Yeowart The shortlist The August/September selection Behind the brand Oxsight
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35-39 PERSPECTIVES
Voices from optics and beyond Perspectives Dr Julie-Anne Little, the Birmingham & Midland Eye Centre team, Leonie Milliner My vision Boxer, Khalid Ayub
“It is an honour to step up and serve” Dr Julie-Anne Little – newly appointed chairman of the AOP Board, and a senior lecturer in optometry and vision science at Ulster University PAGE 35
Disney, Getty, Betsy Peake, Hakim Group
07-25 SPOTLIGHT
15
The return of 100% Optical in 2022
CET 65-90 Education and training for the eye care practitioner
39
22 8
65 CET welcome 66 21st century low vision care: new devices 70 Gaining insight: practitioner perspectives of the cataract journey 74 Treatment of children with amblyopia 79 Omega-3 and ocular health: what’s the deal? 84 Cases in casualty 86 Ancillary tests in practice 90 CET author Q+A: Dr Michael Crossland In this edition of OT, practitioners can test a range of competencies: OPTOMETRISTS // 6 THERAPEUTIC OPTOMETRISTS // 2 DISPENSING OPTICIANS // 5 CONTACT LENS OPTICIANS // 2
ONLINE
41-54 IN PRACTICE
Disney, Getty, Betsy Peake, Hakim Group
Business insight and career development The discussion Reflections from the first optometrists to gain the IP qualification 12 years ago Pre-reg focus Luke McRoy-Jones and Emily Mather How I got here OTÕs IP insider, Ceri Smith-Jaynes Becoming a business owner Nasir and Ameerah Riaz Ahmed Key milestones Setting up an IP-centric practice What I have learned Running a special cohort of IP training during the pandemic How do I... “Deal with referral refusals?” The AOP’s Roshni Kanabar explains Life as a locum Rebecca Rushton
Cover story
The IP crowd Well-trained and experienced independent prescribing optometrists have demonstrated their clinical prowess. How can this increasingly valuable qualification develop in the future? PAGE 56-62
OT video highlights
A roundtable on presbyopic patients with astigmatism Watch the video on
www.optometry.co.uk
91-98 ENDNOTES
Jobs The OutsideClinic’s take on recruitment I could not live without... ”My binocular indirect ophthalmoscope,” says hospital optometrist Amy Unwin Last word Russell Peake’s secret life
Contact the OT team with your experiences, observations and lessons from practice today: newsdesk@optometry.co.uk Follow us on Twitter @OptometryToday Like us on Facebook OptometryTodayJournal Follow us on Instagram @optometry_today
August /September 2021
www.optometry.co.uk 5
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Contents
CONTENTS
picture this VERSION
Spotlight
REPRO OP
08 OT REPORTS
Understanding the impact for optics of lockdown restrictions' gradual easing
19 CLINICAL ROUND-UP
Can plastic screens help to prevent the spread of COVID-19 in practice
24 AOP SUPPORT
Launch of the AOP's mentoring programme, plus OT's CET survival pack
SUBS
PICTURE THIS ART PRODUCTION CLIENT Jaylord Plaza/IAPB
A golden glow Taken in Kolhapur, India, the photograph ‘Visual Discomfort’ shows a man taking part in the local festival of Haldi. The photo, captured by Jaylord Plaza, forms one of the submissions in the International Agency for the Prevention of Blindness’ World Sight Day Photo Competition, which is open until 18 October 2021.
August /September 2021
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VERSION
HOW OPTOMETRY IS ADAPTING TO A NEW NORMAL
SUBS
Editor: John White johnwhite@optometry.co.uk Deputy editor: Emily McCormick emilymccormick@optometry.co.uk Senior content editor: Lucy Miller lucymiller@optometry.co.uk Assistant editor: Selina Powell selinapowell@optometry.co.uk
ART PRODUCTION CLIENT
Senior reporter: Kimberley Young kimberleyyoung@optometry.co.uk Web content and social media executive: Leah Boyle leahboyle@optometry.co.uk Clinical editor: Dr Ian Beasley ianbeasley@optometry.co.uk Clinical editor for multimedia: Ceri Smith-Jaynes cerismithjaynes@optometry.co.uk Video production editor: Laurence Derbyshire laurencederbyshire@optometry.co.uk CET enquiries: 020 7549 2076 CEThelp@optometry.co.uk AOP membership and OT subscription team: subscriptions@aop.org.uk
Advertising: Richard Ellacott 020 3771 7242 richard.ellacott@thinkpublishing.co.uk Advertising production: aop@ccmediagroup.co.uk Senior designers: Grant Pearce, Juanita Adu Client Engagement Director: Anna Vassallo Executive director: Jackie Scully Published bimonthly for the Association of Optometrists by Think Media Group 20 Mortimer Street, London, W1T 3JW Printed by Acorn Web, Normanton Ind Estate, Loscoe Close, Normanton, West Yorkshire, WF6 1TW All rights in and relating to this publication are expressly reserved. No part of this publication may be reproduced in any form or by any process without written permission from the AOP or the publisher.
8 www.optometry.co.uk
From mask wearing to social distancing, OT details the implications for the profession as measures imposed during the pandemic eased on 19 July The end of many COVID-19 restrictions on 19 July within England was billed as a milestone moment – but amid rising case numbers, it was unclear at the time of publication whether certain measures would need to be reimposed. While for some the occasion was a welcome return to a semblance of
FACE MASKS: THE APPROACH TAKEN BY PRACTICES IN ENGLAND
A
lthough the legal requirement to wear a face mask eased in many settings in England on 19 July, within optometry, both patients and staff were asked to continue wearing masks when visiting an optical practice. Head of professional advancement and governance at the Hakim Group, Claire Slade, confirmed that the existing policy on mask wearing and personal protective equipment (PPE) remained in place at Hakim Group practices. Director of professional services at Leightons Opticians & Hearing Care, Andrew Bridges, shared that practices are keeping all existing safety measures in place. Paul Morris, director of professional advancement for Specsavers, confirmed that, in line with
August /September 2021
BLACK YELLOW MAGENTA CYAN
normality, others expressed concern about the easing of restrictions that are designed to protect those most vulnerable to disease. How will the return to a ‘new normal’ affect optometry? OT sets out the implications of the changes for the profession and asks optometrists for their views on the path forward.
guidance, colleagues will continue to wear PPE including masks until further notice. Patients will also be reminded that practices are classified as healthcare environments, and so will be asked to wear a face covering unless exempt. Dan McGhee, director of professional services
the practice. McGhee added that it is expected there will be a decreasing number of people wearing face coverings over time. Optometrist Emma Spofforth, who has a compromised immune system, told OT that the easing of restrictions around mask wearing in public and rising case
“I think wearing face masks adds a level of protection for vulnerable people. I feel like we have been ignored” Emma Spofforth for Vision Express, highlighted that staff continue to wear face masks, as well as additional PPE based on risk assessments. Patients are encouraged to wear masks and adaptations are made to ensure that patients who decline to wear a mask have a safe journey through
rates means that she does not feel comfortable going back to work. Spofforth said that she did not think vulnerable people were taken into account in government planning. “I think wearing face masks adds a level of protection for vulnerable people. I feel like we have been ignored,” she said.
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REPRO OP
August/September 2021 Volume 61:04 Issn 0268-5485 ABC certificate of circulation 1 January 2020 – 31 December 2020
S O O C I A L D I S T A N C I N G
ptical bodies set out guidance for practices in England in July confirming the need to follow the College of Optometrists’ ’amber phase’ guidance, and the General Optical Council’s supporting statements for the amber phase. This means continuing to follow infection prevention and control guidance, including the use of PPE, and ensuring social distancing where possible. During the pandemic, Bayfields developed its ‘Baysafe’ model for providing eye care in adherence with Government and industry guidance. Angela Wiggins, clinical and business development director at Bayfields Opticians and Audiologists, confirmed that from 19 July practices have continued to follow the Baysafe (version two) protocols, with regards to wearing PPE, maintaining social distancing and clean-down procedures, and enquiring about COVID-19 symptoms at the appointment booking stage. However, the practice group is no longer requiring the compulsory use of glasses, visors, gloves and aprons. Practices adopted an opendoor policy, but maintained restricted browsing to manage floor space and social distancing. Ball & Gatehouse Opticians operates an appointment-based system for all services, including glasses collections, adjustments and repairs. Sight tests are 40 minutes long, with Optomap included in all private sight tests. Practice director, Nicola Gatehouse, confirmed existing measures remained in place at the Wirral practice after the easing of restrictions on 19 July. “The virus is very much still around and whilst I agree we have to try and get on with normal life, some precautions are still needed,” she emphasised. Mohamed Ayyaz Kasmani, director and principal optometrist of Feltham Eyecare Centre, shared that
his Middlesex practice is continuing to book patients in by appointment-only and maintain the existing protocols. PPE has formed a staple of everyday practice for optometrists, and this is something the practices were comfortable to continue, with each of the practices agreeing that they plan to continue asking patients to wear a face mask in the practice. This is particularly important for Kasmani, as a kidney transplant patient and therefore someone who is immunosuppressed. “We have to remember that there are many optometrists, dispensing opticians and practice staff members who are vulnerable and they need protecting.” Dan McGhee, of Vision Express, confirmed practices are
“The virus is very much still around and whilst I agree we have to try and get on with normal life, some precautions are still needed” Nicola Gatehouse continuing to follow IPC guidance from optical bodies, with practice adaptations remaining in place. This means “no change” to the way customer flow is managed, with tensile barriers and floor markers available, rigorous cleaning and hygiene measures and Perspex shields on slit lamps, front desks and between customer dispensing desks. Specsavers’ Paul Morris also confirmed there has been no change to its current consultation guidance, or social distancing measures. Screens and floor signage remains in place, along with cleaning and sanitising infection control processes. Practices have been reminded to maximise ventilation, and to leave doors open for as long as possible between patients.
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OT Reports
SPOTLIGHT
OT Reports SUBS ART PRODUCTION CLIENT
SCOTLAND Scotland moved to level zero on 19 July, and planned to move beyond this level on the 9 August at the time of publication. From 19 July, physical distancing reduced to one metre in all indoor public settings, and outdoors, but the requirement to wear face coverings remained in place. A memorandum issued on 6 July advised community optometry practices in Scotland to continue following the IPC and PPE guidance set out in Health Protection Scotland documentation. David Quigley, chair of Optometry Scotland, told OT in July: “The most recent guidance issued by the Scottish Government requires us to continue following its COVID-19 guidelines for all primary care providers.
T
he Government’s plan for the path out of lockdown confirmed that restrictions on in-person teaching and learning in universities, put in place due to COVID-19, will be lifted. However, many universities have planned to continue the use of certain measures such as wearing face masks and hybrid approaches to teaching – combining face-to-face and online lectures. Speaking to OT, Dr Rakhee Shah, optometrist and lecturer at City, University of London, explained that the optometry course had been able to restart several clinical elements over the past year, following strict guidelines around PPE and with smaller numbers of students. Exams have remained online, meanwhile, and will continue to be delivered in this way for the summer exams in August. “Going into September, because
10 www.optometry.co.uk
“I think it is highly likely that practitioners and patients alike will wish to maintain higher infection control levels for some time” David Quigley This means scrupulously following strict infection control procedures and PPE guidance, with the wearing of gloves and aprons to be considered on a risk-assessed basis.” Optometry Scotland welcomed confirmation from the Scottish Government that PPE for the provision of NHS services will continue to be provided at no cost to community practices until 31 March 2022. “I think it is highly likely that practitioners and patients alike will wish to maintain higher infection control levels for some time,” Quigley continued. NORTHERN IRELAND Northern Ireland planned to ease some COVID-19 measures from 26 July, including reducing the legal requirement for social distancing to one metre indoors and reviewing the use of face coverings. For community optometrists, there is no change to guidance.
the cohorts are quite big, our plan is that live lectures will be delivered online rather than in person,” Shah explained, with advice from the university to keep to a maximum of 40 students in a room at any one time. For tutorials, which are typically delivered in groups of fewer than 40 students, the aim will be to facilitate these as discussion-based sessions on campus for lectures delivered online. “The clinical sessions will be carried out at a pre-COVID-19 level in terms of the breadth of clinical experience they will be getting, but there will be a cap on the number of students present in a room at any one time,” Shah said. This is what is currently planned for the new year, Shah explained, but added: “Normally by now we would have a concrete timetable, but it is still a case of planning as
Shutterstock
REPRO OP
WALES Wales planned to move to level zero from 7 August at the time of publication. Optometry Wales chief executive, Sali Davis, told OT in July: “We are pleased to see that Welsh Government will continue to expect anyone accessing eye care services to wear a face covering – this will remain a legal requirement which means that practices will continue to be supported with PPE and the right kind of protection in terms of infection control. We are seeing activity levels in Wales rising each day to rates of pre-COVID-19, so this continued protection is welcomed by the profession.”
THE ACADEMIC IMPACT
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SOCIAL DISTANCING: WHAT IS HAPPENING ACROSS THE UK?
we’re going along because we just don’t know when things are going to change.” The course has been waiting for guidance from professional bodies and the university regarding face coverings and social distancing, Shah said, adding: “I think the general preference would be to still be wearing masks, particularly in a closed-room setting, but we are waiting for the guidance.”
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INDUSTRY
Moorfields Eye Hospital
Observe and measure all the main structures and surfaces of the eye Posterior OCT
ART
SeeAbility received the title of overall winner at the 2021 Charity Awards, recognising the organisation’s work in persuading the NHS to provide sight tests for children with learning disabilities in special schools across England. The charity also received the award in the Health and Medical Research category.
Anterior OCT OCT-A Angio OCT OCT-B Biometry OCT True colour fundus imaging
PRODUCTION
Kering Eyewear has formed an agreement to acquire luxury eyewear brand, Lindberg. The deal is subject to approval by competition authorities but is expected to complete in the second half of 2021. Kering Eyewear suggested the addition of the brand to its portfolio would reinforce its position in the luxury eyewear segment, and amplify Lindberg’s reach.
CLIENT
“I would recommend that anyone considering a new OCT scanner in 2021 seriously look at the Optopol range. I have been very impressed with the scan quality, ease of use and comprehensive functionality of the software” Sundeep Kheterpal MA MRCOphth FRCSEd
01438 740823 sales@bibonline.co.uk bibonline.co.uk
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50%
“We have had a lot of people come in and say that it is great to have an opticians in the village” Linda Southin, business development manager at Edmonds & Slatter, reflected on the one-year anniversary of the group’s new practice in Kibworth, Leicestershire. With the opening of the new location delayed due to England’s first lockdown, the practice opened in June 2020 and has seen a positive response, with many people seeking local services.
rise in demand for services has been recorded by OutsideClinic this year, which is also on track to achieve a record turnover. The domiciliary provider attributes the rise to the post-pandemic preferences of patients aged over-65, with many choosing to book home visits rather than visit their High Street practice due to COVID-19.
EssilorLuxottica completed the acquisition of a 76.72% ownership interest in GrandVision from HAL Optical Investments, at a price of €28.42 (£24.32) per share. EssilorLuxottica executives said this is the perfect time to expand its retail network “as the industry returns to growth following the pandemic,” with the company confirming that it would ensure GrandVision and its 37,000 employees are integrated successfully.
“If I’m designing glasses, I’m always talking about personality and what the details do”
Eyewear designer, Tom Davies, gave OT a behind-the-scenes insight into designing eyewear for the cast of Disney’s Cruella film, which launched this year. Davies produced over 120 frames for the film, including multiple frames for the key characters. Watch the interview online: www.youtube.com/watch?v=L4YJUO-PJuA
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SUBS
More than just an OCT
Disney
REPRO OP
Camden Council has passed a resolution to approve planning permission for the Oriel project, a joint initiative between Moorfields Eye Hospital NHS Foundation Trust, UCL Institute of Ophthalmology and Moorfields Eye Charity which would bring together eye care, research and education in a new purpose-built facility at St Pancras Hospital.
the edit
SPOTLIGHT
THE EDIT 60 DAYS IN 16 STORIES
SCIENCE & VISION
Moorfields Eye Hospital
Pixabay/Sofie Zbořilová
Researchers at the University of Waterloo have developed an imaging technology that could support the diagnosis of eye disease before structural change and functional loss. Described in Scientific Reports, researchers developed the photoacoustic remote sensing (PARS) system, which uses multicoloured lasers to image human tissue without contact. It is hoped that clinical trials using the PARS technology will begin within two years. Dr Reena Chopra, a Moorfields Eye Hospital optometrist, has received the George Giles postgraduate research prize from the College of Optometrists, recognising her work applying artificial intelligence to disease detection in ophthalmology. Dr Chopra discussed her research in an interview with OT in 2019, available at: https://bit.ly/3yJNY2D
1 in 5
babies who underwent cataract surgery had developed glaucoma after 10 years, a study in JAMA Ophthalmology found. The study followed 110 infants who received cataract surgery. Researchers felt the results support the need for children who have had a cataract removed to be seen at least once a year by an eye care provider.
PROFESSIONAL SUPPORT
Pixabay/Paul Diaconu
General Ophthalmic Services (GOS) data from Northern Ireland revealed a decrease in the number of sight tests performed in the past year, in line with restrictions imposed due to the COVID-19 pandemic. Statistics revealed that 2020–21 saw around 311,000 GOS sight tests performed – a 34% decrease compared to 2019–20. For every four sight tests provided, three were for patients under the age of 16, or 60 or over.
The NHS has launched a £160 million initiative with the aim of easing the waiting lists that have formed for elective surgery during the pandemic. A highvolume cataract service will be included in the funding boost, with plans also including equipment such as 3D eye scanners and services like one stop testing facilities and pop-up clinics. The initiatives will be implemented within 12 areas and five specialist children’s hospitals.
Shutterstock/Geobor
NHS England has confirmed to the Optometric Fees Negotiating Committee that General Ophthalmic Services will remain a national contract after announcing its plans to transfer all primary care contract management functions to Integrated Care Boards from April 2022. The Health and Care Bill, before Parliament at the time of writing, will change NHS commissioning structures in England, including the establishment of new ICBs.
IN PRACTICE
Optometrist and practice owner, Ameerah Riaz Ahmed, shared how her family has motivated her to pursue her aspirations in optometry and practice ownership for OT’s My inspiration feature.
“It’s still a very difficult time in practice, and we are just starting to see how the various lockdowns are affecting the NHS waiting lists. The next few months will certainly be interesting.” As the easing of lockdown restrictions in England approached in July, optometrist and practice owner, Simon Berry, shared his thoughts on the path ahead and the cautious approach he is continuing to take in practice.
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“This journey through our lives and careers is a constant learning and listening process”
A number of eye care professionals were recognised in the Queen’s Birthday Honours list. Former president of the Royal College of Ophthalmologists, Caroline MacEwen, became a Dame Commander of the Order of the British Empire. Lead nurse consultant at Moorfields Eye Hospital, Adam Mapani, and former chair of the Royal National Institute of Blind People, Eleanor Southwood, became Members of the Order of the British Empire. Residential care manager at Blind Veterans UK, Blanche Black, received a Medal of the Order of the British Empire.
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OT is launching the CET survival pack to help members and subscribers ensure they have met all competencies required before the end of the cycle. Find out more about OT’s CET survival pack on page 25.
100% OPTICALI SUBS
The countdown begins
ART
Event director, Nathan Garnett, and OT’s clinical editor and the head of education for the AOP, Dr Ian Beasley, share insight into what is on the cards for the January 2022 show
PRODUCTION CLIENT
Media 10 and the AOP are gearing up for the return of physical events, with the eighth edition of 100% Optical set to be held at the ExCeL Centre in London on 22–24 January 2022. This year saw 100% Optical held as a virtual event for the first time due to pandemic restrictions, bringing together more than 1800 delegates for the two– day online event. Now event organisers are preparing for the 2022 show and planning to bring the profession back together for an in-person conference and exhibition, with Nathan Garnett, event director of 100% Optical, sharing: “We are planning our biggest line-up to date of speakers, education, and new and returning features.” “We have had plenty of time to work with the AOP and our partners on honing the content for this event,” he explained. Suggesting “there is going to be so much to cover,” Garnett said this will range from clinical education to “discussing and sharing how we recover from the pandemic, what the future looks like with a rapidly evolving High Street, and changes to healthcare more generally due to be felt first-hand.” Over 220 exhibitors have already signed up for the event, with “all of the big names you would expect,” Garnett said. He shared that the event team is working to secure “the unique and interesting eyewear brands that people love to see.” The exhibition will see the addition of more pharmaceutical suppliers, as well
as contact lens providers, and event organisers are also keen to bring back the fashion shows, “a hallmark of 100% Optical” which took on a new virtual form this year to adjust to the online platform.
“We are planning our biggest line-up to date of speakers, education, and new and returning features” Nathan Garnett, event director for 100% Optical The Optical Suppliers Association will be at the event for the first time following the purchase of Optrafair in summer 2020, a move which Media 10 suggests has made 100% Optical “the only major UK exhibition serving the optical industry.” CPD: the start of a new scheme OT’s clinical editor and the head of education for the AOP, Dr Ian Beasley, shared insight into the education plan for 100% Optical, which will see the return of multiple feature areas and education hubs, providing content delivery across multiple streams. Beasley hinted: “We always bring something new to each event, so watch this space.” The education programme will see a range of peer discussions, Beasley confirmed, adding that key topics on the agenda will include: “Assistive technology for patients with low vision, diagnosis and treatment of
keratoconus, managing dry eye patients, management of patients with choroidal naevi, and many more to follow.” The 2022 event will follow the launch of the General Optical Council’s new Continuing Professional Development (CPD) scheme, with the current Continuing Education and Training scheme ending in 2021. “The education programme will take into account the new changes to the scheme, providing a soft landing for practitioners as we all adapt to this new era of CPD,” Beasley shared, adding: “In the lead-up to the event and over the weekend itself, the AOP will be on-hand to support delegates on meeting the requirements and allow them to get a head start on fulfilling their obligations under the new scheme.” OT will be exploring the transition to CPD in the October/November edition. Planning for the return With the return of physical events more certain and as the country works towards the lifting of restrictions (at the time of writing), Garnett shared: “It is so good to be planning an event again. “Large scale events coming back is the last part of the restrictions being eased, so it also feels like we are approaching a point where we can learn to live with COVID-19, rather than it curtailing so many normal aspects of our lives.” Looking back on the impact of the pandemic, Garnett said: “The last two years have made people realise how important the events industry is, and we have been extremely heartened by the support we have had from the optical sector as a whole.” 100% Optical is due to be held between 22–24 January 2022 at the ExCeL Centre in London. Registration will open in September, with more information to be found on www.100percentoptical.com
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HEALTH
A face mask that detects COVID-19
Clinical round-up
CLINICAL
NEWS
A prototype mask developed by engineers at MIT and Harvard University can detect whether the wearer has a COVID-19 infection within 90 minutes. The technology, which is described in Nature Biotechnology, incorporates small disposable sensors that are capable of being fitted on to other garments or adapted to detect other viruses. Professor James Collins, of MIT, highlighted that as well as detecting viral and bacterial compounds, the freeze-dried sensors could one day detect toxic chemicals – such as nerve toxins. Nguyen et al. DOI: 10.1038/s41587-021-00950-3
REPRO OP
OT’s Selina Powell reviews the latest clinical news and research papers
SUBS ART
GLAUCOMA
Insight on coffee intake and glaucoma risk PRODUCTION
DO PLASTIC SCREENS PREVENT THE SPREAD OF COVID-19?
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CLIENT
droplets – called aerosols – which linger Nestled between restaurant diners, in the air have a significant role to play in placed in front of supermarket cashiers, the transmission of the virus. inserted between office desks and even “When you exhale – whether that is installed at the Houses of Parliament breathing, speaking, singing, laughing – – since the outbreak of the pandemic, you produce droplets. The normal view there are few areas of life that remain of the bigger droplets is that they fall due unsegregated by a transparent screen. to gravity, like when you drop an orange. But how effective are plastic barriers in preventing the transmission of COVID-19? A barrier would stop them. The smaller droplets stay in the air. They just follow OT spoke with Howard Stone, a where the air goes,” Stone said. professor of mechanical and aerospace “We know this because we smell engineering at Princeton University, for perfume and we see smoke – that can his thoughts on whether evidence on easily pass around the effectiveness Whether or of physical barriers “Where possible, if you are barriers. not that happens, in preventing the not wearing a mask and and how long it transmission of COVID-19 backs up not vaccinated, don’t share takes, depends on the overall air flow their ubiquity. air with people” in the room which Stone has is dictated in a contributed to significant part by the ventilation in the research exploring how flows created room,” he added. during breathing and speaking could Stone said that while physical barriers contribute to the spread of COVID-19 by provide a degree of protection, the focus asymptomatic individuals. should be on wearing masks, increasing Stone shared that plastic barriers ventilation, ensuring air flow and became common due to emphasis at socialising outdoors if possible. the beginning of the pandemic around “The picture now is that everything you the role of bigger droplets in spreading can do to increase ventilation with fresh COVID-19. air to effectively dilute the virus so that Because of this focus, people were you breathe in less contaminated air is the encouraged to regularly clean surfaces, best strategy,” he explained. maintain social distance and put in “Where possible, if you are not wearing place measures like barriers when social a mask and not vaccinated, don’t share air distancing was not possible. However, with people,” Stone added. current evidence suggests smaller
Researchers have published new findings connecting coffee intake to glaucoma among patients with a family history of elevated intraocular pressure (IOP). Scientists examined the relationship between IOP, caffeine intake and self-reported glaucoma diagnosis in a study published in Ophthalmology. They also assigned each participant an IOP genetic risk score. Overall, high caffeine intake was not associated with a risk of developing elevated IOP or glaucoma. However, among people with a genetic predisposition towards high IOP, greater caffeine consumption was linked to a higher IOP and higher glaucoma prevalence. Kim et al. DOI: 10.1016/j.ophtha.2020.12.009 MYOPIA
Over-correcting myopia may exacerbate progression
A new study published in JAMA Ophthalmology has found that overminus lens therapy has the potential to increase myopic progression in children. Scientists found that distance exotropia control was significantly better among children assigned overminus spectacles during the trial – but this benefit waned as children stopped wearing the spectacles. The researchers also found that among the children assigned overminus lenses, there was roughly one third of a dioptre greater myopic shift than in the control group. Chen et al. DOI: 10.1001/jamaophthalmol.2021.0082
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ROUND UP
SPOTLIGHT
SPOTLIGHT VERSION
INDUSTRY PROFILE
Fighting the myopia epidemic
SUBS ART PRODUCTION
In late 2019, the World Health Organization released its first ever World Report on Vision. It recognised that myopia is increasing globally at an alarming rate, with nearly five billion people or 50% of the world’s population predicted to be affected by the condition by the year 2050, including 10% with high myopia. While being near-sighted in itself is problematic for those of us who are so afflicted, without early identification and intervention there are associated increases in lifetime risk for further visual impairment resulting from eye diseases such as cataract, retinal detachment, myopic maculopathy, glaucoma and optic neuropathy. Significant recent scientific research has identified a number of interventions to potentially control myopic progression so we felt it was our duty to get this message out to our members and the broader vision care sector. Simply correcting refractive error is no longer sufficient and that is why we believe there needs to be an established standard of care that may prevent or delay the onset of myopia or slow its progression.
CLIENT
Historically, optometrists have simply corrected myopia and even with the recent research and treatment options now available, many have been slow to embrace this evidence and adopt the proven interventions that may halt or slow its progression. The World Council of Optometry’s (WCO) adoption of a standard of care resolution on behalf of its 38 affiliate members and 45 country members, representing more than 114,000 optometrists, is a resounding message that the global optometry community must do more. It’s now incumbent upon our country members to make fighting this global epidemic their top priority, and that starts with embracing a standard of care. While the WCO recognises that it takes time and resources to achieve the changes that we’re striving for, there are three main components that all optometrists should embrace as the first steps toward curbing this public health issue. We call it the three 'M's. Mitigation – which involves optometrists educating and counselling parents and children during early and regular eye examinations on lifestyle and other factors to prevent or delay the onset of myopia. Measurement – optometrists evaluating the status of the patient during regular comprehensive vision and eye health examinations, such as measuring refractive error and axial length whenever possible. And management – addressing the patient’s needs by correcting myopia, while also providing evidence-based interventions, for example, contact lenses, spectacles, and or pharmaceuticals, that slow the progression of myopia for improved quality of life, and better eye health into the future. 20 www.optometry.co.uk
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The role optometry can play in raising the public perception of myopia starts with educating families, the broader healthcare community, public health entities, and optometric peers about the seriousness of myopia. Working with staff, optometrists should provide up-to-date materials on myopia and have conversations with parents about the importance of eye exams beginning at an early age. Early diagnosis and treatment of myopia is critical to stemming this epidemic. As for the public in general, discussions should incorporate lifestyle factors including time spent outdoors, and the longterm vision implications that may occur if a child's myopia is not properly treated. Parents, including those who are myopic themselves, may not otherwise realise how far this field has progressed since their own childhood. This also involves educating ourselves as optometrists. We need to look at reputable studies that examine evidencebased approaches shown to prevent or delay the onset of myopia or halt or slow its progression. The optometric community must continue to pursue further education on myopia management; the data and
“Simply correcting refractive error is no longer sufficient and that is why there needs to be an established standard of care that may prevent or delay the onset of myopia or slow its progression” Dr Scott Mundle, immediate past president of the World Council of Optometry
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REPRO OP
Dr Scott Mundle, immediate past president of the World Council of Optometry, on the decision behind the resolution to make myopia management a standard of care – and what comes next for practices
Myopia insight
information available are rapidly evolving, strengthening practitioners’ skills and knowledge. The practice of optometry varies around the globe, which may limit the scope of practice of some practitioners. If there are limitations, we still have an obligation to do what is in the best interest of our patients. Establishing a referral or shared service network can be a key component to applying myopia management as a standard of care. I think that optometrists historically had a hard time referring to another practitioner, thinking that they’ll lose that patient. I think that actually the patient would so appreciate that you want to give them the best care that you’re sending them to a specialist. Regardless of where they are located, practitioners should implement myopia management approaches to the highest scope possible as allowed within their particular region.
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Bringing myopia management into practice requires a fundamental change in our approach to patient care. One barrier is low awareness of myopia and myopia management among parents. Studies have shown that parents believe they know what myopia is, but few are able to correctly identify it as short sightedness or near sightedness, and that parents deem eye exams as less of a priority than visits to their primary care doctor or dentist. The lack of recognition and delay in comprehensive examinations leads to a greater risk for high myopia and its health consequences. Another barrier is the perceived cost of myopia management treatment options. Not all families can afford the out of pocket expense. The key here is making sure we educate parents in a way that they can clearly see the value of the myopia management treatment option that it will give their child. Think of it as an insurance policy – you pay up front so that the consequences are hopefully less in the future. Historically, optometrists have often been their own worst enemy in this as they often assume patients can’t or don’t want to pay for the best treatment. My position in practice has always been: if this patient was a family member, would you recommend the best level of care? Don’t assume your patients aren’t willing to accept the cost of the best care. The last thing you would want to hear is a patient finding out there were options available that you didn’t suggest and asking why they weren’t offered. When discussing myopia, probably the trickiest part is managing the health aspect – nobody wants to hear the bad news. As soon as you see somebody who might be leaning towards myopia, I think you can have that dialogue – the sooner the better. What we can do is give out documentation right off the bat to say: 'Here’s where we’re at, and here’s where we could be headed.' It is helpful to have parents look at this and realise: 'If I do nothing, this is going to happen. But if we can treat it, we have some chance for success.' My message to optometrists is always to do what’s in your patient’s best interest and get actively involved in our profession. There’s not a lot of people on our team so the more that we work together, the better off the patients are and our profession is going forward.
The NICER study:
ASKS
INFORMING MYOPIA MANAGEMENT The Northern Ireland Childhood Errors of Refraction (NICER) study explored children’s vision and cycloplegic refractive error over time, indicating predictive factors for myopia. OT found out more about the findings and the applications.
THE NICER STUDY
The research looked at 400 children aged six and seven and 600 aged 12 and 13 who were followed up three years, six years, then nine years later.
WHAT RISK FACTORS WERE IDENTIFIED? Refractive error at an early age. The study found refractive error of less than +0.75D of spherical equivalent under cycloplegia at six to seven years of age is a significant risk factor for developing myopia by at least 16 years. Axial length at age six to seven years of over 23mm. The NICER study found that eyes of 23.19 mm or more in length were at significantly increased risk for developing myopia by 16 years of age. Family history of myopia. A child with one myopic parent is six times more likely to become myopic by the age of 16 than someone who has no myopic parents. In the NICER study, children with two myopic parents were seven times more likely to be myopic at 12–13 years. Using a combination of these metrics, children at greatest risk of becoming myopic before the age of 10 can be identified: they are children aged 6–7 years with lower ser (< 0.19d), at least one myopic parent and longer axial lengths (≥ 23.19 mm). HOW DOES THE STUDY HELP TO INFORM APPROACHES TO MYOPIA MANAGEMENT? The NICER team developed the PreMo Risk Indicator using the data from the study to stratify patients’ risk. “It’s important to identify a child before they even become myopic. Because if you can push back myopia onset until you’re older, you have slower-growing eyes and you’ll progress less quickly,” Professor Kathryn Saunders, subject lead for Optometry & Vision Science at Ulster University emphasised. While biometry can’t be changed, patients can adjust their lifestyles to potentially slow the progression of myopia. Saunders said: “I try to talk about having a healthy visual diet and the importance of balancing what your eyes are doing as you would with any part of your body. The includes the idea of healthy sleep and activity patterns.” Read more from the NICER team through OT's Q&A online
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REPRO OP SUBS
An ecosystem for myopia ART
Manufacturers across contact lenses, spectacle lenses and optical equipment are equipping practitioners with more options for approaching myopia management
PRODUCTION CLIENT
The way that practitioners approach myopia in children is changing rapidly as the profession accelerates towards myopia management as a standard of care, with manufacturers across eye care supporting this drive through research, guidance and new products and services. Accelerating solutions Speaking to OT, Mark Draper, director of marketing and national accounts for CooperVision UK & Ireland, said awareness of myopia management as a standard of care, “has been growing steadily over the last few years,” with the subject ”a rapidly evolving field of research.” CooperVision has contributed to this growth through published studies and papers, Draper explained, as well as the launch of CooperVision’s MiSight 1 day contact lens and Brilliant Futures Myopia Management Programme. The programme incorporates the MiSight 1 day daily disposable contact lenses with ActivControl Technology, along with tools, support and education. It also includes a professional accreditation programme, delivered through CooperVision’s online Learning Academy, to equip practitioners to develop a myopia management practice before gaining access to Brilliant Futures. Draper confirmed that 2324 practitioners have now been accredited. Communicating the issue of myopia is key, with Krupa Patel, CooperVision senior manager for myopia management, 22 www.optometry.co.uk
professional services Europe, Middle East and Africa, telling OT that the company “will be supporting practitioners by launching a consumer campaign this summer raising awareness of myopia management with parents.” As public awareness grows, practices will need to bear this in mind. Patel shared: “The need to consider parental awareness will continue to grow and this will be an expected offering for their children.” Speaking to OT earlier this year, CooperVision president, Daniel McBride, emphasised the need for a “rich field” of treatments for myopia management, and the company has made a number of partnerships with the aim of supporting developments in this field. This includes CooperVision’s intention to enter a joint venture with Essilor in acquiring the myopia management spectacle lens company, SightGlass Vision Technology, followed by CooperVision’s acquisition of No7 Contact Lenses, as a separate but complimentary business within its CooperVision Specialty EyeCare group. Taking a holistic approach Menicon launched its Menicon Bloom Myopia Control Management System in the Netherlands in 2019 and in the time since, it has been preparing to launch in all markets. Menicon professional services manager, Josie Barlow, told OT: “We’ve been making tweaks and advancing the system to ensure that it can
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SUPPLIER INSIGHT
offer everything that practitioners and patients need.” The system is set to launch later in 2021. Describing Menicon Bloom as a “holistic approach,” Barlow explained that it encompasses an ortho-k lens for overnight wear and a daily disposable, soft myopia control lens – both CE approved for myopia control – as well as strategies for monitoring and analysing the patient’s progress, and communication tools. As part of plans to support conversations around myopia, Menicon will be providing training with practitioners and the wider practice team. Barlow explained: “Everybody has to be on the same page. From the very first person that greets the patient or parent,” adding that training will not only cover how to use the system and fit the contact lenses, but support the practice “to be able to talk confidently about Menicon Bloom and myopia control generally.” The company is producing an app which will facilitate communication with the eye care professional (ECP), meaning “issues with anything from comfort, compliance and application can be addressed much faster and more frequently.” The app will also support continuous monitoring of the patient’s progress, which can then be analysed when back in the practice. “We believe that the protocols and the communication that we have put in place will mean that there should be a much higher success rate of compliance, a more successful treatment path for patients and an increased ability to address any issues that may arise or occur,” Barlow told OT. Menicon has also been working across the sector, announcing a collaboration with Johnson & Johnson Vision earlier this year through which the companies aim to expand the availability of therapeutic contact lenses.
A complementary offering The past year marked the arrival of Hoya’s Miyosmart spectacle lens in Europe. Andy Sanders, professional services director at Hoya Lens UK, said: “Miyosmart is the first myopia control spectacle lens launched in the UK which has been validated by a two-year randomised controlled trial which showed an efficacy of on average 60% and the third-year follow-up study showing efficacy was sustained.” Considering how the lens contributes to the range of options needed to address myopia management, Sanders explained: “As the lens is fitted just like a progressive lens design, it is easily incorporated into the practice portfolio, even if other myopia management solutions are not offered. “In practices that already offer myopia interventions, such as ortho-k or specific
axial length measurements, corneal topography and dynamic pupillometry to support myopia management. Speaking to OT, Danielle Lee, clinical affairs specialist for Topcon, shared that though the ‘gold standard’ for myopia management, until recently, devices used for measuring axial length have been out of the price range of many practices as they were aimed more towards surgery, with the Myah device “looking at it more in terms of optical management at an earlier stage.” With a suite of dry eye tools, the dualfunction purpose of the device also helps to reduce any challenges to adoption. Discussing the role of the device in the ecosystem of myopia management tools, Lee told OT: “Reports such as the Johnson & Johnson Vision Managing Myopia
“The need to consider parental awareness will continue to grow” Krupa Patel, CooperVision senior manager, myopia management, professional services for Europe, Middle East and Africa contact lenses, Miyosmart offers a broader range of patient suitability,” Sanders continued, adding that the lens can also provide a complementary spectacle treatment for patients when contact lenses are removed. Hoya also developed an accreditation process for ECPs to gain access to the lens. Across the UK and Ireland, nearly 2000 ECPs are now accredited, a figure that is growing daily, Sanders said: “The majority of whom are regularly prescribing Miyosmart lenses for myopic children after careful consultation.” To support practices in offering the Miyosmart lens and communicating the option with patients, the company has a range of marketing material available, including patient leaflets. Hoya has also developed an in-practice training programme to support the introduction of Miyosmart to parents and children, Sanders explained, adding that this will be made available as an additional online training module. Providing the gold standard In 2020, optical manufacturer Topcon launched its Myah myopia and dry eye device in Europe. The device provides the instrumentation needed to take
Clinical Guide, released at the end of last year, suggest examining children at least once between the ages of three and five to establish baseline. “By utilising a device like the Myah, which captures axial length measurements and allows you to plot progression of growth as well as variation in the rate of growth, optometrists have the ability to intervene earlier and perhaps make a greater impact on the visual outcome for the patient,” she added. As well as capturing key data, the device can aid patient engagement, Lee said: “By screening younger patients who are at risk of becoming myopic, or high myopes, you can engage them throughout their development, offering reports and visual representations of the effect which treatment is hoping to achieve.” To support practitioners, Topcon has created video resources through its EyeTube platform and has recently introduced an upgrade enabling optometrists to review patient data in relation to growth curves, incorporating the axial length dataset collected by Erasmus University. The software also enables clinicians to review patient examinations on a PC, providing greater flexibility.
Look out for OT’s Myopia guide in partnership with CooperVision – available in October Communicating the risks Jason Higginbotham, managing director of Birmingham Optical, agreed that there had been an increase in interest in the devices the supplier sells, including the Myopia Master. The Oculus Myopia Master supports the main measures for myopia management refraction, axial length and keratometry in an all-in-one device, along with “a comprehensive range of questions built in that all complement to a range of algorithms which both predict future myopia and also help to monitor treatments,” Higginbotham shared. The device also makes suggestions for treatments, he added, “or the clinician can enter therapies and advice into the patient’s record which can even be emailed to them.” To aid practices in using the device, Birmingham Optical is compiling a support pack which will include online training and education material, user videos and guides, patient questionnaires, access to online triage software, key stats and figures and marketing support. Using this and data from the device, the company aims to make it easier to better explain "what the long-term risks of having high or pathologic myopia are.” Looking ahead, Higginbotham added: “We also intend to work more closely with key suppliers of therapeutic lenses, contact lenses, soft and ortho-k and other potential therapies.” Beyond the practice, Higginbotham identified a need for greater public awareness, adding: “Every child should really be screened for myopia, and this should start at an early age.” The Oculus Myopia Master, supplied by Birmingham Optical
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Supplier insight
SPOTLIGHT
AOP to launch mentoring programme REPRO OP
The scheme will support the development of newly-qualified optometrist members by connecting them with professionally experienced AOP members
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The AOP has developed a new mentoring programme for newlyqualified members, which will launch this September. Through a dedicated platform on the AOP website, the AOP Mentoring Programme will pair newly-qualified optometrists with volunteer mentors to receive one-to-one support for a period between three to six months. Sarah Melzack, AOP membership benefits officer, said: “The new AOP Mentoring Programme is a way for us to connect professionally experienced AOP members with newly-qualified members to help support their development during their first year in practice.” She continued: “It’s been in the pipeline for some time, however with the difficulties and challenges in practice brought about by the pandemic, we thought launching something like this
“For mentees, our hope is that this will provide them with a dedicated and unique source of support; someone who has their back”
to help newly-qualified optometrists negotiate a world they were perhaps not quite prepared for, would be a great way to help keep them steady whilst they find their feet.” Aiming to support members on the newly-qualified membership grade, the AOP suggested the programme can help mentees to improve their understanding, skills and knowledge, as well as grow in self-confidence. How will it work?
The AOP Mentoring Programme will be accessed through the MyAOP section of the association’s website. Through the dedicated platform, both mentors and mentees will be able to create a profile and will be matched according to their preferences for receiving or providing support. Mentoring matches can then be reviewed and accepted, Melzack said, with the mentee then responsible for organising an initial meeting, which can be face-to-face or virtual, “to discuss expectations and how best to work with one another.” There are no mandatory requirements to the scheme, though it is recommended mentors and mentees
On the agenda: HOAC The conference for hospital optometrists returns as a one-day online event in September The AOP has launched a day of education for hospital optometrists, bringing together eye care professionals for a series of interactive lectures and peer discussions. This year, the Hospital Optometrists Annual Conference (HOAC), hosted by the AOP, will be held as a virtual one-day event on Saturday 25 September. The event, running from 10am to 4pm, will be delivered online for the second time due to the pandemic and ongoing uncertainty regarding restrictions around event delivery. Dr Ian Beasley, AOP head of education and OT clinical editor, explained: “The key themes have been agreed and commissioned by the AOP’s hospital optometrists committee to ensure the content meets the needs of the key target audience.” The programme will include four lectures and two peer discussions, with lecture topics covering ocular oncology, new perspectives on glaucoma, ophthalmic emergencies and the use of artificial intelligence to predict disease from ocular images.
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have virtual or in-person contact once a week, Melzack shared. At the end of the mentoring period participants will be asked to provide feedback to enable the AOP to continue improving and expanding the service. Mentors will be able to pause between relationships, or take on multiple mentees. Mentees will be able to apply for a mentor at any point whilst on the AOP’s newly-qualified membership grade, and will also be able to request new mentors once their initial relationship has closed. Melzack shared: “For mentees, our hope is that this will provide them with a dedicated and unique source of support; someone who has their back.” “Whether they have defined developmental goals, or just need a sounding board from someone neutral and outside of their practice, their mentor will be there to help them work through the issue,” she added. For those who might be interested in signing up as a mentor, Melzack suggested this could be an opportunity to “give back, develop their professional network and, fundamentally, help to develop and nurture a confident and capable younger peer.” She added: “Who knows what they might also learn from their mentee, too?” The scheme is already open to mentors to register their interest by emailing mentoring@aop.org.uk. The programme will officially launch for newly-qualified optometrist members to register for a mentor in early September.
Tailored peer discussions will be available for optometrists and therapeutic prescribers. Each lecture will offer one interactive CET point for optometrists. Speaking of the event, Beasley said: “In the absence of face-to-face education, the online delivery of HOAC provides an opportunity to bring the community of hospital optometrists together from the comfort of their own homes to learn and share insight through the interactive sessions on offer.” The lecture sessions are also open to optometrists practising in other settings, Beasley confirmed, which he suggested will allow for optometrists “to earn CET and broaden their scope of understanding of secondary care patient management.” HOAC will be held online on 25 September. More details about the event and information on how to register will be made available on the AOP website: www.aop.org.uk/hoac
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AOP on your side
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Ceri Smith-Jaynes, clinical multimedia editor for OT Can you tell us about the OT CET survival pack? The General Optical Council’s (GOC) three-year CET cycle finishes at the end of 2021. With the hard deadline looming, it's time for members to check their dashboards on MyGOC and plan their learning to ensure they are on target to meet all competencies and gain the points needed to keep on the register. With so many competencies to cover, it’s far too easy for one or two to have slipped through the net. This is where the OT survival pack comes in handy. The OT survival pack is a suite of noninteractive CET articles and videos, covering every single competency for every type of registrant: optometrists, dispensing opticians, therapeutic prescribers and contact lens opticians. It is available to all AOP members and OT subscribers.
What will the pack include? For the survival pack, OT is republishing recent CET material – seven articles and two videos – with brand new multiple-choice exams. The pack provides a total of nine non-interactive CET points and covers all 31 competencies. How will members and subscribers access the pack? The survival pack will launch in September. AOP members and OT subscribers can access the pack in the same way they usually take OT CET, by logging in to their account and browsing the Active CET page under the CET and skills guides tab. How will this resource support members and subscribers? AOP members and OT subscribers will be able to mop up any missing competencies with high-quality learning exercises. It’s also an
opportunity to hit the goals members have set themselves in their personal development plan at the beginning of the cycle. After all, the GOC sets a minimum points requirement, but there is no maximum. Do you have a key message for members and subscribers about the upcoming end of the CET cycle? If AOP members or OT subscribers are short on points, I strongly recommend starting to plan now and not rushing for CET points at the last minute. If lacking interactive CET, members can look out for webinars and peer discussions, or apply to lead their own peer review. The OT survival pack will be available until 28 December 2021 but members need to leave some time to action any queries and
“I strongly recommend starting to plan now and not rushing for CET points at the last minute” accept points on MyGOC. The GOC is usually closed over the Christmas and New Year period, making it difficult to iron out any problems at the eleventh hour.
The OT CET survival pack will be available to members and subscribers from September: www.aop.org.uk/ot/cet
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AOP roundup
SPOTLIGHT
OT FOCUSES ON
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Rainbow hues
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Belly Balloon Photography
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FOCUSES ON... EYEWEAR FOR CHILDREN
A host of new colourways have been added to the Cébé Light Junior collection of children’s frames. The range of colours available for the ‘Alea’ and ‘Mio’ styles for children aged between one and three has increased by five for a total of nine options, including lavender matte (pictured in the ‘Alea’ frame). Four colours have been added for the ‘Flora’ and ‘Oreste’ styles, taking the available colourways up to eight. www.cebe.com
ART PRODUCTION
Hit list
The trends, launches and looks
CLIENT
A carnival of colour
Distributed by Continental Eyewear
Playful patterns
Continental Eyewear, part of the Millmead Optical Group, has highlighted two new additions to the Lazer Junior collection, featuring bold patterned sides and “bright candy colours.” The ‘2200’ oval frame (pictured) has a simple front and fun patterns along the sides and is available in colours including grey, navy, purple and rose. The ‘2204’ round frame is available in pastel shades with swirling patterns. www.continental-eyewear.com
A world of imagination
International Eyewear has highlighted the range of 18 frames from its licensed brand, Roald Dahl eyewear. The frames feature original Quentin Blake illustrations with characters and quotes from the books, including the ‘Roald Dahl RD15’ (pictured) inspired by the Fantastic Mr Fox. Considering how the collection will evolve, the company told OT: “In our new developments we want to go further in showcasing the Roald Dahl message that, ‘The world can be tough, but with a combination of imagination, determination and heart, everyone, no matter how small, can shape their own wonky story.’” www.internationaleyewear.co.uk
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Roald Dahl by International Eyewear
Eyespace has introduced the new season of its Rock Star collection. Models include the ‘Avril’ frame (pictured) which offers a “punk style” with a dual side pin branding and an ombre effect. The frame is available in an ombre red and purple crystal, or a purple and blue crystal. Emily Andrews, Eyespace product director, told OT: “The latest collection from Rock Star is a carnival of tropical colour with brand new acetate materials and colourways celebrating youthful energy” www.eyespace-eyewear.co.uk
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LOOK
Q&A ME & MY GLASSES
Optometrist and lifestyle blogger, Lizzy Yeowart, on a colour with big impact potential
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Red is symbolic of many things: love, anger, health, war. What these have in common is passion – and here are three red eyewear styles to get passionate about.
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JF Rey PRODUCTION CLIENT
Patty Perreira
‘Leonie’ by Boz has a two-tone lacquered finish on the eyebrow which emphasises the glamorous butterfly shape. The right end tip is signed with Boz’s iconic red kiss. Boz’s ‘Leonie’ in red, light blue, khaki www.jfrey.fr
The co-founder and designer of the eyewear brand, Barton Perreira, tells OT about her favourite styles
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Courtesy of Barton Perreira
I have seven to 10 pairs of glasses with prescription lenses that I rotate depending on my mood. In my personal archive of optical frames and sunglasses, I have thousands of pairs that I draw inspiration from when designing for Barton Perreira. I own all my favourites from past collections I designed for, and from my recent Fear of God and 007 collaborations. In optical frames, I like rectangular shapes, cat’s eye, and retro-vintage inspired round frames. For sunglasses, I love aviators and angular shapes. I can’t resist a beautiful butterfly silhouette. Right now, my favourite frame is our ‘Chisa’ style. It’s bold, versatile, and looks good on men and women.
It’s been a very proud moment for our brand to work with the James Bond franchise. The ‘Joe’ sunglass is a remarkable frame. It was exciting to breathe new life into an existing style with additional colours inspired by locations in the film. We are thrilled to continue to work with EON on new styles, with our upcoming range, The Legacy Collection. Eyewear is the first thing people see when they are talking to you. It should be the most important accessory investment you make for yourself. There are rules and guidelines out there, but you should really pick a style that reflects your character and enhances your personality and style.
Woow eyewear ‘Carry on 2’ by Woow is a man’s style full of positive energy. In these unprecedented times, a joyful spirit is at the heart of the brand’s intentions. Woow’s ‘Work out 2’ in bright red www.wooweyewear.com
Emmanuelle Khanh Style ‘7065’ by Emmanuelle Khanh is from the French designer’s latest collection, which is described as radical and whimsical. Each piece is finished in block colours that are almost chrome-like in finish. Emmanuelle Khanh’s ‘7065’ in vermilion red www.ek.fr/en
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Face a Face has released a new selection of frames that explore “the art of deconstruction” to imagine new shapes, utilising cut-outs, coloured acetates and quirky details to create the designs. The ‘Shift’ model has a geometric offset frame edge, inspired by raw acetate sheets bonded together during the manufacturing process. The cat’s eye panto and ‘feline’ rectangle frames feature a five-piece hinge and a heightened burnishing. www.faceaface-paris.com
SHORTLIST THE LATEST PRODUCT LAUNCHES
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Frames
Parisian spirit ART PRODUCTION
Charmant’s Elle Eyewear has launched a new Made in France line, highlighting the brand’s French connections with the new collection made in Oyonnax. The range includes eight optical frames and two sunglasses. Styles celebrate the “Parisian spirit” ranging from retro-inspired shapes to oversized models, and a variety of cat’s eye frames. Models include ‘Juliette’ (pictured), described as an ‘undeniably self-confident look’ with a thin and lightweight acetate front in a variety of colours, embellished with a glittery side detail. www.charmant.com
CLIENT
Drops
The Body Doctor has launched two new eye drops to relieve dry eye and irritated eyes: the Eye Doctor Daily Refresh Eye Drops, which contain 0.1% sodium hyaluronate, and the Eye Doctor Intensive Relief Eye Drops, which contain 0.3% sodium hyaluronate. The eye drops relieve dryness and irritation caused by factors like heating, air conditioning and dust allergies, while the intensive option can also provide relief for irritation caused by triggers such as smoke, pollen and after surgery on the eye. Both feature a dispensing pump. www.positiveimpact.co.uk
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Charmant / Elle
Soothing solutions
To feature in OT’s Hit list, contact kimberleyyoung@ optometry.co.uk
Lenses
True colours
Bollé has launched a new line of Volt+ sunglass lenses, in what the company says is the first ever created using artificial intelligence. Bollé tested over 20 million combinations to develop a patented solution which allows wearers to see colours more vibrantly, with a 30% colour enhancement, whilst maintaining white balance. The company suggest the lenses also offer high contrast, improved depth perception and high-performance polarization. The lens is available in four variations including Volt+ ultraviolet polarized (pictured). www.bolle.com/gb Equipment Contact lensesi
Expanding availability
CooperVision has expanded the parameters available in its Biofinity XR toric contact lens range. The addition of sphere powers from ±10.50D to ±20.00D nearly doubles the number of available prescription options specific to the lens to 32,792. The company suggested this makes it easier for eye care professionals to fit astigmatic patients. www.coopervision.com
An ultra-wide view
Mainline Instruments has highlighted iCare’s latest accessory – the Eidon Ultra-Widefield Lens. The company suggested a single image with the new lens can present 120° and takes less than a minute, while a mosaique style image can be quickly taken to show 200° in a panoramic view. The new lens provides images in all different modalities available on the device, including autofluorescence, infrared and fluorescein angiography. The lens can be screwed onto the Eidon devices and is fully automated. www.main-line.co.uk
Sunglasses
On the wing
Silhouette has unveiled its latest range of Accent Shade sunglasses. Featuring protection against UVA, B and C, the range introduces two new styles – a women’s and a men’s frame presenting rimless designs and retro shapes. The new frame for women adds a dramatic touch to the butterfly shape with a subtle cat’s eye and soft nose bridge. The colour palette includes a warm gold lens paired with matte ink frame (pictured). www.silhouette.com
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Q&A BEHIND THE BRAND
OXSIGHT SUBS
CEO, Dr Rakesh Roshan, on the company’s newest product
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Oxsight describes itself as a vision artificial intelligence company and provides devices to enhance the remaining vision of people with visual impairment Customers fly in from around the world to test and purchase Oxsight products – the furthest has been from New Zealand Oxsight planned a “big day” in August with an individual who helped with product trials and has given birth to her first child. The company told OT: “We can’t wait to give her the opportunity of seeing her baby’s face in detail for the very first time.”
ANATOMY OF A FRAME TOP: Oxsight; RIGHT: Komono’s ‘Avery’ in solid smoke
OT columnist, Lizzy Yeowart
Clockwise from left: The Oxsight Onyx device, for users with central vision loss; Dr Rakesh Roshan
What is the latest device that you released? There are several types of major sight impairment. Our company’s strategy has been that, given the nature of these types of sight loss, you cannot have one solution that addresses them all. Oxsight Crystal was designed for people living with peripheral vision loss. But that technology would not work for central vision loss issues and that led us to design Oxsight Onyx. This product is in the final stages of product development and manufacturing of some parts has already started. We are hoping to launch in summer. What has the development of Oxsight Onyx involved? There have been at least three and a half years of research and development that led to this product. It’s always tempting to push something to the market very quickly, but we develop our products through an iterative process where we test the devices in each stage of the development cycle with our customers. What effect has COVID-19 had on Oxsight? We were about to scale up the sales of Oxsight Crystal. When COVID-19 came it was difficult to engage with investors and we were not able to sell glasses because most of our customers were shielding. Instead we focused on accelerating the development and testing of Oxsight Onyx. Oxsight Onyx has a significant appeal and we have more than 1000 people on our database who are waiting to buy this. We have set up a large distribution deal in the US and we are working with potential distributors here in the UK.
Powerful silhouette
Bold details
Made from cellulose propionate
Category-3 scratch resistant polycarbonate lenses
In a nutshell Manufacturer // Komono Frame // ‘Avery’ Colour // ‘Solid smoke’ Web // www.komono.com/en_BE
Marbled colourway
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Perspectives VERSION REPRO OP
Perspectives Voices from optics and beyond
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“It is an honour to step up and serve as chairman of the association. We are here to be a leading voice for the profession”
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Dr Julie-Anne Little
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or me, the AOP has always been the voice of the individual optometrist. We are a broad church, and it is important that we reflect the needs of members who work in many modes of practice. I have been a member of AOP Council for a number of years and I have seen first-hand how hard the AOP works to listen to its members and engage with the key issues. The legal defence and the clinical negligence cover we offer is something that, as a member, you hope you will never need – but for those that do, there is unparalleled support on offer from the AOP. It is an honour to step up and serve as chairman of the association. We are here to be a leading voice that advocates for positive change to shape the profession. There are many challenges ahead, and we at the AOP are focusing on what the future should look like in the next five to 10 years. We are seeing rapid innovation in telemedicine and tech, coupled with changes in healthcare delivery. Yes, we can expect our scope of practice and professional roles to evolve; what is crucial is that this change comes alongside appropriate remuneration structures, and recognition from the NHS that optometry is a core part of healthcare provision. Day to day I work at Ulster University, delivering education to the next generation of optometrists. I also work in the university eye clinic and conduct clinically relevant optometric research. This mix of roles is important to me. I am proud to be an optometrist and keep up my clinical skills. It gives me a wider view of the sector – particularly on how the education of the next generation needs to be shaped and making
the most of the opportunities to create a What is your view? skilled and confident workforce. One of our Email OT with tasks at the AOP is to work with others to your comments ensure there is a strong professional career newsdesk@ for graduates to step into. COVID-19 has optometry.co.uk been very tough on the current generation of optometry students and pre-regs. As a profession, I think we must do more to shape and mentor our future generation, including early career professionals. COVID-19 has produced unprecedented challenges for our everyday practice, and those challenges are different for different members. Think of the owner of an independent who is concerned about the financial viability of the practice, while trying to create a safe and comfortable environment for staff and patients. Or the employee categorised as clinically vulnerable who is working in close proximity to their patients – which let’s not forget is unusual in healthcare – and is concerned about whether the personal protective equipment on offer is sufficient. “Put simply, our A current important conversation is taking place about how we practise profession does not now that restrictions have been lifted. get the glory” The AOP, in partnership with sector colleagues, has produced guidance which will be important to our members and provide reassurance. There are many optometrists who will embrace the use of masks in the long-term – particularly when thinking about the close proximity elements of a sight test. The AOP team will continue to produce resources to support members and help practices navigate the ‘new normal.’ The tipping point I am really proud to be part of a profession that has shown true backbone, continuing to diligently support healthcare in the community and in the hospital setting despite the challenges. Put simply, our profession does not get the glory, but it does a tremendous job to provide eye care to the nation. Over the last year, I have become more aware than ever of the importance of
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AOP at 70 Dr Julie-Anne Little and Mike George on the role of the AOP 70 years on www.optometry. co.uk
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maintaining good mental health. I am proud of the continued value of the AOP Peer Support Line for members. I am also excited about the development of the AOP’s new mentoring programme, and I encourage members to get involved. In educational terms, COVID-19 has made a lot of people consider the benefits of pursuing a professional certificate or some kind of additional learning. As the number of people coming forward to take the independent prescribing (IP) qualification continues to grow, this movement provides an important lever for the profession to discuss how optometrists can support eye care services in primary and secondary settings. We are at a tipping point. The early IP adopters pioneered a new way of working
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“The recovery of our services continues to gather pace”
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Dr Waheeda Illahi, Rosie Auld, Dr Emma Berrow and Dr Peter Good
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COVID-19 insights Keep up-to-date with the latest news and advice online www.aop.org.uk/ ot/coronavirus
he Delta variant of COVID-19 poses a potential risk of a third wave in the UK as the transmission rate increases within the community. As Heads of Service (HoS) at the Birmingham and Midland Eye Centre (BMEC), we are not dreading the looming wave, but are rather weary of the consequences. From a service delivery perspective, the pandemic has given us a crash course on crisis management as we have led our services and supported our colleagues through the most challenging of times. It has been well documented that the morale of NHS staff who have worked under sustained pressure throughout the pandemic has been affected, and the strain of COVID-19 fatigue is creeping into hospitals across the country as the long road to recovery continues amidst uncertainties. Our hospital is no exception to this. BMEC has always been a close-knit community, providing specialist tertiary level care in the West Midlands as well as a vibrant
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but found there was not the structure in place in the NHS for them to utilise those skills. Today, almost 10% of the profession has the qualification and therefore is in a better position to have a robust and meaningful conversation about eye care provision. If we were developing the IP course now, I would argue there would not be a distinct step between the theoretical component and the practical part. The interface between the two is often a bottleneck, and this has been shown during the pandemic as optometrists have not been able to access hospital eye departments for clinical placements. Dr Julie-Anne Little is AOP chairman of the Board, and a senior lecturer in optometry and vision science at Ulster University
hub for teaching and training in ophthalmology services. Team spirit has been high, with close interactions between departments and multidisciplinary teams. Seventeen months into the pandemic, with the constant wearing of masks and social distancing, as well as conversion of almost all teaching programmes to online webinars, the dynamics in our hospital have visibly altered. On the one hand, professional boundaries between ophthalmologists, optometrists, orthoptists and other allied health professionals have become less relevant, and colleagues continue to show tremendous camaraderie and support. Contrastingly, departments are becoming more insular as the focus on clearing backlogs has increased, and there is less time for interaction between departments. We are very hopeful that the former pre-COVID-19 era BMEC close-knit community feeling will return. In terms of patients, the recovery of our services continues to gather pace, and the demand for specialist ophthalmic services is ever-increasing. Committed teams and good forward planning are enabling our current recovery plans for the optometry, orthoptic and visual function services to remain reasonably well on track. COVID-19 Pathway Improvement Programmes have been launched with NHS England/ Improvement, focusing resources on a small number of specialities in order to streamline outpatient services in the post-COVID-19 era. The new programmes incorporate work carried out by key bodies who have contributed to The
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National Eye Care Recovery and Transformation programme. The key principles in the programme to restore eye care services include: optimising the use of the primary care optometry workforce; referral filtering; risk stratification and clinical prioritisation of patients; the scaled use of digital enablers (connectivity, virtual and video consultations); and monitoring and managing lower risk patients in the community through primary care optometry and diagnostic treatment hubs. In order to deal with ophthalmology backlogs, there is work on establishing high volume cataract hubs as well as high volume, low complexity diagnostics hubs. Managing backlogs on the ground There is increasing evidence-based literature highlighting the impact of COVID-19 on various disciplines and subspecialties within ophthalmology services. The need for virtual and video consultations has been accepted as a norm in reducing the number of patient visits to hospitals. Virtual consultations are invaluable in specialities such as the low vision services. However, they are of limited value in complex contact lens fitting or vitreoretinal clinics where a physical examination is necessary. Our Trust is already outsourcing some ophthalmic services, with the emphasis on those with the longest waiting times: glaucoma and medical retina. The safety of both of these services will depend on the quality and reliability of the diagnostic tests. Robust audit and governance processes are essential to ensure that tests performed in high volume diagnostic hubs are reliable. Virtual consultations that are followed up with a letter to the patient and their GP do not give patients as much opportunity to express their concerns or ask questions. Telephone consultations post virtual review are a better option, but they are more time-consuming, and are therefore less favoured in the newly designed pathways. Independent prescriber optometry placements are planned to resume from October 2021, and orthoptic trainees have already returned for onsite training. In the visual function department, the scientific trainee practitioner training support is now back to pre-COVID-19 levels and we are fully supporting our medical teams in training junior doctors. Patients who have been under the hospital eye service long-term often present varying accounts
of the information they have heard in the news or on social media in relation to COVID-19 when attending for their appointments. As professionals, it presents us with opportunities to re-enforce the importance of vaccination and how they should remain mindful of the risks posed by COVID-19. We also remind them they should continue to follow the existing rules and infection control and prevention guidance. As HoS, we continuously try to protect our team members from working extended days and weekends, which has benefitted staff morale after such a tough year. For small, specialised departments such as visual function, it would be a struggle to stretch over evenings and weekends, especially alongside sick leave and annual leave cover. As demand is expected to surge, lower banded bank staff may be employed to cover more basic skills, freeing up experienced staff to pick up complex electrophysiology and ophthalmic imaging. As HoS, our greatest asset is our staff. An essential part of the COVID-19 recovery process within the tertiary centre setting is not only to consider the length of our waiting lists and to come up with solutions using existing staff, but also to acknowledge that the “Professional wellbeing of our colleagues must remain an absolute priority as we boundaries between learn to live with varying forms of ophthalmologists, the virus. Dr Waheeda Illahi is a consultant optometrist and head of optometry services, Rosie Auld CBE is head of orthoptic services, Dr Emma Berrow is consultant ophthalmic electrophysiologist and head of visual function, and Dr Peter Good is a consultant neurophysiologist at the Birmingham & Midland Eye Centre
optometrists, orthoptists and other allied health professionals have become less relevant, and colleagues continue to show tremendous camaraderie and support”
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IP consultation Share your views with the AOP policy team policy@aop.org.uk
ollowing the recent publication of our new education and training requirements for optometrists and dispensing opticians, the General Optical Council (GOC) is now looking towards updating the requirements for independent prescribers, as well as contact lens opticians (CLO). Independent prescribing (IP) for optometrists was first introduced in 2008, following a joint consultation by the Medicine and Healthcare Products Regulatory Agency (MHRA) and the Department of Health (DoH). Optometrists with an independent prescribing specialty can take responsibility for the clinical assessment of a patient, establish a diagnosis and determine the clinical management required, including prescribing, where necessary. As of August 2021, there are almost 1100 IP optometrists on our register. To become an independent prescriber, one must: be a registered optometrist; have been practising in the UK and registered with the GOC for two full years before beginning the clinical placement; and train in competencies which focus on the consultation, prescribing effectively and prescribing in context. What does the future of IP look like? The current qualifications for IP were introduced in 2011. As part of our review of optical education, we are proposing new updated requirements for IP. First, trainees will acquire a single GOCapproved qualification leading to specialist entry to the GOC register in either the additional supply, supplementary prescribing and/or IP categories, instead of the two sequential GOC-approved qualifications required at present (the theoretical component, normally delivered by a university, followed by the College of Optometrist’s Therapeutic Common Assessment). Second, the approved qualification will be either an academic award or a regulated qualification at a minimum of Regulated Qualification
38 www.optometry.co.uk
Framework (RQF) (or equivalent) Level 7. Third, the trainee’s supervision can be coordinated by an appropriately trained and qualified registered healthcare professional with independent prescribing rights (called a designated prescribing practitioner or DPP) rather than an ophthalmologist (designated medical practitioner or DMP). The DPP must be an active prescriber competent in the clinical area(s) they will be supervising the trainee in, have the relevant core competencies and be trained and supported to carry out their role effectively. Fourth, an outcomes-based approach will be used to specify knowledge, skills and behaviours using an established competence and assessment hierarchy known as ‘Miller’s Pyramid of Clinical Competence.’ Last, IP registrants will not be required to renew their specialty separately and supply details of prescribing decisions undertaken in the previous 12 months.
The COVID-19 pandemic has impacted everyone, everywhere, in many ways, and this includes the way optical education and training is undertaken. Over the past several years, the profession has become established and therefore some current requirements are no longer needed. Currently, registrants can only undertake a clinical placement as part of IP training under the supervision of an ophthalmologist within the hospital eye service. As we go forward, it’s important that we hear views from various people across the wider sector as we finalise these new IP requirements. We look forward to working together to prepare registrants for the future to ensure patients and the public continue to receive high quality eye care. Leonie Milliner is director of education at the General Optical Council
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“Preparing independent prescribers for the future with new updated requirements”
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“My biggest role model apart from Muhammad Ali would be my dad” Khalid Ayub
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doesn’t wear contact lenses or glasses. It is a real y dad was a boxer when he was younger. game changer. I can judge the distance and be more When I was three, he got me a punch ball. confident in my boxing. My dad didn’t think much about it – it was Ortho-k gives me the ability to do what I want just something for if I was bored. When I was 10 years and to box at close, mid and long range comfortably. old, I had my first fight. From there, I have never I don’t have the risk of a contact lens falling out or looked back. I’ve won four English titles; I have won sweat irritating my eyes. a Great Britain title and I have represented England My optician Simon [Mann, from Daybell and within international tournaments. Choo, part of Hakim Group] has helped me so much I have never been pushed into boxing, although my with them. He has dad got me into it. I been patient and have found a love for worked hard to it. For people who make sure that I don’t know, boxing am getting the best just seems like a experience for my punch up, but I don’t boxing and life in think of it like that. general. Boxing is a tough My ultimate sport, but I see it goal is to become more as an art form. a world champion. I look up to I work hard, I Muhammad Ali. am dedicated Although he was and disciplined. criticised at the Everything I do time, after he retired is focused on and even now, boxing. With every people look up to training session I him because of the put my all into it way he was inside and outside of the “I have found a love for it. For people who don’t because I believe that’s the attitude ring. His style was know, boxing just seems like a punch up, but you have to have so different to all the I don’t think of it like that. Boxing is a tough to get to the top. others from that time sport, but I see it more as an art form” My biggest role period. A lot of people model apart from doubted him, but he Muhammad Ali would be my dad. We are always never had any doubt in himself. together when it comes to boxing. Without him I I do get nervous, but I feel that the nerves help me wouldn’t have started boxing. Everything that I to perform better because I am more alert. Once I am have done is because of him. I always listen to my in the ring I am alright – it is just the build up to the dad and take in what he says. fight. When you are in the ring, you block out the My parents do worry but they know that I put crowd because of the adrenalin. everything into training. From their perspective, I have been wearing Eyedream ortho-k lenses for they know that I have done the preparation before I about eight months. It is amazing. I only wear them go in the ring. at night so when I go out, I am just like anyone who
Patient leaflets The AOP has produced a series of downloadable eye condition leaflets www.aop.org.uk/patients
Halifax boxer and ortho-k contact lens wearer, Khalid Ayub, 19, claimed English and Great Britain titles as an amateur boxer, representing England at international competitions. He is now a professional boxer signed by MTK Global.
August /September December 2021 2017
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In practice 45 Pre-reg focus
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Luke McRoy-Jones on milestone moments in his placement and nearing qualification
47 How I got here
OT’s Ceri Smith-Jaynes on her career journey and becoming an IP optometrist
Business insight and career development
53 How do I...
The AOP’s Roshni Kanabar advises on what to do if your referral is refused
THE DISCUSSION ART PRODUCTION
The class of ‘09
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OT speaks to Susan Bowers, Ross Henderson and Martin Hood – three of the first class of optometrists to gain their independent prescribing qualification when it was introduced 12 years ago
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n 2009, 33 trailblazing optometrists were the first in the UK to become independent prescribers. Among them were Susan Bowers, Ross Henderson and Martin Hood. Each had previously completed their additional supply and supplementary prescribing qualifications but had a thirst for continued professional development and felt that independent prescribing (IP) created the opportunity to provide patients with a full
circle of care, offering access to treatment closer to home. “I wanted to be an IP optometrist as it would mean that I could do more,” Bowers told OT when asked why she completed the qualification, explaining: “It was very satisfying as an optometrist to do my IP qualification as it meant I would have a larger sphere of expertise and it gave me a unique selling point in that I was different to my peers and could do more.”
For Hood, it was about expanding his skills and helping to ease the burden on the hospital eye service (HES). “I was curious and wanted to extend my professional expertise – I felt it would enable me to deal with more patients in practice who I may have otherwise had to refer into the HES,” he said. He explained that, over the years, being able to
54 Life as a locum
Rebecca Rushton on the opportunities she has embraced from locuming in the pandemic
provide a wider service for patients has allowed them to receive their care locally, while offering him a more interesting variety to his day and taking stress off eye emergency services. “I felt the onus to provide that service,” he said. Scottish-based optometrist Henderson agreed, sharing that, for him, “it has always been about the patient.” “Practically, if you see a patient and you make a suggested diagnosis about their eyes, the next step is to be able to do something about it, offering them the healthcare they require from start to finish.” The IP qualification was established for optometrists in the UK in 2009, allowing those who completed the qualification to officially prescribe any licensed medicine for conditions affecting the eye and surrounding tissues within their recognised area of expertise and FRPSHWHQFH competence. Prior to its LQWURGXFWLRQ introduction
“Pester your local GPs and insist that you have an FP10 pad to save them having to write prescriptions for you all the time – pester, pester, pester” Susan Bowers
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much went on in the background and, in fact, a chance meeting at a clinical conference in Athens, Greece between Bowers and the ophthalmologist teaching the course at City, University of London, Roger Buckley, may well have played a pivotal role in what the qualification looks like today. “I unexpectedly met the ophthalmologist who I knew would be lecturing on the course at City. Speaking to him, I explained how I felt that applying for optometrists to have access to a closed list of drugs would handicap us; I had seen this happen for nurses and had experience of how the tiny list of drugs that we could use for additional supply had shackled us,” Bowers told OT, sharing: “He explained that he would look into it further and winked. Today we can prescribe everything in Chapter 11 on the BNF, so he must have listened.” Experience
Being among the first to practise as IP optometrists has come with both challenges and rewards, as Henderson highlights. “It was quite a lot of hard work going through the process as one of the first because you often don’t have a structure of support in place. It has been a steep learning curve, but it has also been
very rewarding,” he shared. Working in independent practice, on qualification, Henderson decided not to market his skills, but instead to allow it to evolve slowly. “Initially I was prescribing for dry eye and minor eye conditions, which allowed me to build up my skills. Then, with time, I started to see more complex patients. I am now confident to prescribe oral aciclovir and systemic antibiotics when needed,” he shared. Today he writes about 150 prescriptions a year which he says is “not a high number,” and feels he would have “built up and developed my skills a lot faster if I was working in accident and emergency, or something like that,” he said. This is a notion that Hood agrees with in both theory and practice, describing working in hospital eye emergency as “invaluable” for enabling him to use and expand his IP experience. Having worked in eye emergency for at least one day a week since his training, Hood explained: “Being in that environment means that some of the things that come through the department are on the edge of my competency and while there are lots of things I can deal with, there are also strange or quirky things that I am sometimes uncomfortable with. You
“Working during lockdowns was a very rewarding time due to the volume of patients who were coming into practice who needed a prescription and therefore really needed you” Ross Henderson
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have to be aware of what you don’t know and what your limitations are and learn by experience. In those instances, colleagues are happy to give me a second opinion. I find that really helpful as an ongoing CPD educational experience.” Hood also highlights the benefits that his experiences in eye emergency provide him in community practice. “I know what happens in eye emergency and how the system works. I have a better understanding of the mechanics; what is an emergency and what is a priority,” he said. “I can also transfer my experiences back into my practice. 12 years ago I wouldn’t have dreamt about some of the things that I am very relaxed about dealing with in the community such as taking foreign bodies out,” he added. On qualification, Bowers felt excited about using her new skills. “I had done all of the training and I knew what I was doing. I was excited to be able to use my abilities to the full,” she shared. However, she was disappointed that glaucoma
was not an area that IPs could prescribe for. “I felt, ‘crickey,’ another thing they are telling me I can’t do, so I immediately started the training,” she told OT. As a clinician, it was important for Bowers to continue with her education and she went on to complete her certificate, higher certificate and diploma in glaucoma. “Education is the most important thing; you need to know what’s coming up and what’s in the future. You shouldn’t stand still,” she emphasised. COVID-19
Through the pandemic a light has been shone on the value of IP optometrists as they have been able to support the HES and deal with a wider range of patients in the community. For this trio, the pandemic has provided them with the opportunity to use their skills to the fullest, while expanding their experiences. “If I wasn’t IP qualified, I wouldn’t have been open during the pandemic,” Henderson shared. “Working during lockdowns was a very rewarding time due to the volume of patients who were coming into practice who needed a prescription and therefore really needed you. We saw a lot of patients who would have normally gone directly to the hospital and, mostly, we were able to manage them. It was very challenging as I saw a much wider range of more serious pathology than I ever had before,” he added. Hood also saw patients who may have previously gone directly to the HES
but “didn’t want to go into the hospital setting and were more comfortable visiting us,” he shared. Being an IP optometrist made a “huge difference” to Bowers during the pandemic. “I could use all my skills,” she said. “The hospital was shut down for three months doing telephone triage and emergencies only. But we could continue to see real life patients when wearing PPE. If you have a piece of metal embedded in the eye, you need it taken out and that can’t be done over the phone,” Bowers stressed. For Bowers, having her glaucoma certificate proved invaluable during the pandemic. “I wasn’t seeing glaucoma cases in my practice previously, but with the hospital not seeing many patients they were referred to my practice. I managed patients who felt that their medication might not be working or that their pressures were high in the community,” she said. FP10 pads
Once qualified, while IP optometrists are able to officially prescribe, securing an FP10 pad to allow them to write and sign an NHS prescription for their patients seems to be a contentious topic. Without an FP10 pad, they can prescribe privately or choose to refer the patient to their GP, for example, for an NHS prescription. How an IP optometrist can secure an FP10 pad in England differs from one region to the next and of this trio who have been IP qualified for over a decade, not all have access.
Henderson received his GP10 pad, the Scottish equivalent to an FP10, in 2014 when the country rolled out access nationally. To have this pad was one of the primary reasons he trained as an IP. “It took time but it works well and means that everyone gets treated equally,” he shared. In the area that Bowers practises in, Coventry and Rugby, every IP optometrist has an FP10 pad. However, this has not always been the case, and is certainly still not the case for those practising across England, she stressed. It took Bowers 11 months from the day she became IP qualified to receive an FP10 pad. “I was making all the GPs locally prescribe for me and driving them up the wall. It ended up being their idea to get me a pad to save them time.” The value of having access to a pad is now recognised and funded locally. Despite this, Bowers is clear that long-term FP10 pads should be provided via a national
“You have to be aware of what you don’t know and what your limitations are and learn by experience” Martin Hood
system in England to ensure all IPs have access. Sharing advice on securing an FP10 pad, Bowers said: “Pester your local GPs and insist that you have an FP10 pad to save them having to write prescriptions for you all the time – pester, pester, pester.” Why IP?
Gradually over the last decade, more optometrists have become IP qualified, with schemes such as MECS and CUES demonstrating the value of the qualification to the profession. Having a network of IP peers around him is something that Henderson feels is of particular value. “We network locally. It provides me with colleagues to bounce ideas off of.” “Similarly a WhatsApp group for all the local IP optometrists acts as a useful forum to get advice when I’m stuck,” he added – something that he encourages IP optometrists to set up in their local areas. For this trio, there are a number of reasons why it is important for optometrists to consider IP training and beyond. A primary reason for all is the impact it can have on supporting the HES. “The more IPs there are, the wider schemes such as MECS can be rolled out and
in turn we can help free up the HES for more emergency cases,” Hood emphasised. “Being an IP optometrist allows you to offer the best care for your patients, and if there’s more things that we can provide and deal with for our patients more locally, I think there should almost be an impetus to try and do that,” he added. For Henderson, IP is for the many rather than the few. “We are care professionals and clinicians when we qualify, and IP allows us to expand on that. There are so many potential routes in our profession nowadays, but when you are working in a practice like mine and can follow up on your patients from start to finish, it’s such a rewarding thing to do.” When discussing the future for IP, Bowers is passionate that this network of optometrists is key to the HES. “Ophthalmologists are so busy, they need IPs to help them. They will never cope if we don’t.” In the future Bowers is upportive of a five-year doctorate in optometry that allows graduates to “qualify and be able to prescribe.” “It would mean that optometrists could start prescribing privately and in the community straightaway, reducing the demand on hospitals,” she said, adding: “We can and should be looking to develop our profession and IP helps us do that.”
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“The finishing line is beginning to appear”
Education Library.
OT's Education Library contains CET, skills guides and CPD www.optometry.co.uk/ cet/education-library
Pre-reg optometrist and AOP Councillor, Luke McRoy-Jones, on being signed off for Stage 1, preparing for Stage 2 and looking ahead to the OSCEs
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fter what has been a challenging year for prereg optometrists across the country, the finishing line is beginning to appear. With the uncertainty I faced last summer, along with hundreds of fellow optometry graduates, I had wondered where I’d be at this point in terms of progressing through the Scheme for Registration. However, I’m proud of where I am, both on the Scheme, and in terms of my confidence and experience as a trainee optometrist. Progressing nicely
At the end of June, I reached an important milestone – I was signed off from Stage 1 after a successful Visit 4. Stage 1 had seen me carry out over 750 refractions, over 460 dispenses, and a number of contact lens episodes. Achieving all Stage 1 competencies is an important stepping-stone on the route to qualification. Now that Stage 1 has been completed, I hope to receive my Stage 2 assessment dates shortly and, if successful, there may
Emily says…
be the opportunity to attempt the OSCE in the autumn. Of course, the COVID-19 pandemic has had a significant impact on the way in which trainees have progressed through the Scheme this year. One of the biggest changes I have encountered has been the provision of virtual assessment and the move to a virtual Hospital Eye Service placement, which I’ve been working through in recent months. While
with more revision and preparation for assessments. However, I’ve really enjoyed beginning to re-engage with my social life outside of work in recent weeks and months, with the easing of restrictions. In the coming months, I’m looking forward to contributing to a number of AOP projects, policy positions and member services, as part of my role on the AOP Council and its policy committee.
“I'm confident that my degree and the Scheme are just the start of my training as I enter a changing and exciting profession with so much opportunity” it’s been disappointing to not have the opportunity to spend time in my local hospital eye department and develop relationships with the consultants whom I refer to, the College has created a set of online modules that can be completed in a flexible manner. Looking ahead
I anticipate that the following months will be filled I would tell my early pre-reg self to… not be too worried about not knowing everything just yet, it will come with time. Nobody expects you to be a perfectly polished optometrist when you first start your pre-reg. Some days will be great and you’ll feel like you’ve made
I first joined the AOP Council and its policy committee in 2019. During the pandemic, I also chaired its student committee, overseeing and contributing to the Association’s extensive work to support its student and pre-reg members during what has been an incredibly challenging time for those undertaking education, as well as those involved in the loads of progress, other days won’t be so good – but that means you’re learning – and the next time you’re faced with a challenge, you’ll know what to do.
delivery of education. I’m proud of the work that’s been achieved, and I look forward to working with the AOP at a critical time for all those in the profession. Last month, I attended my first meeting of the new AOP Council year, which gathered Councillors old and new. I believe we will form a dynamic and passionate Council for the year ahead. The end of the beginning
With the finishing line now in sight, I’m beginning to ask myself: ‘What’s next professionally?’ As someone who enjoys learning, the thought of sitting still doesn’t appeal, and with the direction in which the profession is heading, with enhanced community services and the expansion of an optometrist’s role, I feel it is pivotal to upskill and engage with opportunities so you can offer the best care to your patients. Therefore, I’m confident that my degree and the Scheme are just the start of my training as I enter a changing and exciting profession with so much opportunity. be afraid to do so. Learning is such an important part of the pre-reg year, and if you don’t ask for help when you need it, you’ll never learn.
The most important thing I’ve learnt so far in my prereg is… ask for help and don’t
Emily Mather is a preregistration optometrist at Moorfields Eye Hospital, London.
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were shocked to see me and rather cross that I wasn’t him. At first, I was offended by the patients’ reaction to me, but I learned to see it as a challenge and I worked harder, trying to impress them.
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OT’s clinical multimedia editor, Ceri Smith-Jaynes, discusses her journey into optometry – and why she decided to gain her IP qualification
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When the time came to explore degree courses at school, I was split between natural sciences and optometry. Optometry won
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through because there was a tangible and stable job at the end of it all. After some work experience in a practice, with the exceptionally inspiring Professor Christine Purslow, I was hooked. I went to UMIST in 1996, arriving just after the IRA bombing had devastated the city centre. One day I changed out of my lumberjack shirt and DMs and donned my tidiest clothes, wandered into Dollond & Aitchison (D&A) in Hereford and asked for a summer job. The manager
took me on, and she got me onto the company’s pre-reg scheme. My pre-reg year was spent in Oldham, which turned out to be the ocular pathology capital of the North. I think every page of Kanski’s textbook turned-
up in my consulting room during that year. In 2000, the 10 qualifying exams were mostly viva voce with a few station-exams; I lived with two other pre-regs and we would fire questions at each other during the washingup, to practise speaking our knowledge out loud. On qualification I stuck with D&A. I suddenly found
myself in St Helens, as the sole practitioner without a supervisor to ask questions of. I was grateful for my optometrist friends in those first months; we were doing peer discussion long before it became a formal requirement. A friend bought a practice from a retiring optometrist in Blackburn and asked me to work there. The trouble
was, the older gentleman had decided to go quietly without telling any of his patients. I spent a couple of years trying to win round people who
“I felt that optometry would probably move towards the management of eye conditions in the community in the future and it was time to learn or get left behind”
After a while, I felt I needed to diversify my working week
– I did some locuming and I worked for Newmedica in a hospital glaucoma clinic. Now I work two days a week for OT and the AOP, and spend the rest in a lovely independent practice in St Annes-on-the-Sea. It was the AOP’s London Therapeutics Conference and the SECO conference in Atlanta that inspired me to study IP. I regarded the
American optometrists with envious eyes and drew my plans to do what they do. I felt that optometry would probably move towards the management of eye conditions in the community in the future and it was time to learn or get left behind. The owner of the practice I work at was supportive so, when Health Education England encouraged a cohort of optometrists from the North West to apply, I jumped at the chance. When seeking a hospital placement to complete my IP qualification, I had to face the challenge of my faltering confidence. I was
now in my forties, with more responsibilities than in my carefree student days. Would I be able to learn as easily as I could then? Could I handle the workload while working full-time? It turns out, you just have to schedule the time and stick to it. I really enjoyed it in the end.
“My Plan B?” Science. I always get a little green-eyed at conferences when I see people present their research. I think something botanical or marine, although recently I have become interested in microbiology and epidemiology.
My hospital placement was shamefully easy to obtain. I wrote to the head of
ophthalmology at my local hospital before starting the university course and he said ‘yes.’ I spread out the placement, doing half a day each week. At the risk of admitting my Schadenfreude, the highlight of my placement was seeing a real Acanthamoeba keratitis and a case of papilloedema in the hospital clinic. As a result of the pandemic, we have had a CUES scheme installed in my area, which
has presented me with more opportunities to use my IP skills than before. We’re getting referrals from the local eye clinic as well as GPs. Being an IP makes me feel like I have levelled-up; I
understand more and I’m enjoying the revitalising effect of pushing my comfort zone. There’s also more respect from the patients when I manage their problem through to resolution, without having to send them to someone else. Get in touch Share your career journey with OT. Email lucymiller@ optometry.co.uk
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lmost one year after the pandemic hit, optometrists Ameerah Riaz Ahmed and Nasir Ahmed officially purchased their first practice, Cacoullis Opticians, in Halesowen, West Midlands. Despite admitting that practice ownership was never the plan, after welcoming their daughter during the first lockdown, the pair had a change of heart. A chance call
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Taking matters into her own hands, one day as her sixweek-old daughter slept Riaz Ahmed picked up the phone and called the local practice where she and her family used to have their eyes tested when she was younger. “I called the owner on the off chance,” she said with a laugh. “I didn’t know that he was looking to retire and I hadn’t even told my husband about it. We had a general chat and he invited us to the practice to talk further. My husband came home from work and I said: ‘We are going to see a practice.’” After that visit, the pair looked into the purchase more seriously. They gained access to the accounts and when the second lockdown was announced continued discussions with the then owner via Zoom. They also extensively researched the area and the patient demographic in order to inform their decision-making. Originally established in 1965, Riaz Ahmed had memories of the practice as a child and already knew the area “fairly well.” Speaking about the decision to purchase she explained that she had observed how the pandemic has caused a lot of people to stay and shop locally.
48 www.optometry.co.uk
THE PATH TO PRACTICE OWNERSHIP
BECOMING A BUSINESS OWNER
“It just felt right” Optometrists Ameerah Riaz Ahmed and Nasir Ahmed speak to OT about how the pandemic and having their first child during lockdown 1.0 led them on a career path they never intended However, under the ownership of a dispensing optician, the practice used locums to provide eye exams and was not operating at capacity. “The practice turned new patients away during the pandemic,” she told OT. “I saw such potential in the practice and knew as optometrists we could build capacity, with demand already there,” she added. Sharing the moment they picked up the practice keys, the duo said: “We took our daughter with us and gave her a tour; it felt so surreal.” Being prepared
Prior to becoming business owners, the optometrists experienced varied careers in a range of settings, from High Street and hospital clinics to domiciliary. “We wanted to try everything before deciding what we wanted to do long term, and for me, independent practice was the area that I enjoyed. It was the personal service, more time with patients and no sales pressure,” Ahmed said. A couple of months into ownership, both optometrists
admit they are learning a lot. “As the owners, we wear a lot of hats and are still getting to grips with a lot of things,” Riaz Ahmed told OT. “Going from being an employee to an employer is a big jump. You are not trained in any of this. For me as an employer now, it’s important that I take care of my employees.” Future gazing
Speaking about the future, Riaz Ahmed is clear: “We want to focus on building this practice and creating a highquality, personal offering.” Within the next three to five years, the owners hope to have completed a refit in order to modernise the practice, while reviewing the frame collection to best meet the needs of its patient demographic will be an ongoing process. In the next 12 months, they hope to introduce new enhanced services, as well as revisit the patient journey to focus on providing a personal touch. “We can’t wait to meet all our patients and welcome new ones to the practice,” Riaz Ahmed said.
How does it feel to be a practice owner? Nasir Ahmed (NA): It feels like a great accomplishment to be able to become a practice owner at such an early age. It has rekindled my passion for the profession and I have been able to practice quality optometry at my own pace. Ameerah Riaz Ahmed (ARA): The feeling is quite surreal, especially knowing that every single patient is taking time out of their day for your service in your own practice. It’s a feeling that I never quite want to take for granted. What are your top tips for purchasing a practice? NA: As cliché as it sounds, just go for it. It’s a big learning curve, but you will very quickly find your feet and wonder why you never made the jump sooner. ARA: Don’t be apprehensive. If you feel something is right, do your research, look at the patient demographic, look at the location, and go for it. Try not to get too overwhelmed by the process. It is a journey. There may not be immediate gratification, but it’s about the whole journey and looking at the long-term vision ahead.
Get in touch Share your practice ownership journey. Email emilymccormick@ optometry.co.uk
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KEY MILESTONES
ART PRODUCTION
“One of the most valuable commodities we have is IP”
CLIENT
Practice owner Peter Frampton was in the first class of optometrists to qualify in independent prescribing, in 2009. More than a decade on, he explains how having an IP workforce has huge benefits for the contact lens side of his business
01 I decided that I wanted 02 Patients don’t always to get all my optometry staff IP-qualified, and I was lucky that I had staff who were willing. For a while I was the
only IP in the practice. We learnt a lot. Everyone could prescribe via me, so they were all getting experience. I jumped the first hurdle, then I got the next person to do it, and so on. If you want to supply a quality service to all your patients and not be there yourself seven days a week, you really do have to have more than one IP optometrist in the practice. My goal was to be able to offer, from Monday to Saturday, an IP optometrist on the premises at all times. We’ve been at that stage for a while, now.
know to walk into your practice initially. I’ve been
IP-qualified for so long that people locally know that if they’ve got something wrong with their eyes, they can come to this practice. But that doesn’t happen overnight. You don’t suddenly get your IP qualification and expect patients to start storming through the doors. You’ve got to build up a reputation, both with GPs and with the community, and that only comes with time. We allowed it to happen naturally. We were lucky.
I knew I wanted to do this long before there was any official IP qualification. My Master's in therapeutics gave me a knowledge base, so I started requesting that GPs prescribe things, instead of referring to the hospital. You start on the cases that are non-sight threatening, and given time you start asking for slightly more significant medication.
03
The benefits are enormous, particularly to our contact lens patients.
In Northumberland, we have no funded services. We simply charge patients, and virtually all of them accept that, because they’d rather be dealt with in the community than drive to a hospital. We also have a feebased contact lens service. Patients are paying us a fee for our clinical services, so we have to provide a service they will value. One of the most valuable commodities we have is IP. I’ll tell them that if they have a red eye, or irritable eyes, they shouldn’t go anywhere else. I don’t care if we’re fully booked, we will see them. We’re really pushing the clinical side of contact lenses. Some optometrists will say there’s no funding stream for IP. Well, there is if you’re a contact lens practitioner. If you’re selling contact lenses, you are selling a medical appliance
“Being IP-qualified can really enhance your contact lens practice, and the opportunities within that are unreal”
that carries a risk. To be able to supply a service that solves the problem without sending patients to hospital is a critically important thing, cost-wise for the clinical commissioning group and service-wise for your patients. Being IPqualified can really enhance your contact lens practice, and the opportunities within that are unreal.
04
We’re now bringing through other senior leaders, and getting all the aspects of the department coordinated and then, hopefully, rapidly working over the rest of this year.
We’re strong because we’ve got a strong group; one of my IPs has been working with me for 25 years. It’s about continually developing, but also maintaining the ethos. We’ve got IP as the educational standard now, and we’re building on that with more qualifications. To educate, educate, educate, and keep honing it, is the plan. At this stage, I’ve pretty much achieved my goals for the practice. From a medical optometry point of view, obviously you’ve got to keep fighting. It’s competitive. I would certainly like to have more people paying into our funded schemes, which is something we’ve got to push for. My ultimate goal is to keep my patients out of hospital. I think, in being able to do that, we supply a really valuable service in the community.
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IN PRACTICE
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WHAT I HAVE LEARNED
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“IP allows us to reduce the burden on hospital eye services”
PRODUCTION
Amit Sharma, optometrist and director at Pinder & Moore Opticians in Kingswinford, and lecturers at Ulster University, Dr Julie McClelland and Patrick Richardson, discuss a special cohort of IP training
Ulster University
CLIENT
What led Hakim Group to set up a cohort for independent prescriber training? Amit Sharma (AS), optometrist and director at Pinder & Moore Opticians, a Hakim Group practice:
In April 2020, I had a conversation with our CEO and founder, Imran Hakim, about enrolling myself onto an independent prescribing (IP) course and he suggested we secure a cohort for some of our optometrists at Hakim Group. The thought process behind this was, especially with COVID-19, having this qualification would enable us as a group to support our hospital eye service (HES) colleagues further, as there would be more conditions we could manage in practice. We didn’t know how long lockdown was going to be and so we thought, if there are going to be optometrists who are potentially furloughed, it could be a good chance to upskill. I contacted all the universities that provide
IP training and continued with Ulster. The university typically only takes a cohort of 15 students on its IP course so we were not only asking if they could accommodate our optometrists, but if we could have a special cohort of over 100 people. Whilst we were in the planning stages for the IP course, Hakim Group was running the Stronger Together forum to help independent practices with the challenges of COVID-19. As we had the authorisation for 120 students, this presented a great opportunity to extend some of these places to our independent friends. Around 50 optometrists joined the course from the independent sector. What has the special cohort meant for the optometrists? AS: It’s a win-win in many
ways. For professionals, we’re giving them an opportunity that they potentially contemplated. It benefits the practice because it gives us
another unique selling point compared to others in the locality. Thirdly, and the key motivating factor for us, is that it allows us to reduce the burden on HES because there’s an opportunity to be able to manage a lot of conditions in-house that normally would have had to be referred. What can the IP qualification mean for patients? AS: The benefit for eye care
professionals is being able to manage your patient. Although there are some instances where there is nothing that as optometrists we can do, I think we always want to try and do whatever we can for our patient there and then, in practice, because the patient is in our care. If we can see them through because of that additional qualification then obviously, it’s better for them. The speed of management is key as well and if you’re able to manage patients in-house then it’s more convenient for them. What adaptations were needed to run the special cohort of IP training? Dr Julie McClelland (JM), senior lecturer at Ulster University and IP course director: This was a great
opportunity to upscale our programme for this special cohort. We initially had to gain approval for this increased cohort from the General Optical Council and Ulster University. As a relatively small team, we approached eight IP optometrists who we had worked with previously to ask them if they would consider taking on an e-tutor role for the larger cohort.
These IP optometrists undertook an e-tutoring programme prior to becoming involved with the teaching and assessment. They were all experienced clinicians with teaching experience and adapted very quickly. This experience has allowed us to see what we can potentially do with the IP programme and our other distance learning courses. What has it been like to run the course this year? Patrick Richardson (PR), lecturer and optometry clinic manager at Ulster, and an IP optometrist: The
pandemic definitely affected the optometrist’s perspective of how they manage their patients. It was great to hear stories from the students about how they had to adjust their practice to conduct telephone consultations and manage patients remotely. The pandemic has also opened-up and strengthened communication with our ophthalmology colleagues as we have all had to try to deliver eye care in a slightly different way. What role do you feel IP optometry will take in the future for eye care? PR: I really believe that IP
is important for the future of eye care. Community IP optometrists will be the key to helping to reduce the number of referrals into the HES, and those based within hospitals will continue to widen the scope of their role and enhance their clinical knowledge and skills. Share your story Get in touch if you would like to share your experience with OT kimberleyyoung@optometry.co.uk
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WIHL
IN PRACTICE
HDI
IN PRACTICE VERSION
HOW DO I...
REPRO OP
Deal with referral refusals
For more information To read more on safe practice, visit the AOP website: www.aop.org.uk/adviceand-support/clinical/ clinical-governance
AOP clinical and regulatory advisor, Roshni Kanabar, discusses a range of scenarios SUBS
T ART PRODUCTION
here are a few instances in practice where an optometrist may find themselves in a situation where their referral may be refused. These include: The hospital has refused to accept your referral The patient has refused to consent to a referral The practice has refused to accept your internal referral. In the AOP’s clinical and regulatory team, we often encounter enquiries where this is the case.
CLIENT
What do I do if the GP or hospital trust rejects or refuses my referral?
If you have referred a patient to a medical practitioner because you have detected signs of injury, disease or abnormality, and have performed all the additional examinations that are clinically indicated and necessary, then you can reasonably assume that you have fulfilled your obligation as set out in the Opticians Act. If the hospital eye department or GP rejects your referral then they are likely to be liable if a civil claim ever arises. We do however advise that practitioners try to find out why the referral was rejected, and try to remedy this and manage the patient appropriately. It may be that to do this you need to contact the place that you referred the patient to in order to find a way forward. Local referral
pathways can change so often that it can be hard to keep up, especially if you are a locum optometrist. Different areas will have different pathways and certain forms or ways they prefer you to refer. For example, hospital departments may prefer you to phone them first for urgent referrals, rather than send the patient directly to them. It could also be that certain hospitals only accept referrals from people outside of their immediate area on weekends and anything that can wait till the next week should go to a more local hospital. If you still believe that the referral has been rejected without good reason, you could raise this with your Local Optical Committee for advice. What should I do if a patient is refusing to be referred?
Sometimes you may come across a situation where a patient has rejected or refused a referral. This is a difficult situation as we have more insight into the consequences of refusing treatment. In this situation, we would normally recommend writing to the patient by recorded delivery, setting out your findings and advice, and the possible consequences of not following your advice. You may wish to include a referral letter and advise the patient to take this to their GP (or A&E if the matter is urgent) if they change their mind.
Sometimes patients need time to consider their options and may be hesitant to consent to a referral until they have had time to think about it or discuss it with their family or a friend. Therefore, you should also invite the patient to contact you at the practice if they want to discuss it further. Ultimately, if your patient decides against a referral, even after you have taken the steps above, then you must respect their right to refuse treatment. It is vital though that you keep a record of all your correspondence with them and make thorough clinical notes. If you feel that your patient lacks the mental capacity to make decisions about their own healthcare, you may need to take further steps, however, we advise members to contact the AOP to discuss this. We have more information on safe practice on our website. I’m leaving a practice and my employer won’t accept internal referrals. What can I do to ensure my followup patients are managed appropriately?
We often receive enquiries from optometrists, particularly locums, who are concerned about the managing and following up of patients after they have left the practice. We have developed an internal referral template, available
Three steps to success 1. Find out why a referral has been refused and try to remedy the reasons for rejection 2. If a patient refuses a referral, write to them explaining the reasons for it and the consequences of refusing or delaying referral 3. When you are leaving a practice, internally refer any outstanding patients that require follow ups and send an email to the practice owner explaining this if required. on our website, along with information on how to use it. We have had instances where employers are unwilling to accept these and we would therefore recommend sending an email to the practice owner, explaining that, as you are leaving the practice you are unable to follow up on these patients and therefore the most appropriate way to ensure they are managed properly is to internally refer to another practitioner (attach the referrals). It is not appropriate for the practice to send you patient data once your engagement with the practice has finished and therefore you should not agree to this.
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LIFE AS A LOCUM
IN PRACTICE VERSION
LIFE AS A LOCUM
A DAY IN THE LIFE
REPRO OP
“I like locuming much more than I thought I would”
SUBS
Sunday On a Sunday night, I will look through my diary to see what I have booked for the week ahead. I will look up any train times and buy any tickets that I might need.
Locum optometrist, Rebecca Rushton, shares her experiences as a locum in a new city when the pandemic hit
ART
I decided to become a locum around six years after I qualified as I wanted a bit more flexibility. I wanted to
PRODUCTION
be able to take holidays more easily. But also, I wanted a bit more freedom with my diary for the times when I may want to work a bit more to earn a little more money. I admit, I like locuming much more than I thought I would.
CLIENT
The pandemic aside, it is a lot more secure than I thought it would be. The variety and the different places that I have worked is much greater than I ever thought it would be. I’m a lot happier than I thought I would be. There are two things that I don’t like about locuming.
The first is doing my own accounting and invoicing; I’m always worried that I’m going to make a mistake. The second is that, being a locum, I don’t get to follow up on patients, particularly those who I have referred, I don’t get to see their results. You can miss those human connections as a locum.
a patient in Southampton for a refractive surgery consultation and for whatever reason I needed him to see his optician. Four days later I was locuming in Winchester and he was there. It was such a coincidence. The pandemic presented at quite an awkward time for me; I had just moved back to
Southampton about 10 days before the first lockdown. I had a few dates in my diary and was obviously looking to book more. But everything just stopped in March 2020. I was without any work whatsoever until roughly the beginning of July. Bookings started to pick up over the summer and I was able to make new connections and work in more places. I was pretty busy again by September/October. However, early January it cooled off again until early March. Since then I have been working solidly. It’s been ridiculously busy since then. Lockdowns can be a scary and nerve-racking time, but
ABOUT REBECCA
Qualified: 2006 Previous roles: Resident optometrist in a multiple Based: Southampton.
54 www.optometry.co.uk
An experience that has been memorable for me as a locum was when I saw
you have to have faith that one day, somebody will need your services again and it is just a question of how you are going to survive between
now and then. Most clinics are working at reduced capacity due to social distancing, cleaning and changing personal protective equipment between patients. In my mind, there should be less demand for locums, but it doesn’t seem to be the case. When I went back into practice after the first lockdown there were lots of adjustments. Trying to
do everything you need to do is stressful, particularly while adjusting to living in a pandemic and thinking about how patients could be sick but asymptomatic. There are also so many new rules and regulations in place; trying to keep on top of those was a challenge at the time as well. Reflecting on the last 15 months, I have been very lucky and I have managed to find some interesting new jobs. Two of them involve
working from home, which I never thought that as an optometrist I would be able to do. The first is working for a refractive surgery company doing consultations online; I love refractive surgery so it’s a complete dream role. The other is helping to set up a contact lens website, acting as general optometric adviser and checking the content to ensure it is clinically sound.
4-7.30am I set my alarm depending on where I am working. It can be anytime from 4am to 7.30am. Before leaving I check that my bag is packed and I have all my kit with me. I also take a packed lunch as some practices are nowhere near anywhere, so I like to be prepared. 9am On arriving, the first thing I do is find a manager and introduce myself. They will usually show me around. I like to know which room I am going to be in so I can set up and get used to any equipment that I may not be familiar with, making sure it’s all switched on. 1pm Usually during lunch, I try to switch off from work so will talk to people in the staff room or I’ll read a book. 5pm At the end of the day, I will make sure that all of my referrals have been done and I have spoken to the manager about any issues. When I have finished my day’s work, I like to go home and switch off. I hate the idea of things lingering.
AOP Locum Register Find out more: www.aop.org.uk/locumregister
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INDEPENDENT PRESCRIBING VERSION REPRO OP SUBS ART PRODUCTION
OT talks with clinicians about how independent prescribing has changed their practice – and explores how the qualification can develop in the future
CLIENT
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Feature, 1
n emergency eye department is a study in the vulnerability of the sense that people cherish the most. Patients present with disease and injury afflicting every aspect of the ocular anatomy and visual system. Clinicians must stay calm while assessing where the problem is, what has caused it and how they can help. Independent prescribing (IP) optometrist, Daniel Todd, has shown along with colleagues that well-trained and experienced IP optometrists can perform this fleet-footed detective work at least as safely as consultant ophthalmologists. When Todd began working as a hospital optometrist eight years ago, a relatively small proportion of IP optometrists worked in emergency eye departments in England. “There was a limited evidence base. We wanted to look at the diagnosis and prescribing decisions of IP optometrists in that setting,” he shared. Todd and his colleagues began a study comparing IP optometrists to consultant ophthalmologists in the diagnosis and management of patients presenting at the emergency eye department. Over a two-year period, 321 participants were first assessed by one of three experienced and welltrained IP optometrists, and then assessed by one of eight consultant ophthalmologists. The study team found that there was “almost perfect” agreement in diagnosis between the two professional groups as well as concordant clinical decision making. Todd highlighted that the results show appropriately trained and experienced IP optometrists can safely contribute to the multidisciplinary team in acute ophthalmic services.
“We demonstrated that patients who would have traditionally been diagnosed and managed by ophthalmologists could be managed safely by our IP optometrists. This evidence is the first to validate IP optometrists extended role in acute ophthalmic services and opens up an area where we can contribute more,” Todd observed. Th e bac k log
Evidence for the value that IP optometrists can offer in managing an extended range of conditions comes at a time of burgeoning wait lists within secondary care. Data released by the NHS in July revealed that there were 5.3 million people waiting for elective care – the longest waiting list since records began in 2007. Within this group, 336,733 people had waited more than a year for treatment, while 7403 people faced a delay of over two years for treatment. Todd shared that IP optometrists can play their part in addressing the backlog both in acute settings and in primary care through schemes such as the COVID-19 Urgent Eyecare Service. “I would hope that IP optometrists in the community would act as a first port of call to assess, diagnose and, where appropriate, manage urgent conditions; it is a good use of resources and makes the most of our skills,” he said. An aspect of the study that surprised Todd was how many patients were seeking care for minor conditions at the emergency
“Dealing with a patient’s acute problem is satisfying. It is good to see when the patient has turned a corner at follow up. We are at a time where resources are stretched. If we can contribute in ways that will improve the service and make it more effective, it’s a win-win really”
IP optometrist Daniel Todd
department rather than visiting their local optometrist. “At the time – this was pre-pandemic – there were still a lot of non-urgent conditions presenting – things like dry eye and blepharitis. These are really things that should be getting assessed in the community. It highlights the question, ‘What is motivating patients to turn up to A&E rather than go to their local optometrist?’,” Todd emphasised. General Optical Council (GOC) research published this year that found only one in three members of the public would visit an optometrist if they woke up with an eye problem.
“ I WOU LD H O PE THAT I P O PTO M E TR I STS I N TH E CO M M U N IT Y WOU LD AC T AS A FI RST PO RT O F CALL TO AS S ES S , D IAG N OS E AN D, WH E R E APPRO PR IATE , MANAG E U RG E NT CO N D ITI O N S” Dan i e l To d d August /September 2021
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IP IN SCOTL AN D:
REPRO OP
BY TH E N U M B E RS
SUBS ART
optometrists in Scotland are IP-trained
PRODUCTION CLIENT
studied IP at Glasgow Caledonian University last year
The findings could lead to improvement in care such as more efficient triage Todd highlighted. “If patients are identified at triage as being manageable by an IP optometrist or an ophthalmic nurse then they can be directed as such, which frees an ophthalmologist to see complex cases requiring medical intervention,” he shared with OT. Todd is quick to highlight that the findings from this study are limited by the fact they apply to a small group of IP optometrists from one hospital, who all had at least 10 years’ experience. The same results may not be replicated in IP optometrists who have just qualified, he added. However, Todd would like to see more research critically examining the care provided by IP optometrists to build on the evidence base for their extended role in acute ophthalmic services. E x p lor i n g t he e v i d e n c e
Todd observed that because the research examined the management and diagnosis of different conditions, it gave clinicians an idea of the strengths and training opportunities among the IP workforce. Because IP optometrists have traditionally worked in glaucoma, practitioners in the study were quick to spot this condition – on one occasion identifying narrow angle glaucoma when it was initially missed by a consultant ophthalmologist. In contrast, an IP optometrist, unlike the consultant ophthalmologist, missed a transient ischaemic attack in a patient with neurological symptoms. A case like this would require a medical work up and prescription of blood thinners, Todd shared. “It’s important to know your scope of practice, your limitations and when to refer to other colleagues,” he said. 58 www.optometry.co.uk
Dr Nicola Carey, from the University of Surrey, was part of a team examining the evidence around optometric therapeutic prescribing for the GOC. The study was commissioned by the optical regulator to inform decisions about how therapeutic qualifications might develop in the future through the Education Strategic Review. Carey highlighted a scarcity of evidence on the impact of optometrist independent prescribing – even though the qualification has existed for longer than a decade. She observed that this lack of data can be a hindrance when informing a business case of the added value that IP brings. “Unless you have data on the uptake, use and impact on patient care from service delivery you are not in a negotiating position to say, ‘This is really working for us’.”
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Carey highlighted that that the challenges for IP identified in the research include fragmented commissioning within England, a shortage of clinical placements and issues around the funding of training. “My feeling is that optometrists are keen to realise their professional aspirations and it’s clear that it does work well but there are challenges in implementation. There are practical challenges with respect to getting people trained and practical challenges in providing the service if it is not commissioned,” she said.
“ U N LES S YO U HAVE DATA O N TH E U PTAKE , US E AN D I M PAC T O N PATI E NT CAR E FRO M S E RVI CE D E LIVE RY YO U AR E N OT I N A N EG OTIATI N G POS ITI O N TO SAY, ‘TH I S I S R EALLY WO R KI N G FO R US’ ” D r N i co l a Car e y
Feature, 2
Da
Carey, who is a qualified nurse independent prescriber, shared that therapeutic prescribing within optometry has several key differences when compared to non-medical prescribing in other professions. For example, other healthcare professions complete the practical and theoretical elements of their qualification concurrently in contrast to IP optometrists who complete a placement that is separate to their coursework. There is also a requirement for IP optometrists to be supervised by an ophthalmologist, whereas for other healthcare professions they can be supervised by any other nonmedical prescriber. “One of the challenges that people shared is that there is a shortage of ophthalmologists and there is quite a big backlog. They were talking in terms of thousands of people waiting to get clinical placements. If you adopted a new model, you wouldn’t be reliant on having Lo to be signed off by ck i n g to n an ophthalmologist you could have it done by an optometrist or pharmacist,” Carey shared with OT. A Glasgow Caledonian University study published in 2011 surveyed 38 IP optometrists – which at the time represented 60% of all registered IP optometrists within the UK. Within the group, half of respondents reported referring patients less frequently after they became IP qualified. Survey respondents reported issuing 10 prescriptions per month on average, with 87% prescribing on a daily or weekly basis. Only one in three IP optometrists had access to a prescription pad. The remainder either requested prescriptions by written order or through a GP/ophthalmologist.
I P a n d r e f e r ra l rat e s
vi
d
Glasgow consultant ophthalmologist, David Lockington, contributed to research that was published in July last year assessing the distribution of IP optometrists within Scotland and referral rates. “There appears to be an everincreasing number of optometrists achieving IP which is great for them and the patients they evaluate in primary care. IP optometrists seem to be well-distributed across Scotland, and they seem to increasingly be using their skills,” he told OT. However, the study did not find that increasing numbers of IP optometrists was reducing referrals to secondary care – in fact, since 2010, referrals to hospital eye services have increased by 118%. Since 2013, Lockington has taught and supervised optometrists undertaking clinical sessions for their IP qualification in the West of Scotland Optometry Teach and Treat Clinic. “Without doubt, every optometrist presenting themselves for IP training with me has been keen to learn and engaged to use their skills appropriately,” he said. However, Lockington has concerns that the current system does not permit the skills of IP optometrists to fully flourish post-qualification. “The traditional eye care pathway has been a one-way conveyor belt to the hospital, with no exit door,” he shared. “We need to have a system which is more like a revolving door, where the appropriate patients can be seen, investigated and treated by the competent eye care professional and returned back into primary care for monitoring where possible,” Lockington emphasised. IP programme lead at Glasgow Caledonian University, Mhairi Day, shared that following the
“Before qualifying as an IP optometrist, I would know what treatment the patient required but would be unable to prescribe it which was frustrating. As I am able to manage more patients in practice, this saves time within my clinic which may have been spent on the phone organising referral to the local HES”
IP optometrist Dr Stephanie Kearney
outbreak of the pandemic NHS Education for Scotland (NES) and the Scottish Government funded an additional 70 training places for IP optometrists. As a result, Glasgow Caledonian University had an intake of 220 optometrists studying IP – more than double the usual number of trainees. Optometrists from across the UK completed the training which was offered online due to the pandemic. Glasgow IP optometrist, Dr Stephanie Kearney, observed
“TH E TRAD ITI O NAL EYE CAR E PATHWAY HAS B E E N A O N E-WAY CO NVEYO R B E LT TO TH E H OS PITAL , WITH N O EXIT D OO R ” Davi d Lo c ki n gto n
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that IP enables optometrists to manage more complex conditions within the community rather than referring to hospital. “Patients therefore have a less stressful experience as they are able to be managed by their familiar and local optometrist. As IP optometrists are able to prescribe from an extensive range of drugs, this also allows for individualised treatment for each patient,” she highlighted to OT. Kearney, who is an AOP Councillor, added that Scotland has a significant number of optometry practices based in rural areas. “Having a local IP optometrist improves the accessibility and quality of care in these areas,” she emphasised. Within Scotland, a GP10 prescribing pad can be obtained from the NHS Health Board the IP optometrist works in. Locums can obtain an GP10 pad from the health board they most
“ O N R E FLEC TI O N , IT WAS TH E B EST WAY TO LEAR N AS WE WE R E TH ROWN I N TH E D E E P E N D ” P e rva z e Jan
frequently work for – which can then be used across all NHS Health Boards within Scotland. Kearney shared that, as an IP optometrist, it is rewarding to be able to diagnose and manage patients in practice rather than refer them. “Before qualifying as an IP optometrist, I would know what treatment the patient required but would be unable to prescribe it which was frustrating. As I am able to manage more patients in practice, this saves time within my clinic which may have been spent on the phone organising referral to the local HES,” she said. Stepping up during C OV I D -1 9
“We were able to see patients promptly in the community and thus reduce the need for patients to travel to hospital during a pandemic. Patients really valued being seen in the local community in a quieter, safer environment compared to a trip to the hospital during the pandemic”
IP optometrist Marc Drake
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In Wales, following the outbreak of the pandemic the unique skillset of IP optometrists was harnessed to ease the burden on secondary care. The Cardiff and Vale University Health Board introduced the Independent Prescribing Optometry Service (IPOS) one day after the first lockdown on 24 March, 2020. Four optometry practices with IP optometrists provided emergency eye care within the community, managing 92% of cases without an onward referral. IP optometrist at Osmond Drake in Penarth, Marc Drake, shared with OT that IP optometrists in Wales gained access to W10 prescribing pads in February, 2020, one month before the going into the first lockdown. Working in a practice involved in IPOS,
Drake received referrals from other optometry practices as well as the emergency eye clinic at the University Hospital of Wales. “We were able to see patients promptly in the community and thus reduce the need for patients to travel to hospital during a pandemic. Patients really valued being seen in the local community in a quieter, safer environment compared to a trip to the hospital during the pandemic,” he said. Drake shared that he was proud his team were able to provide a meaningful service to patients during the pandemic. The initiative also fostered closer ties with ophthalmology – which Drake hopes to see continue into the future. “IPs should develop their skills in a way that suits them and their patients but at the same time we need to continue to build bridges with our secondary care colleagues,” he said. Pervaze Jan, an IP optometrist at Direct Eyecare in Cardiff, told OT that many of the conditions that he managed through IPOS were complex. “On reflection, it was the best way to learn as we were thrown in at the deep end,” he said. “For me personally, seeing patients’ conditions resolve as a result of our unique skill set in diagnosis and treatment from initial presentation to discharge is very rewarding,” he added. In the future, Jan would like to see optometry evolve clinically to reflect the unique skillset of the
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profession and the advanced diagnostic equipment that optometrists have access to. He noted that IPOS has gained recognition among his peers who are now confident to refer patients to the service rather than hospital. “I know that IPOS has inspired other optometrists to study for the IP qualification,” Jan said. Brian McKeown, an IP optometrist and AOP Councillor based in Northern Ireland, shared with OT that being IP qualified has given him the confidence to diagnose and treat conditions in practice, saving his patients a trip to accident and emergency or their GP. “I can also act as a sounding board for the other optometrists in the team to help manage patients,” he shared. Since COVID-19, a group of more than 40 IP optometrists in Northern Ireland have kept in touch through WhatsApp, seeking guidance on cases and organising Continuing Education and Training. “There is a real belief that IP optometrists are able to manage more conditions in the community and there is a lot of goodwill which has come out of the pandemic,” McKeown emphasised. In terms of future development of IP within Northern Ireland, McKeown would
“TH E R E I S A R EAL B E LI E F THAT I P O PTO M ETR I STS AR E AB LE TO MANAG E M O R E CO N D ITI O N S I N TH E CO M M U N IT Y AN D TH E R E I S A LOT O F G O O DWI LL WH I C H HAS CO M E O UT O F TH E PAN D E M I C” B r ian M c Keown
US optometrists will run hands-on labs demonstrating the use of lasers and minor surgical techniques at an event organised by IP optometrist Michael Johnson and colleagues UK IP optometrists will learn from their US contemporaries about the use of lasers, injections and minor surgery at an event in December. Dr Michael Johnson, an IP optometrist involved in organising the course, shared with OT that the foundations will be taught to enable clinicians to work within their scope of specialist practice more comprehensively. “International experts will cover treatment decisions, consent, management of complications, and relevant law,” he said. Johnson noted that the traditional centralised model of delivering ophthalmology has left many people unable to access eye care. “There is a clinical and human need for another way. It is not simply a matter of expanding capacity, but an opportunity to improve how things are done.”
like to see an IP-specific pathway commissioned. “To reach our
He shared his view that there is a need for teams based in the community, who autonomously manage a wide range of eye disease – not just minor eye conditions. Johnson added that optometrists must trust themselves to take responsibility for doing what is in the best interests of their patients. “Waiting to be told what to do and shying away from challenges will cause optometry to become a simulacrum of a profession,” he said. The event will run from December 9–12 at BMA House in London. Although the event was fully subscribed at the time of publication, a limited number of additional places will be made available. Contact ocellus.ltd@ gmail.com.
“TH E R E I S A C LI N I CAL AN D H U MAN N E E D FO R AN OTH E R WAY. IT I S N OT S I M P LY A MAT TE R O F E XPAN D I N G CAPAC IT Y, B UT AN O P P O RT U N IT Y TO I M P R OVE H OW TH I N G S AR E D O N E ”
full potential in Northern Ireland there needs to be a pathway to let us work and grow – to allow us to manage those more acute conditions and continue to build a great relationship with secondary care,” he shared. “It happened during the pandemic when we were needed and there was real hope that change would happen to utilise these skills,” he added. August /September 2021
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INDEPENDENT PRESCRIBING VERSION REPRO OP
Easing th e bur den on secon dary care in West Ken t
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In West Kent, IP optometrists helped to ease the burden on secondary care through the Acute Primary Care Ophthalmology Service (APCOS). The number of monthly cases seen through the service increased from 371 in January, 2020 to 641 in June, 2020. Over the same period, the number of patients seen through the hospital’s rapid access clinic declined from 861 in January to a low of 372 cases in April. Cases at the rapid access clinic rose to 610 by June. However, this is still lower than pre-COVID
attendances – with more patients seen in the community over the same month. Professor Ejaz Ansari explored the effectiveness of the service alongside IP optometrists Manish Patel and Dr Deacon Harle in their research published in Journal of Optometry in January this year. Harle noted that it is important to show that IP optometrists can be commissioned to safely manage a broad range of conditions and support the hospital eye service. “This has implications not only for crisis situations, but locally it has made the hospital trust
realise that there are many more suitable cases that can be repatriated to this community service to help share the increasing burden of cases,” he observed to OT. Harle shared his hope that the APCOS model has the potential to be rolled out within other areas of the UK. “There are as many therapeutic IP registered optometrists in the UK as there are ophthalmologists. If we don’t use these skills effectively, beyond simple primary eye care services, then patient care will be delayed and significant avoidable blindness will occur.” Dr Deacon Harle
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AOP COUNCIL IN FOCUS
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AOP Councillors discussed how the GOC can improve its handling of illegal practice at the latest Council meeting
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he issue of illegal practice in the optical sector, a new AOP mentoring scheme and NHS commissioning of primary eye care across the UK were among topics discussed at the latest AOP Council meeting held virtually on 9 June. The meeting began with Council chairman Dr Julie-Anne Little inviting new members of Council to introduce themselves briefly. The meeting marked the beginning of a new structure for the AOP Council, with 14 Councillors elected to represent members by geographic constituency and 20 designated Councillors representing specific membership groups. Outgoing AOP chief executive, Henrietta Alderman, discussed the membership organisation’s strategy, structure and key objectives for 2021. The presentation was Alderman’s final appearance before Council ahead of her retirement, with the AOP’s new chief executive, Adam Sampson, stepping into the role on 14 June. Councillors had the opportunity to discuss the AOP’s
response to the General Optical Council’s (GOC) stakeholder survey on illegal practice in the optical sector. The AOP response to the survey was subsequently published on the AOP website following the meeting. AOP policy director, Tony Stafford, highlighted that the pandemic has driven more consumer behaviour online. “We are very aware that this is an area that is changing constantly.”
“We are very aware that this is an area that is changing constantly” AOP policy director Tony Stafford Councillors shared their views on areas of illegal practice within the optical sector that pose the highest risk of harm, how these areas might change over the next few years and how the GOC could improve its strategy on tackling illegal practice. Raising public awareness around contact lens safety and updating registrants on the action the GOC takes
against illegal supply were among suggestions raised by Council. Councillors highlighted the need for the GOC to increase its understanding and engagement with social media which can be used as a platform for illegal practice and for distributing unsafe advice to patients. They noted that both the AOP and GOC have a role to play in supporting whistleblowing, with the potential for anonymised streamlined reporting of illegal practice. In response to the stakeholder survey, high-risk areas of illegal practice highlighted by the AOP included supply without supervision or verification, contact lens substitution without appropriate clinical oversight and the supply of ready readers and adjustable focus spectacles. At the meeting, the AOP Council voted for two members of Council to join the AOP Board. Independent prescribing Councillor, Fatima Nawaz, and North West England Councillor, Dharmesh Patel, were elected to join the Board. Presentations were also delivered on NHS commissioning of primary eye care within the UK and a new mentoring scheme that the AOP is introducing.
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CET Intro
CET IN THIS ISSUE
Education and training for the eye care practitioner
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21 century low vision care: new devices st
LEARNING OBJECTIVES
• Understand the therapeutic
management of cataract surgery complications
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LEARNING OBJECTIVES
• Be aware of the complications LEARNING OBJECTIVES
• Be able to advise patients with low
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vision on technological solutions to support their needs • Be aware of apps and accessibility options that are available to help patients with visual impairment
that can arise following cataract surgery
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Treatment of children with amblyopia
LEARNING OBJECTIVES
• Be able to explain the benefits of omega-3 to patients
• Be aware of the evidence relating to the benefits of omega-3
LEARNING OBJECTIVES
• Be aware of the evidence for the
use of omega-3 supplements to modify the risk of ocular disease
LEARNING OBJECTIVES
• Be able to explain the benefits of omega-3 to patients
• Be aware of the evidence relating to the benefits of omega-3
LEARNING OBJECTIVES
• Be able to explain the benefits of
omega-3 to contact lens patients with dry eye disease • Be aware of the evidence relating to the benefits of omega-3 for dry eye disease
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Cases in casualty
LEARNING OBJECTIVES
• Be able to advise patients with CLIENT
low vision on technological solutions to support their needs • Be aware of apps and accessibility options that are available to help patients with visual impairment
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Gaining insight: practitioner perspectives of the cataract journey
LEARNING OBJECTIVES
• Be able to manage patient
expectations ahead of cataract surgery • Be able to make appropriate referral decisions for patients with cataract • Be aware of the risks and benefits of cataract surgery
LEARNING OBJECTIVES
• Be able to explain to patients
about the management options for amblyopia • Be able to identify and manage children at risk of developing amblyopia
OCT scans
• Manage patients presenting with anterior segment pathology
LEARNING OBJECTIVES
• Assess cases of anterior and
LEARNING OBJECTIVES
• Be able to explain to patients
about the significance of amblyopia • Be aware of the different management options for patients with amblyopia
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LEARNING OBJECTIVES
• Be able to interpret retinal
Omega-3 and ocular health: what’s the deal?
posterior segment pathology and manage the patient accordingly
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Ancillary tests in practice
LEARNING OBJECTIVES
• Be able to interpret corneal topography plots
• Be able to interpret visual field plots
• Be able to interpret OCT results • Be able to interpret IOP data THE CET EXAMS WILL EXPIRE ON:
EXAM QUESTIONS & REFERENCES MCQs for OT’s CET exams appear online at www. optometry.co.uk. Exams cannot be submitted after this date. Please note that when taking an exam, the MCQs may require practitioners to apply additional knowledge that has not been covered in the related CET article. CET points will be uploaded to the GOC within 10 working
days. AOP members and subscribers will then need to log into the CET portfolio by clicking 28 on ‘MyGOC’ on the GOC website (www.optical. org) to confirm points. Visit www.optometry.co.uk, and click on the ‘Related CET article’ title to view the article and accompanying ‘references’ in full.
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DECEMBER 2021
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21st century low vision care: new devices Dr Michael Crossland PhD, MCOptom, DipRVI
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This article gives an overview of new high-tech devices designed for people with visual impairment, which provide high magnification, contrast enhancement, field expansion and text-to-speech. Introduction
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In the early 1990s, televisions weighed as much as a small child and computer monitors took up half of a large desk. Despite this, research groups attempted to mount smaller versions of these screens in a headset for use as a low vision aid (see Figure 1).1 Today’s screens are far smaller, brighter and lighter, and head-mounted displays are again being used for people with visual impairment. This article describes these exciting new devices, discusses their advantages and disadvantages and reviews scientific reports about electronic headmounted low vision aids. The article also shares the author’s personal experience of working with patients in clinic while using these devices.
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Figure 1
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Electronic head-mounted magnification Lightweight head-mounted screens are used for a variety of occupational applications including warehouse work, firefighting and medical education. They are also used by gamers, for watching films and for social activities such as online meetings. Several manufacturers have adapted this technology to be used as a low vision aid. Here, the author will concentrate on some of the more popular devices currently available and those for which there is published scientific research. SightPlus SightPlus (GiveVision, Birmingham, UK) is a headmounted low vision aid based on using a Samsung smartphone with a Homido virtual reality (VR) headset. The design is wireless and settings are adjusted with a Bluetooth remote control. The system enables magnification from 0.7x to 24.3x on a screen with a 110° diagonal field of view. The image can be viewed naturally or using one of four enhancement modes: contrast and enhanced (both of which highlight edges); reversed contrast; and a text mode, where print is yellow against a black background. Figure 2 shows SightPlus in use at low magnification in ‘enhanced’ mode. Note that there are two images as it is presented through the headset to each eye individually.
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Figure 1 The Low Vision Enhancement System (LVES) developed in the early 1990s by Johns Hopkins Wilmer Eye Institute and the NASA Stennis Space Center. Image courtesy of Dr R Massof, Johns Hopkins University
A study by the author of 60 adults with low vision demonstrated that SightPlus gave an impressive improvement in visual acuity (VA) of more than six lines on a logMAR chart (0.63 logMAR).2 It also improved contrast sensitivity, from an average of 0.99 log units (10%) to 1.37 log units (4.3%). Many participants were enthusiastic about using this system for tasks as diverse as television, reading, theatre and college. Several people highlighted that it would be particularly helpful for intermediate tasks such as reading with their children or helping them with their homework. The brightness of the image meant that people with reduced night vision, such as those with retinitis pigmentosa, thought it would help with low light tasks including looking in cupboards or checking who was at their front door at night. Although many of the study participants liked SightPlus, 45% did not think it would help them. The main reasons for this were its weight, appearance, image lag on the display, being able to do things just as well with their own low vision aids and the fact they were unable to walk with the device.
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with visual impairment. The newest version provides up to 24x magnification with contrast enhancement modes that can be customised to the wearer. It also has several options for reading text, including displaying words one at a time and text-to-speech reading. It weighs about 200g and has a diagonal field of view of around 35°.3 A study of eSight showed slightly greater improvements in visual function than SightPlus, with an immediate improvement of 0.74 logMAR (seven lines) on average, with a 0.57 log unit improvement in contrast sensitivity.3 There was an important difference in study Figure 2 Example patient view on SightPlus (low magnification, design between the research on SightPlus and ‘enhanced’ mode) eSight: in the SightPlus study the device was Some people experience ‘cyber sickness’ in VR shown to every person who attended a hospital environments. Four participants (7%) in the author’s low vision clinic, whereas the eSight study included study experienced nausea when wearing SightPlus, four people only if they ‘demonstrate motivation to wear felt dizzy, three had a headache and one (with a history eSight eyewear.’ of dry eye) complained of ‘sore eyes.’ These symptoms In a follow-up study after at least three months of improved as soon as they took the device off. owning an eSight device, Lorenzini and colleagues found that 19 of 109 people (17%) had stopped using OxSight glasses it.4 Reasons for abandoning the device included headache, discomfort when wearing eSight and OxSight is another British company, who make two finding it too heavy. Perhaps surprisingly, younger electronic devices for visual impairment: Crystal and subjects were more likely to stop using eSight than Onyx. Crystal is based on Epson wearable glasses and older participants. has a wired control unit. Although providing lower levels of magnification and a smaller field of view than Figure 3 SightPlus, it is significantly lighter. It also provides image minification down to 0.3x, to expand the visual field for people with hemianopia, retinitis pigmentosa, or glaucoma. Crystal has a clear screen, so that the user’s peripheral vision is unaffected (see Figure 3), with the magnified region occupying a relatively small area of central vision. Onyx is a newer device that can be used as handheld binoculars, or can be clipped into a frame for head-mounted use. The screen on Onyx is completely enclosed. Figure 2
eSight Unlike devices that use existing headsets, eSight is a product designed and manufactured specifically for those
Figure 3 OxSight Crystal
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Figure 4
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Figure 4 OrCam MyEye in use
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OrCam MyEye In contrast to electronic devices that make a scene more visible, Orcam’s MyEye uses artificial intelligence to translate the image into words. It consists of a small camera and processing unit, weighing 22.5g, which is attached to the side of a pair of glasses using a magnetic clip (see Figure 4). Its main function is reading print aloud, which it can do in more than 20 languages. It works best for printed text but can also read handwriting, signs, and, for example, railway station departure boards. To read print, users either tap the side of the device, or point towards the text which they would like to read. MyEye includes other features such as face recognition, identification of banknotes, colour recognition, and barcode scanning (to identify products). Orcam’s Read Smart is a simpler, cheaper, handheld device which only has the reading function enabled. Orcam devices have been shown to help task performance on a non-validated battery of visual tests including reading an email, identifying a box of cereal and reading a sign in a hallway.5 An advantage of MyEye is that it is quite discreet. In particular, people with long hair can hide the device until it is used. The author has found it to be helpful for people who have collected lots of books for retirement then lose their vision before being able to read them. The author also has several patients who use these systems for reading at work. Smart glasses Glass was launched by Google in 2013. Its current
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iteration, Glass Enterprise Edition 2, is marketed primarily for industrial and medical applications. Experimental low vision applications for Glass include magnification6 and image edge enhancement,7 which can boost the visibility of steps, kerbs and other low contrast features. Limitations of this system include its small field of view (about 15°), its relatively low level of magnification (8x) and a very low refresh rate (seven frames per second). A further problem is that the screen on Glass is offset and only available on the right lens, causing problems for people with visual field loss and those who see better with their left eye. For these reasons and others, Google Glass is still not widely used by people with visual impairment, although Microsoft has announced that their Soundscape navigation app will soon be available on this platform. Soundscape also works well with smart glasses which incorporate speakers, such as Bose Frames. Microsoft is currently developing low vision apps for their Hololens 2 wearable head-mounted display.8
Limitations of high-tech low vision aids The author’s research showed that some people who tried SightPlus thought they could perform tasks just as well with their existing optical magnifiers, or their smartphone. This emphasises that high-tech devices should be demonstrated as part of a comprehensive low vision assessment including refraction and demonstration of optical low vision aids. The author has heard reports of people who have purchased these very expensive devices, only to find at a later date they can read just as well with, for example, a simple hand magnifier. Devices that magnify the whole visual field cannot be worn when walking around as the magnified view reduces the visual field9 and affects the vestibulo-ocular reflex,10 which can lead to balance problems and falls. Battery life and start-up time are still a concern with several of these systems and many people are not willing to draw attention to themselves by wearing quite obvious head-mounted systems.11 The author recalls one person he saw in the low vision clinic who bought a head-mounted electronic magnifier for watching football matches. He was uncomfortable with the attention he received so reverted to listening to audio description at the match but still uses the device for playing video games with friends.
Buying and paying for these devices These devices are far more expensive than conventional low vision aids, generally costing several thousand pounds.
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About the author n Dr Michael Crossland is a senior optometrist at Moorfields Eye Hospital and an honorary senior research associate at University College London. He graduated with a BSc in optometry from Aston University in 1998 and was awarded a PhD by the University of London in 2004. He works in adult and paediatric low vision clinics at Moorfields and has published more than 40 peer-reviewed journal articles on low vision. He is particularly interested in the impact of visual impairment on children and new technology for people with low vision.
In England, university students with visual impairment are eligible for Disabled Students Allowances of up to £5,849 for specialist equipment to help with their course.12 The amount available is approximately the same in Wales, Scotland and Northern Ireland. Students require a needs assessment for this funding to be agreed, which is coordinated by Student Finance England, Student Finance Wales, Student Finance Northern Ireland, or the Student Awards Agency in Scotland. Access to Work is a government scheme that enables people with permanent disability (including visual impairment) to receive specialist equipment, adaptations, or support to stay in the workplace. It is available to employees, interns, self-employed people and apprentices, but not to people doing voluntary work. The author is aware of many people with visual impairment who have received electronic head-mounted low vision aids through the Access to Work scheme. Some employers will provide these systems without the formal Access to Work procedure being followed. People can apply for Access to Work help through the gov.uk website.13 The RNIB produce a very helpful factsheet on this scheme.14 National and local charities sometimes fund these devices. For example, Guide Dogs and VICTA provide technology grants for people under the age of 18 or under 29, respectively. People who have worked in certain professions may be eligible to specific grants, as are those who have specific diseases, or who live in certain parts of the UK. Some people receive grants from their local Rotary Club or Lions International branch. The website disability-grants.org is a good starting point to find suitable funding sources. One young adult recently seen by the author had sudden and severe visual impairment caused by Leber’s congenital amaurosis. A keen darts player, his local darts league raised money for him to receive one of these devices, in the hope he could rejoin the team using a head-mounted electronic low vision aid. Other people self-fund these devices, or even use crowdfunding sites to raise money. For people with significant income, the blind person’s allowance means they can earn an additional
£2,520 each year tax free. Some people will save this money to buy assistive devices. These devices are usually bought directly from the manufacturer. As they are less intuitive to use than a hand magnifier or pair of binoculars, training is usually offered by the manufacturer or distributor. They can also be purchased from some larger sight loss charities, such as the RNIB, in their shops and resource centres.
The future This is a fast-moving, exciting area of optometry and this article does not discuss all of the devices currently available. In an earlier article (OT, December 2020 / January 2021) the author described the importance of practitioners staying up-to-date by listening to podcasts, attending trade fairs and reading low vision articles. Sight Village events are a particularly good place to see the newest electronic devices when they are launched. These events are free to attend, and when circumstances permit, take place annually around the country. The first iPhone was launched 14 years ago and at that time few people realised how ubiquitous smartphones would become. Perhaps in 10 years it will be as common to see someone wearing a head-mounted display as it is to see them using a smartphone on the street. Once this technology is widespread, people with visual impairment may be able to use low vision apps on their glasses without anybody realising what they are doing.
Conclusion New head-mounted low vision aids give very impressive improvements in visual function. Limitations of existing devices, such as their weight, appearance and image lag are improving with each new device launch. Electronic head-mounted low vision aids provide an exciting way for people with visual impairment to perform more tasks independently, but the importance of traditional optical devices should not be overlooked.
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Gaining insight: practitioner perspectives of the cataract journey
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Jo Mackenzie BSc (Hons), MCOptom, PG Cert TLCP, DipTP(AS), DipTP(SP), DipTP(IP), PG Cert HCL SUBS
This CET article considers the possible complications associated with cataract surgery, their prophylactic and therapeutic management, together with the relative risks and mitigating factors for those complications.
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Introduction
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Changes in surgical techniques, including anaesthetic procedures and available prophylactic and therapeutic treatments, together with access to operation simulation for surgical trainees have led to increased numbers of cataract surgeries being carried out with decreased complication rates in recent years, such that National Institute for Health and Care Excellence (NICE) Guidelines for postoperative care now states that ‘patients having non-complicated surgery should not be offered an in-person review the following day’.1 Instead, instructions are given on how to clean the eye the following morning and how to contact the hospital should problems arise. In August 2014, The Royal College of Ophthalmologists (RCOphth) was commissioned by the Health Quality Improvement Partnership (HQIP) to collect data to form the National Ophthalmology Database (NOD),2 as part of the National Clinical Audit and Patient Outcomes Programme (NCAPOP). The NCAPOP is used to inform commissioning decisions with the aim of protecting the public purse while giving the best outcome and value and topics are accepted according to strict criteria.3 For ophthalmology, this has led to a more robust understanding of the rate and severity of complications and the numbers of surgeries being carried out. An initial funding of three years for the NOD was extended by a further two years, so that the funding ended in September 2019; however, the RCOphth has announced that they will continue maintaining the NOD. The data has been published in three annual reports to date and shows improvements in the outcomes of cataract surgery, as well as increasing numbers of surgeries. It is important for optometrists to understand the complication rates and risk factors for cataract surgery in order to both manage patient expectations and prepare patients to give their informed consent as well as making timely referrals. Cataract surgery is said to be the most common surgical procedure performed both in the UK and worldwide, with more than 390,00 cataract operations being conducted in England in 2015/16 and 16,000 in Wales during the same period,4 rising to approximately 414,000 cataract operations undertaken in England and 20,000 in
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Wales in the 2017–2018 NHS year.5 The RCOphth predicts in ‘The Way Forward Project‘ report that there will be a 50% increase in the number of cataract surgeries in the next 20 years,6 which would suggest more opportunities could be made for optometrists to become more involved in the patients’ cataract journey, especially in the pre-operative assessment phase.
What makes a good cataract referral? The most important factors are that the referral is timely and matches the patient’s wishes. The patient should have a basic understanding of the procedure, the risks and benefits and the likely time to recover. Any referral should also follow local protocol as there are a variety of different referral pathways running across the UK, with some trusts accepting direct referrals from optometrists and others having schemes whereby a fee is paid for the optometrist to spend additional time with the patient, counselling them in an attempt to reduce the number of referrals that do not then go forward for surgery. Information for local referral protocol is best obtained from the relevant Local Optical Committee (LOC). In 2009, a retrospective review of 124 referrals showed greater appropriateness of direct optometric referrals compared to referrals made by general practitioners (GPs); however, there is room for improvement in the information included in the referral, as shown in Table 1.7 Notably, 87% of patients referred by optometrists proceeded to surgery in that study and this is not significantly different to the 86% of patients who were listed for surgery in a larger 2017 study of 733 direct cataract referrals, where accredited optometrists used a designated referral form, in Cambridgeshire.8 The rejection rate was mainly due to patients achieving better than 6/12 visual acuity (VA) when they attended the hospital, but this may be because the test was performed at 4m, which can overestimate acuity, then being converted to a 6m Snellen fraction, as opposed to being an actual 6m test. However, VA is not the best indicator of patients who will benefit from surgery and NICE recommend against this criterion being used.1
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Table 1 Data included in referral
Percentage of referrals Optometric referral (n=62)
GP referral (n=62)
Objective visual loss reported
100
87
Pre-operative counselling
97
18
Past medical history
68
95
Drug history
69
94
Resultant operative rates
87
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Table 1 Referral quality; data presentation collated from a study of 124 cataract referrals7
There is a blanket ‘no driving’ rule for 48 hours after the surgery, but of course the patient may only then resume if they meet the required vision standards. The patient must be counselled for any expected change of refraction and it may be useful for them to obtain a pair of ready readers for the initial post-operative period where appropriate. The range of focus with a near addition in pseudophakia is notably very restrictive. For a patient who has already lost their useful accommodation, this will not be a noticeable change; however, for a patient who is younger and was either pre-presbyopic or had some residual accommodation, this will represent a marked change in their visual ability which may be difficult to adapt to.
The incidence and seriousness of complications Despite the rising number of cataract operations performed, complication rates in cataract surgery have been shown to be reducing. At the 2018 RCOphth congress, Ferris attributed a 38% reduction in the numbers of intraoperative posterior capsule ruptures (PCR), with or without anterior vitreous loss, to trainee surgeons having access to the simulation equipment, Eye-Si,9 which equates to around 3,400 fewer complications having occurred. Only data from operations that were performed for the benefit of sight improvement where no other procedure was combined were used in the statistical analysis. PCR is an important complication as there is a 40% greater risk of post-operative retinal detachment in a patient who had PCR compared to one who has not. Further, it also complicates the insertion of a posterior chamber intraocular lens (IOL) and adversely affects the visual outcome. Major risk factors for PCR have been identified as: hard cataract, uncooperative patients, extended continuous capsulorhexis, subluxated lens, myopia, patients with previous vitrectomy, poor pupil dilation and posterior polar cataract (PPC); the larger the diameter of the PPC, the greater the risk of PCR, with diameters >4mm carrying greater risk.10 VA loss is the other measure of complications used in the NOD, showing an overall reduction in occurrence of 37% from 2010. VA loss is classed as ‘a doubling or worse of the visual angle’.6
The most common complication of cataract surgery is post-operative inflammation and the most frequently occurring complication to cause reduced vision is pseudophakic cystoid macular oedema (PCMO).11 While the pathogenesis is not fully understood, there is agreement that light toxicity, inflammation, vascular instability and vitreoretinal traction all play a part.12–14 A 1–2% incidence has been reported in patients without risk factors and studies have shown that diabetic patients have a relative risk of 1.8x of PCMO after cataract surgery compared to those without diabetes; the risk increases further to 6.6x in the presence of retinopathy.15 PCMO also occurs more frequently in patients who exhibit marked postoperative inflammation.14 The action of topical non-steroidal anti-inflammatory drugs (NSAIDs) is to block the cyclooxygenase enzymes responsible for the production of prostaglandin, thus inhibiting the breakdown of the blood-retina barrier, which is said to contribute to PCMO. A systematic review by Kessel et al of 15 randomised controlled trials comparing the use of topical steroidal and NSAID drops for safety and efficacy in the management of post-operative inflammation and prevention of PCMO concluded that there was low to medium-quality evidence that NSAIDs were more effective in controlling postoperative inflammation and that there was highquality evidence that NSAIDs were more effective in preventing PCMO, without evidence of any increased events. Their recommendation, therefore, was to use NSAIDs prophylactically after routine non-complicated cataract surgery.16 For diabetics, topical nepafenac 0.1% three times a day is recommended for three days prior to surgery and 90 days post-operatively.17 The pre- and post-operative NSAID regimen is also recommended for patients with previous PCMO, previous retinal vein occlusion, epiretinal membrane and prostaglandin use.18 Knowing the ocular history, the optometrist is well placed to write a salient referral and inform the patient accordingly. Tumour necrosis factor alpha (TNF-α) has also been
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Figure 1 Reflection from IOL edge (PD)
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Incident light rays from temporal direction
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Shadow from IOL edge (ND) Figure 1 Positive and negative dysphotopsia. Reproduced with kind permission from JS Bhalla and S Gupta
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implicated in the pathogenesis of ocular inflammation and studies have also shown that PCMO can be safely and effectively treated with intravitreal injections of infliximab to inhibit TNF-α.19 The most catastrophic complication of cataract surgery is endophthalmitis and a multicentre study investigated the incidence and possible mitigating factors for this event. In a prospective, randomised, partially masked study, with four treatment groups, which was conducted by 24 ophthalmology units, 16,603 patients were recruited. Only 29 presentations of suspected endophthalmitis occurred, with 20 of these having a proven infective endophthalmitis. This gives an overall incidence in this population of 0.12%. Analysis of the different treatment regimens showed an increased risk of 4.92x in the absence of an intracameral prophylactic cefuroxime being administered at the end of the procedure. It was found that entering the eye through a clear corneal incision (CCI) as opposed to a scleral tunnel was found to increase the risk of endophthalmitis by 5.88x and having a silicone IOL, as opposed to an acrylic one, increased the risk of endophthalmitis by 3.13x. Any surgical complication increased the risk 4.95-fold and endophthalmitis was more likely to occur with an older surgeon.20 A recently published 16-year long study by Moser et al, taking into account 55,984 surgeries, showed a decline in the incidence of endophthalmitis following the introduction of intracameral cefazolin and a further, sustained decline following the change of post-operative topical ofloxacin to moxifloxacin, giving an incidence of only 0.0037%.21
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Even the type of anaesthesia used affects the type and incidence of complications. Different ophthalmologists prefer different anaesthetic regimens and there has been a recent drive towards non-injection regimens, but even local anaesthesia (LA) carries a risk. LA options include topical anaesthetic drops with intracameral injection, a peribulbar injection, retrobulbar injection or a sub-Tenon’s injection. Longer, myopic eyes are at increased risk of perforation during peribulbar and retrobulbar anaesthesia, particularly if the axial length is over 26mm.22 A study of 50,000 patients with 26,857 patients having retrobulbar and 23,143 peri-bulbar injections found one in 760 eyes had scleral perforation by the injection, of whom all had staphyloma.22 Of these, two required cryotherapy, three required vitreoretinal procedures for retinal detachment and a one had subretinal haemorrhage. It showed 42.8% of the perforated eyes had a VA of worse than 20/160 and one case requiring multiple retinal detachment surgeries developed proliferative vitreoretinopathy and poor VA. Complications from LA are not restricted to ocular presentations and include life-threatening events. A prospective 13-month study to determine current LA practice and the incidence of LA-related adverse effects included one profound vasovagal episode, one silent myocardial infarction, one anaphylactic reaction and one supraventricular tachycardia. The authors found the distribution of anaesthesia to be 3.4% general anaesthesia, 92.5% LA alone and 4.1% LA with sedation. Techniques for the approximately 357,000 LA cataracts were: 8.8% peribulbar, 1.3% retrobulbar,
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About the author n Jo Mackenzie graduated from UWIST in 1986 and was a hospital optometrist for the majority of her 30-year career, taking an extended role in glaucoma clinics before becoming senior lecturer at Portsmouth University in January 2016 and returning to the NHS in 2019. She took the independent prescribing qualification in 2009 and
50.5% sub-Tenon’s, 1.4% subconjunctival, 13.8% topical, 24.2% topical-intracameral LA. There were seven globe perforations, one cilioretinal artery occlusion and one severe corneal oedema in this cohort.23 A combined LA and mydriatic preparation, Mydrane (Théa Pharmaceuticals Ltd), is now available and has been shown to be effective and safe, giving superior comfort during the surgery. Pupil dilatation reaches 95% within 30 seconds and the drops are more stable than topical mydriatic drops.24,25 It is a standardised ophthalmic combination of tropicamide 0.02%, phenylephrine 0.31% and lidocaine 1%, administered as an intracameral injection. In the comparative study conducted by Labetoulle et al,25 surgeons reported that IOL insertion was less challenging with Mydrane than topical mydriatics and all patients reported no discomfort. The relatively recent phenomenon of seeing arcs and rings of light in pseudophakia was first described by Arnold in 199426 and was later termed ‘dysphotopsia’ by Tester in 2000,27 but has become commonplace, with many patients experiencing this. Dysphotopsia occurs when oblique light is internally reflected by the IOL at a point close to its edge, so this phenomenon takes place in naturally large pupils or in scotopic or mesopic conditions. Positive dysphotopsia is where the reflected light is projected onto the retina to give an arc or ring of light29 and is typically observed when walking down a road with streetlights on after dark or when there are passing car headlights. Educating the patient to change the angle of their head may be useful. The prevalence of positive dysphotopsia has reported ranges from 1.5% to 67%, with most studies showing 12% to 35%27,29,30 in the immediate postoperative period, decreasing to 0.2% to 2.2% over the next 12 months.30 Negative dysphotopsia is a penumbra formed when light is scattered such that it leaves a crescent of retina that is not illuminated and is perceived as a dark shadow,31 being more prevalent with a smaller pupil31,32 and more likely with a sharp-edged IOL design.32 The formation of positive and negative dysphotopsia is illustrated in Figure 1.28 Lens design and material influence the likelihood and strength of the dysphotopsia, because internal reflection
regularly facilitates peer discussion sessions for the College of Optometrists. She was awarded the Giles Van Colle Memorial Award in 2005 for her research into The Use of Contact Lenses in the Management of Anisometropic Amblyopia, an award given for the most significant contribution to paediatric optometry.
occurs when the angle of incidence exceeds the critical angle and the retinal image becomes more concentrated with increasing refractive index. An unequal biconvex IOL design focuses its internally reflected light on an area 60 times smaller than that of an equiconvex design,33 again increasing the brightness of the dysphotopsia and increasing the chance of symptoms. A square edge design further increases the chance of the phenomenon32 and frosting the edge of the IOL can reduce the incidence.29 Capsular bag contraction causes the position of the Table 1 IOL to alter with time, altering the refraction, but also being the possible mechanism for the reduction in symptoms of dysphotopsia, as the distance between the iris and the IOL reduces, often to 0.06mm or less.28 The development of posterior capsular opacification (PCO) is associated with younger age at surgery, coexisting glaucoma and the use of hydrophilic IOL. It also tends to occur earlier in the younger age group and in those with a history of uveitis.33 Its formation is due to the migration of epithelial cells from the anterior lens to the posterior capsule fibres, where they form and secrete a protein not usually found in the lens. Haloes around lights and other typical glare symptoms may occur again often before the vision becomes appreciably blurred and patients should be counselled to have an eye examination should these symptoms start to recur and affect the quality of life again. Clinically significant PCO requires treatment with yttrium aluminium garnet (YAG) laser capsulotomy, which will usually eliminate the symptoms.
Conclusion With increasing understanding of the pathogenesis of many of the complications of cataract surgery, both prevention and management strategies have improved and complication rates have reduced, changing the riskto-benefit balance for many patients. It is important for optometrists to keep abreast of such developments and understand the risk factors and possible complications and how they might apply to each patient, in order to give appropriate advice and make timely, informed referrals for cataract surgery.
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Treatment of children with amblyopia
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Fabrizio Bonci Dip Optom (ITA) SUBS
This article outlines the options for optometric management of children with amblyopia.
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Introduction
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Care of a child suspected of having amblyopia requires a comprehensive optometric evaluation, including a focus on the risk factors for amblyopia such as family history of strabismus, anisometropia, congenital media opacities or other ocular disorders.1 The preliminary diagnosis of amblyopia is made on visual acuity (VA) assessment with prompt treatment required to optimise a successful outcome.2
VA assessment
LogMAR charts with letters or Lea symbols (see Figure 1) should be considered in children with CLIENT
amblyopia for VA assessment at distance and near as the size of letters change in steps of 0.1 log units between one row and the next with the same degree of legibility. Each letter has a value of 0.02 log units which provides better VA quantification than traditional Snellen charts, especially for patients with poorer vision. Due to the crowding phenomenon, where isolated letters and those at the beginning or the end of lines are more easily identified, the Pediatric Eye Disease Investigator Group suggests using crowded bars around individual letters for clinical trials in amblyopia.3 The Kay Picture Test consists of a series of very familiar pictures which allows VA to be determined for young children (see Figure 2). The exam is conducted at a distance of 3m and allows VA assessment in logMAR units from -0.1 to 1.0 as well as providing the equivalent Snellen sizes of 3/2.4 (6/5) to 3/30 (6/60). The pictures are crowded to provide an accurate acuity measurement as soon as the child is able to recognise the pictures, typically at age two years and above. Some suggest that in children presenting with strabismus and latent nystagmus, evaluation of VA in the amblyopic eye should be done under binocular conditions, using vectographic or anaglyphic filters, or holding a fogging (plus) lens in front of the non-amblyopic eye.4–6 The therapeutic sequence for amblyopia includes optical correction, occlusion or penalisation, and vision therapy.
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Optical correction The refractive status in a child suspected of having amblyopia should be evaluated under non-cycloplegic refraction followed by cycloplegic refraction using 1.0% cyclopentolate HCl.7 Cyclopentolate 1.0% is sometimes used in combination with phenylephrine and/or tropicamide for children with dark irides. Some practitioners suggest the use of a topical anaesthetic prior to the instillation of the cyclopentolate to promote penetration of the cycloplegic into the eye. Dynamic retinoscopy, performed prior to cycloplegia, provides a rapid evaluation of accommodative ability and is particularly useful in children at risk of accommodative disorders such as those with Down’s syndrome, cerebral palsy and those with high hyperopia.8,9 The author successfully uses the dynamic retinoscopy technique described by Hunter.10 The key to the technique is the neutralisation of the retinoscopic reflex that occurs when the child accommodates on a target adjacent to the retinoscope. In this type of retinoscopy, the child is asked to fixate on a distant target such as a letter or a symbol. The reflex is evaluated in both eyes, and a with movement should be observed (relaxed accommodation). It is also important to check all meridians in case astigmatism is present. The child is then instructed to fixate on the near target (a letter or a symbol), with the retinoscope and target held approximately at a normal reading position (see Figure 3). The with movement will rapidly change to neutral or a slight against movement. If neutralisation is not reached, the practitioner should try to move back slightly to see if accommodation is borderline, or encourage the patient to look at finer print. The examiner, retinoscope and target should move together as a single unit. The patient is asked again to fixate on the distant target and the reflex should rapidly convert to a with movement. Now, the practitioner should move closer while the patient maintains fixation on the near target for a longer period of time; this places more demand on the accommodative system, which helps to estimate whether the accommodative effort is sustainable.10 Positive powered trial lenses are added
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momentary accommodation only, or accommodative lag). The Mohindra retinoscopy technique is particularly useful for practitioners who are not permitted to use cycloplegic agents or for conducting frequent follow-up assessments without repeated use of cycloplegic agents (see Figure 4).11 In this technique, the stimulus is the dimmed light source of the retinoscope in a darkened room. The darkness of the room helps the child to keep their attention on the retinoscope’s light. The examination is conducted at a distance of 50cm with one eye occluded and hand-held trial lenses are used to find the neutral point. Once the retinoscopy result Figure 1 Folding paediatric chart with Lea symbols is obtained, the refractive error is calculated by adding -1.25DS to Figure 2 the gross finding. In general, the level of refractive correction for anisometropes should aim to fully address any imbalance between the two eyes although, in the absence of accommodative strabismus, a symmetric reduction of up to 1.50D in spherical correction may be appropriate.15,16 Interestingly, Nordlow provided full optical correction with conventional or iseikonic lenses in a group of fouryear-old children with 2.00D of Figure 2 Single Crowded Kay Picture Test. Image courtesy of Kay Pictures, UK anisometropia.17 The author found that two thirds of the children with to the correction to neutralise the reflex. The result of conventional lenses continued to demonstrate reduced dynamic retinoscopy can be described as normal (rapid, VA, whereas only one in 15 children with iseikonic complete, and steady) or abnormal (incomplete, sluggish lenses did. In addition, the author found that children Figure 1
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only);7 this is often termed ‘full correction’ with no requirement to subtract an allowance for cycloplegia. In exotropia, undercorrection of the hyperopia might be preferable to aid control of the deviation, assuming VA is good. Contact lenses are particularly useful in cases of anisometropia to reduce aniseikonia, eliminate prismatic effects and to manage weight issues, peripheral distortions and visual restrictions associated with spectacle lenses.18,19 Wallace et al found that in children aged three to six years with no previous treatment, optical correction alone improves VA in most cases of anisometropic amblyopia, with resolution in at least one third.20 The study also highlighted that most cases of resolution occurred with moderate amblyopia (VA range 20/40 to 20/100), while in those with severe amblyopia (VA range 20/125 to 20/250) it improved by an average of three lines. In children with deprivation amblyopia the decision of whether or not to perform surgery is difficult because the cause of deprivation may not be the only factor, for example, in those with mild cataract and anisometropia. In these cases, a trial of conservative management with spectacles and patching to determine the amount of VA reduction that is due to visual axis obstruction is suggested in the first instance.2
Figure 3
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Add and prism
Figure 3 Dynamic retinoscopy
with iseikonic lenses had better foveal fixation. The Royal College of Ophthalmologists suggests prescribing the full amount of hyperopia in all forms of esotropia (having corrected the retinoscopy result for working distance
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Once the best optical correction is prescribed, and if ocular misalignment remains, the next step to consider in the sequence of management is to prescribe lens power in the form of an addition, or prism. An addition, in the form of bifocal lenses, can be considered to relax accommodation and improve ocular alignment in cases of eso deviation at near due to a high accommodative convergence/accommodation (AC/A) ratio (see Figure 5). Furthermore, positive addition can also be prescribed in the management of accommodative insufficiency, which is often detected in amblyopic patients.21 In cases of exophoria, a negative addition of up to -3.00D can be prescribed and gradually reduced as control improves with the help of vision therapy.22 Hunter gives a clinical example of a five-year-old child with hyperopic anisometropic amblyopia in the right eye treated with spectacles and atropine penalisation of the left eye, instead of occlusion.10 The child’s refractive status under cycloplegia was R +3.50DS L +0.50DS. In these cases, it is also worth considering whether a bifocal lens is necessary to help the amblyopic eye focus at near. Dynamic retinoscopy with the best distance optical correction in place and the left eye under cycloplegia can help to determine if the amblyopic right eye can
accommodate properly.10 Where the amblyopic eye does not accommodate reliably, in Hunter’s opinion, a bifocal lens should be considered for the amblyopic eye until the accommodation is found to improve in that eye.10 Prism can be prescribed when ocular alignment is not achieved with the best optical correction, this being particularly the case in patients with vertical heterophoria. The minimum amount of base-out prism, determined using the Mallett fixation disparity test, is often prescribed in cases of decompensated esophoria. Vision therapy, in terms of convergence exercises, is the treatment of choice in cases of decompensated exophoria at near or convergence insufficiency.21
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Figure 4
Occlusion Occlusion and appropriate optical correction has remained the mainstay of treatment for amblyopia since the 18th century.23 A meta-analysis shows no statistically significant difference between part-time and full-time occlusion with the minimum effective occlusion duration to observe maximal improvement in VA considered to be six hours per day.24 Although six hours of occlusion is as effective as full-time occlusion in the treatment of severe amblyopia, two hours of occlusion is as effective as six hours for moderate amblyopia.25 Total occlusion is the most common form of therapy and is often the first line approach. The patch is rarely fitted to the spectacles and is instead worn directly on the skin so that no light can enter the occluded eye. A Bangerter foil can be considered to reduce vision in the non-amblyopic eye to give partial occlusion. These foils are a series of translucent membranes that are applied in a similar manner to Fresnel prisms, that is to say, directly to the lens surface with moisture. Binasal occlusion is a type of sector occlusion used in the treatment of functional vision disorders such as esotropia, amblyopia, and non-strabismic vision deficits (see Figure 6).26 The purpose of binasal occlusion is to promote use of the amblyopic eye when both eyes are open.26
Penalisation Atropine 1% or 0.5% is sometimes used when wearing a patch is not tolerated well by the child. The action of the atropine is maintained by instilling the drug on alternate days or only for weekend use27 and has been shown to be as effective as occlusion for logMAR VA of 0.3-0.7 with maintenance of VA demonstrated over long-term follow up.28,29 Atropine can be considered as an alternative treatment to conventional
Figure 4 Mohindra retinoscopy (note that the high level of room light in this image was for photographic purposes only) Table 1 Figure 5
Figure 5 Bifocal lenses in a child with anisometropia and convergence excess due to high AC/A ratio
occlusion, with fewer compliance issues and avoids the psychological consequences of wearing a patch. Optical penalisation is another method that can be used to both blur the vision of the non-amblyopic eye and augment the VA in the amblyopic eye. The eye can be penalised for near, distance or all distances.
Vision therapy Active vision therapy can be considered in amblyopic patients to enhance passive treatment such as spectacle correction or occlusion. The purpose of vision therapy
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is to normalise sensory-motor function and eliminate competitive inhibition of the dominant eye towards the amblyopic eye.30 Vision therapy is effective when the child can be actively engaged, maintain some level of cognition and visual attention, but can be less effective in some children with special needs. Activities that are very effective for children with amblyopia are those requiring motility and fine fixation such as reaching, pointing, kicking or even grabbing (see Figure 7). A binocular approach to therapy for amblyopia involves any treatment whereby both eyes are being used, but the amblyopic eye is primarily performing a given visual task. For example, dichoptic treatments are a specific type of binocular therapy that uses dichoptic contrast balance, whereby the contrast level of the dominant eye is reduced to negate suppression to a level where the contrast sensitivity of the two eyes is equal and balanced in pursuit of the given visual task.31
Figure 6
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Stability of treatment
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Figure 6 Binasal occlusion in a child with right eye esotropia and amblyopia Figure 7
Regression after successful treatment for amblyopia has been shown in 25% of young children (< seven years old) within the first year following cessation of therapy, while in older children (seven to 12 years old), VA improvement is sustained for at least one year following cessation of occlusion.32,33 In those affected by severe amblyopia, initially treated with more than six hours of daily occlusion, regression occurred in 42% of patients, but only in 14% of patients treated with patching for two hours a day.32
Conclusion This article outlines the role that optometrists play in detecting and investigating cases of amblyopia in children. The different approaches to treatment can be considered on a case-by-case basis and whether or not they fall within the scope of the individual practitioner’s experience or require onward referral for specialist intervention.
About the author
Figure 7 Monocular activities during a vision therapy session in a child with amblyopia in the right eye
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n Fabrizio Bonci is the clinical optometry lead and vision therapist at Ocular-Optikus Clinic in Kecskemét, Hungary. He has mostly worked in eye clinics in Italy and was also a clinical research fellow at the Department of Clinical Neuroscience and Mental Health, Imperial College London, Charing Cross Hospital.
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Omega-3 and ocular health: what’s the deal?
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Iain Johnson BSc (Hons), FBDO CL SUBS
This article provides an overview of the literature on the use of omega-3 for ocular health.
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Introduction There is a growing debate surrounding the use of omega-3 supplements for eye health: some practitioners swear by its use and efficacy, while others feel that it is of little benefit at all. In an ideal world there would be a solid answer based on research and it would be case closed for or against their use, but as with most research (especially nutritional research), there are conflicting views. Possibly the most cut-and-dried consensus was for their use in dry eye, but even this is being challenged. All of this leaves busy practitioners with the dilemma: should I recommend omega-3 supplements to my patients or not? And if I do, what are the benefits?
Why omega-3? One of the main reasons that omega-3 supplements are so popular is because of their role in inflammation, and specifically their ability to help lower (or more precisely, resolve) inflammation.1 Epidemiological studies have shown a positive correlation between fish intake and a variety of conditions such as heart disease, dementia, macular degeneration and dry eye.2 Oily fish contains
high concentrations of omega-3 oils and it is these oils that are thought to offer most of the health benefits. There are many clinical papers that provide good evidence that omega-3 lowers inflammatory levels in isolation with a supplement;3 this is important because when you eat oily fish it’s not just omega-3 that you’re ingesting. Let’s use salmon as an example – here are just some of the vitamins, minerals, lipids and amino acids: taurine, vitamin D, choline, phosphorus, vitamin B6, potassium, pantothenic acid, selenium, vitamin B12 iodine, biotin and eicosapentaenoic acid (EPA), and docosahexaenoic acid (DHA). So, it is very difficult to pick out omega-3 and say that this is the only component that is responsible for the benefits we see in epidemiological studies. This doesn’t really help us as practitioners because we can’t really offer a piece of fresh fish with every eye examination. Nevertheless, we do know that omega-3 helps to lower inflammation. Omega-3 is an essential fatty acid along with omega-6, which means that we need to obtain certain levels from our diet; that is to say, our bodies cannot produce their own.4 With the
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average person in the UK only eating one third of a portion of fish per week, it’s easy to see how we don’t get enough omega-3 in our diet.5 Omega-6 is present in most foods and generally speaking our levels are much higher,6 so there isn’t a widespread deficiency. The caveat here is that not all omega-6 fatty acids are the same. Some produce a strong pro-inflammatory action and others are inherently anti-inflammatory, much like omega-3.7 In general, we don’t have high levels of the anti-inflammatory omega-6 compounds in the Western diet, but we do have plenty of pro-inflammatory omega-6. Therefore, there is often a blanket statement that omega-6 fatty acids are pro-inflammatory and omega-3 fatty acids are anti-inflammatory, but this is an oversimplification. It is important to know that certain sources of omega-6, such as borage oil and evening primrose oil, have been shown to be beneficial for reducing inflammation8 including eye conditions associated with inflammation such as dry eye.9
So why is inflammation an important consideration for eye health?
Inflammation is thought to play a role in almost all degenerative conditions, including ageing itself. The term inflammaging is often used to describe how accelerated ageing can occur with excess inflammation and how inflammation tends to increase as we age.10,11 There is also a strong association with eye conditions, such as dry eye disease.12 Inflammation is also important in longer-term eye conditions like age-related macular degeneration (AMD).13 Fish consumption has long been considered protective for macular health, with some
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epidemiological studies showing a strong correlation in a dose-dependent fashion – that is to say, the more portions of oily fish consumed per week the lower the incidence of AMD.14 At this point it would be easy to say that omega-3 is associated with reduced inflammation and as inflammation is a major driver of many disease states, including eye disease, we should recommend it. Case closed?
Why the controversy?
While there have been a large number of studies showing a benefit from omega-3 for dry eye15–19 and epidemiological data suggesting its protective role in the pathogenesis of macular degeneration,20–24 there have also been key papers that have found no such benefit. Some of the biggest were the age-related eye disease studies (AREDS) for AMD and a recent dry eye study (the dry eye assessment and management (DREAM) study), both of which found that there was no benefit over a placebo. AREDS The original AREDS study provided clinicians with the backing they needed to promote several key nutrients to help slow the progression from intermediate to advanced AMD. These included beta-carotene, zinc, vitamin C and vitamin E. The follow-up paper, AREDS II, allowed this formula to be tweaked, with beta-carotene being removed for safety (due to increased risk of lung cancer in smokers) and two key ingredients adding further benefit: lutein and zeaxanthin. One of the formulas that was tested in AREDS II contained omega-3 and at the end of the study the authors concluded that this provided
no additional benefit when added to the formula.25 Again, this isn’t completely cut and dried because there have been many criticisms of the study design, such as the use of multivitamins from participants before the study commenced and the higher levels of healthy nutrition (including omega-3) pre-study from the health conscious volunteers.26 This is important because if the participants already had high enough levels of omega-3, would we really see any benefit from adding more? Furthermore, would we have seen a much greater benefit if participants had low levels of omega-3 to begin with – something that could be expected in the typical western diet?27 Post-study analysis actually found that those who had higher levels of EPA and DHA to begin with (two important components in omega-3) had a lower chance of developing advanced AMD.28 EPA and DHA, two long chain essential fatty acids, are thought to be key for the long-term protection of the macula. DHA is very important during development and plays an essential role in the nervous system.29 The retina is also rich in DHA, accounting for approximately 50–70% of the fatty acid content of the photoreceptor rod outer segments.30 One of the roles that omega-3 plays here is to reduce the damage caused from ultraviolet light and oxidative stress.31 With a protective effect being found from those with higher levels pre-AREDS and the epidemiological data on fish intake, perhaps it is a longer-term protection that omega-3 offers, which would be challenging to verify with a controlled trial unless it was conducted over decades. At this point it is impossible to say, hence the uncertainty on the role omega-3 plays in this regard. DREAM: no benefit? The DREAM study was one of the first dry eye papers that looked at omega-3 over a relatively long duration (more than one year). The conclusion from this study was that there was no benefit from omega-3 over the placebo (olive oil). Again, this has caused some controversy because technically speaking there was a large benefit found in both the placebo group and the treatment group – with 61% of the treatment group and 54% of the placebo group having a 10-point or more reduction in their ocular surface disease index scores (OSDI).32 Importantly, the participants were permitted to continue with their existing dry eye management alongside the intervention, which may have accounted for some of the improvements. One aspect of this study that also generated
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controversy was the choice of placebo, olive oil, as this is one of the compounds that is thought to be responsible for the health promoting effects of the Mediterranean diet. Not only is this diet considered to be one of the healthiest in the world, it is also associated with good eye health. One observational study graded the level of Mediterranean foods (MDS) and correlated this data with AMD prevalence and found that those with the highest MDS scores had 50% less chance of developing neovascular AMD than those with the lowest scores.33 Some of the compounds found in olive oil are potent anti-inflammatory and antioxidant agents.34 So, while omega-3 was found to only have a marginally better result than the placebo, the placebo itself was also effective and this is no surprise considering its inflammation resolving properties. It could be considered as more of a comparison study with two active interventions rather than a true placebo-controlled trial.
Is there a question about omega quality?
Omega-3 is a polyunsaturated fat that is very unstable and unsuitable for high temperature cooking.35 As an unstable oil, it is susceptible to rancidity and the manufacturing process differs between supplement companies. Some manufacturers will use farmed fish whereas others will only use wild fish, some will contain higher levels of the long chain fatty acids EPA and DHA, others will contain lower. A study highlighted some of the problems with omega-3 supplements where the researchers analysed 45 commercially available products and tested the levels of EPA and DHA along with some of the biomarkers associated with rancidity. More than half of the products contained less than 89% of the stated dose of EPA and DHA on the label and the majority tested positive for the early signs of rancidity.36 The effects of ingesting rancid fish oil are unknown, but it is certainly food for thought when selecting a product. There are several pharmaceutical grade omega-3 supplements on the market and these may well be the best option for safety and efficacy considering the disparity between products.
What about other nutrition?
We have discussed the role that omega-3 plays in inflammation and how inflammation is at the heart of many disease states. But omega-3 is not the only dietary anti-inflammatory agent. Fruits, vegetables, nuts, seeds and many other natural foods have a strong anti-inflammatory effect on our bodies.37 The exact
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cet 4, 2
Dry eye, ocular surface disease
cet 4, 3 VERSION REPRO OP
About the author SUBS
n Iain Johnson is a contact lens optician with additional qualifications in nutrition and exercise science. He regularly writes and lectures on the subject of nutrition and eye health, as well as dry eye. In 2019, he was awarded the Optician Contact Lens Practitioner of the Year and was a finalist for the BCLA’s dry eye award and AOP’s Contact Lens Practitioner of the Year.
ART PRODUCTION CLIENT
nutrients vary, with a large list of phytochemicals that have been shown to be protective for overall health and more specifically eye health.38 Studies have shown that an antioxidant supplement alone (without omega-3) can be an effective treatment for dry eye, with a statistically significant improvement in tear stability, tear volume and clinical signs after 12 weeks of supplementation.39 Epidemiological research has correlated the intake of foods containing some of these phytochemicals with lower risk of AMD40 and the AREDS studies found a reduction in the progression from intermediate to advanced AMD with a multivitamin.41 There are early data suggesting a protective role from green leafy vegetables in glaucoma incidence.42 This begs the question: why do we focus on just omega-3? When addressing dry eye, omega-3 is just one of the many options that we can use as an adjunctive to our treatment plan. Some of the omega-6 fatty acids have also been shown to improve dry eye signs and symptoms,9 along with certain vitamins and minerals39 – so a product containing multiple nutrients could prove more effective than relying on omega-3 alone.
Purified oil and olive oil Another theory as to why some supplement studies do not stack up to their fish intake comparisons is to do with their absorption inside the body. When we eat fresh fish, we get omega-3 along with a whole host of other compounds, many of which may offer protection to the delicate nature of omega-3. Supplement manufacturers are aware of this and often add antioxidant compounds such as vitamin E to help stop rancidity. But there has been some interest in switching to lipophilic polyphenols that effectively protect the omega-3 both in the bottle and in the body. One such lipophilic polyphenol is olive oil, the very same placebo used in the DREAM study. Olive oil as a supplement has a very high bioavailability and can help to ensure that there is no pro-oxidant effect from taking an inherently antioxidant supplement. A future study combining these two compounds could prove to add to the efficacy of omega-3 as a supplement for eye health.43
82 www.optometry.co.uk
Conclusion
It is very difficult to draw definitive conclusions on the benefits of omega-3 based on the research we have available to us at this time. Epidemiological data has shown that a diet rich in oily fish (which is a great source of omega-3) is protective for eye health. While it could be other components in the fish that offer the protection, or other lifestyle or dietary habits, we know that omega-3 is anti-inflammatory, and excess inflammation is linked to a variety of eye conditions, including AMD. Diseases associated with ageing often take decades to develop and because of this, they are incredibly difficult to study in a controlled manner. Outside of animal models we are left with observational data, at least for now, and this is in favour of a diet rich in omega-3. Dry eye disease is much easier to study than AMD because of the timeframe and there are papers that have found a benefit from supplementary omega-3. The DREAM study conclusion suggests that it does not perform any better than a placebo, but this is oversimplified considering the participants all continued with other treatments and the choice of placebo, a known anti-inflammatory ingredient. There was a huge improvement in OSDI scores across the board, so it’s hard to say what single component was responsible for this improvement. Perhaps one of the key takeaways from this study was that anti-inflammatory oils are beneficial for dry eye – not just omega-3. This is not necessarily a bad thing because if it was just omega-3 that was beneficial then it would be harder to discuss a dry eye product with patients without the question mark over all the other omega-3 supplements that can be bought from the supermarket, often at very low prices and of unknown quality. Instead, if we have a situation where a blend of specific oils is beneficial then we know that the products have been specifically designed for dry eye with an assurance over their quality. This puts the clinician in control of the treatment and allows for follow up and careful observation of the results.
August /September 2021
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VRICS VERSION
1
Cases in casualty
CET
POINT
REPRO OP
Alan Hawrami BSc (Hons), MCOptom, Prof Cert Glauc, DipTP(IP) SUBS
This article features a series of cases that commonly present to eye casualty. Readers are invited to review the images and access additional resources where necessary to answer the questions.
Image A
Image B
ART PRODUCTION CLIENT
A patient presents with a two-day history of mild left eye discomfort and no other symptoms. They have never had this before.
A patient presents with a one-day history of a very tender lump on the upper eyelid. They report that they normally get styes on the eyelids, but they resolve themselves.
01 Based on the image and the history, what is the least likely diagnosis? a) Episcleritis b) Subconjunctival haemorrhage c) Scleritis d) Uveitis
04 Which other symptom would you expect the patient to have? a) Colour vision loss b) Photophobia c) Epiphora d) Floaters
02 Which of the following would be most useful to help aid diagnosis? a) Instilling fluorescein b) Instilling phenylephrine 10% c) Schirmer test d) Instilling proxymetacaine
05 What sign would you least expect with this type of presentation? a) Blocked meibomian glands b) Lid swelling c) Relative afferent pupillary defect d) Lid erythema
03 What is the most appropriate management for this patient? a) Urgent referral b) No referral, reassure and advise the patient that the condition is self-limiting c) Oral steroids d) Topical steroids
06 What would be the least effective management option? a) Eyelid cleaning b) Hot compresses c) Eyelash epilation d) Eyelid massaging
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August /September 2021
BLACK YELLOW MAGENTA CYAN
Image C
07 What is the key finding in the image? a) Entropion b) Ectropion c) Hyperaemia d) Madarosis 08 What other diagnostic test should be used to help direct the management? a) Tear break up time b) Slit lamp examination with fluorescein c) Retinal examination d) Optical coherence tomography (OCT) 09 What could the interim treatment consist of? a) Bandage contact lens b) Lubricants c) Epilation d) All of these options
VRICS
Image D
This patient was seen previously at the hospital for a branch retinal vein occlusion. He reports a one-week history of vision loss in the affected eye. 10 What does the OCT show? a) Macular oedema b) Choroidal neovascularisation c) Macular telangiectasia d) Vitelliform dystrophy 11 What would the most likely first-line treatment consideration be? a) Topical steroids b) Panretinal photocoagulation c) Intravitreal anti-vascular endothelial growth factor d) Fluocinolone acetonide 12 Which of the following is a risk factor for this condition? a) Hypertension b) Ocular hypertension c) Increased body mass index d) All of these options
About the author n Alan Hawrami qualified as an optometrist in 2012 and has extensive experience working within the hospital eye service, mainly in a casualty setting. He currently shares his time between hospital and working
as a locum for various community ophthalmology clinics. Alan is also undertaking a master’s degree in advanced clinical optometry and ophthalmology at University College London.
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VRICS 1
Pathology
VRICS VERSION
1
Ancillary tests in practice
CET
POINT
REPRO OP
Prashant Shah MCOptom, PGDipOphth, DipClinOptom and Yashita Shah MCOptom, PGDipOphth SUBS
This article assesses the use, features and practical applications of ancillary tests commonly used in practice.
ART
Image A
Image B
Baseline (R)
One-week aftercare (R)
L
R
PRODUCTION CLIENT
A 13-year-old patient attends for a contact lens fitting. Baseline refraction: R -2.00DS L -2.75DS. Unaided visions one week later: R 6/6+1 L 6/6+3. 01 Based on the history and images above, what treatment has been undertaken in the right eye? a) Corneal crosslinking treatment for keratoconus b) Pre and post corneal graft c) Pre and post laser refractive surgery d) Orthokeratology 02 In relation to treatment aims, which of the following is false? a) To slow down myopia progression b) To be free of spectacles c) To be free of contact lenses during waking hours d) To permanently correct myopia 03 Which of the following parameters is not usually measured with the equipment used to obtain the images shown? a) Pupil diameter b) Horizontal visible iris diameter c) Corneal endothelial cell count d) Corneal astigmatism
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August /September 2021
BLACK YELLOW MAGENTA CYAN
An 80-year-old female patient with a history of hypertension presents for a routine sight test. 04 What type of visual field defect is shown in the image? a) Left homonymous hemianopia b) Right homonymous inferior quadrantanopia c) Bitemporal inferior quadrantanopia d) Bilateral nasal step 05 Based on the patient history and images, which of the following is the most likely cause of the defect? a) Left parietal lobe lesion b) Right parietal lobe lesion c) Lesion at optic chiasm d) Glaucoma 06 Which of the following statements is false? a) The normal monocular visual field is approximately 60° superior and nasal, 70° inferior and 90° temporal b) Post-chiasmal lesions produce homonymous defects which respect the vertical midline c) The Esterman test is performed monocularly using the patient’s reading prescription d) Visual field testing is useful to assess defects arising from glaucoma, neurological pathology and retinal disease
Image C
VRICS
Image D
A 65-year-old patient presents with visual acuities of R 6/6 L 6/36. The patient had bilateral cataract surgery five years ago. Optical coherence tomography (OCT) is shown for the left eye.
A 40-year-old patient presents with intraocular pressures (IOP) of R 23mmHg L 23mmHg and central corneal thicknesses (CCT) of R 570μm L 580μm. 10 Which of the following statements about the instrument shown is false? a) The applanated area is 3.06mm in diameter b) It takes the ocular pulse into account, hence only one reading is required c) It follows the Imbert Fick law d) To get the correct reading, the outer edges of the mires must be aligned
07 What is the likely diagnosis? a) Full thickness macular hole b) Lamellar hole c) Geographic atrophy at macula d) Cystoid macular oedema 08 Which of the following statements is false? a) Differential diagnosis in this case includes a partial thickness hole b) OCT scans are useful to indicate the presence of vitreomacular traction and the extent of the lesion c) The majority of cases are due to ocular trauma d) The lesions are more common in females in their 50s and 60s
11 Which of the following instruments is not used to measure IOP? a) Tono-Pen b) Goldmann applanation tonometer c) iCare rebound tonometer d) Pachmate
09 Which of the following statements about OCT is false? a) OCT angiography is useful for assessing neovascular membranes in age-related macular degeneration b) OCT angiography requires an injection of contrast dye c) OCT can be used to assess the anterior chamber angle d) OCT is useful in glaucoma screening and monitoring
12 Which of the following factors would cause IOP to be overestimated? a) Reduced corneal rigidity b) Increased CCT c) Post laser refractive surgery d) Too little fluorescein during applanation tonometry
About the authors n Prashant Shah is an experienced optometrist and CET author with postgraduate diplomas in ophthalmology and in clinical optometry.
n Yashita Shah is an experienced optometrist working in independent practice. She holds a postgraduate diploma in ophthalmology.
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VRICS 2
Diagnostics
cet q&a
CET VERSION REPRO OP
“Always do the work that sounds most interesting” Dr Michael Crossland OPTOMETRIST
SUBS
Dr Michael Crossland is a senior optometrist at Moorfields Eye Hospital and an honorary senior research associate at University College London. He works in adult and paediatric low vision clinics at Moorfields and has published more than 40 peer-reviewed journal articles on low vision.
ART
If you could change one thing about the way we work, what would it be? Across all areas of the profession, I’d like to see less focus on the numbers of patients we see and more on the quality of care provided.
PRODUCTION
What are you most proud of? For me, it is successfully working part-time and maintaining a healthy work/life balance. What advice would you give your younger self? I’d say don’t be motivated by money. Always do the work that sounds most interesting.
CLIENT
What do you like most/least about your working day? What I most enjoy is learning from people with visual impairment what their life is like and the strategies they use. Working with hospital IT systems is what I like least. How do you manage a work/life balance? I find having clear boundaries between clinical work, research, writing and home times helps. And I try to have least one screen-free day per week. What do you do to unwind? I listen to Test Match Special in the bath. You have won the OT lottery. What are the first three things you would do with the £1m jackpot? I would put some aside for my daughter’s future; buy an original Eames armchair; and probably give the rest away.
MICHAEL’S 10-SECOND CHALLENGE Kindle or hardback? Hardback Cheese or chocolate? Cheese Apple or Android? Apple Takeaway or fine dining? Takeaway Trainers or heels/brogues? Trainers Beach bum or culture vulture? Culture vulture Strictly or X Factor? Strictly (as long as there’s nothing good on Radio 4).
90 www.optometry.co.uk
CETs IN OCTOBER/NOVEMBER n Communication essentials: cultural competence in practice Linda Moore n Heterophoria – which cases need treatment? Bruce Evans n Cushing’s syndrome Dipa Michalik n Prescribing prosthetic and therapeutic coloured contact lenses Melanie Frogozo n Casualty cases Alan Hawrami n Ocular complications of diabetes Prashant Shah
LIVE CET
OT has a range of CET videos and articles available online, including:
n Infection control and prevention – 2021 update n Macula, magnifiers and more n Can contact lenses still be an option for patients with dry eye disease? n Persistent epithelial defects: covering the gaps n The causes and impact of amblyopia n Anterior eye cases in practice
The CET articles are available at www.optometry.co.uk/cet
Dr Ian Beasley
is the clinical editor for OT and head of education for the AOP, with responsibility for delivering education in the journal and at face-to-face events. He began his career as an optical technician and later went on to train as a dispensing optician ahead of qualifying as an optometrist in 1997. In 2013, Dr Beasley became the first person in the UK to graduate with a doctorate in optometry from Aston University and received a research excellence award from the College of Optometrists in the same year for his published work on susceptibility to pattern glare following stroke. He maintains strong links with academia as a visiting lecturer at Aston, and recently completed a PhD which explored the effect of peripheral defocus on axial growth and modulation of refractive error in hyperopes.
Do you have an idea or request for a CET article? Email the clinical editor ianbeasley@optometry.co.uk
August /September 2021
BLACK YELLOW MAGENTA CYAN
91OPTAUG21166.pgs 27.07.2021 16:40
Jobs VERSION REPRO OP
Jobs
www.aop.org.uk/ot/jobs
SUBS
MY CAREER ADVICE
“DON’T BE SCARED OF DOMICILIARY”
PRODUCTION
What is the one piece of advice that you’d give to someone who wanted to work for the OutsideClinic?
CLIENT
Don’t be scared of domiciliary. The domiciliary world is quite misunderstood. It actually brings with it a fulfilling, soul-satisfying career that allows you to connect with your patients and do what you do best whilst giving you back your work-life balance. We don’t work weekends or Bank Holidays so that you can get a bit of normality back in your life.
If you care about people, like we do, and want to make a difference to people’s lives, then OutsideClinic would be perfect for you.
How important is the cover letter in applications that you receive? We don’t insist on a covering letter; however, I think there is value to adding one. It allows you to highlight areas you are passionate about and express your personality in ways that a CV cannot.
When you’re shortlisting candidates, what’s the very first thing that you look for?
What’s the biggest mistake that someone can make in an interview for OutsideClinic?
We don’t just look for candidates who have experience. We believe that many candidates out there would be the perfect fit for domiciliary, but they have never tried it in fear of the unknown. That is why we encourage those without that experience to apply as well. All optometrists have the skills, qualifications and ability to succeed in domiciliary optometry. We offer comprehensive bespoke training and support tailored to each individual so that you will have the confidence to provide exemplary optical care.
We are looking for candidates with a genuine interest in the role and in OutsideClinic, so being unprepared for the interview and not doing your research on the company will show. Make sure you know your CV and what strengths you can bring into the position – our hiring managers want to get to know you as well as your recent achievements. But don’t forget that the interview is the perfect opportunity to get to know us too – ask questions so that you know we are the right fit for you.
“We believe that many candidates out there would be the perfect fit for domiciliary, but they have never tried it in fear of the unknown. That is why we encourage those without that experience to apply as well”
WHAT STEPS DOES WORK FLEXIBILITY HAKIM GROUP TAKE TO How do you goTHE about ENSURE THAT HIRING ensuring PROCESSfairness IS FAIR?and equality in your hiring process? Do you have specific programmes in place to ensure that?
We have the same consistent process for all candidates monitored by our in-house recruitment team. We shortlist people based on their ability to do the role, but we understand that some candidates have other commitments. That’s why we have recently introduced new flexible contracts to support people with obligations outside of work, and we always provide additional staff support where required. As a company, we want to do everything we can for you to achieve a better work-life balance while still having a fulfilling and rewarding career.
A new employee is preparing for their first week at OutsideClinic. What tip would you give them to be successful? Remember that it’s all a learning curve. We tailor your induction to you, so whether you have had lots of experience in the domiciliary sector before or none at all, we will work with you to achieve the most from your career with OutsideClinic.
August /September 2021
BLACK YELLOW MAGENTA CYAN
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Shutterstock
ART
Recruitment manager at OutsideClinic, Jim Gilbert, shares insight into the company’s recruitment process and how to succeed in the UK’s biggest domiciliary eye care provider
ICLW VERSION REPRO OP
Marketplace Services and products for the practitioner
SUBS
MY BINOCULAR INDIRECT OPHTHALMOSCOPE
ART
Hospital optometrist, Amy Unwin, shares how a piece of equipment that she first encountered at uni has become her go-to for fundus examinations in the hospital setting The benefits
PRODUCTION CLIENT
There are many benefits of the bio headset in day-to-day testing. It provides a clear image and is quick to perform. Plus it is great for those patients who have ‘ants in their pants’ and don’t have steady fixation. It is suitable for all patients: children, D L U newborns, adults, O IC E IV L wheelchair users and NOT . .. T U those with learning WITHO difficulties. It is portable undus examinations have always and could also be great for been a key role for optometrists, domiciliary work. and I’m sure most will use either a It has a longer working distance direct ophthalmoscope or a Volk lens that allows the examiner to be at arm’s to carry out fundus examination. While length from the patient, which is more both are excellent pieces of equipment, appropriate for testing in the pandemic. they do depend upon your patients’ cooperation. As a hospital optometrist, I carry “My paediatric patients out a lot of fundus examinations on respond well to my ‘robot both children and those with learning hat,’ and I always have a difficulties, which is why I absolutely few illuminated toys or a could not live without my binocular flashing disco ball to help indirect ophthalmoscope. distract them while carrying I remember picking up the bio headset at university for the first time out the exam” and thinking: ‘Good job I’ll never It has a wide field of view. Using a need this in practice.’ I thought it was 20D lens, for example, you can achieve mainly used by ophthalmologists and a view equivalent to around eight disc I was certainly not in a rush to pick diameters. This is great for screening it up when I started in the hospital as you can see gross abnormalities in clinic. However, like anything, with a glance as you can see the optic nerve practice and patience, I have become a and macular in the same view. big advocate of the bio headset. I also Furthermore, it allows the optometrist feel it has been a very reliable piece of to prioritise the magnification or equipment while working throughout field of view (FoV). For example, the the COVID-19 pandemic as it gives a practitioner can control what they are good fundus view from arm’s reach.
F
prioritising by changing the power of the condensing lens. Lenses range from 15–40D. While a 20D lens is a standard lens for general examination, allowing x3 magnification and a FoV of approximately 45 degrees, a 30D lens offers x2 magnification, but a larger FoV of approximately 65 degrees. It is important to note that the higherpowered lenses offer less magnification, but a greater FoV, and are advantageous for those with smaller pupils.
Disadvantages
With every piece of equipment there are disadvantages to consider. Firstly, it provides low levels of magnification, and high levels of illumination. Secondly, optometrists should be aware of dilation. Especially when learning the technique, examination is much easier on a dilated pupil.
Don’t judge its appearance
The binocular indirect ophthalmoscope isn’t the most fashionable piece of equipment in our armoury. Therefore, I find it best to make a joke of this. My paediatric patients respond well to my ‘robot hat,’ and I always have a few illuminated toys or a flashing disco ball to help distract them while carrying out the exam. The real game changer for me is when I manage to achieve a glimpse of the fundus that I might not have otherwise achieved, as this can really make the difference between a timely diagnosis and a more accurate referral to the ophthalmologist. I’m not surprised that the binocular indirect ophthalmoscope isn’t a popular tool as it is unfamiliar for so many of us. However, if you do have a bio headset available, I would encourage you to give it a go. Just be mindful that it does take practice.
August /September 2021
BLACK YELLOW MAGENTA CYAN
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91OPTAUG21137.pgs 27.07.2021 15:40
last word
LAST WORD
REPRO OP SUBS ART PRODUCTION CLIENT
Optometrist and head of contact lenses at Specsavers, Russell Peake, on delivering telegrams by bike in Warwick and Leamington
“People have sent some really significant messages – it has been a privilege to deliver those” 98 www.optometry.co.uk
M
y brother in law’s neighbour collects typewriters. He has over 100 in his house. I rang him up and he said that he would find me one. Telegrams have been something I have thought about doing for quite a long time, but it was only once I got a classic 1960s Olivetti typewriter earlier this year that I started. My parents had telegrams around their house – some from my grandparents’ wedding, and one my dad sent my mum in the 70s saying ‘I can’t wait to see you tomorrow.’ I always thought telegrams were nice keepsakes. It is different from the normal way that you receive messages these days. It is mainly done through the website spatelegram.com or Instagram (@spatelegram). Someone sends me a message, I type it up and then deliver it on my bike. A couple of times the weather has been a bit cold and miserable but I don’t mind – I just get my waterproof layers out. We feed the birds here and I’m a big fan of the longtailed tit so that’s what I chose to draw for the logo. When
My secret life
Do you have a personal passion to share with readers? Get in touch with selinapowell@ optometry.co.uk
delivering a telegram, you are flying from one place to another, so it made sense. There have been a mix of messages and people of all ages have been sending them. I have delivered a few to elderly relatives who are shielding saying how they can’t wait to see them again. I’ve done a number of telegrams for new arrivals, including one congratulating a family on the birth of their twins. People have sent some really significant messages – it has been a privilege to deliver those. I got an email back from a grandmother saying that the telegram had made her day and brought back memories. It has been lovely where it has given that sense of nostalgia for the older generation. I am not currently charging for the telegrams. I am asking for people to donate if they want to Guide Dogs UK. Myself and my wife are both optometrists and we board guide dogs at our house. It is a very relevant charity for us – knowing the impact that the dogs can have. Being someone who sits on a laptop most of the day, it is so different to use the typewriter – to see it physically printing out the letters. On your phone, errors are autocorrected, and on your laptop, mistakes are highlighted. The typewriter does none of that. I will tell people there might be errors, but it is part of the charm.
Betsy Peake
VERSION
MY T SECRE ... S LI F E A
August /September 2021
BLACK YELLOW MAGENTA CYAN
91OPTAUG21136.pgs 26.07.2021 11:15
INNER COVERS SPREAD
VERSION
Bausch + Lomb ULTRA®
Change the trajectory of childhood myopia
The latest innovation in reusable contact lenses across a complete family* 53,55,56,57
Get your young myopic patients started with myopia management today! REPRO OP
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22
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SUBS
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ART
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PRODUCTION
NEW
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CLIENT
Introducing the Brilliant Futures™ Myopia Management Programme Brilliant FuturesTM is a comprehensive programme from CooperVision, which incorporates the proven MiSight® 1 day daily disposable contact lenses with ActivControl® Technology with tools, support and education for you and your patient.
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Getting started guide including patient charter
In store materials Communication resources Social media toolkit Early access to new education and marketing materials from Brilliant Futures™
1. Chamberlain P, et al. A 3-year Randomized clinical trial of MiSight® lenses for myopia control. Optom Vis Sci. 2019;96:556–567. 2. Chamberlain P, et al. Further comparisons of myopia progression in new and established myopia control treatment (MiSight® 1 day) groups. BCLA paper presentation 2019. *To access ongoing support materials a minimum of 18 pack must be purchased over a three-month period. †Compared with a standard singlevision one-day lens over a three-year period. ‡Children new to contact lens wear aged 8-12, n= 130 @ 1 month after dispense. §No clinically meaningful change in refractive error -0.25D or less from baseline after 3 years compared to 4% in the control group. II>95% of children were successfully fit with MiSight® 1 day or Proclear® 1 day.
©2021 CooperVision. CooperVision®, ActivControl®, MiSight® and Proclear® are registered trademarks of The Cooper Companies, Inc. and its subsidiaries
SPHERICAL
FOR ASTIGMATISM
MATERIAL:
MoistureSeal® Technology
and see every detail
WATER CONTENT:
46%
MODULUS: OXYGEN TRANSMISSION: LENS DESIGN TECHNOLOGY:
70 163 Dk/t @ centre for -3.00D
114 Dk/t @ centre for -3.00D
Aspheric optics to reduce inherent and OpticAlign™ Design with spherical induced spherical aberration aberration control
163 Dk/t @ centre for -3.00D
104 Dk/t @-3.00D
3-Zone Progressive Design™ with centre-near aspheric optics
3-Zone Progressive Design™ OpticAlign™ Design
BASE CURVE:
8.5 mm
8.6 mm
8.5 mm
8.6 mm
DIAMETER:
14.2 mm
14.5 mm
14.2 mm
14.5 mm
CENTRE THICKNESS:
0.07 mm @ -3.00D
0.10 mm @ -3.00D
0.07 mm @ -3.00D
0.11 mm @ -3.00D
SPHERICAL POWERS:
+6.00D to -12.00D (in 0.50D steps above -6.00D)
+6.00D to -9.00D (in 0.50D steps above -6.00D) Available in -2.75D Cylinder
+6.00D to -10.00D (in 0.25D steps including plano)
+3.00D to +1.00D -1.00D to -5.00D in 0.25D steps
Low: up to +1.50D spectacle Add High: from +1.75D spectacle Add
Low: up to +1.50D spectacle Add High: from +1.75D spectacle Add
ADD POWERS:
8,9,18
FOR PRESBYOPIC ASTIGMATS
samfilcon A
LENS MATERIAL TECHNOLOGY:
GO BEYOND VISION
FOR PRESBYOPIA
CYLINDERS: AXES: ORIENTATION MARK / AXIS INDICATOR: VISIBILITY TINT: WEAR SCHEDULE: REPLACEMENT SCHEDULE:
-0.75, -1.25, -1.75, -2.25, -2.75
-0.75, -1.25
10° to 180° (in 10° steps)
10°, 90°, 170°, 180°
Orientation mark at 6 o’clock Axis indicator varies with axis
Orientation mark at 6 o’clock Axis indicator varies with axis
Light Blue Daily wear, up to 7 days extended wear Monthly
* Latest technology in soft reusable lenses across a complete contact lens family. † Vs Acuvue® Oasys®, Biofinity® and Air Optix® Aqua.
BLACK YELLOW MAGENTA CYAN
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OUTER COVERS SPREAD
Journal of the Association of Optometrists
NEW Bausch + Lomb ULTRA® Multifocal for Astigmatism VERSION
AVAILABLE
IN STOCK
£9.95
REPRO OP
AND READY TO SHIP
1,2,3,4
OPTICALIGN™ DESIGN
SEAMLESS vision
STABLE
ART
3-ZONE PROGRESSIVE DESIGN™
Axis indicator designates axis of cylinder power7 (30˚ example shown)
DISTANCE INTERMEDIATE
PRODUCTION
NEAR
CLIENT
Bausch + Lomb ULTRA® for Presbyopia5 -3.00D High Add
0.0
Near
Distance
-1.5 -2.5 -3.0 -3.5 -4.0 0.0
0.5
1.0
1.5
2.0
2.5
3.0
“ PAT I E N T S R E A L LY VA L U E D B E I N G SEEN IN THE LOCAL COMMUNITY IN A QUIETER, SAFER ENVIRONMENT”
On-eye clinical results2
ROTATION
CENTRATION
MOVEMENT
0 to 5 Degrees
95%
Excellent
86%
Adequate
100%
6 to 10 Degrees
5%
Good
14%
Excessive
0
11 to 15 Degrees
0
Fai r
0
Insufficient
0
> 16 Degrees
0
Poor
0
Adherence
0
Radial Displacement (mm)
3 distinct zones with consistent power in each zone Nimo power profile
Bausch + Lomb ULTRA® and Biotrue® multipurpose solution
THE DUAL COMFORT COMBINATION
SAVE THE DATE
11,22
“ON REFLECTION, I T WAS T H E B E S T WAY TO L E A R N AS W E W E R E T H R OW N I N AT T H E DEEP END”
22-24 JANUARY 2022
Call now for your Fitting Guide and to order Trial Lenses
EXCEL LONDON
N 0845 602 2350 E cs.vc.uk@bausch.com D www.bausch.co.uk/ultra-mfa
g Why optometrists are embracin independent prescribing
Please read the Instructions for Use (IFU) for important product use and safety information associated with Bausch + Lomb ULTRA® contact lenses.
ULTRA, MoistureSeal, Biotrue and 3-Zone Progressive Design are trademarks of Bausch & Lomb Incorporated or its affiliates. All other product/brand names and/or logos are trademarks of their respective owners. ©2021 Bausch & Lomb Incorporated or its affiliates.
UMT.0016.IE.21
Product Launches | CPD Points | Fashion Catwalks
www.100percentoptical.com OFFICIAL UK PARTNER
MEDIA PARTNER
#100optical @100optical
/ www.optometry.co.uk
* When the ECP followed the fitting guide 1. ULTRA® Comfort Experience™ for Presbyopia Data Analysis Phase 1 + 2. 2017. 2. Bausch + Lomb ULTRA® Multifocal for Astigmatism stabilisation study. 3. Bausch + Lomb, 2013. Perceptions of Bausch + Lomb PureVision® 2 for Presbyopia (#815). Rochester. 4. Bausch + Lomb., 2016. A study to evaluate the product performance of two designs of soft toric lenses (#ROC2-16-016). Rochester. 5. Reindel, W., et al., 2015.Ergonomic Utility of Progressive Multifocal Contact Lenses: A Comparison of Power Profiles Across Near, Intermediate and Distance Zones. AAO Poster Presentation. 6. The 2020 Study of US. Multifocal contact lens market. 7. Hovinga,K.R., 2016. Summary of ULTRA® for Astigmatism Orientation and Axis Markings (#LDR168019). 8. Reindel et al. Use of digital devices and reports of dry eyes: Performance of a novel silicone hydrogel lens among contact lens wearers. Poster presented at the American Optometric Association Annual Meeting, Boston, MA, June 2016. 9. Steffen et al. New technology yields dehydration resistance. Poster presented at the American Academy of Optometry Annual Meeting, Denver, Colorado, November, 2014 11. Millward Brown., 2010. Biotrue® Product Test (#640). 16. Bausch + Lomb, 2013. A study to evaluate the product performance of a new silicone hydrogel contact lens (#817). Rochester. 17. Merchea, M., Wygladacz, K.A., et al., 2014. Comparative Surface Smoothness Durability of a Novel Silicone Hydrogel Material. Association for Research in Vision and Ophthalmology 2014 annual meeting. 18. Hoteling, A., Nichols, W., et al., 2014. PVP content of a silicone hydrogel material with dual phase polymerisation processing. American Optometric Association Annual Meeting; 2014, Philadelphia, PA. 19. Bausch + Lomb, 2013. 16 Hour bilateral dispensing evaluation of methacrylamide lenses as compared to Air Optix® Aqua, Acuvue® Oasys® and Biofinity® lenses (#ROC2-13-002). 20. Schafer, J., Reindel, W., et al. Use of a novel extended blink test to evaluate polyvinylpyrrolidone(PVP) contact lens containing polymer performance. 22. Reindel, W., Mosehauer, G., et al., 2018. Patient comfort, vision and cleanliness over 12-months of Samfilcon A Lens Wear. Poster presented at AAO. 23. Micromass Communications Inc., 2017. Statistical Analysis of Bausch + Lomb ULTRA® for Astigmatism Lenses Challenge Patient Survey. (n=426). 53. Pence, N.,2014. Contact Lens Design and Materials. Contact Lens Spectrum [e-journal]. https://www.clspectrum.com/supplements/2014/october-2014/breaking-the-cycle-of-discomfort/contact-lens-design-amp-materials [Accessed 8/12/2020]. 55. Sulley, A., 2005. Practitioner and patient acceptance of a new silicone hydrogel contact lens. Optician 6017 (230), pp 15-17. 56. Barr, J., 2004. An avalanche of products, compliance and the FCLCA. Contact Lens Spectrum [e-journal]. https://www.clspectrum.com/issues/2010/december-2010/ product-spectrum [Accessed 15/12/20]. 57. Mack, C., 2008. Contact Lenses 2007. Contact Lens Spectrum [e-journal]. https://www.clspectrum.com/issues/2008/january-2008/contact-lenses-2007 [Accessed 8/12/20]
BLACK YELLOW MAGENTA CYAN
“One day I’ll be a vlogger” Slow their myopia not their ambition
SLOWS PROGRESSION BY
59%
1
Rotation, centration and movement at dispensing
-1.0 -2.0
Page 41
THE INDEPENDENT PRESCRIBING EDITION
Power (D)
Intermediate
In practice The IP class of 2009
“ H AV I N G A L O C A L I P O P TO M E T R I S T I M P R OV E S T H E AC C E S S I B I L I T Y A N D Q UA L I T Y O F C A R E ”
Orientation mark helps measure rotational stability and assists patients during insertion7
For illustrative purposes only.
-0.5
2
≤5°on 95% of patients
near, far and in-between1
0.5
www.optometry.co.uk
Available in stock and ready to ship so you can reduce your patients’ waiting time and fulfil their vision needs sooner. August/September 2021 / Volume 61:04
SUBS
Combines the seamless vision1 presbyopic patients want with the lens stability for their astigmatic needs.2,6
August/September 2021 Volume 61:04
CET Omega-3 and ocular health: what's the deal?
Perspectives Professional boundaries have become less relevent
In practice Reducing the burden on the eye hospital service
Page 79
Page 36
Page 51
Introducing the Brilliant Futures™ Myopia Management Programme with MiSight® 1 day contact lenses, clinically proven to reduce the rate of myopia progression by 59% and axial length by 52% in children.1 Make a difference to your young myopes’ lives now and you can help protect their vision of the future.2 To find out more and begin your myopia management journey visit coopervision.co.uk/practitioner 1. Chamberlain P et al A 3-year Randomized Clinical Trial of MiSight® Lenses for Myopia Control. Optom Vis Sci 2019;96:556–567. Over a 3 year period, MiSight® 1 day reduced myopia progression on average by 59% compared to a single vision contact lens. 2. Tideman JW, Snabel MC, Tedja MS, et al. Association of axial length with risk of uncorrectable visual impairment for Europeans with myopia. JAMA Ophthalmol. 2016;134:1355-1363.
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