OT August/September 2022

cover VERSION

Journal of the Association of Optometrists

Perspectives Actioning sustainability changes in your practice Page 34

£9.95 REPRO OP

August/September 2022 Volume 62:04

www.optometry.co.uk

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August/September 2022 / Volume 62:04

SUBS CLIENT

THE SUSTAINABILITY AND OPTICS EDITION

Keeping afloat The role of optometry in creating a more sustainable future / www.optometry.co.uk

CPD Tips for identifying dry eye

Spotlight 100% Optical’s new look for 2023

In practice Recognising and managing imposter syndrome

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Welcome

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y dad, when he worked, was a journalist.

Well, that is perhaps overegging it a bit: what he actually did was to write the storylines and dialogue for the comic strips in teenage girls’ magazines. The editors would give him deadlines months in advance, but the day before he was due to drop the scripts off in London, he would pull an all-nighter; one of my most vivid memories of him is coming down in the morning to see him slumped over his typewriter, covered in cigarette ash and surrounded by a sea of discarded pages.

Today, I find myself up against my own deadline, writing this Welcome note on one of the days where it is predicted that the UK will break the all-time temperature record. The feeling on the internet is clear: this may be the summer when climate change moves from a theory to a reality in the popular imagination and the usual climate denial tweets will forever now be met with incredulity and scorn. By the time you read this, the climate debate may have taken a sudden upward shift in political priority.

Equally, while that shift seems inevitable right now, today’s experience may just be filed alongside the summer of 1976 as a curious episode in history. In this context, the subject matter of this edition – the need for our profession to look seriously at the environmental impact of its work – is perfectly timed.

What is the environmental impact of the frames and lens manufacturing process? How can we make disposable contact lenses more sustainable? How do we take advantage of new technology and offer remote, yet safe, consultation?

This is a challenge for organisations like the AOP too. In the past year, we have been prioritising sustainability by moving to become an entirely paperless organisation, increasing our online training and staffing offers to reduce travel, and ensuring that the updating of our office is maximising the use of recycled materials. But like everyone else, we know there is more we could do, and we will be working hard to reduce our carbon footprint further.

I remember that even in the fabled summer of 1976, our science teachers were telling us that this was not normal and was evidence of the impact of the past few hundred years of human activity on the climate of the world. We have been procrastinating for over 40 years. It is time we actually got down to action.

“We have been procrastinating for over 40 years. It is time we actually got down to action”

Adam Sampson, AOP chief executive

August /September 2022

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Welcome

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Contents

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Spotlight

The AOP’s event programme

The news in digest Picture this Behind the scenes on OT’s front cover photoshoot OT reports New AOP Councillors share their thoughts on the profession’s big issues The edit Optics in 16 stories Clinical round-up A review of the latest clinical news and research papers 100% Optical OT reports on the show’s new look and sustainability goals Industry profile Eyespace on its drive to use sustainable materials, with Emily Andrews Supplier insight Tailored lenses for driving AOP roundup The AOP’s five-year strategy, and the release of its new events programme

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“Under the new scheme, registrants are now responsible for uploading evidence of CPD completion rather than the provider” Dr Ian Beasley, head of education PAGE 21

23-31 HIT LIST

The trends, launches and looks OT focuses on...

Sustainability in contact lenses Me and my glasses Photographer and writer, Amelia Le Brun Get the look // Anatomy of a frame With Lizzy Yeowart The shortlist The August/September selection Behind the brand Waterhaul

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33-37 PERSPECTIVES

Voices from optics and beyond Perspectives Dr Julie-Anne Little, Simon Berry, James Conway, Saqib Ahmad My vision Golfer, George Woolgar

“It doesn’t cost anything to start asking questions” Optometrist, Simon Berry PAGE 34

Neubau; Getty; Amelia Le Brun; Jason Thomas

07-21 SPOTLIGHT

OT and its wrapper are produced on paper from European mills meeting the highest quality and environmental standards. The journal and paper wrapper are fully recyclable.

51 CPD 67-90 Professional development for the eye care practitioner

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67 CPD welcome 68 Microtropia: a practitioner-friendly guide 72 Retinal detachment: achieving the best possible outcome 76 Practical tips for the identification of dry eye 80 Bifocal lenses: are your standards up to standard?

86 Retinal cases in secondary care 88 All about the eyelids 90 CPD author Q+A: Megan Zabell

ONLINE

41-55 IN PRACTICE

Neubau; Getty; Amelia Le Brun; Jason Thomas

Business insight and career development The discussion A trio of business owners dicuss bringing sustainability into practice How I got here Optometrist, Bobby Sarvat Fida The workshop Socially responsible investing advice from Lloyd & Whyte Life as a locum Pete Sharma Eyes on wellbeing Susie Edwards on recognising and managing imposter syndrome Pre-reg focus Holly Leitch and Caroline Mansfield Key milestones An ECOO survey on members’ experiences during COVID-19 IP and me Kevin Wallace

Cover story

Sink or swim OT talks to optometrists Ceri Probert,

Tim Morgan and Bethan Roderick about how the profession can work together to create a sustainable future. Plus, ophthalmologist, Dr John Buchan, discusses the sustainability of eye care in secondary care

OT video highlights

OT’s latest interactive CPD Video explores myopia

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Watch the video on

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Contact the OT team with your experiences, observations and lessons from practice today: newsdesk@optometry.co.uk

www.optometry.co.uk/CPD

Jobs Haine & Smith’s managing partner, Angela Davey, on why attitude is everything I could not live without... ”JJV’s contact lens recycling scheme,” says optometrist, Bhavin Shah Last word Anthony Josephson’s secret life

Follow us on Twitter @OptometryToday Like us on Facebook OptometryTodayJournal Follow us on Instagram @optometry_today

August /September 2022

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Contents

CONTENTS

Picture This VERSION

Spotlight

REPRO OP

08 REPRESENTING THE PROFESSION OT speaks with the AOPʼs new Councillors about key issues within optics

15 INDUSTRY PROFILE

Eyespaceʼs Emily Andrews on using sustainable materials

16 SUPPLIER INSIGHT

OT explores how tailored lenses for driving are adapting to modern road conditions

SUBS ART PRODUCTION CLIENT Grant Pearce

Into the deep Optometrists (from left, above) Ceri Probert, Bethan Roderick and Tim Morgan braved the water in order to highlight the importance of sustainability for OT's August/ September cover shoot.

The trio were photographed at Llyn Brianne – a reservoir in the headwaters of the River Tywi in Wales. Probert, Roderick and Morgan have signed up to a framework and award scheme that

encourages primary care providers to take steps to reduce their environmental impact. Morgan encouraged fellow optometrists to consider what steps they can take to create a world they want to live in.

“I acknowledge that we are not perfect, but what I hope is that today is the worst that we ever are and tomorrow is a bit better,” he said. Read more about their efforts in Sink or swim? on P57-64.

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OPTICS IN 2022:

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THE CHALLENGES, CHANGES, SUCCESSES AND THE FUTURE

August/September 2022 Volume 62:04 Issn 0268-5485 ABC certificate of circulation 1 January 2021–31 December 2021

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Editor: Emily McCormick emilymccormick@optometry.co.uk Deputy editor: Lucy Miller lucymiller@optometry.co.uk Features editor: Selina Powell selinapowell@optometry.co.uk

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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 CPD enquiries: 020 7549 2076 CPDhelp@optometry.co.uk AOP membership and OT subscription team: subscriptions@aop.org.uk

Advertising: Matt Hall 020 3771 7257 matt.hall@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.

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New AOP Councillors share their thoughts on the profession OT spoke to the AOP’s new Councillors – Adnaan Ahmad (franchisee/joint venture partner optometrist), Summaya Ali (newly-qualified and early career optometrist), Laura Josephs (undergraduate student optometrist) and Karen Gennard (south west

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WHAT ISSUE IN OPTOMETRY IS THE MOST IMPORTANT TO YOU?

“One of the main issues in optometry right now is around recognition – the recognition of the profession as a healthcare provider,” University of Manchester optometry Master’s student Josephs told OT. “I think it is really frustrating that optometry is not recognised as a healthcare role – when you go onto the NHS website, it’s not listed as an allied health profession, and there is no support for students in terms of NHS funding either,” Josephs highlighted, adding: “Yet optometrists are taking on more roles within the healthcare arena.”

This is the direction that Josephs wishes the profession takes moving forward.

August /September 2022

England) – about the big issues facing optics, the challenges and successes experienced during the pandemic, and the future direction of the profession.

“I am all for these developments, but that is why I think optometry should be recognised fairly,” she said.

“It is really frustrating that optometry is not recognised as a healthcare role – when you go onto the NHS website, it’s not listed as an allied health profession” Laura Josephs (undergraduate student optometrist)

Ahmad feels that optometry is going through a “massive” transition period and there are many issues that need to be discussed that affect the role of the optometrist. “[As a profession] we have the ability to help ease the pressure on the hospital eye care service and GPs, and although there are some schemes in place, I believe we can do a lot more,” he shared, adding: “We adapted during COVID-19 and I believe the learnings can transcend optometry into a better way of working in the future.”

Linked to the role that optometrists could play in the future, Ali feels that the biggest issue right now is “how long a patient has to wait once referred to have their initial appointment

“Everyone played an important role in ensuring a good level of service was provided. Lots of staff went above and beyond and this in turn creates a strong workforce” Summaya Ali (newly-qualified and early career optometrist)

at the hospital eye unit.”

She highlights the time between the stated follow up appointment and when the patient is actually seen and the impact on the patient’s ocular prognosis.

For new south west England representative Gennard, it is the recently closed General Optical Council’s call for evidence on the Opticians Act that could lead to some of the biggest challenges over the coming years.

“There is huge potential for the way we work to change. It is important that all areas of the profession are consulted and represented on these matters, and that we work together to build a model of optometry that is fit for purpose in the coming years.”

WHAT DO YOU FEEL THE PROFESSION’S BIGGEST CHALLENGE WAS DURING THE PANDEMIC AND WHY?

For Ali it was: “Knowing which patients to prioritise based on their clinical needs and the urgency of the ocular condition they present with, and knowing which appointments can be deferred.”

Ahmad also highlighted the need to “safely administer eye care to those most in need, whilst deciding who to see and who not to see during the very early phases of the pandemic.”

He explained that the “domino effect” of the pandemic on cataract progression for patients referred 18 months ago who are now having to wait “an extra year” for surgery can already be seen. The delay has “left them massively with worsening eyesight,” he said.

For Gennard, the biggest challenge was about “keeping ourselves, our staff and our patients safe, particularly in the early days of the pandemic.”

Josephs shared insight into her education experiences and the

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“There is huge potential for the way we work to change” Karen Gennard (south west England regional representative)

challenges she faced during the pandemic. “Going into university not even once a week for just an hour for some practicals made it really difficult going into my third year when it came to seeing patients – like many of my peers, I had never done a full sight test on a patient,” she said.

WHAT DO YOU FEEL THE PROFESSION’S GREATEST SUCCESS WAS DURING THE PANDEMIC AND WHY?

“The development of COVID-19 Urgent Eyecare Services (CUES),” said Josephs, without hesitation. “People came together to establish a service that ensured patients and their eye care was protected.”

“Its development highlighted the role that optometrists can play in the delivery of emergency eye care and that we are vital healthcare providers,” she added.

Similarly for Ahmad a “huge success” came from the collaboration between different healthcare practitioners as well as different companies. “Working together and helping each other was an amazing achievement,” he emphasised.

Collaboration and teamwork is also top of Ali’s list. The pandemic saw “all staff

working collectively as a team,” she told OT. “Everyone played a role in ensuring a good level of service was provided. Lots of staff went above and beyond and this in turn creates a strong workforce,” she said.

Gennard was impressed by how the profession found new ways of working. “The way we implemented new systems and ways of working is a credit to the profession. It gives us a platform to build on in coming years,” she said.

“Working together and helping each other was an amazing achievement” Adnaan Ahmad (franchisee/joint venture partner optometrist)

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OT Reports

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SPOTLIGHT

REPRO OP

Commonwealth leaders made a long-term commitment to childhood eye health during a meeting in Kigali, Rwanda, on 20–25 June. The 54 leaders at the Commonwealth Head of Government Meeting agreed a “multi-pronged approach for access to screenings and affordable vision treatments, especially for children.” In a statement, the leaders also highlighted the progress made in increasing access to quality eye care, including eliminating blinding trachoma and early detection of glaucoma.

SUBS

Full Catalogue & Prices Available Online

“It’s been in my head for 15 years”

ART

bibonline.co.uk

Lisa Laurent, founder of Good Karma, a frame supplier with a social mission, spoke to OT about the journey of the brand, which launched this year. Read more online: bit.ly/3cl9N2F

PRODUCTION CLIENT

The Body Doctor, behind The Eye Doctor range, received its second Queen’s Award for Enterprise in the Innovation category from the Lord-Lieutenant of West Yorkshire. The company received the award for its Sterileyes patented antibacterial compresses.

New start Refits Package deals For more information, please contact us on: 01438 740823 sales@bibonline.co.uk bibonline.co.uk

“Our latest analysis suggests that spectacles enabled with SightGlass Vision Diffusion Optics Technology offer a promising new approach to myopia control for six and seven-year-olds” Andrew Sedgwick, CEO of SightGlass Vision, spoke on the release of clinical trial results which analysed 24-month data from the Cypress trial. Held across 14 sites in the US and Canada, researchers randomised and dispensed lenses to 256 eligible children between six and 10 years old with myopia between -0.75D and -4.50D.

Glaucoma UK has highlighted that the number of people living with glaucoma in the UK is expected to increase by almost a third between 2020 and 2035.

During Glaucoma Awareness Week (27 June to 3 July), the charity emphasised the importance of regular sight tests for detecting the signs of glaucoma early and reducing the chance of further sight loss.

420%

Inspecs Group reported a significant growth in revenue in 2021. The group reported revenue of $246.5 million (approximately £205.8 million), an increase of 420% on 2020, in its financial results for the year up to 31 December 2021.

Johnson & Johnson Vision completed CE Mark activities for the Acuvue Oasys MAX 1-Day and Acuvue Oasys MAX 1-Day Multifocal contact lenses. The launch follows research that found 71% of eye care professionals see patients who are experiencing eye discomfort related to screen time. The lenses are expected to be available in the UK in autumn 2022.

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The Commonwealth Secretariate

VERSION

INDUSTRY

the audit

SPOTLIGHT

THE EDIT

SCIENCE & VISION

Research published in Journal of Clinical Investigation Insight found that higher levels of the protein, angiopoietin-like 4, accurately predicted

clinical outcomes within a group of patients with age-related macular degeneration (AMD).

By measuring VEGF and angiopoietinlike 4 levels, researchers identified with 85% specificity those likely to need monthly eye injections.

“This is a tool that can give people an invisible assistant throughout their day to stay focused without losing access to the information they need to feel confident in any situation” Drew Perkins, chief executive of Mojo Vision, shared his hopes for the smart contact lens, Mojo Lens, following a trial in June. Perkins described this as the first on-eye demonstration of an augmented reality smart contact lens with completed features.

Burnley General Hospital hosted a corneal foreign body removal workshop for 23 optometrists and two contact lens opticians. Sponsored by Scope Ophthalmics, organisers said they hoped local publicity of the event would lead to greater public awareness that they can visit their optometrist in the case of a corneal foreign body.

PROFESSIONAL SUPPORT

WCSM/Mark Witter Photography

The Lord Mayor, Alderman Vincent Keaveny, called for workplaces to consider how they can be accessible to people with sight loss at an event by the Worshipful Company of Spectacle Makers. Speaking at the Where are the eyes in inclusion? reception, Keaveny shared that only one in four people with sight loss in the UK are in employment, meaning there are 40,000 blind and partially sighted unemployed people in London alone. Read more insight from the event online: bit.ly/3RGEgIz

87%

An AOP survey around the General Optical Council’s call for evidence on the Opticians Act received responses from 2445 members.

Of the respondents, 87% believed it is not possible to safely separate the refractive and eye health elements of the sight test. The research informed the AOP’s response to the call for evidence, which can be read online: www.aop.org.uk/opticiansactresponse

“It is notable that just as many people with an emergency eye problem would now seek initial care from an optician as a GP” Director of regulatory strategy at the General Optical Council, Steve Brooker, reflected on the findings of regulator’s 2022 public perceptions research.

Brooker noted that the picture differs across the UK, with the proportion of people likely to visit an optometrist first if they woke up with an eye problem highest in Scotland.

IN PRACTICE Specsavers has launched a new hybrid programme for pre-registration optometrists that will provide an insight into domiciliary optometry, as well as practice placements. Through the domiciliary summer placements, students will shadow one of Specsavers’ domiciliary partners visiting patients in private homes and care facilities, and cover the full patient journey. The launch of the new programme follows the introduction of domiciliary summer placements last year, and marks a first for Specsavers.

“Despite all the challenges posed by the pandemic, my drive hasn’t wavered”

Newly-qualified optometrist, Balpreet Dhillon, told OT about her ambition of owning a practice, and what Johnson & Johnson Vision’s Success Through Education Programme has meant to her.

Read the full interview online: bit.ly/3IIrtkT

Optometrist and independent practice owner, Stephanie Lipsey-Liu, has released a children’s book that aims to educate young patients about why they might need glasses in an accessible format. The book, We love our glasses, explains sight conditions including myopia, hypertropia, astigmatism and anisometropia, as well as the benefits of different types of glasses.

August /September 2022

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Burnley General Hospital

85% SPECIFICITY

60 DAYS IN 16 STORIES

VERSION

CORONAVIRUS

COVID-19 and dry eye

Clinical round-up

REPRO OP

OT’s Selina Powell reviews the latest clinical news and research papers NHS INTRODUCES NEW RETINOBLASTOMA TEST

SUBS ART PRODUCTION Getty/Vicki Smith

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NHS England has rolled out a new test that is capable of identifying babies at risk of developing retinoblastoma while they are still in the womb.

The Non-Invasive Prenatal Diagnosis procedure was developed at Birmingham Women’s and Children’s NHS Foundation Trust.

A blood sample is taken from the mother before birth, with genetic analysis determining whether the baby is at risk of retinoblastoma. The test can also predict whether the disease is likely to develop in the baby’s siblings.

Treatment can start on the affected eye as soon as the baby is born. It is estimated that the new test could identify 50 infants with childhood eye cancer each year.

The Birmingham Women’s and Children’s NHS Foundation Trust is also developing a post-natal test for retinoblastoma patients using eye fluid that could identify whether the baby is at risk from other cancers later in life.

County Durham resident, Siani Bainbridge, 22, had retinoblastoma as a child and took part in the testing programme before the birth of her son,

“The introduction of this pioneering new test is fantastic news”

NUTRITION

Small study finds eating goji berries may prevent AMD

Oscar. After Oscar was diagnosed with eye cancer, he received treatment just a week after he was born.

“Given that the tumours were quite severe when he was born, the fact he could be treated straight away definitely affected his outcome,” Bainbridge said.

In response to the development, NHS chief executive, Amanda Pritchard, highlighted: “The introduction of this pioneering new test is fantastic news for babies and their parents.”

VISUAL TESTS IN OLDER ADULTS LINKED TO MISDIAGNOSIS Australian researchers have highlighted that using visual tests to screen for cognitive impairment could result in the misdiagnosis of those with latent vision problems.

Describing their findings in Scientific Reports, the University of South Australia scientists emphasised the importance of considering vision when assessing cognitive function.

“When vision is not accounted for, low test scores may inaccurately indicate poor cognition,” they stated.

The researchers recruited 24 study participants with normal vision who completed two tests of cognition – one involving vision-dependent reaction tasks and the other based on verbal fluency.

When the participants wore goggles that simulate the vision of someone

with age-related macular degeneration (AMD), they scored lower on the tasks involving reaction time while there was no statistical difference on the tests based on verbal fluency.

Study lead, Anne Macnamara, highlighted that a mistaken cognition score as a result of poor vision could trigger psychological problems such as anxiety and depression.

“People with AMD are already experiencing multiple issues due to vision loss and an inaccurate cognitive assessment is an additional burden they don’t need,” she said.

She emphasised that those conducting tests can perform quick and simple vision screening tests before assessing cognition, and should always include verbal tasks as part of the assessment.

Researchers from California in the US have highlighted the potential health benefits of goji berries within a new study published in Nutrients.

The scientists highlighted that healthy middle-aged adults who regularly consumed the fruit experienced increases in their macular pigment optical density (MPOD) which can prevent or delay the onset of agerelated macular degeneration.

The study involved 27 participants between the ages of 45 and 65 who ate either 28 grams of goji berries or a supplement containing lutein and zeaxanthin five times a week for 90 days.

Li et al.

DOI: 10.3390/nu13124409 DRIVING

Vision screening and safety in older drivers

Researchers from the University of Alabama at Birmingham in the US have concluded that the negative impacts of involuntary driving cessation on older adults are likely to outweigh the safety benefits of vision screening.

The study involved 2000 licensed drivers from Alabama aged 70 and older who had their visual acuity, contrast sensitivity, useful field of view and visual field sensitivity tested.

They also underwent a Motor-Free Visual Perception Test.

Explaining the results of the study, Professor Cynthia Owsley highlighted: “Vision screening in older drivers does not identify those who are likely to have collisions in the future.”

McGwin et al.

DOI: 10.1016/j.ophtha.2022.04.013

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CLINICAL

NEWS

Researchers from The Chinese University of Hong Kong have highlighted a link between COVID-19 and dry eye disease.

A study published in Clinical and Experimental Ophthalmology describes analysis of 109 healthy participants and 228 people who were recovering following a stay in hospital with COVID-19.

All study participants received a comprehensive eye examination and completed questionnaires on ocular symptoms. Participants recovering from COVID-19 were asked about symptoms before and after their COVID-19 diagnosis.

Within the group of patients diagnosed with COVID-19, around one in five (21%) reported one or more symptoms related to dry eye disease.

Wan et al.

DOI: 10.1111/ceo.14066

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Clinical roundup

SPOTLIGHT

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100% OPTICALI

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A fresh new look OT spoke to event organisers about the show’s new look and sustainable aims

PRODUCTION CLIENT

The ninth edition of 100% Optical will bear a brand new look, as event organisers prepare for the optical trade show, due to be held from 25–27 February 2023.

“We’re freshening up the look and feel of the show with a new forwardlooking and bright creative,” explained show director, Nathan Garnett.

Reflecting on the 2022 show, he told OT: “The feedback from delegates was amazing. It set a really high benchmark for us to beat next year, but we’ve got ideas about how we’re going to do that.”

Registration for 100% Optical, which will be held at ExCeL London, will open in September.

Highlighting that plans are “well underway for an extensive education programme,” Dr Ian Beasley, AOP head of education and OT clinical editor, explained that: “The programme will be catered to the continuing professional development (CPD) requirements of all

SUSTAINABILITY AT EXCEL LONDON IN NUMBERS: ExCeL London uses 100% renewable electricity In 2021, 71% of the venue’s waste was recycled, with the remainder used to create refuse-derived fuels ExCeL London is home to the UK’s largest wormery, of approximately 300,000 worms, that break down food waste into compost for the venue’s green spaces.

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practitioners and will provide the ideal opportunity for members to work towards their personal development plan.”

In the meantime, Beasley reminded members to ensure they have earnt the minimum six CPD points required for the first year of the cycle and uploaded evidence of completion to their MyGOC. He added: “Members can visit the AOP’s events page, or OT’s active CPD exams, for opportunities to participate in education.”

Sustainability at 100% Optical As part of the sustainability focus for this issue, OT looked at how the event aims to make a difference.

Garnett said: “Every year we look at what we can do that is more efficient and sustainable.”

In 2022, 100% Optical introduced a digital show guide, reducing the amount of printing required. Many of the stands are built from modular aluminium systems that can be reused, and organisers also consider how furnishings such as carpets can be recycled or reused.

The 2022 show also saw a growth in the number of companies promoting biodegradable, recyclable, or regenerative products and processes.

IN REVIEW: 100% OPTICAL 2022

9680 attendees

across three days

Two in five

attendees were first-time visitors

7760 CPD points issued over 3708 seats

VISITORS

29% were optometrists 13.18% were dispensing opticians 7.56% were practice owners.

Considering this, Garnett shared: “That’s exciting, because everyone is going in the same direction.”

ExCeL London has a number of initiatives to reduce its impact on the planet, such as signing up to the Net Zero Carbon Emissions Pledge, committing to a 50% reduction in emissions by 2030, and recently earning the Triple Crown of Sustainability Award.

Natalie Sykes, ExCeL London’s sustainability manager, told OT: “Our vision is to be a sustainability leader within our industry,” as well as inspiring others to “play their part.”

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VERSION

INDUSTRY PROFILE

Responding to environmental threats in eyewear REPRO OP

Emily Andrews, product director and chief sustainability officer for Eyespace, on the drive to use sustainable materials, and the role of consumers in shaping change

SUBS

the introduction of comprehensive capsule offerings utilising reclaimed ocean plastics within our Rock Star and Basebox collections. Eyespace’s designer partners, Aspinal and Range Rover/Land Rover, are also aware that sustainable materials are the new backbone for premium retail. We work harmoniously with both of these luxury brands towards a mutual goal that sees environmental responsibility as an absolute priority.

ART PRODUCTION CLIENT

Eyespace has been at the forefront of environmentallyconscious business practices for several years. Our journey into sustainability moved up several gears almost four years ago, prompted by an uneasy and increasing awareness of the extreme volumes of plastic waste polluting our oceans and waterways.

As an industry we are adopting new, sustainable behaviours at an extraordinarily fast pace. One of Eyespace’s greatest industry-wide challenges – which, if we are doing our job thoroughly, should never go away – lies in the investments needed into the research and development of new sustainable materials.

It is no longer enough for companies to pay lip-service to insubstantial sustainability commitments. Our products hold certifications for all sustainable materials, including evidence of biodegradability (BS EN ISO 14855-1:2012 and ISO 15985:2014) and declarations for any specific claims. We believe that companies need to be the gatekeepers in terms of raw material selections, so auditing, certification and exhaustive research and development lies at the heart of our decision-making processes. This is how we ensure that

every eco-friendly product we put to market is genuinely sustainable and safeguarded by accountability.

There is no industry that isn’t making moves to a more sustainable future, and this is largely being driven by shifts in consumer buying decisions. We encourage every eyewear supplier to sign up to the Optical Suppliers Association’s Green Charter, which launches later this year, and all practitioners to tackle their suppliers to change the status quo, putting pressure on them to remove single use plastics and to switch to 100% recycled or biodegradable alternatives, including demo lenses.

The urgency to respond to environmental threat is greater than ever. There is an increasing awareness from Gen Z and Alpha, who are educating their family and friends on the changes that need to be made. We are shaping our product launch innovations to meet this customer group’s desire for eyewear that makes a difference, so the latest addition to Eyespace’s sustainable portfolio sees

“If every individual ups their investment in a greener future, the result will be win-win for all of us”

Research indicates that over a third of consumers are willing to pay more for products manufactured in sustainable materials. The eyewear industry has a responsibility to offer consumers sustainable frame options that facilitate eco-friendly choices. As an industry, we can overcome the challenge of reducing material cost prices by producing more frames in sustainable materials and where a sustainable option is available, it should be the only choice. It is a selffulfilling prophecy: the more normalised sustainable eyewear becomes, the more accessible the cost becomes, and so more and more consumers will be in a position to access them.

We are committed to becoming a carbon-neutral organisation by 2030.

Domestically, we are making purchase decisions that support local suppliers and are working with electric-powered courier services, while our warehouse team uses eco-friendly packaging materials, and recycle and re-purpose as much waste as possible. Other initiatives include transitioning case designs to incorporate recycled materials, and switching to folding designs, which reduce weight, cargo and warehousing space. Every Eyespace product range now includes sustainable frame choices.

It takes dedication, commitment, and follow-through to make sustainability succeed in business. But if every individual ups their investment in a greener future, the result will be win-win for all of us.

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industry profile

SPOTLIGHT

VERSION REPRO OP SUBS

SUPPLIER INSIGHT

PRODUCTION

With car dashboards looking increasingly space-age, and the introduction of bright LED headlights and street lamps, the need for optimised vision when driving is greater than ever. OT found out more

CLIENT

Driving lenses are supporting patients with optimised performance tailored to modern road conditions.

Describing the challenging conditions that face drivers, Andy Sanders, professional services director for Hoya, said: “The driving environment has changed exponentially over a few years, with car dashboards progressively looking increasingly like the Starship Enterprise, rather than the analogue type many of us grew up with.”

Along with car headlights that utilise super-bright LEDs or Bi-Xenon technology, 39 million licensed vehicles on the roads, an increase in cycle traffic and a rising average age of vehicle drivers, Sanders added: “It’s no wonder that drivers are looking for an optimum driving solution.”

Research by the RAC has revealed that nearly 90% of drivers feel some or most headlights are too bright, causing dazzle, and that this is a worsening problem.

Paul Hopkins and Dr Navneet Gupta, professional services managers for Zeiss, noted an increased installation of LED street lighting, which is brighter than traditional lighting methods and has a spectral transmission towards the blue end of the visible light spectrum.

“This can increase glare and dazzle, and reduce contrast,” they shared.

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“Drivers want to feel safe on today’s ever-busier roads,” the professional services managers said, with eye care professionals (ECPs) in a “prime position” to offer advice and lens solutions.

What patients look for Mark Robertson, head of manufacturing for the independent lens manufacturer, Caledonian Optical, suggested that occupational lenses have increased in popularity. This is partly attributed to the fact many people have been working from home on digital devices, and so are open to solutions that suit specific tasks.

With pandemic restrictions lifted, Robertson said: “We’re starting to see a big increase in driving lenses themselves.”

Despite this, patients might not know that solutions as tailored as driving lenses are available.

Robertson advised asking lifestylerelated questions to determine whether the lenses could be suitable, such as:

“It is a great opportunity for the ECPs to offer a second pair of glasses or talk more about these task-specific lenses” Mark Robertson, head of manufacturing for Caledonian Optical

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Optimising vision Sanders shared that lenses made for the driving environment typically feature elements like atoric surfaces to optimise peripheral vision whilst supporting binocular vision, “crucial for stereopsis and reaction times.”

Features to reduce blue light scatter offer more comfortable vision, he shared, especially when driving in poor weather or at night, while anti-reflection coatings can support low light vision.

Hoya offers a range of EnRoute lens designs to suit different wearers and drivers. Features of the lens include a glare filter to reduce reflections and glare from oncoming traffic, and support for clear vision in the far distance.

Progressive lenses incorporate Integrated Double Surface Design for wider visual fields and switching between distances, and Balanced View Control for a stable image perception.

The company also provides EnRoute Pro, an option ideal for professional drivers, with a design that is further optimised for the viewing distance of the dashboard and mirrors and an additional contrast-enhancing filter.

Zeiss

ART

Tailored lenses for driving

‘How often are you driving? Do you drive more during the day, or at night? And do you find that sunlight or glare is a problem?’

Sanders agreed that, “ECPs should consider the full driving environment and under what circumstances the glasses are to be worn.”

For example, a person who drives for a living may desire a lens tailored more for driving, whereas a patient who has a short commute to work may require a more blended solution.

“Patients are looking for comfort and clarity in vision across the whole lens so that with rapid focusing and refocusing associated with driving tasks, they remain fully aware of their surroundings whilst benefiting from a reduction in disabling glare, both at night, in poor weather conditions and during the day,” he said.

Supplier insight

“More people are realising, particularly after lockdown, that one pair of glasses is no longer enough” Andy Sanders, professional services director for Hoya Comfort in all conditions Zeiss described its DriveSafe range as everyday lenses designed with the challenges of driving in mind, aiming to enhance vision in low light conditions and reduce perceived glare.

Both the single vision and progressive lens options are designed with freeform technology. Mathematical models and algorithms optimise the lenses to account for pupil size, Gupta and Hopkins said, with Zeiss Luminance Design Technology aiming to minimise the effects of aberrations.

The Zeiss DriveSafe Progressive Lenses are designed to maximise the distance and intermediate fields of vision to assist with changing gaze between road, dashboard and mirrors.

In addition, the Zeiss DuraVision DriveSafe coating can block out shorter wavelengths of light that are responsible for the effects of glare from LED lights.

Greater visual acuity Caledonian Optical offers a range of materials for lenses, including Drivewear Transitions designed for the environment while on the road.

Combined polarised and photochromic technology aims to provide “the best of both worlds” in reducing glare and adjusting the tint of the lenses to suit each driving condition.

OT

The company worked with IOT to introduce its Digital Ray-Path 2 technology, which incorporates the wearer’s accommodative capacity into the lens calculation to minimise oblique aberrations. The lens includes a ‘night vision’ zone, which compensates for the difference in refractive error that occurs between day and night, providing greater visual acuity and reducing eye strain, Robertson shared.

The varifocal design has been provided with an extra-wide distance field and intermediate zone, maintaining the lens accuracy to the edge of the lens.

Robertson highlighted that this can support drivers gathering information from the dashboard at a quick glance, while concentrating on the road.

Opportunities for practice Reflecting on the value of occupational lenses, Robertson told OT: “It is a great opportunity for the ECPs to offer a second pair of glasses or talk more about these task-specific lenses. The patient benefits when they are driving, and it increases sales for the practice too.”

Sanders said it makes sense to offer specialist vocational solutions to patients as part of the consultative process of determining their best visual solution.

“More people are realising, particularly after lockdown, that one pair of glasses is no longer enough,” he noted.

RAC research has found that 22% of drivers wear lenses that reduce glare for driving, the Zeiss professional services managers pointed out, adding: “With so many options now available from different manufacturers, it is important that ECPs keep up to date, make clinically relevant lens recommendations, and satisfy both a market need and a business opportunity.”

AOP DRIVING STANDARDS RESOURCES

The AOP has a range of resources for examining drivers. This includes advice on completing the vision section of the D4 Medical Examination report for bus and lorry drivers, as well as detailed guidance for practitioners who feel a patient’s vision no longer meets the minimum standards, available at: www.aop.org.uk/dvla With an estimated 2900 road casualties caused by poor vision every year, the AOP regularly campaigns on the importance of sight tests for drivers and is calling for a change in the law to ensure drivers have their sight tested at regular intervals. More information on the Don’t swerve a sight test campaign is available at: www.aop.org.uk/dontswerve

CDR-9000 Auto Phoropter

CRK-1P Auto Refractor/ Keratometer

CLM-1C Auto Lensmeter

HDC-7000 Visual Acuity Software

ASKS

01438 740823 sales@bibonline.co.uk bibonline.co.uk

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MEMBER SUPPORT

Placing optometrists at the heart of primary care

Raising the profile of the profession As part of the AOP’s five-year strategy of building external influence and policy making, the organisation highlighted the need to extend and expand its influence within the sector and externally to system leaders and the wider population.

This would support its aims to raise awareness of, and promote, the

SUBS ART PRODUCTION CLIENT

AOP appoints sustainability steering group As part of the move, sustainability leads will be named across the organisation The AOP has established a steering group to guide activity towards achieving long-term sustainable and environmental goals within the membership organisation. With a focus on achieving net-zero and reducing waste, the steering group will launch a sustainability policy and strategy to underpin the AOP’s work on environmental issues.

Sustainability leads will be appointed across the organisation to “champion green issues and achieve targets,” the AOP said.

In March this year, the AOP joined with optical sector bodies to release a joint statement of intent on environmental sustainability. The collaborative statement included a commitment to reduce emissions in the industry in line with the UK target of lowering emissions by 78% by 2035.

Key priorities for the group include: Completing a sustainability assessment of the AOP Reviewing the procurement of services and products Continuing a move towards sustainable member services and digital products Raising staff and member awareness of sustainability and environmental issues.

Updates from the AOP on sustainability can be found through the Facebook, Instagram, or Twitter pages @The_AOP.

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optometry sector’s activities, the AOP shared, in the face of health reforms, innovative technologies, regulatory changes and clinical advancements.

Plans include market research into how members view the future of the profession, and to better understand the public perception of optometry.

The organisation also aims to build relationships with employers, peers and policy influencers to deliver opinion leadership as a leading voice in the primary care sector. Linked to this, the AOP will develop its public affairs work to better inform and influence members of government.

The AOP is encouraging members to get in touch if they would like to be involved in activities to raise the profile of the profession. This can range from hosting MP visits to participating in media activities.

Members interested in supporting the AOP’s work can get in touch with John White, AOP communications director, at johnwhite@aop.org.uk Find out more about the context behind the AOP’s five-year strategy on page 38 or read the plans in full online at: www.aop.org.uk/fiveyearstrategy

NATIONAL EYE HEALTH WEEK REVEALS KEY THEMES The AOP has confirmed plans to support the campaign through social media Optical professionals have been urged to participate in National Eye Health Week, taking place from 19–25 September.

Each day of the campaign has a different theme, including: children’s eye health (covering myopia), good vision for driving, live well to see well, minor eye conditions, eye tech (including assistive technologies and optical instruments), and eye health during the menopause.

A resource pack is available to download from the Vision Matters website: visionmatters.org.uk The AOP has confirmed it will be supporting the campaign activities by promoting eye health resources across social media throughout the week.

Professionals can get involved by using the official hashtags: #EyeWeek, #VisionMatters, and #FrEyeDay.

Getty/kate3155

The AOP has encouraged members to get involved in plans to enhance the public profile of the profession, as part of a broader vision for the future of the membership organisation.

In June, the AOP launched its five-year strategy, which outlined the ambitions and priorities of the membership organisation from 2022 to 2026, and illustrated proposed projects.

REPRO OP

The AOP’s five-year strategy seeks to build on its external influence championing the eye health agenda

Shaping future activity Adam Sampson, AOP chief executive, emphasised the need for the strategy to prepare for the future of eye care, sharing: “Our members have a role to play at the very heart of the primary healthcare system.”

The AOP’s strategy centres around five key pillars that will drive activity: creating a vision for legislation and regulation, building external influence and policy making, the AOP’s role in the future of healthcare, economics in the optical sector, and the AOP’s future business model.

The AOP has created a five-year roadmap to achieve its goals, ensuring members will be supported and have a voice in the direction of the profession.

AOP EXPERT

AOP EXPERT

Commercial

Education

Ava Williams, AOP events manager

Dr Ian Beasley, head of education and OT clinical editor

How have the 2022 events been received so far?

We have had a good uptake, including the return of faceto-face events. We ran a series of peer review and discussion workshops in partnership with Johnson & Johnson Vision and have more planned. We held our first MAYopia Day, which over 2300 delegates attended.

What does the schedule look like for the rest of 2022?

We have 21 events planned for the remainder of the year, including peer reviews, discussion workshops and webinars.

What is your focus for the next six months?

Our next cycle of events launched in early August, so we were preparing for that, and we are in the early stages of planning for 100%

Optical 2023. We are looking at how to improve the way we communicate with event delegates and will be implementing new methods of keeping attendees updated and reminding members of any events they may have booked.

What key message do you have for members?

If members have booked an event but are no longer able to attend, we would ask that they ensure they cancel as soon as possible to open the space up to those on our waiting list. This can easily be done via their MyAOP account, or by emailing us at events@aop.org.uk. We would also remind members that, after attending a CPDaccredited event, certificates will be available to download within 10 working days from their MyAOP account.

What key topics have been covered so far this year?

The first half of the year has given our members a gentle introduction to the new CPD scheme, covering core themes and targeting specific areas of clinical interest, including our MAYopia Day. Clinical articles and videos through OT have covered a broad range of topics that can be viewed as practice exams in OT’s Education library at: www.optometry.co.uk/cpd/ education-library What is on the agenda in the next few months?

We will have a full day of online education at the Hospital Optometrists Annual Conference, with a series of webinars accessible to all members, providing a platform for shared learning, along with peer reviews tailored specifically for those working in secondary care.

There will be a continuation of our health and wellbeing webinars, as well as face-toface professional development courses, each offering 15 interactive CPD points.

What tips do you have for the end of the first year of CPD? I advise members to remember that registrants need to earn a minimum of six CPD points in the first year of the cycle, so be sure to log on to the GOC portal to ensure this requirement has been met.

The latter half of the year is a good opportunity for registrants to revisit their personal development plan to make sure they are on track and update where necessary.

It is also important to emphasise that under the new scheme, registrants are responsible for uploading evidence of CPD completion rather than the provider.

August /September 2022

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AOP Update

SPOTLIGHT

Focus On VERSION

Energy efficient bases

REPRO OP

As part of its sustainability strategy, CooperVision has focused on the footprint of its facilities, including conserving energy and using renewable sources. Currently, 100% of operations in its New York facility run on wind-based energy, while the renewable electricity at one of CooperVision’s UK facilities (pictured) is generated from biomass. The company has been recognised with certifications from Leadership in Energy and Environmental Design, and a top rating from Building Research Establishment Environmental Assessment Method. www.coopervision.co.uk

FOCUSES ON...

SUSTAINABILITY IN CONTACT LENSES

SUBS ART PRODUCTION

Hit list

The trends, launches and looks

CLIENT

Taking a step with offsetting

Alcon has partnered with the social enterprise, Plastic Bank, to remove one tonne of ocean-bound plastic waste from coastal communities for every tonne of plastic used in Alcon Precision 1 and Dailies Total 1 contact lenses and packaging.

The partnership will operate in nearly 70 countries. Recyclable plastic and cardboard is already used in Alcon’s contact lens packaging, but the company said the new collaboration represents an additional step in its work to improve its plastic impact. www.uk.alcon.com

Making recycling accessible

Johnson & Johnson Vision has expanded its Acuvue Contact Lens Recycle Programme. The company has partnered with TerraCycle, to make zero waste boxes available to partnering practices nationwide, for recycling contact lens waste. Johnson & Johnson Vision will be funding 3500 zero waste boxes in 2022, providing capacity for the recycling of approximately 5.6 million lenses, blister packs and foils. www.acuvue.co.uk/recycle

Scoping out changes

Bausch + Lomb has said it is identifying its carbon emissions to determine CO2 footprint per site and per business unit, identify areas of opportunities for carbon reduction, and develop capital and project plans to reduce carbon to meet 2030 and 2050 carbon action goals. The company is identifying its scope one and two carbon emissions, (those from sources owned or controlled by a company). Bausch + Lomb also has a drive towards zero landfill operations, and to mandate for energy efficiency in new manufacturing developments. www.bausch.com

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GET THE

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LOOK

Q&A ME & MY GLASSES

Optometrist and lifestyle blogger, Lizzy Yeowart, on three brands offering frames made from recycled materials or reducing waste through small batch production

SUBS

Sustainable eyewear companies are changing the narrative by creating fashionable eyewear for the conscious consumer.

ART PRODUCTION

Custom creations

CLIENT

Amelia Le Brun

As an on-demand product, O-SIX Custom eyewear is only produced when it is required, eliminating waste and deadstock. www.thema-optical.com

OT talks to the photographer and writer about changing styles and aligning with brands that strive for good

1

3

2

4

Amelia Le Brun

I own three pairs of spectacles and around six pairs of sunglasses.

I like to have options. I don’t really have a usual style. It depends entirely on my mood, outfit and thoughts at the time of buying or being fitted for new glasses. I like and wear everything and anything.

I’ve worn spectacles for about four or five years. I’m religious about going to the optician. My eyes are how I work, make a living and perceive the world, and they are incredibly important to me.

It was during a regular check-up that I was advised to start wearing glasses. My eyes are my business.

Sunglasses have to be comfortable and make me want to wear them.

Eyewear is just like the shoes you put on, or the way you style your hair. It is an opportunity to demonstrate who you are and what you’re about. Glasses offer an external layer of style, and this is the reason I don’t have favourites.

It is about the mood of the day and where you are going.

I have always been drawn to companies who are striving for good in this world.

It’s important for me to be aligned with companies that match my values. It is a joy to be a Pala Eyewear ambassador, and I feel lucky to work alongside and create imagery for a company that does nothing but good and focuses on improving the world we live in.

Sustainability first Crann eyewear blends elegance and edginess, using 100% recycled and sustainable materials. Crann has partnered with the Native Woodland Trust and carries the Guaranteed Irish licensed mark. www.crann.co

Delightful denim Mosevic manufactures in small batches and infuses waste denim with a bio-resin to create a sustainable material that resembles carbon fibre. www.mosevic.com

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MMG

HIT LIST

VERSION

Cosmetics

Eye-friendly beauty

REPRO OP

Positive Impact has added Eyes Are The Story to its portfolio. The optocosmetics brand focuses on eye health with clinically tested and validated formulas created specifically for contact lens wearers, and those with sensitive or dry eyes. Before launching the brand the founder, Amy Gallant Sullivan, worked in the field of ocular surface disease for 20 years and felt there was an unmet need for eye-friendly products. www.positiveimpact.co.uk

SHORTLIST THE LATEST PRODUCT LAUNCHES

SUBS

Spectacles

For the explorers ART PRODUCTION

Neubau has released its New Generation Explorers collection.

The three new models are made from the brand’s natural3D material, which is extracted from GMO-free castor oil, and produced in a no-waste 3D-printing process. The models, including ‘Siggi’ (pictured), draw on ‘avant-garde’ styles. In July, Neubau revealed that its production facilities in Austria had reached carbon neutrality. www.neubau-eyewear.com

CLIENT

Equipment

Refraction systems

Contact lenses

Every dioptre matters

CooperVision has expanded its MiSight 1 day contact lenses to include higher prescriptions, now covering -0.25D to -10.00D (0.50D steps after -6.00D). The move means that MiSight 1 day covers 99.97% of prescriptions for Asian children and Caucasian children, who have myopia and less than 1D of astigmatism. Elizabeth Lumb, director of global professional affairs, myopia management, for CooperVision, said: “Every dioptre matters.” www.coopervision.co.uk

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Grafton Optical has launched SiVIEW, a software solution that connects refraction equipment to support an integrated refraction system. The artificial intelligence technology provides guided subjective refraction examinations and produces a detailed refraction report.

The device is manufactureragnostic so can link equipment from multiple manufacturers into a seamless refraction system. www.graftonoptical.com

To feature in OT’s Hit list, contact kimberleyyoung@ optometry.co.uk

Children

Over the rainbow

Look Occhiali – Made in Italia has introduced ‘Arcobaleno’ (‘rainbow’ in Italian) frames for children, aiming to convey a “message of optimism and hope.” A technopolymer, NIL, is used for lightweight frame fronts in a solid colour. The sides of the frames are made from Xinox, an alloy of hypoallergenic non-toxic steel, with an ombre hounds-tooth texture. www.lookocchiali.it

Accessories

Chic chains

Götti Switzerland has launched a range of chunky dual-toned glasses chains. The chains are made in Switzerland through a 3D printing process that uses polyamide powder. Up to 80% of raw materials are saved in this process compared to traditional production processes, the company said. There are 12 different combinations, designed to fit any pair of frames. www.gotti.ch

Spectacles

Pretty pastel

Puccini eyewear, by International Eyewear, has highlighted its ‘Puccini 318’ and ‘319’ models with lamination detailing. The styles include stainless steel fronts with handmade acetate sides that feature tonal colour block lamination in a delicate pattern. www.internationaleyewear.co.uk

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Shortlist

HIT LIST

VERSION REPRO OP

Q&A BEHIND THE BRAND WATERHAUL

SUBS

Kieran Hill, head of B2B sales

Clockwise from left: The Waterhaul team collect ghost gear; Kieran Hill; the Harlyn Aqua frames

WATERHAUL // ART

1

Waterhaul frames are made from 100% recycled fishing nets

PRODUCTION

2

The fishing nets and ghost gear used in the frames is collected by the Waterhaul team from the Cornish coast

3

The company launched a campaign to recycle single use personal protective equipment into litter-picking tools.

Who is the team behind Waterhaul?

In 2018 Harry Dennis and Gavin Parker founded Waterhaul, a company focused on our impact on the environment. They are both marine biologists and avid surfers from the coast of Cornwall and they were encountering the most harmful and abundant form of ocean plastic, which is fishing nets and discarded gear. They wanted to revalue that waste material into a resource, so they launched the eyewear brand.

What makes Waterhaul eyewear unique for practices?

CLIENT

We use 100% fishing net material and that’s really unique in itself. But we have the story behind us too: we produce litter picking equipment and we’re hands-on collecting the nets ourselves, so it’s such a great story for practices to convey to their own customers. Within the optical world, it’s that one-on-one relationship between the optician and their customer that is so important.

What are your short-term goals?

In the short-term, we want to solidify ourselves within the UK and grow our brand reputation. We also want to increase our impact because our core value is focused on the impact. We hope to soon be able to start processing the nets and ghost gear that we find through our own, small-scale facility that we have just acquired in Cornwall.

The aim is to get this up and running in the next six to 12 months. It is very early days, but it is something we are excited to be working on.

ANATOMY OF A FRAME

Fashion-forward, original design

Small rectangular cut-outs give the ‘rising sun’ effect

Unpicking a standout frame, by OT columnist Lizzy Yeowart

Handmade in Normandy In a nutshell Manufacturer // Struktur Frame // ‘The Sunrise’ Colour // Chili crush Web // www.struktur-eyewear.fr.

Available in five vibrant colours High gloss acetate

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BTB

HIT LIST

Perspectives, 1

VERSION REPRO OP

Perspectives Voices from optics and beyond

SUBS

“We are not just doing it for show; it is about making changes for the collective good”

ART

Dr Julie-Anne Little

PRODUCTION

A

Getty/Malte Mueller

CLIENT

s consumers, over the last few years many of us have become increasingly more sustainability conscious. We have been recycling a lot more and embedding sustainability practices into our home lives as we more frequently consider how we buy, use and reuse the products we consume. As a result, it is only natural that this way of thinking has transferred into our professional workplace. I believe it is really important that as a profession we are trying to create more sustainable processes across optics. It has also become clear that customers really appreciate efforts being made in this area. But of course, we are not just doing it for show; it is about making changes for the collective good and doing our bit to promote sustainability because we want to be part of that solution and not part of the problem.

In our industry paper waste and plastic waste are two important areas for consideration where change needs to happen. For practices, moving from paper to electronic records feels like low hanging fruit and something that is achievable for those who are yet to migrate. When making this transition, practices must also consider the change in processes and the patient journey that may be required in order to minimise related paper waste.

I feel that there are both sustainability and cost efficiencies to be had in other paper-based systems that we use in practice too, including the writing and sending of hard copy letters to patients and other healthcare professionals.

This highlights, once again, the importance of IT connectivity between optometry and other healthcare professionals.

Much plastic and cardboard waste also arrives in practices. Ensuring that there are systems in place to recycle or reuse this, as well as the products, is important. I have heard about examples of contact lenses recycling schemes that provide consumers with the opportunity to recycle their lenses and associated packaging in practice, but I think much more needs to be done in relation to spectacles. While consumers are increasingly welcoming sustainable changes, these processes have to be made easy.

At Ulster University, the eye clinic has adopted a paperless model and recycles as much as possible, in line with the university’s wider sustainability ethos. All staff across the university are encouraged to act in a paperless manner. The university also promotes ways to get to campus without using your personal car – this could include cycling, public transport or car-pooling. I think there is opportunity for practices to do more in this area in regard to patient transport to their practice. Many community practices will be on efficient bus routes that they could inform patients about. I have worked in practices where the receptionist would advise patients on transport methods, but this is very ad hoc. Practices could showcase these efforts more effectively, highlighting options such as electric car charging points, or bike rack facilities for example.

Dr Julie-Anne Little is an optometrist , chairman of the AOP Board, and a senior lecturer at Ulster University.

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What is your view?

Email OT with your comments newsdesk@ optometry.co.uk

AOP Council Read OT’s report from the latest AOP Council meeting on page 38. The full report can also be read online: www. optometry.co.uk

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“My practice’s sustainability journey began with the products” Simon Berry

SUBS PRODUCTION CLIENT

Business insights Keep up-to-date with the latest news and advice online www.aop.org.uk/ ot/in-practice

Sustainability and patients One of the difficulties opticians have with sustainability is knowing which patients are bothered about it. I have certainly had

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experiences where I haven’t mentioned sustainability to a patient and they have come back later and asked about it.

Ahead of giving a lecture at a conference last year, I surveyed my patients to see what their thoughts were about sustainability. I found that around 90% of people were concerned about sustainability, but only 50% thought that there were any issues in our industry.

I gave the same questionnaire to the opticians at the conference to try and compare answers, and it had some interesting results. One of the questions I asked was, ‘Would you pay more for a guaranteed sustainable frame?’ Around 70–80% of patients said they would, while opticians said they would take less profit from a sustainable frame.

A sustainable business Whilst my practice’s sustainability journey began with the products, over the years we have done a number of things in practice too. We use a green company for our energy, we have changed some of the windows, we use TerraCycle to recycle frames, and we are certified as carbon neutral.

Considering these things in practice is just as important as choosing sustainable products. My advice to business owners considering making sustainability changes to their practice would simply be to start. It doesn’t cost anything to start asking questions of manufacturers.

Simon Berry is an optometrist and practice owner of Simon Berry Optometrists in Durham, which celebrated its 20th anniversary in June.

Getty/Malte Mueller

ART

I

t wasn’t a conscious decision when I started on my practice’s sustainability journey.

As an independent opticians, almost by definition we buy and sell products, and if we sell a particular product or frame, I feel that we are endorsing it. Therefore, from the very beginning I wanted to do my best to source products that were manufactured in the most sustainable and ethical ways.

The first step I took was to start asking the questions. When a frame rep came into practice, I would ask where the frames were made and what they were made from.

Everyone had different responses.

“My advice to I remember one company, called Zeal, that were really helpful – they business owners even went back to the farmers considering where the castor plants are farmed making for the oil used in the process sustainability of making the frame. However, changes to mostly I was met with blank looks. their practice The reps were from distributors and were so far removed from the would simply be manufacturing process, finding the to start” information just wasn’t possible.

Initially it was just about finding out the information. Sharing it with patients came a lot later when, in 2016, I developed a questionnaire for all manufacturers so I could share the answers with consumers and see what their reaction was. Today we ask 10 questions around 10 different areas of sustainability and how the product is made. We use the answers to grade the product as to how sustainable or ethical we feel it is.

The results from the questionnaire are published on our website, and when we are talking about frame choice with patients we are able to reference that information.

“Don’t be frightened of sustainability.

By ignoring it, you are going to do yourself a disservice” James Conway

M

illmead’s sustainability journey began five or six years ago. One of the first things we did was to change the light bulbs at our Liverpool office to LEDs. This began us on our sustainability mission, and today the list of changes we have made is vast. Yet the journey will always be ongoing as we have learnt the importance of always questioning ourselves and what we are doing.

At Millmead the changes that we have made can be split into two categories. There is the core, which is product-based in terms of how we make products, and then there is the periphery, which is how we provide the product and everything else.

Getty/Malte Mueller

Changes at the periphery As a business we now recycle all paper and cardboard waste, and have invested in a waste compactor at our Liverpool facility that allows us to reduce the volume of the waste by 90%.

This means that we are sending less to landfill and reducing our carbon footprint. We have also introduced a consolidated shipping model to our customers, which helps to both reduce our carbon footprint as well as the cost to the customer. All of the cardboard boxes we use, including the tape that binds them, are made from recycled materials, and the polybags that are used in these deliveries are biodegradable.

We also want to encourage our staff to act more responsibly. Everyone has been given a metal reusable water bottle, we have a bike to work scheme, and are in the process of building a bike shed and installing electric charging points in our car park. Throughout all of the changes that we have made our theme has been to try and reuse something that has already been created rather than make something new.

cases from recycled PET in the UK. This has massively increased our case manufacturing over the last 12 months. There are so many benefits to producing these cases in this way – it’s time saving, cost saving and better for the environment. Earlier this year we extended Continental Eyewear’s Cameo collection with the launch of our Cameo Sustain range.

The frames in this collection, which is about eyewear reincarnated, are made of recycled PET. Plastic waste remains one of the industry’s biggest problems. We want to highlight and raise people’s awareness about this and are working with the renowned sustainability designer, Yair Neuman, to do so. By shining a light on the “On becoming issue and acknowledging the scale more sustainable, of the problem we hope we can help I would advise expedite a solution within industry.

practices to

Sustainability in practice initially find On becoming more sustainable, I something that is would advise practices to initally find easy to achieve” something that is easy to achieve.

This could be stocking a particular product or encouraging staff to car share or cycle to work. I would also encourage practices to appoint a sustainability champion.

This provides staff with someone to share their ideas with. Some of the best ideas we have had at Millmead have come from our staff. There is a belief that when you go down this route, it’s costly, but this is not always the case. Don’t be frightened of sustainability. By ignoring it, you are going to do yourself a disservice.

James Conway is CEO of Millmead Optical Group, which manufactures and supplies frames, lenses and cases. Last year it celebrated its 75th anniversary and retains its identity as an independent, family-owned organisation.

The product changes On the product side, there have been three or four big projects to date. The first, within our Optoplast case arm, was a move to making

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Perspectives, 2

PERSPECTIVES

VERSION REPRO OP

“Nothing in the Opticians Act will be changing tomorrow” Saqib Ahmad

SUBS ART PRODUCTION CLIENT

Why change the fundamentals?

The Opticians Act is woven through the very fabric of the optical profession and the services it provides. This is why the GOC’s call for evidence on the Opticians Act is a big deal for the AOP and our members, for optics and for patients. So why run this call for evidence?

For several years the Government has been carrying out work within the Department of Health and Social Care (DHSC) to review how all healthcare professionals are regulated. Some of the more radical possibilities from that work could see the GOC merged into a ‘super regulator.’

Whilst the GOC may not be perfect, removing it could reduce the understanding of optical practice in the regulation setting, and even weaken the perception of the profession in wider healthcare. With regard to why the call for evidence has come about, the answer is simple – opportunity. The GOC used the opportunity created by the DHSC’s drive for reform to review the provisions in the Opticians Act. The starting point of this process is the recently closed call for evidence and associated consultation on the future of optical regulation.

“We believe that the whole of the sight test must remain under the control of the optometrist as other options increase the risk to patients”

AOP response To read the AOP’s response, visit www.aop.org.uk/ opticians actresponse

The sight test Protecting the integrity of the sight test was at the cornerstone of our response to the call

36 www.optometry.co.uk

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for evidence. The GOC asked if the refraction and eye health checks could be regulated as separate episodes of care. Like our members, we passionately believe it must remain as a single inseparable sight test. We know that NHS service funding needs improvement. But our current Act allows innovative and more equitable systems to develop, without risking the delayed diagnosis that sight test separation would lead to.

The GOC also suggested that refraction in the sight test could be carried out by other professionals without changing legislation. We believe that the whole of the sight test must remain under the control of the optometrist as other options increase the risk to patients.

We are supportive of GOC proposals to extend its regulation of business as a mandatory requirement on all organisations that provide legally restricted optical services. This will help balance the playing field between individual and business registrants, as risks in practice are rarely attributable simply to the practitioner.

However, this must happen in a fair way.

The road ahead The good news is that nothing in the Opticians Act will be changing tomorrow. The profound implications of changes to the Act, its scope and scale for optical practice, demand that there is further robust consultation on proposals and that this is both transparent and responsive to feedback. The future process of any resulting legislative changes will likely take a few years. Our members will continue to be an essential guide to how we respond to whatever lies ahead. As the membership body for the optometric profession, we will continue to listen to the views of our members and work with our sector partners and stakeholders to lead and influence future changes to clinical practice and the development of the profession.

Saqib Ahmad is a policy officer at the AOP.

Getty/Malte Mueller

W

e’ve all heard about the Opticians Act and its importance for optometry – from defining the legal framework in which millions of sight tests are delivered each year, to regulations about the sale and supply of spectacles and contact lenses. It even defines how the GOC is constituted, its responsibilities for setting education standards and holding professional registers. But considering it was established over 60 years ago, does it still work today? This is one of questions that the GOC’s call for evidence on the Opticians Act posed.

MY VISION

“You’re learning every day with golf” George Woolgar

T

I found out that I had keratoconus when I went to his year is my first year back playing golf fullthe optometrist [Hakim Group practice Daybell & time. I picked up a tropical disease in 2016, which Choo] in Chesterfield when I was 20. I noticed my took about a year and a half to get treated, then eyesight was getting really blurry.

I injured my wrist while playing in a tournament From the start, it was quite difficult to find a lens in Egypt. For three years, it was stop and start, then to fit. After a while, my optometrist found these COVID-19 hit in 2020.

Synergeyes lenses and I have never looked back. The I imagine there would be quite a few people in my comfort and the durability situation who would want of the lenses is key. to hang their boots up. I am Golf is a high 35 now so I am not a spring performance, sensitive chicken anymore but the game. Your eyes have a benefit of golf is that you can massive demand on them. remain competitive as you It is a stationary ball and get older. teeing off happens very There is the desire to keep quickly – 0.08 seconds. The on going and keep improving. ball can travel at a speed of That is what motivates me. I 175 miles per hour. There enjoy the competitiveness of are changes in light and golf and the fact that every weather. You have different day is different. Some days grasses with completely you can play absolutely different grains. fantastically – you feel like The artistry of shotyour hand eye co-ordination is making is important; using perfect, everything goes right, your putter as a brush to and then the next day you are paint a line. When you tee a completely different animal. off, you are painting a line I was around four when I in the sky. started playing golf. My dad Your vision has to be and my grandad played golf. so sharp because it is the Now my four-year-old difference between winning son has a little club from his grandparents. My dad “Some days you can play absolutely and losing. You only get one shot. It’s not a team is a role model for me. He fantastically – you feel like your where you have other is always there. Support is a hand eye co-ordination is perfect, sport people to look after you. massive thing. everything goes right, and then You have one go and if Golf is a whole package – the next day you are a completely that is not good enough mental and physical. You can’t you go home. have any weaknesses. If you different animal” You’re learning every do, then you get left behind. At single day with golf. One of my old coaches said, a normal golf tournament, you’re playing against around 150 people and you can’t control what they are doing. You ‘The day you stop learning, is the day you give up.’ can control your actions. People break under pressure. But It is a unique sport. No one can ever say they have completed the game of golf. you have to stay within yourself and play the golf course.

Patient leaflets The AOP has produced a series of downloadable eye condition leaflets www.aop.org.uk/patients

George Woolgar, from Chesterfield, is a tournament golf

professional and three-time winner of the PGA EuroPro Tour.

He wears SynergEyes contact lenses after being diagnosed with keratoconus in his early 20s.

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Perspectives, 3

PERSPECTIVES

AOP COUNCIL

AOP COUNCIL VERSION REPRO OP SUBS ART

“THE SECTOR IS GOING TO BE TRANSFORMED”

PRODUCTION

Councillors discussed how optometry’s overarching legal framework could be reimagined at the latest AOP Council meeting

CLIENT

A

planned overhaul of legislation that underpins optometry practice in the UK was discussed at the latest AOP Council meeting (8 June, Crown Plaza Hotel King’s Cross).

AOP chief executive, Adam Sampson, provided an update to council on the Association’s five-year strategy. He noted that as well as changes within the organisation, with a new chair and new chief executive, the strategy comes amid a state of broader flux. Advances within technology, the challenges of the NHS backlog and planned changes to the Opticians Act all contribute to a shifting professional landscape.

“All of these things mean that the sector is going to be transformed in the next 10 years,” Sampson highlighted.

Sampson noted that while it is unlikely that the Opticians Act will be changed in the next two to three years, the General Optical Council’s (GOC) call for evidence can be seen as “the firing of the starting gun” for the AOP to develop its own vision on how the profession should evolve.

AOP Councillors had the opportunity to discuss key areas of the GOC call for evidence in small groups.

Sharing his group’s views on delegation of refraction, AOP 38 www.optometry.co.uk

Councillor, Ali Yasen, highlighted that many tasks can be delegated, noting that there are now computer systems capable of completing certain activities. “It is about those tasks being overseen by the optometrist,” he emphasised.

Yasen noted that the role of providing advice, guidance and recommendations should remain with the optometrist and not be delegated.

“The sector is going to be transformed within the next 10 years” AOP chief executive Adam Sampson He discussed the benefits and disadvantages of separating the sight test into refraction and eye health elements. The possible advantages include that it may be cheaper for the patient, while separation could also provide an opportunity for the development of dispensing opticians and free up time for optometrists.

However, turning to the disadvantages, Yasen highlighted the potential for the breakdown of communication between those responsible for different elements of the sight test. He also noted that

the approach to refraction is often informed by knowledge of the patient’s eye health. As spokesperson for his group, AOP Councillor Vijay Anand emphasised that the supervisor of delegated tasks should be on site and there should be a limit to the number of staff who can be delegated to.

Summarising the points raised by her group, AOP Councillor Josie Evans highlighted that the ultimate decision about clinical management of the patient should remain with the optometrist.

She added that optometrists should be responsible for determining which tasks are delegated.

In making this decision, the optometrist could evaluate the value created by delegating the task compared with the potential risks associated with delegation. Group spokesperson, AOP Councillor Paul Chapman-Hatchett, emphasised the importance of locum optometrists attending practices understanding what the processes for delegation are. They also need to be confident in the skills, training and associated audit trail of the individuals who are undertaking delegated tasks.

Speaking for his group, AOP Councillor Tushar Majithia highlighted that when supplying contact lenses, there should be an obligation for the supplier to check that the prescription is in date. He added that there could be a QR code on contact lens packaging linking to online information on contact lens care.

On the subject of technology and remote care, Majithia noted that remote appointments may be more convenient for some patients and free up capacity for other patients to be seen face-to-face.

However, he highlighted the data security issues associated with some new forms of technology.

Majithia also noted that there may be barriers to those with limited financial resources or digital literacy in accessing new online platforms.

AOP Board appointments Following an election at the June AOP Council meeting, AOP Councillors, Francesca Marchetti and Dr Rachel Hiscox, were elected to the AOP Board.

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Discussion VERSION REPRO OP

In practice 46 How I got here

SUBS

West Yorkshire optometrist, Bobby Sarvat Fida, lets OT in on her varied and unexpected career

47 The workshop

Insurers Lloyd & Whyte explain how you can approach socially responsible investing

Business insight and career development

50 Life as a locum

Locum optometrist, Pete Sharma, on how he balances work with life-long learning

THE DISCUSSION ART

Bringing sustainability into practice PRODUCTION

Independents and multiples are switching their focus to sustainability – but what does that mean on the ground?

OT found out

CLIENT Getty/nadia_bormotova

S

ustainability might seem like a complicated, multifaceted concept. So, how do businesses go about incorporating it in practice?

How can practical solutions realistically be adhered to, whilst patients are streaming through the doors?

For Peter Telfer, managing director at Hakim Group’s Urquhart Opticians, which has 11 practices in Scotland, it is about incorporating sustainability into each

aspect of the patient experience – and that starts with suppliers, “from frame choice and lens selection to aftercare and contact lenses.” A recent addition has included stocking Coral Eyewear, which uses discarded materials from landfills and fishing nets to create ophthalmic frames and sunglasses.

Telfer said: “All Coral’s packaging is recycled, and the cases and cloths they

provide are made from recycled materials. The introduction of an ecofriendly brand has been well received by our patients; we know sustainability is a focus for a lot of people.”

Another sustainable action that Urquhart has in place is refillable lens cleaner bottles, which can be purchased and are also given to patients when they collect spectacles.

“We have refill stations in each practice,” Telfer said,

55 IP and me

The AOP’s Kevin Wallace outlines the situations that would lead him to refer rather than treat a patient

“so it’s easy for patients to refill their bottle instead of buying a new one.”

Urquhart is also a drop-off point for recycling contact lenses as part of the Johnson & Johnson Acuvue Contact Lens Recycle Programme, and also names Shamir, which launched its new Metaform lenses this year, as its main supplier. Metaform lenses use less water, energy, and material for production than previous offerings, Telfer said.

Specsavers, through its joint venture partner model, has also been paying close attention to what happens in practice, and how head office can support these changes.

“Sustainability matters at all levels of the business, from store to CEO,” Tracy Pellett, the multiple’s sustainability director, told OT. “We support each other in our individual and collective sustainability journey – including through the Specsavers Sustainability framework.”

The framework outlines Specsavers’ ambition “to make a positive difference to our people, our communities and our planet,” Pellett added.

In-store activity in 2021–2022 included fitting LED lightbulbs in all new, relocated and

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Discussion

IN PRACTICE VERSION

THE DISCUSSION

REPRO OP SUBS ART PRODUCTION CLIENT

refurbished practices, and working with audiology partners to create a more efficient system for shipping hearing aid batteries. The use of plastic cases for audiology equipment has been reduced, and an audit of plastic packaging used in stores and within supply chains is being undertaken.

Specsavers has also launched ReWear, a natureinspired range of frames that is partially made from recycled, post-consumer plastic waste, allowing customers to “choose a more environmentallyconscious frame.”

Dr Angela Smith, optical commercial manager at Asda Opticians, is conscious that customers are looking for sustainability: before the pandemic, the highest volume of correspondence to the company’s CEO was about sustainability.

Customers’ concerns switched to safety in 2020 and 2021, but now sustainability is their top focus again.

The multiple currently stocks four sustainable adult brands. Children’s frames will be added in September, with more following in March 2023.

“I’m pleased that there are two kids’ brands

“The introduction of an eco-friendly brand has been well received by our patients; we know sustainability is a focus for a lot of people” Peter Telfer

42 www.optometry.co.uk

coming in,” Smith said, “Those customers are the most vocal. A lot of our correspondence is from children.”

Smith is asking, though, if some of Asda Opticians’ frames can be sustainable, why can they not all be? She hopes that, in the future, this can become a reality, to avoid virgin material being created unnecessarily.

“Sustainability is about quick wins,” she said.

“When you start doing the little things, the big things actually don’t seem impossible anymore. More of our products should be made from more sustainable material, because it all adds up – especially if the whole world moves on and follows with these materials.”

Smith added that Asda Opticians was among the first multiples to launch sustainable frames. “I’m really pleased everyone else is doing it now. Often, in retail, there’s talk about wanting to be exclusive. But I want everyone to have sustainable frames, because it’s the right thing to do,” she said.

There is a cost aspect, too: “The more people who buy into it, the more it can be at different price points,” Smith said. “I can’t get the frames at my opening price point at the moment. Other people need to get on board, and we’ll get prices down.”

Despite her ambitions, Smith is realistic about the practicalities of sustainability. She flags a webinar she attended recently, which advised optometrists

“When you start doing the little things, the big things actually don’t seem impossible anymore” Dr Angela Smith

to install lights that would go off if there was no movement in the room – “but you can’t have that, because you stay still having an eye test. So, you need to think about these things.”

One change that practices could make, she said, is in display cabinet lighting, which is often designed to stay on permanently.

Future vision

What do our trio hope happens in the coming years, in terms of sustainability?

Specsavers has appointed CEO John Perkins as chief sustainability officer, making it clear that this is a priority at the top of the business.

Dedicated roles, focused on sustainability, and new governance structures, with both global and regional sustainability committees, have also been introduced.

Other targets include becoming climate positive by 2035, which Pellett hopes to achieve by reducing operational emissions, focusing on packaging and product waste, and looking at the way materials are produced, where they come from and their journey.

Closer attention will also be paid to what happens to products once they reach the end of their life.

Pellett wants to emphasise that Specsavers is “reviewing our impact on the world to ensure we are sustainably making a difference.”

She added: “We’re challenging ourselves to make better sense of the role we play in the lives of the people we work with, the communities we serve, and the planet. We’re looking at everything through a new lens, to ensure we’re doing all we can to change lives for the better.”

At Urquhart, Telfer is looking at new ways to incorporate sustainability, including adding electric car charging points and assessing practice insulation.

Smith wants Asda Opticians “to drive the market, continuing the path we’re on, working with suppliers and it not being an exclusive product.”

She added: “It’s about doing it for the right reasons, even if no customers find out. It’s the right thing to do.

We need to push it further, and never be complacent.”

Smith’s personal goal is to see 100% of Asda Opticians’ frames being made from sustainable materials, which she predicts might take three to five years.

But, she said: “If we can make that work commercially and the suppliers can offer that much variety, it seems doable.”

She added: “The more customers see sustainability, the more they’re asking for it. That’s why I’m happy to push it harder. I think that will make it the norm – and that’s only for the best.”

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HIGH VERSION REPRO OP

HOW I GOT HERE

SUBS

“It has made me a better optometrist” Bobby Sarvat Fida on the value of balancing hospital and High Street work, and providing eye care in a high security prison

ART PRODUCTION

Initally I studied law at university. It was a shock that I had six or seven contact hours per week, and the rest of the time I had to read. I thought, “Where’s the

CLIENT

structure?” I had a great year socially, but a rubbish year academically. I didn’t know what I was doing. I wanted to be right or wrong, not in the grey area. Quickly I thought, “I’ve made one of the biggest mistakes of my life.”

Within three weeks, I rang the University of Bradford and asked about the chances of transferring to their optometry course. They said

“Come back next year, and we’ll give you first dibs.”

When I started optometry, I remember thinking, ‘This is it.’ It just clicked, and I knew this was what I wanted.

It was challenging to get a pre-reg placement in a hospital. I was fortunate to

have two interviews at Leeds Teaching Hospital, and to be offered a place at both.

Only 30% of pre-regs passed on the first go at that time. Pre-regs were often failing on the routine eye test.

In a hospital you don’t do routine – Monday morning can be cataracts; Tuesday afternoon might be glaucoma.

46 www.optometry.co.uk

You’re good at cataracts, but connecting it all doesn’t come naturally to a hospital pre-reg.

They gave me half a day a week to go into a High Street practice. I said, “That’s not enough. I want to do a day.”

I found my own placement, and alternated between two practices. One was miles away, but I thought “at least it gives me a full day to learn how to be what I’m going to be at the end of this. Not just to pass my exams, but to be good at what I’m doing.”

that didn’t come, so after a year or two I stopped working there and started at the University of Bradford, supervising clinics. Students ask you questions that you haven’t thought of. It keeps your brain ticking.

one day available, so I committed to that.

One of the hospital optometrists also worked at Specsavers. She spoke to them and I took on work across two of its practices, which taught me routine practice alongside my hospital work. It was nice to do both.

I’d been holding out for an opportunity in the hospital

I would have been a teacher – that was something that I wanted from an early age.

I loved Specsavers, but I missed contact lenses.

I started working with LOCSU in August last year.

Once you stop using that skill, it’s hard to get it back. That’s why I took an Asda opportunity. Because healthcare was new for them, they were very open to ideas. The Wakefield practice had a diverse patient set, from the very young to the very old. We quickly knew we had a loyal base. Asda has always been very flexible. I feel looked after, and that’s why I’ve stayed with them.

I’d been in a mentoring circle with a group of women, and that was fresh in my brain. We’d explored how men and women apply for jobs. Something that stuck out was, “I’m looking at the two or three things I don’t know how to do. There are so many skills I do have, but I’m focusing on the negatives.”

Usually, when men look at job applications, they think, “I can’t do that. I can do that.

I’ll give it a go.” There’s a difference in how we apply.

It struck me that I was doing the same thing, and it was holding me back.

About 10 years ago, I spent time testing eyes one day a week at Wakefield Prison.

It was completely different to what we’re used to on the High Street. We could find

“Prisoners have the same problems that we do: they can’t read a newspaper, can’t read their post, their glasses have broken” I loved hospital optometry, but there was no full-time job available at Leeds on qualification. There was

“My Plan B?”

that they’d had a security risk and the whole place was in lockdown. It was variable and challenging. Prisoners have the same problems that we do on the outside: they can’t read a newspaper, can’t read their post, their glasses have broken. It’s quite easy to forget where you are.

Your decision making is different in a prison. Glasses have to go through checking, in case they can be used as an implement. I had to take a step back and think, “Is that going to work?”

When I joined Asda I’d got married that year and had a baby, so they’ve been on my journey with me: marriage, baby, then divorce, and being a single mum. They’ve

always been accommodating.

Recently they’ve given me opportunities to do more: auditing optometrists, working as a clinical lead, compliance work.

It has made me a better optometrist. I’ve just started a secondment as an optical compliance manager. It’s a unique opportunity to have that secondment and then go back to clinical work. I’m excited to be offered that opportunity.

Get in touch Share your career journey with OT. Email lucymiller@ optometry.co.uk

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VERSION REPRO OP

by offsetting your carbon footprint by investing in clean technology. This can help you create positive change, without compromising on return.

Socially responsible investing

THE WORKSHOP SUBS

Socially responsible investing

ART

In each edition, OT answers a question from an AOP member. Here, we explain what you need to know about ethical investing

The scenario PRODUCTION

Jyoti, AOP member I run a chain of independent practices, and after a few years of healthy profits I’m looking to begin investing.

Could you provide some advice on sustainable investments, and where to start with this subject?

CLIENT

The advice Daniel James, director of client services, Lloyd & Whyte

Getty/ipopba

O

nce you have recently reached a point where your practice is doing well and your profits are looking healthy, you may have been wondering how to invest in companies that ethically align to your values and goals.

Climate change, pollution, geopolitical conflict and sky-rocketing food and fuel prices have resulted in people becoming increasingly aware of the fragility of the earth. Many want to act in a way that helps.

Both seasoned investors and those starting out are increasingly aware of the power of their pound, and

“Both seasoned investors and those starting out are increasingly aware of the power of their pound”

are turning to sociallyconscious and ethicallycentred investment opportunities.

Recent data shows that 68% of people in the UK would choose sustainable investments if they had the chance, with numbers rising to 70% for women, 74% for millennials, and 77% for people with over £25,000 of investable assets.

The latest Investment Association UK figures showed a continued rise in ethical investing, with responsible investment funds receiving a net retail inflow of £1.6 billion.

Practising ethical or socially responsible investing

These methods of investing link your ethics with your finances, and can potentially offset negative impacts of your work, such as frequent use of plastics. One way you can facilitate change is

Socially responsible investing looks at the broad picture of how and where you invest, rather than looking at avoiding or including certain business or business practices. It aims to achieve capital growth whilst supporting inclusive economic developments by investing in environmentally and socially responsible practices. This means that in some cases certain business types will not be used within a portfolio, such as arms or certain petrochemical companies, but in other cases, proactive and forwardthinking companies who are looking to change and develop could be.

Sustainable themes such as healthcare, social housing, education, the circular economy and renewable energy will form the core of the investment.

In some instances, companies are invested in to help provide access to the investment boards so shareholder activism can be used. This provides the shareholder with the ability to influence corporate decision making, policies and behaviours, which either improve the success of the company or steer management into making more ethical and socially conscious decisions.

Environmental, social and governance funds

Environmental, social and governance funds (ESG)

tends to work on looking at what businesses are currently doing. Do they meet set criteria already and if so, can they be included within a portfolio? ESG takes a broad view on the investment opportunities and options available to you. It looks to deploy or invest in businesses that are already implementing good practices, and businesses that have future policies which are shaping their business model in a positive way, such as oil companies that are investing heavily in green energy in an attempt to move away from oil production more quickly. There will be a ‘buy’ or ‘avoid’ list, but funds will still look to work within similar areas and opportunities.

A first step towards sustainable investment

Lloyd & Whyte’s independent financial advisers offer expert advice on ethical investing. Lloyd & Whyte is proud to be part of the Benefact Group – a charity-owned family of financial services companies that give all available profits to charity and good causes.

The Benefact Group is the fourth largest corporate donor in the UK. Book a financial review on 01823 250750 or email info@ lloydwhyte.com AOP support Find more business advice online: www.aop.org.uk/ advice-and-support/business

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Workshop

IN PRACTICE

LOCUM VERSION REPRO OP SUBS

LIFE AS A LOCUM

ART

“Upskilling always helps”

PRODUCTION

Pete Sharma explains how prioritising learning has helped him thrive as a self-employed locum When I started as a locum, I wish I had known…

The event that made me understand this was…

CLIENT

That there was more than enough work to go around, even locally.

When I started, I was overbooking. I found myself working six or seven days a week in different areas, which was good initially, but you easily get worn down.

I realised this when…

I joined locum recruitment agencies. There’s also a Vision Express app, a Boots app, a Specsavers app, and a lot of websites.

Once I started using agencies, I realised they were able to get me work closer to home. Suddenly I wasn’t overbooking; I was less tired. I realised this after a year of locuming, travelling around.

“I’m always studying something on the side. Locum life has let me do that”

50 www.optometry.co.uk

going to be new equipment, and it takes time to find out how it works. You might fall behind in a clinic. Sometimes it can be quite daunting, especially if you’ve got an elderly patient and they’re waiting, and you’re trying to get your head around things.

I always tell myself to test the eyes, check the patient’s health; do my normal procedure. If you know your basic skills, which we do, the rest will catch up. For the first few hours, every time I’m in a new place, everything going smoothly is what I hope for.

The advice I’d give to new locums is…

I’ve started going in a week before my first shift, to visit Agencies started letting the store, work out what me know when they had the equipment is like, and work near me, sometimes what their system is.

10 minutes down the road.

An independent I’m Then it was about getting starting at soon has a myself through the doors new optical coherence and building the tomography (OCT) relationships. I’d machine, and I’m MY KITBAG do one shift, and going to go in ESSENTIAL IS... build up my and play around A blue Volk lens reputation with with that, so that I’ve had since that practice that when I start my pre-reg from there.

I’ll know exactly As a locum, if how that particular you do a decent job and model works and it’ll happily talk to the staff, be a smoother day. you find that the managers always call you back. The Practices can make life first couple of years I was easier for locums by… building my reputation: Sometimes we don’t know working hard, turning what the protocols are, up on time, following the for example how to refer procedures, and being nice a patient in a different to everybody. Once the county. Locum packages reputation is there, you’re can help with that. If they always going to get calls give us a checklist, we whenever work is available. know how to log in, what the referral criteria is, and My biggest locum maybe what they expect challenge is… of the locums for the day.

When you go to a new Do they expect contact lens practice, there is always checks; do they want you

to pre-screen for them? Do they want us to help them out on the shop floor if they are busy? One of the stores did that, and I knew straight away, at 9am, what they wanted of me.

One change I’ve seen whilst locuming is…

Upskilling has become increasingly important.

Over time I’ve taken on Minor Eye Conditions Service (MECS) and independent prescriber (IP) qualifications. I’ve done my MiSight training.

Being familiar with OCT helps too. If you have training in those things, you tend to be called more for shifts. Over the years, some of the apps have started to ask what you are certified in. Upskilling always helps.

My favourite thing about being a locum is…

The flexibility. I like to do a few days in practice, and upskill on the other days. I’m always studying something on the side.

Locum life has let me do that. In 2020 I did my MECS; in 2021 I did my professional certificate in glaucoma, and this year I’m doing my IP. I can also take a lot of time off, which is harder when you’re employed, especially in the summer when practices get busy.

Now, I can take the whole month off – but if I need to catch up on work, I can do 10 days in a row if I want to. There are no limits.

AOP support If you are thinking about becoming a locum, and want to talk this through in more detail, contact regulation@aop.org.uk

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he clients I work with often say, “I wonder if I’m good enough to do this. I wonder if I can take the leap to go for this senior position.”

I realised that, from a career happiness perspective, it was important to share coaching techniques to help others clear out their inner gremlins and have the confidence to take control of their careers.

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Imposter syndrome ART

Imposter syndrome describes individuals, often high achievers, who have attained success in their work or life, but find it difficult to internalise their achievements and have feelings of selfdoubt. They might feel that, at any moment, someone could tap them on the shoulder and say, “What are you doing? You are not good enough to be in this role.”

People with a strong inner critic have difficulty associating their performance or accomplishments to their own competence and skill. Instead of celebrating their achievements and strengths, they’ll attribute their performance to external factors such as luck or help received from others.

Our self-limiting beliefs can get in the way of being able to progress in our lives and careers. Luckily, there are things you can do to tackle these beliefs.

Valuing yourself. You can’t please people all the

Join the AOP’s new wellbeing webinar series EYES ON WELLBEING

“Imposter syndrome transcends all groups of society” Susie Edwards, director of training and executive coaching organisation, WonderIf, on how to recognise and manage your imposter syndrome

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time, but when you take care of yourself and value your needs and wants first it enables you to support others around you. It does, however, start with yourself Defining your values. It is useful to write these down, so you can identify when they are being compromised as well as being met Aligning your values.

You should ensure that your values are aligned with what you are doing. Think about the people that you work with, the environment that you are in, what you are doing day-to-day, and how you can look at this balance.

When your inner critic surfaces, one approach is to turn it on its head and into an inner coach. There are three steps to this: Look at how you talk to yourself. This includes your

Getty/TarikVision

Other ways the AOP is supporting your health and wellbeing The AOP Mentoring Programme is an opportunity for student, pre-registration, newly-qualified and locum optometrist members to receive free impartial support from more experienced optometrists.

Find out more on the AOP website: www.aop.org.uk/ advice-and-support/aop-mentoring-programme

thoughts, behaviours, and actions. Talk to yourself as you would your best friend Ask whether this is based on your perception of the situation, or the reality.

Feelings can spiral based on fear and the unknown aspects of a situation Write down one obstacle you are facing. What is the block that is preventing you

The AOP’s happiness webinar series aims to equip members with practical skills that will help them reconnect with their happiness.

The next webinar (27 September) will be facilitated by Susie Edwards and will focus on learning how to value yourself and how to put your needs first. Book via the AOP’s events page: www.aop.org.uk/events

also about keeping yourself psychologically safe. Know what you want to say yes to, so that you have the clarity to say no to things that don’t align. If people are coming to you for support, create the boundary. Ask, “What is

“People with a strong inner critic have difficulty associating their performance or accomplishments to their own competence” from moving forward with the idea, project, or task?

What are you able to take control of?

Self-compassion

All this is connected to selfcompassion, which is made up of three aspects: kindness, common humanity, and mindfulness. Self-compassion means being understanding towards yourself when you suffer, fail, or feel inadequate. It recognises that suffering and personal inadequacies are part of the human, rather than purely individual, experience. It is

the most important thing we should focus on?”

Mindfulness is a nonjudgemental, receptive mindset in which we observe thoughts and feelings without trying to suppress or deny them. It helps you to stay aware, rather than being a passenger of your feelings or criticising yourself.

Practise speaking your emotions out loud. Instead of seeing them as negative, accept them and name them.

The next time you feel an emotion, say “I am angry” or “I am upset,” and see if you feel differently afterwards.

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Wellbeing

IN PRACTICE

Pre reg

IN PRACTICE VERSION

PRE-REG FOCUS

REPRO OP

“It feels unbelievable that a year has come around so quickly” Holly Leitch, pre-reg optometrist at Urquhart Opticians in Kilmarnock, discusses preparing for her OSCEs and the most interesting clinical findings of her year

Education Library.

OT ’s Education Library contains CPD and Skills guides on 31 topics www.optometry.co.uk/ cpd/education-library

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ntering what I hope will be the final months of my pre-reg, I am beginning to feel excited as I look towards the finish line. This year has been tough, balancing studying and preparing for upcoming assessments, and working in practice full-time. It feels unbelievable that a year has come around so quickly, I am looking forward to soon having independence in my clinical decision making and to continuing to face new challenges every day.

The final hurdle

At the moment my main focus is perfecting all the skills I have learned throughout the year, in order to prepare for the upcoming Objective Structured Clinical Examinations (OSCE).

The OSCE is designed to put practical skills, communication, and knowledge to the test, so every aspect must be perfected in order to be successful. On top of this my daily focuses

giving me confidence in my diagnosis and treatment of patients – specifically, understanding prescriptions to ensure minimal intolerance or error in refraction.

Patient encounters

An interesting clinical finding I have encountered was a case of a vitreous haemorrhage and retinal tear. This was my first view of a retinal

“So much of the knowledge that I had from university was taken from theory, and throughout this past year I have understood how this works in practice” have been staying on track at every stage.

At this point in my prereg I feel I have learned more than I could have imagined. So much of the knowledge I had from university was taken from theory, and throughout this year I have understood how this works in practice and in the real world. This has allowed me to become so much more competent, As I enter the final months of my pre-reg year… I’m feeling good about the career that I’ve chosen. I think it is both challenging day-to-day and rewarding in the long-term. I can see myself enjoying what I do for a long time.

Caroline says…

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are centred around time keeping and organisation as I have moved to normal test times, and I find the key to staying ahead of this is to be prepared for what is coming through the door.

Staying on top of my studies can be one of the most difficult parts of the Scheme for Registration: one-to-one meetings with my supervisor every week help to hold me accountable and ensure I

tear and first time seeing tobacco dust through the slit lamp. This case taught me so much about what to expect in cases like this and how to interact with the patient when a finding like this presents itself.

Another encounter that sticks in my brain is a patient who was experiencing headaches due to uncorrected astigmatism. After

receiving his glasses, the patient’s symptoms were totally relieved. Being able to solve the problems patients are having is the most gratifying part of this career and makes all the stress of exams and assessments worthwhile.

Throughout the year I have been engaging in Johnson & Johnson Vision’s STEP programme, as well as the Optom Academy pre-reg courses.

These have helped me at all stages, and are invaluable in preparing me for the final stage.

Both programmes provide a mock OSCE course with feedback, which I am looking forward to attending.

A practical simulation of the assessment will help immensely in my preparation. As well as this, I am using the College of Optometrists’ website and reviewing all the competencies in order to maintain my knowledge of the wide range of conditions, treatment and management options.

My key focus at the moment… is putting into practice all I have learnt over my pre-reg and at university, and committing the information to memory.

The encounter forced me to use different communication techniques, and to make sure my routine was patientfocused.

My most interesting patient so far… was an elderly lady, who was living with dementia.

Caroline Mansfield is a prereg optometrist at Specsavers Haverfordwest, Wales

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Council of Optometry and Optics (ECOO) – to bring people together to share knowledge, to be able to move forward.

Five facts about ECOO ECOO has 23 members A member is a country, and you can have more than one association per country Anything that requires a vote is one vote per country The UK members are the AOP, FODO, ABDO and the College of Optometrists AOP chairmain, Dr Julie-Anne Little is a member of the ECOO executive committee.

03

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“There have been positive lessons” ART

Ann Blackmore, ECOO secretariat manager, on facilitating a survey of members’ COVID-19 experiences ahead of the organisation’s General Assembly this spring in Dublin

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01 We did work two

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years ago and then again last year on what support services we could provide during the pandemic, and as a result have a COVID-19 information hub on our website. To coincide with

our first in-person meeting in two years, which took place this May, we thought it would be a good time to run a survey, to look for the positives: what did members learn coming out of the pandemic?

There have been positive lessons, and I think it’s true for all industries that we can learn to behave and deliver services in different ways. The much more rapid advance of digital, in health but also in services to members, is very much what the survey was about.

Getty/Nuthawut Somsuk

02

The survey focused on the experience of our associations, and by

extension their members’ experiences, during the pandemic. We wanted

to find out whether associations had changed the way they delivered services to members, or whether they had experienced an increase or decrease in membership, for example. What were their members telling them about their experiences?

The questions explored what our members did differently. We wanted to find out what the experience of associations were, and whether there were lessons that were useful to share across member countries. We wanted to get a better understanding of what the experience was. Was it uniform, or were there differences in different areas? It was about sharing learnings, which is very much the role of the European

“I think it’s true for all industries that we can learn to behave and deliver services in different ways”

We ran the survey in April, about six weeks before our General Assembly (May), and closed it two weeks beforehand. Some of our

23 member countries are small, and we didn’t get responses from all of them.

Malta and Cyprus are both very small in terms of the number of optometrists, but then you have places like the Netherlands, which has a very big and active member association.

They’re very different.

04 With an online survey,

you’re never quite sure what response rate you’ll get.

We had 17 responses, which is not bad. It’s always about getting that mix, including qualitative information. I think we gathered useful information.

05 We collected the data

and shared our findings in a presentation at our General Assembly, highlighting suggestions and insight into what members said they were doing. There was room for discussion, largely around whether this reflected people’s experiences, and whether they recognised the findings that had come from it. The overall feeling was positive, both for optical practices and the national associations across Europe. The lessons they’ve learnt mean they are now more resilient as organisations, because they’ve had to review what they do, and why they do it and how.

06

The survey was very much a learning piece for us. How can we better

support and help develop an association? The size and state of the optical profession and their national associations differ from country to country.

The UK associations are well developed so are less likely to need guidance, whereas Slovenia is more likely to need help, because their association is much smaller and in a much earlier stage of development.

07 I wouldn’t say that

the survey marks the end of our work on COVID-19.

It did feel, though, like we needed to do something that said, “Let’s move on from it. We might have to live in a different way now, but this is the opportunity to review what’s worked, and what we’re going to do next. Now, we can start to focus on other areas of work. We’ve taken the opportunity to learn.”

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IN PRACTICE

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eye on him for a while to make sure that his problem resolved as expected, with a low threshold for anything appearing out of the ordinary.

IP AND ME

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“I am looking forward to providing a community glaucoma service”

PRODUCTION

Kevin Wallace, IP optometrist and AOP clinical adviser, on treating a patient who had recently been trekking in the Amazon, and erring on the side of caution with contact lens patients I became an IP optometrist because…

CLIENT

It seemed the obvious step to take. I had been interested in treating more acute conditions for a few years, and having more abilities and access to more treatments made that possible. It was also encouraged by NHS Education for Scotland sponsoring the course.

I’ve now spent half of my career working with IP, and it would feel strange to be without it as managing anterior eye conditions now forms a significant part of my workload.

My latest case was…

It’s the time of year where I have seen a lot of patients with severe allergic conjunctivitis. It’s obviously not particularly serious, but the patients are very uncomfortable and keen for a resolution. Without being able to prescribe I would be limited to medications that aren’t effective for

an acute episode, so they would have a delay while trying to get the prescription from their GP. We also keep appointments for people who phone with a problem and have been able to see them the same day when required, which also reduces any delay in getting the treatment.

My most memorable case was…

I can still remember the first time I prescribed an antibiotic tablet for severe lid margin disease, which wasn’t responding to topical treatment – that just felt an extra step beyond the usual eye drops and ointments.

Now it is a fairly common occurrence.

The case I would be reluctant to treat is…

I definitely think carefully about prescribing for contact lens wearers. I wouldn’t treat an ulcer in a contact lens wearer – I would generally send those to my local eye department so they can scrape and culture the ulcer before starting treatment.

My ambitions for the future of IP are…

IP optometrists taking a greater The case that responsibility DID YOU KNOW? kept me up for a range In the 2000–2021 financial at night of eye year just under 1.5 million was… conditions eye examinations were performed by optometrists I try to that used to or ophthalmic medical avoid this be treated in practitioners in Scotland as much hospital, and – 700,000 fewer than in as possible, being paid 2019–2020 although a properly for it. few years ago In Scotland, I did see a patient we will shortly have with what appeared to be a a new scheme for complex fairly straightforward case conditions management. of recurrent corneal erosion.

The scheme will provide a He had been trekking in pathway for referring to an the Amazon jungle at the IP optometrist for a range of time of the initial abrasion, conditions and an improved which made me a bit fee structure. This is an uncomfortable. acknowledgment that the I can’t say that I didn’t service needs appropriate sleep, but I kept a close funding to be sustained.

“We are aided by the General Ophthalmic Services system in Scotland being accessible by everyone and for any eye condition” Being IP qualified has helped the reputation of my practice by…

Being seen as the people who can fix eye problems.

We are aided by the General Ophthalmic Services system in Scotland being accessible to everyone and for any eye condition. We get a lot of referrals from local GPs, and 90% of cases are treated by us. Patients appreciate the prompt attention and the ability to easily get in touch if they have problems.

The benefits IP brings to the business are…

Patients who present with a sore eye tend to be happy when it has been treated, and they tell people about it.

I believe that the implications of IP on other areas of optometry are…

I am looking forward to providing a community glaucoma service when it is launched in Scotland, and IP is vital for that. That will relieve the pressure on the stretched Hospital Eye Service, and again provide patients with convenient local care at an appropriate fee level for the practice. If a suitable product is approved I’m sure there will be a demand for eye drops for myopia control too.

Get in touch If you have an IP case study that you would like to share, email lucymiller@optometry.co.uk

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IP and me

IN PRACTICE

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Sink or swim?

OT talks with eye care professionals in Wales about how the profession can work together to create a sustainable future

ART PRODUCTION Jason Thomas

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ptometrist Ceri Probert lives next to an ocean that is grasping at the land.

In Aberystwyth, climate change can be seen in clouds casting shadows dark as squid ink across the ocean, rainfall lifting sandwich boards and road cones from the pavement, the ocean spray battering colourful townhouses.

“We regularly get floods on the seafront. Our practice is up on a hill, so we are relatively safe, but the businesses on the front tend to take a hammering,” Probert told OT. An hour’s drive north, residents of Fairbourne have been told by Gwynedd Council that the low-lying town will not be defended from sea level rises beyond 2054.

Roads, shops and infrastructure will be dismantled as the village returns to marshland, while the village’s 700 inhabitants will be forced to find a new place to make their home.

With climate change on his doorstep, Probert is passionate about advocating for the role that optometrists have to play in embracing a sustainable future.

“We are only a small cog in the grand scheme of things, but I think if, as an industry, all of us make little changes then we can be part of a larger change,” he emphasised.

Alongside his wife, Probert is codirector of three optometry practices in mid-Wales – Aberystwyth, Aberaeron and Machynlleth.

The couple had been considering how they could become more sustainable from a personal perspective but realised that a significant component of their environmental footprint is outside of home. “Really our biggest impact is the business – we needed to start changing that as well,” he said.

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A FRAMEWORK FOR CHANGE Probert and Williams was one of three optometry practices that signed up to the Greener Primary Care Wales Framework and Awards pilot.

The Public Health Wales initiative involves optometrists, GPs, pharmacists and dentists signing up to improve their sustainability across a number of categories.

At the end of the year, the evidence primary care contractors have submitted is audited and they are awarded bronze, silver or gold status depending on how many actions they have completed.

Through the pilot, Probert created an ethical and environmental sourcing document as well as a 10page list of actions to improve the sustainability of his business – each with a cost and deadline.

“It runs right from changing the light bulbs over to LEDs to calculating our carbon footprint,” Probert shared.

“We have looked at our general procurement – for example office supplies, tea and coffee – and have examined them from a sustainability perspective,” he added.

Patients are not automatically given a new spectacle case with each set of frames. They can instead choose a donation to an environmental charity in lieu of a new case.

SMALL STEPS

In Cardiff, signing up to the Greener Primary Care Wales pilot has inspired optometrist Bethan Roderick to create a sustainability ‘wish list’ – from installing solar panels to cultivating a bee-friendly green roof with grass and flowers.

She plans to petition the council for an electric car charging point in the car park behind Canton Optical.

“Every time an idea comes to me, I will jot it down,” Roderick said.

Growing up in suburban Hertfordshire, a trip to the countryside was an all-day activity for Roderick.

After she moved to Cardiff in 2000, Roderick gained a new appreciation for the wilderness in easy reach of

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“We can be part of a larger change”

Jason Thomas

Ceri Probert her new home. “I don’t want to lose this lush green land which we live in,” Roderick observed.

Roderick has replaced the disposable ballpoint pens at her practice with metal refillable pens, while she personally uses a fountain pen with a bottle of ink to write patient records.

This is the most common way that the topic of sustainability will come up with patients.

“The conversation usually starts when the patient notices I’m using a fountain pen and says ‘Oh, I haven’t

seen one of those in years.’ And then I will explain why I am using it,” she told OT. A drive to reduce the amount of plastic in Roderick’s life saw her learn how to make her own soap.

“I was always asking myself ‘Do I really need to have this plastic in my life?’,” she shared.

Like Probert, Roderick realised the contrast between the steps she was taking to become more sustainable at home and the impact of her business.

In order to reduce the footprint of her practice, she switched to a

green energy supplier and changed the light fittings to LEDs. Roderick acknowledges that there is potential to become overwhelmed when trying to become more sustainable.

“You can believe that you have to be perfect all the time. But it is more about everyone doing their bit – what they can afford and what is going to work for them. It is about making swaps and little changes,” she said.

Turning to barriers to sustainability within the profession, Roderick pointed to the high proportion of

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“I don’t want to lose this lush green land which we live in” products within optometry that contain plastic.

She added that because of the business model within optometry, there is a drive to sell glasses in order to cover overheads.

“Our entire profession is driving this need for new spectacles, new frames and new lenses, so that we can pay the bills and pay the wages,” Roderick observed.

“I think if we could divorce healthcare from the sales side of the profession, that would make it a lot easier for practices to be more sustainable,” she said.

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on sustainability moving into the mainstream. She would like to see environmental considerations become integral to business – rather than something that is confined to the home or learned about at school.

“It’s getting into the mindset where sustainability is not a hobby along the lines of being interested in knitting – it is something that we all have a responsibility to contribute to because we all live on the same planet,” she said.

STORM WARNING While rainfall in Wales creates verdant scenery, the increasing frequency of extreme weather events

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has taken a toll on its towns and cities. A succession of storms in February 2020 left 3130 properties flooded across Wales and caused £81 million in damage.

During Storm Dennis, the River Taff reached its highest level at Pontypridd since records began in 1968. At peak flow, the river would have filled an Olympic swimming pool in just over three seconds.

North of Cardiff, the Nant yr Ysfa rain gauge recorded 72% of an entire month’s rainfall within a single day.

“It is an unwelcome reminder of the power of nature, and evidence from climate scientists suggests that we will see more extreme weather

Jason Thomas

Bethan Roderick

events in the future,” Natural Resources Wales (NRW) emphasised in a report assessing the damage.

The report noted that flooding has the potential to have long-term impacts on communities – both physically and mentally.

“The flooding events experienced across large parts of Wales in February 2020 were devastating for many communities, and in many cases, it will take months, if not years, to recover,” NRW emphasised.

As with other effects of climate change, it is the often the most deprived communities that take the longest to recover from flooding.

In Wales – where those in the least deprived areas are expected to have 19 more years of healthy life than those in the most deprived areas – existing societal divides have the potential to be exacerbated by the impact of climate change.

SUSTAINABILITY FOR ALL

F ive tips FOR MAKING YOUR OPTOMETRY PRACTICE MORE SUSTAINABLE

1 2 3 4 5

Inform patients about ways to promote spectacle use for duration of life Let patients know about more sustainable contact lens options Offer recycling services for single use plastic contact lenses Advise patients whether a new case is required with every new pair of spectacles Move towards paperless clinical records.

Source: Public Health Wales

Growing up in north Wales, optometrist Tim Morgan observed this disparity in his own community.

“There were huge differences within the area of half a mile,” he highlighted to OT. “I have always felt that is incredibly unfair. When you look across the world, you realise that where you are born has an inexcusably huge impact on your expectations in life,” Morgan said.

He added that sustainability is about looking after others as well as looking after the environment.

“We need to consider the health of future generations as well as the health of the patients who are in the chair immediately in front of us. This is integral to the responsibilities of a healthcare professional,” he said.

In August 2021, the Welsh Optometric Committee became the first optical body within the UK to declare a climate emergency.

The Well-being of Future Generations (Wales) Act, passed in 2015, creates a legal obligation to consider the environmental impact when making policy decisions. “There’s a lot of appetite to make change. In Wales, in particular, the conditions are right,”

Morgan said. Future Generations Commissioner for Wales, Sophie Howe, highlighted the importance of making a connection between climate change and the health of communities.

“For our future generations, climate change is one of the biggest threats to their health and livelihoods,” she said.

“However, we know that our healthcare systems are responsible for high emissions and high levels of waste. And not just our big hospitals, but our community pharmacies, our dental and general practices, and optometry too,” Howe observed.

Morgan, who also took part in the Greener Primary Care Wales pilot, has created a sustainability plan for his practice with seven chapters – covering topics from procurement and waste to public engagement, auditing and research.

“It is a structured way of making improvements,” he shared.

He emphasised the importance of involving the whole team in sustainability initiatives – as each member will have unique insight on how processes can be improved.

“It is not about the principal optometrist telling everyone else what to do. This is the time to innovate. Everyone can – and should – be involved,” he said.

Morgan highlighted that there can be an assumption that improving a practice’s sustainability is expensive – but some of the changes he has introduced in his own practice have reduced his overheads.

For example, posting items less often has had an environmental benefit while also limiting costs.

“It’s not as simple as saying sustainability is a luxury. We need to challenge that instinct. Everybody can win – it is not a simple trade off, where if you improve sustainability it is going to cost you somewhere else,” he said.

Morgan, who describes himself as a “pragmatic hippy,” shared that sustainability is an integral part of his business.

“From the most basic things to how we structure the clinics and

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SUSTAINABILITY

SUSTAINABILITY VERSION REPRO OP

THE ENVIRONMENTAL TOLL OF COVID-19 IN NUMBERS

4-5%

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Global greenhouse gas emissions result from healthcare

3.4 billion

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The estimated number of face masks discarded each day in 2020

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The number of jumbo jet planes that is equivalent to the weight of personal protective equipment (PPE) distributed by the United Nations post-pandemic

3 billion

The number of PPE items that were used between February and August of 2020 in the UK

75%

The proportion of COVID-19 waste that could be avoided through rational use, local manufacturing and safe reuse according to a UK study Source: World Health Organization, Global analysis of healthcare waste in the context of COVID-19, published February 2022

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how we encourage staff to travel – sustainability is part of every process.

It isn’t a case of – on Monday we are sustainable, then we forget about it,” he said.

Although Morgan is passionate about action on climate change, he does not believe that negative conversations on the topic are helpful as there is a risk of numbing people into inaction.

Instead, he encourages people to consider what they can do to create a world they want to live in.

“We are all coming at this at our own pace. I acknowledge that we are not perfect, but what I hope is that today is the worst that we ever are and tomorrow is a bit better,” he said.

WHAT THE UK CAN LEARN FROM LOW-INCOME COUNTRIES Ophthalmologist Dr John Buchan is the programme director of the MSc for Public Health in Eye Care run by the London School of Hygiene and Tropical Medicine.

In June, Buchan and colleagues published a scoping review in The Lancet Planetary Health assessing the extent of existing research on the sustainability of eye care services.

Buchan shared that the current way of operating within eye care is not sustainable.

“We can’t continue at the scale that we are: pumping hydrocarbons from under the ground and turning them into plastics which we then use for a few seconds in some healthcare intervention, then throw away,” he emphasised to OT. Buchan highlighted that standard healthcare practice in high-income countries, such as the UK, is very different to the approach adopted in low-income countries.

For example, in India and most of sub-Saharan Africa, rather than throwing away equipment at the end of the operation, it will be sterilised and then used on the next patient.

Gloves are washed and covered in 100% alcohol between procedures.

“That might sound countercultural for us, but because there is one hospital system in India that is

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doing the same number of cataract operations as the whole NHS in England, this is their practice,” Buchan shared.

He added that despite these differences in practice, infection rates are no higher than within the UK. The roots of a cautious attitude to reusing surgical equipment in the UK can be traced back to an approach that developed following the spread of Creutzfeldt–Jakob (mad cow) disease in the 1980s and 1990s.

The disease was passed on through neural tissue, with research determining that sterilisation was ineffective in killing the prions responsible for disease transmission.

“There became an environment within healthcare where instruments that were used on certain parts of the anatomy were thrown away,” Buchan shared with OT. “In some eye hospitals, almost everything you use for a cataract operation will be thrown away and then incinerated,” he said.

A DISPOSABLE CULTURE More broadly speaking, Buchan highlighted that a “disposable culture” has evolved in the UK over the past two decades.

“The link between what things cost and what they are worth has broken down because of the asymmetry in wages around the world,” he said.

“For instance, metal is dug out of the ground and made into forceps, often in Pakistan, and they are handfinished in a factory, sterilised, put into packaging and shipped around the world. Yet they retail for a few pounds,” Buchan highlighted.

Within the UK, ophthalmology accounts for 9% of outpatient activity.

The volume of activity is expected to increase as the population ages.

Buchan emphasised that in the future both ophthalmologists and optometrists will have to deliver more care within the confines of limited funding and equipment.

“If you have to deliver more care with the same resource, you have to change the way you behave. All of us have to find lighter ways of working – that means financially and

Cover feature, 4

“It’s not as simple as saying sustainability is a luxury. We need to challenge that instinct”

Jason Thomas

Tim Morgan environmentally lighter,” he said.

In 2013, researchers from Cardiff University found that the carbon dioxide produced by a single cataract operation was 181kg.

The researchers estimated that the carbon burden of all cataract surgeries in England over a single year was 63,000 tonnes – or 31,500 return flights from London to New

York. The pandemic has created additional environmental strains through the increased use of personal protective equipment.

It is estimated that in 2020 a total of 3.4 billion face masks were discarded internationally each day.

Buchan believes that clinicians should reassess their approach to risk, taking environmental

considerations into account.

While the individual patient in front of a clinician may not be put at risk by wasteful behaviour, the environmental legacy creates broader concerns.

“We need to challenge this assumption that wasteful behaviour is somehow safer for patients. You are putting people at risk by using up

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the world’s finite resources,” he said.

Buchan highlighted the dissonance he sees in the approach to risk within hospitals when compared to what happens outside their doors.

For example, when Buchan uses a felt tip pen to mark a patient’s forehead before surgery he is required to throw the pen away after a single use.

On the journey to hospital, that patient may have leaned their head on the window pane or touched their face after opening a door.

“I don’t think using a felt tip pen on consecutive patients is really more of a risk than any activity in normal life,” he said.

“Yes, there are possible transmissible diseases out there – but the way we throw some things away is just not sensible,”

“The link between what things cost and what they are worth has broken down” Dr John Buchan he added. Buchan would like to see sustainability become an integral component of research design – so alongside the effectiveness of a given treatment or pathway, the environmental impact would also be considered.

Buchan shared his belief that clinicians have a “moral compunction” to act in the interests of future generations. There is an

CLIENT

“CLIMATE CHANGE AFFECTS US ALL” Angharad Wooldridge, from Public Health Wales, discusses the Greener Primary Care Wales Framework and Award Scheme

How does the framework and award scheme work?

Any primary care contractor in Wales (optometric practices, primary care dental practices, community pharmacies and general practices) can register on the framework for free online. The digital framework contains a number of categories such as procurement, waste and healthy behaviours. Each category contains a mixture of clinical and non-clinical actions for practices to self-select and attempt at their own pace. Further information is provided alongside each action to support practices in completing their chosen actions.

Once an action has been implemented, evidence in the form of commentary or supporting documentation is uploaded to the framework to demonstrate completion.

Each completed action equals one point and as the number of points increases so does the level of award achieved, eg eight points is recognised with a bronze award. At the end of each annual cycle, the evidence submitted by a practice will be audited by trained university students. This year the

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unequal impact to climate change – with those in countries with higher temperatures and fewer resources suffering the greatest effects.

“Within the UK, we could continue to behave as we are and it wouldn’t affect me in my lifetime, but there would be other people in other countries and in future generations who would be profoundly affected if we don’t do our bit,” he said.

framework will close for new evidence submissions on 28 October and the audits will take place on 16 November.

What types of sustainability measures have primary care contractors made during the pilot phase?

Initiatives ranged from calculating a practice’s carbon footprint to encouraging safe inhaler disposal. In relation to the three optometric practices that participated in the pilot, they took on a broad range of actions such as changing to a more environmentally sustainable supplier for their printer and toner cartridges and a local supplier for office supplies; switching to Fairtrade tea and coffee; promoting a ‘spectacles for life’ approach and removing a reglazing fee; and routinely advising patients about whether a new case is required when new spectacles are purchased, to name a few.

Why is sustainability an issue you are passionate about?

Climate change affects us all, but it disproportionately impacts those who are already at the most disadvantage in our society. By working together we can make a positive impact on the future of our planet and safeguard the health and wellbeing of our future generations.

The Greener Primary Care Framework and Award Scheme has completed the pilot phase and all optometry practices in Wales are now eligible to sign up for free online: www.greenimpact. org.uk/greenerprimarycarewales. Those interested in finding out more can contact: greenerprimarycare@wales.nhs.uk or visit www.primarycareone.nhs.wales/topics1/greener-primary-care

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CPD

REMEMBER TO UPLOAD YOUR CPD POINTS

IN THIS ISSUE

MICROTROPIA: A PRACTITIONER-FRIENDLY GUIDE

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BIFOCAL LENSES: ARE YOUR STANDARDS UP TO STANDARD?

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LEARNING OUTCOMES

Practitioners will understand how to investigate and manage cases of microtropia.

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Practitioners will be able to verify bifocal and trifocal optical appliances to the relevant standards Practitioners will be able to delegate the task of optical appliance verification to support staff in line with relevant standards.

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RETINAL DETACHMENT: ACHIEVING THE BEST OUTCOME WITH POSTURING

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Practitioners will be able to give posturing advice to patients with retinal detachment Practitioners will be aware of referral guidelines, treatment and post-operative care of patients with retinal detachment.

C-102191 LEARNING OUTCOME

Practitioners will be able to interpret a range of retinal images.

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ALL ABOUT THE EYELIDS

PRACTICAL TIPS FOR THE IDENTIFICATION OF DRY EYE

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Practitioners will be able to identify abnormalities of the eyelids and manage the patient accordingly.

LEARNING OUTCOMES

Practitioners will be able to elicit relevant detail from patients with dry eye disease Practitioners will understand methods for identifying patients with dry eye disease.

EXAM QUESTIONS, REFERENCES & DECLARING CPD POINTS MCQs for OT’s CPD appear online at www. optometry.co.uk/CPD. Exams in this issue will be live from 13 August to 4 November, 2022. When taking an exam, the MCQs may require practitioners to apply knowledge that has not been covered in the related

CPD article. Visit www.optometry.co.uk/CPD, and click on ‘Related CPD article’ to view the article and accompanying references in full. In the new CPD cycle, registrants are responsible for declaring their CPD points via their MyGOC account (www.optical.org).

If you pass an exam with OT, you will receive a certificate to use as evidence when declaring your CPD points.

Certificates will be available to download in your MyAOP.

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CPD

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MICROTROPIA: A PRACTITIONERFRIENDLY GUIDE

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Professor Bruce JW Evans BSc, PhD, FCOptom, FAAO, FEAOO, FBCLA, DipCLP, DipOrth

This article offers practitioners a digestible summary of microtropia to aid the investigation and management of these cases.

IN BRIEF

1

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POINT

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INTRODUCTION

PRODUCTION CLIENT

Microtropia, or microsquint, may be found as a primary condition, or as a residual deviation after the treatment of a larger strabismus. Microtropia may have inherited characteristics. Anisometropia is often a major factor and a foveal scotoma can result from the confusion of the blurred image with the sharp one in the other eye. Microtropia has also been called Parks’ monofixational syndrome.1 Typically, microtropia develops before age three years, but may break down into a larger angle strabismus and give the impression that a strabismus has developed in later childhood. It is usually an eso-deviation, but microhypertropia and microexotropia have also been described.1

CLASSIFICATION Primary microtropia describes cases when there is no prior history of a larger deviation, and secondary microtropia when a primary comitant larger angle deviation has been reduced with treatment. Another cause of secondary microtropia is a foveal lesion. It has been said that secondary microtropia is more common than primary microtropia.2

CLINICAL CHARACTERISTICS The terminology surrounding small angle strabismus has been confused, but microtropia is now recognised as having certain characteristics in very many cases.

These characteristics are listed below and incorporated into a diagnostic algorithm at the end of this article: 1 Small angle. The microtropia is less than 6Δ in angle.

Some authors say less than 10Δ and others, less than 5Δ.1 The deviation may not show on the cover test; not because it is too small, but because it is a fully adapted strabismus (see below) 2 Anisometropia. There is usually a difference between the refractive errors in the two eyes of more than 1.50D. Occasionally, microtropia will be found in patients without anisometropia. Contact lenses are a better optical correction for anisometropia than spectacles

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3 Amblyopia. There is reduced acuity in one eye, and as the deviation may not be apparent on the cover test, amblyopia may be the first indication of the microtropia. Usually, the acuity is only reduced to 6/9 or 6/12. Very rarely microtropia can be alternating, with no amblyopia 4 Eccentric fixation. Central fixation is lost in microtropia (unless alternating) and there is likely to be a suppression scotoma in the foveal area of the amblyopic eye. The angle of the eccentric fixation is usually the same as the angle of the strabismus, which is why the eye does not move on the cover test: the area of the retina on which the image falls in binocular vision is the same as the eccentrically fixating area (the area used for fixation when the other eye is covered).

Occasionally in microtropia, the degree of eccentric fixation is less than the angle of the strabismus, and in these cases, a very small cover test movement may be seen. Some authors define microtropia as a strabismus in which no movement is seen on the cover test,3 and hence, would not classify this latter type as microtropia 5 Anomalous correspondence. Harmonious anomalous retinal correspondence (HARC)1 is present in microtropia. Therefore, in most cases there will be identity of the retinal area on which the image falls in the patient’s habitual vision with both the area used for fixation monocularly and the anomalously corresponding area. This has been referred to as microtropia with identity and most microtropia is of this type. In these cases, the strabismus is described as fully adapted 6 Peripheral fusion. The eyes in microtropia seem to be held in the nearly straight position of the small angle strabismus by fusional impulses provided by peripheral vision. A form of ‘pseudo-fusional reserves’ can be measured. During the cover test it is, therefore, important to position the cover close to the eye to ensure complete dissociation; otherwise, peripheral fusion may reduce the magnitude of any ocular movement and prevent accurate diagnosis

CPD 1, 1

BINOCULAR VISION

Table 1 Method of use of the 4Δ base out test 1 Select an appropriate target, which should be an isolated target on a large uniform field. A dot (resolvable by the amblyopic eye) on a white, otherwise featureless, wall in front of the patient is ideal. A dot in the centre of a blank sheet of A3 or A4 paper at 40cm is acceptable 2 Introduce the 4Δ base out lens in front of one eye while the eyes fixate the target 3 If the patient has no strabismus, one of two normal responses or a combination of both will occur: a. Both eyes will make a saccadic version movement, followed by a vergence movement of the eye without the prism, or b. The eye with the prism will make a vergence movement, the other eye maintaining fixation.

4 If the patient has a microtropia and the prism is placed in front of the strabismic eye, the image will be displaced within the central suppression area and no movement of either eye will take place 5 If the patient has a microtropia and the prism is placed in front of the non-strabismic eye then both eyes will make a saccadic version movement, but there will be no corrective vergence movement 6 If an abnormal response is obtained, the better eye should be occluded, and the test repeated with the prism just introduced in front of the strabismic eye. If this eye still fails to make a saccadic movement to the prism, this suggests pathology may be present, causing a central scotoma.

7 Pseudo-heterophoria. In many cases of microtropia, the angle of the deviation may increase on the alternating cover test or even if one eye is covered for a slightly longer time than normal for the cover test. When the cover is removed, the eye that was last covered will be seen to return to the microtropia position. It is as if a heterophoric movement is superimposed on the microtropia. This ‘pseudo-heterophoria’ may be larger and more obvious than the microtropia, which may not show at all on the cover test 8 Stereopsis. A low grade of stereopsis has been reported in microtropia, depending on the stereotest used (see later section)1 9 Symptoms. There are usually no symptoms and a good cosmesis.

INVESTIGATION AND DIAGNOSIS

Amblyopia The presence of amblyopia in one eye is usually the first clue that microtropia may be found. The amblyopic eye shows the crowding phenomenon; that is to say, single letter acuity is better than line acuity.1 The foveal scotoma may also result in the patient missing out letters when reading lines on the Snellen chart, or they may read the line more easily backwards (see Figure 1, page 70).

The patient should be tested for eccentric fixation,1 which in microtropia is usually parafoveal and slightly nasal and superior to the fovea in microesotropia.

The depth of amblyopia seems to be the main factor influencing binocularity.4 Cover test For microtropia without identity, the diagnosis is usually made from a strabismic result on the unilateral cover test of between 1–10Δ. As explained above,

microtropia with identity is unlikely to be detected as a strabismic movement with the cover test. There may be an apparent heterophoria movement when the cover is removed, and this could result in the microtropia being missed.

Four prism dioptre test (Irvine prism test) In this test, a 4Δ base out prism is placed before one eye and the eye movements are observed.5,6 The typical response in normal eyes is a small initial vergence movement (which may not be seen), followed by a conjugate saccade (version movement) and then a symmetric vergence movement.7 The theory behind the test is that in microtropia, if the prism is placed before the strabismic eye, the image will move within the suppression area and there will be no movement of either eye.8 If the prism is placed before the nonmicrotropic eye, both eyes will make the initial version movement, but the microtropic eye will fail to make the subsequent vergence movement. When the patient has HARC, the test can still reveal a small suppression area at the fovea which can co-exist with HARC.1 Surprisingly, in most descriptions of the test, the fixation target is not mentioned. The test should only work if the patient is fixating an angular, isolated, target on a large featureless background. If this is not the case (for example, if the patient fixates a letter chart), other detail in the field of view will also appear to move, not just the fixation target. The importance of a fixation target5 was highlighted by Irvine shortly after the initial description of the test,9 but has since been omitted from descriptions of the test. This factor probably explains some confusing results from publications that do not specify whether a featureless background was used.10 Since the strength/depth of suppression is likely to vary with target conditions, it

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is best to avoid an unusually high contrast target. One study evaluated the effect of target parameters, but only included eight cases of microtropia, all of whom had HARC without central suppression and who exhibited normal responses on the 4Δ base out test.11 In some cases where there is amblyopia and no movement on the cover test, it is important to differentiate microtropia from organic amblyopia. It is possible that a central scotoma in organic amblyopia could cause a 4Δ test result like that in microtropia. In these cases, it may be useful to occlude the good eye and repeat the 4Δ base out test monocularly. If there is a large pathological scotoma, as often found in organic amblyopia, there will be no monocular response to the prism. Because any monocular suppression area in a microtropic eye is likely to be lighter than the larger suppression area that occurs under binocular viewing, a microtropic eye should make a version movement to a 4Δ lens that is introduced monocularly. The test method is summarised in Table 1.

Although the 4Δ base out test has been proposed as a diagnostic test for microtropia, the test can give atypical and inconsistent responses,8 particularly in esophoric patients where the 4Δ base out may correct the eso-deviation.12 The present author speculates that this may be because too little attention has been paid to the test target. Concurrent testing for suppression with Bagolini lenses during the 4Δ base out test indicates that in some cases there is a positive response to the test in the absence of suppression, so a positive test implies only that there is no normal motor fusion.13 A polarised letter chart can also be used to detect central suppression and may be a preferable approach.1, 14 HARC The Bagolini lens test or Mallett anomalous retinal correspondence and suppression (MARCS)1 large OXO

Figure 1 An eccentrically fixating eye reading a line of letters. The patient is fixating the letter N in a line of letters. The image of the next letter to the right of N, H, falls on the foveal scotoma and may be missed by the patient, who reads the following letter, A. If the patient reads from right to left, the difficulty does not occur; the image of the letter D, for example, does not fall on the scotoma

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test will show the response typical of HARC.1 The HARC is usually deeply ingrained.

Amsler charts The scotoma may show on an Amsler chart (see Figure 2).1 Stereopsis Stereopsis test results in microtropia will depend on the type of test used.1 For example, the TNO test measures random dot stereopsis and microtropic patients are unlikely to do better than 200”, whereas the result from the Randot circles or Titmus stereotest circles, which measure contoured stereopsis, may be as high as 100”.16 Summary of the diagnosis of microtropia In summary, there is a consensus about some characteristics which are invariably present for a diagnosis of microtropia. There are several other characteristics which some authors argue are necessary and others consider are only sometimes present in microtropia. The algorithm in Table 2 summarises these factors.1

Management

Microtropia is a fully adapted strabismus and typically does not give rise to symptoms unless other conditions are present. Management consists initially of correcting the refractive error; this is particularly important if the patient is under five years of age and has anisometropia. Amblyopia and eccentric fixation should be treated in the usual way.1 Cleary and colleagues found that for one third of their sample, aggressive occlusion therapy not only restored monocular acuities of 6/5 but also eliminated the microtropia.17 Adults with microtropia are usually unlikely to benefit from any treatment.18 Special caution is needed in treating any case of adapted strabismus since if the adaptation is broken down, this could result in intractable diplopia.

The management of decompensated microtropia If microtropia breaks down into a larger deviation, or if monofixational heterophoria is decompensated and giving rise to symptoms, treatment for these conditions may restore the microtropia to its compensated and fully adapted state. The situation here is rather analogous to a heterophoria decompensating and the factors described as causing decompensation may be responsible.1 The sensory and motor adaptations to microtropia described above seem to be less well established and less stable in microexotropia and microhypertropia than in the more common microesotropia.19 Practitioners should be particularly alert to the

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possibility of decompensation in non-esotropic microtropia.20 When a microtropia decompensates, symptoms are often alleviated by treatment (exercises, refractive correction, prisms, or surgery)1 to re-establish the original asymptomatic angle.20

Conclusion

Figure 2 Typical Amsler chart appearance in strabismic amblyopia15

Microtropia is a small-angled strabismus with individual cases demonstrating some of the following features: anisometropia, amblyopia, eccentric fixation, HARC, no movement on cover testing (microtropia with identity), peripheral fusion, pseudo-heterophoria, low grade stereopsis and absence of symptoms. The investigation and diagnosis of microtropia includes the 4Δ base out test and a simple modification to the method of this test is recommended to improve the consistency of results. The algorithm in Table 2 may assist clinicians in the diagnosis of microtropia. It is noted that most cases do not require treatment, with an exception being decompensated microtropia, for which management steps are summarised above.

Table 2 Algorithm to assist in the diagnosis of microtropia1 All the following characteristics must be present for a diagnosis of microtropia Angle less than 10Δ Amblyopic eye with morphoscopic acuity at least one line worse than dominant eye, unless alternating microtropia (rare) Eccentric fixation, unless rare alternating microtropia HARC detected by Bagolini striated lens test, or by MARCS test.1 And at least three of the following characteristics should also be present Angle less than 6Δ Anisometropia over 1.50D Microtropia with identity: angle of anomaly = angle of eccentric fixation, so no movement on cover test Monofixational syndrome: apparent phoria movement on cover test Motor fusion: ‘pseudo-fusional reserves’ can be measured Stereopsis of 100” or more on contoured tests such as Titmus circles, or Randot contoured circles Four Δ base out test shows positive response (with appropriate target) Lang’s one-sided scotoma demonstrated with Amsler charts.

Professor Bruce Evans is director of research at the Institute of Optometry, and a visiting professor to City, University of London and London South Bank University. He is a fellow of the

College of Optometrists and holds higher qualifications including, a Diploma in Contact Lens Practice and Diploma in Orthoptics. He has authored over 250 publications, has given over 250 invited lectures, and has authored eight editions of textbooks, including the sixth edition of Pickwell's Binocular Vision Anomalies.

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RETINAL DETACHMENT: ACHIEVING THE BEST OUTCOME WITH POSTURING

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Laura Ford BSc (Hons), MCOptom, Dip TP(IP), Gavin Orr MBchB, MRCP, FRCS, FRCOphth and Anwar Zaman MA, BMBCh, MRCP, FRCOphth

ART

This article outlines ways to achieve best patient outcomes with posturing before as well as after surgery for retinal detachment.

IN BRIEF

INTRODUCTION PRODUCTION CLIENT

Retinal detachments are one of the commonest eye emergencies in the UK, with NICE quoting an annual incidence of 10–15 per 100,000 people.1 Prompt diagnosis and treatment of this condition has significant impact on patient outcomes.1-4 This article reviews the types of detachment, treatment in secondary care, and how the community optometrist seeing a new detachment can contribute to best patient outcomes by having a discussion around pre-surgery posturing, as well as recognising and promptly referring where indicated, cataract-related myopic shifts after detachment surgery.

TYPES OF RETINAL DETACHMENT A rhegmatogenous retinal detachment is caused by a break or breaks in the retina and accounts for a large proportion of retinal detachments. As the vitreous shrinks, it partly separates from the surface of the retina during which time a retinal tear or break can form. Continued traction from the vitreous on the surface of the retina leads to accumulation of fluid entering the subretinal space leading to a rhegmatogenous retinal detachment.1,4-7 A tractional retinal detachment is caused by traction from abnormal vasculature or scars on the retinal surface or within the vitreous cavity and is commonly seen in patients with proliferative diabetic retinopathy.1-2 An exudative retinal detachment is caused by leakage of fluid into the subretinal space, often caused by an inflammatory or malignant factor.1,2 The associations of each classification of retinal detachment can be seen in Table 1.1

SYMPTOMS AND SIGNS OF RETINAL DETACHMENT Symptoms of a retinal detachment may include photopsia and floaters, visual field defects, blurring of vision or metamorphopsia.1,2,5,8 ,9

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Signs may include reduced visual acuity (VA) dependent on macular involvement or the presence of vitreous haemorrhage, asymmetric intraocular pressure (IOP) (up to 5mmHg lower in the affected eye), mild anterior segment inflammation, tobacco dust (Schaefer’s sign), and a pale, opaque, sometimes wrinkled appearance of the detached retina, obscuring the underlying choroidal features. A relative afferent pupillary defect can be present in the case of an extensive detachment.1,2,5,8,9 All patients with new onset or worsening floaters, photopsia, or a recently noticed visual field defect, should be given a dilated slit lamp examination with a condensing lens and appropriate onwards referral if a tear or detachment is found. If the practitioner is unable to perform an adequate examination, then the patient must be referred to someone who is competent to do this. It would be prudent to issue the patient with some written as well as verbal advice, such as the leaflets on flashes and floaters provided by the Association of Optometrists10 and the College of Optometrists.1,2,4,5,8,9 Giving written as well as verbal advice provides a safety net and helps to avoid patient misunderstanding.

TREATMENT FOR RETINAL BREAKS AND RETINAL DETACHMENT INCLUDING POSTURING Retinal breaks tend to be treated with laser or cryotherapy to create a form of scar, adhering the neurosensory retina with the underlying retinal pigment epithelium (RPE). The treatment is very successful but breaks in other areas can develop.2,4,11 Most rhegmatogenous retinal detachments in the UK are treated with pars plana vitrectomy (PPV), scleral buckling or a combination of the two.11 PPV usually involves removing the bulk of the vitreous and hence vitreous traction. The retina is flattened, usually with air, before treating tears or breaks with

CPD 2, 1

PATHOLOGY, POSTERIOR SEGMENT, RETINA

Table 1 Classification of retinal detachment1

Rhegmatogenous

Tractional

Exudative

Caused by a break or breaks in the retina and associated with:

Caused by traction from scars on the retinal surface or within the vitreous cavity and associated with:

Caused by leakage of fluid into the sub-retinal space and associated with:

• Age • Myopia • Cataract surgery • Trauma • Degenerative retinal lesions • Stickler’s syndrome • Juvenile X-linked retinoschisis • Marfan’s syndrome.

• Proliferative diabetic retinopathy

• Inflammatory (scleritis, uveitis) • Hydrostatic (malignant hypertension, toxaemia of pregnancy)

• Proliferative vitreoretinopathy

• Neoplastic (choroidal melanoma, haemangioma, metastasis)

• Retinopathy of prematurity

• Vascular (Coat’s disease, retinal macroaneurysm)

• Penetrating eye injury

• Maculopathy (neovascular macular degeneration, central serious chorioretinopathy)

• Sickle cell retinopathy • Retinal vein occlusion.

laser or cryotherapy, gently burning or freezing the area surrounding the break to form a seal. A liquid is then injected, such as silicone oil or a gas, to act as a tamponade to hold the retina in place while hopefully adherence occurs.1,2,4,6,7,11 Scleral buckling requires localisation of the break or breaks and applying a buckle which indents the sclera. Scleral buckling itself does not cause adhesion, rather it aids the formation of an adhesion due to cryotherapy or laser, by closing the break between the neurosensory retina and the RPE.1,2,4,6,7,11 Success and visual outcomes are directly related to presenting VA, with macula-off detachments likely to achieve poorer visual outcomes. Results are most successful when treatment is initiated prior to macular detachment and hence prompt referral to secondary care on discovery of a break or detachment is of paramount importance. For maculaoff rhegmatogenous cases, visual outcome tends to be better for patients who had three days or less of macula-off, than those with a longer duration of macula-off, with the visual prognosis likely to reduce for each day the macula is detached.1,2,4,6,7,11,12 Figures 1 and 2 (see page 74) shows a left, macula-off, rhegmatogenous retinal detachment.

This 50-year-old female patient had a presenting VA of 0.44 LogMAR in the affected eye, a history of floaters and a noticeable visual field defect that had progressed over the previous seven days. She was a 3D myope with no history of trauma or any other risk factors and IOP was symmetrical. She was listed for a left pars plana vitrectomy, internal tamponade with C3F8 gas, retinotomy, drainage, retinopexy and cryotherapy under local anaesthetic. She was advised to posture face down for 40 minutes per hour for 10 days after surgery. She was assessed at one-week post operatively, then at five weeks where the macula was

• Congenital disorders (nanophthalmos, optic disc pit).

settling well after surgery, with 30% bubble remaining and a pinhole acuity of 0.14 LogMAR (see Figures 3 and 4, page 75).

POST-OPERATIVE CARE Topical antibiotics, corticosteroids and cycloplegics are routinely prescribed post-operatively, and in some patients, ocular anti-hypertensive agents may also be required. The level of vision will be dependent on whether the macula was on or off prior to surgery and the presence of any gas tamponade. Posturing is required for 40–50 minutes per hour for up to 14 days, and sleeping in certain positions may also be necessary. The posturing patient is basically acting like a spirit level and the concept of having to be still can be considered to be outdated with implications that it is the reduction of head movements as opposed to enforcing head positioning which contributes to best patient outcomes. The authors advise that patients can move around while maintaining the postured position.7,13,14 In cases where a gas tamponade has been used, plane travel is not advisable when the gas bubble is present. This is about two weeks for SF6 and four to six weeks for C3F8. Plane travel with oil is allowable. With respect to driving, if a patient has had retinal treatment in both eyes, they must notify the DVLA. While driving may be permitted in patients where vision is adequate in the unoperated eye, requirements state that blurred vision, even if only in one eye, needs to be notified to the DVLA.15 Any patients with queries over driving may be best directed to a discussion with their surgeon and notify the DVLA where applicable.

A patient is usually followed up at one week, four weeks, eight weeks, three months and six months prior to being discharged.

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Figure 1 Focused on intact retina

GUIDELINES FOR REFERRAL OF RETINAL DETACHMENT FROM PRIMARY EYE CARE PRODUCTION CLIENT

The College of Optometrists’ guidance on referral from primary care recommends that for maculaon detachments, emergency referral (ASAP) is warranted.16 For macula-off detachments, emergency referral (within 24 hours) is advised.16 It is sensible to contact the local eye casualty with the patient still in practice and follow their guidance. By discussing with an on-call clinician prior to sending the patient away, a conversation around posturing can take place should there be a delay to assessment in secondary care.4,8,16

REALISTIC TIME TO TREATMENT FOLLOWING REFERRAL FROM PRIMARY EYE CARE In an ideal world, a patient with a macula-on retinal detachment is referred immediately to a vitreoretinal surgeon for prompt assessment and treatment. Preferably, macula-on detachments are repaired on the same day or the following day, and for macula-off patients, within five days.1,3,4,16 The reality in many trusts throughout the UK, due to both on-call arrangements, anaesthetist availability, theatre capacity and availability, is that immediate vitreoretinal assessment and treatment is not always possible. With this in mind, the remainder of this article will discuss the importance of pre-surgery posturing to maximise the potential of the macula staying attached up to surgery.13,14

INDICATION TO POSTURE PRE-SURGERY Pre-surgery posturing is appropriate in acute retinal detachments,4,13,14 particularly with superior breaks and where patients are not going to be assessed by an ophthalmologist immediately. It is prudent to advise such patients to posture, for 50 minutes per hour, with the face on the side of the detachment to the pillow to minimise the detachment from progressing towards

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Figure 2 Focused on detached retina

the macular region. The patient should lie down opposite to the field defect. For example, a patient with a temporal detachment in their right eye should be advised to posture on the right side. If the detachment is superior, the patient obviously cannot lay upside down indefinitely; if the detachment is inferior, the patient cannot always remain vertically upright. So, alternating laying on the left side and the right side would be sensible advice to offer to these patients. For a patient referred from primary care to secondary care on the same day this should be discussed by the oncall ophthalmologist who sees the patient. However, for a patient seen in primary care, late in the day, who the on-call perhaps does not see until the following day, this advice should be given to the patient prior to leaving the optometric practice. Before providing advice regarding posturing, the practitioner should discuss the case with the on-call ophthalmologist in order to offer the best possible guidance to the patient, and document on the records accordingly.

MANAGING PATIENTS WHO HAVE UNDERGONE DETACHMENT SURGERY IN OPTOMETRIC PRACTICE Any detachment surgery causes an acute change in refraction and normally is stable by about two and a half months. A myopic shift usually of around 1D, but up to 3D, is possible with both buckling and vitrectomy. Although rare, an encircling scleral buckle, if very tight, can cause hyperopia.17-19 The presence of a scleral buckle can lead to an increase in axial length with an expected myopic shift in refraction. The refraction can vary for a period of two to three months after which, if anisometropia is tolerable, prescribing can be considered.17,19 Post-gas, the refraction should be stable at around two to three months, when the gas should have absorbed, after which prescribing of a new refraction can be considered. Silicone oil will usually be

CPD 2, 2

PATHOLOGY, POSTERIOR SEGMENT, RETINA

Figure 3 30% C3F8 bubble remaining

removed, and the eye allowed to settle for two to three months before making spectacle changes.18 These timescales can probably be shortened when no suture techniques have been used.

Any patient undergoing intraocular surgery has a strong chance of developing nuclear sclerotic and posterior subcapsular cataract, both of which can progress at a brisk pace. A repeat refraction within three to four months of prescribing is not unreasonable to look for continued myopic shift which is indicative of cataract progression. A progressive myopic shift often means the prescription will continue to change and cataract surgery is usually advisable. Any patient seen in primary care with frequent myopic shifts or reduced VA due to cataract after detachment surgery should be referred back to secondary care for consideration of phacoemulsification.17,19

CONCLUSION It is important that when a patient with symptoms indicative of a potential retinal break or detachment

Figure 4 Repaired retinal detachment

presents, a thorough dilated assessment is provided.

Where no tear or detachment is confirmed clinically, appropriate guidance and written advice should be given. Where a tear or detachment is confirmed clinically, prompt onward referral should be made.

Where a delay in being seen by an ophthalmologist, or being treated, is unavoidable, advice on posturing could have the potential to limit the progression of a tear or detachment towards the foveal area, so should form a significant part of the advice given to patients.

In following up detachment patients in primary care, awareness of myopic shifts from incipient cataract should indicate to the practitioner a need for onward referral back to secondary care for consideration of cataract surgery.

The community optometrist is well placed to recognise these important signs and symptoms, investigate, action prompt referral for treatment and liaise post operatively where refraction is required outside of the hospital setting and myopic shifts due to cataract are identified.

Laura Ford is a specialist optometrist at Nottingham University Hospital, working in a range of core and extended optometric roles, including clinics in cataract, diabetic medical retina, complex and paediatric contact lenses, and diabetic screening.

Gavin Orr is a consultant vitreoretinal surgeon at Nottingham University Hospital .

He undertook a research fellow post at the University of Southern California in 1984 before training in general ophthalmology at Moorfields Eye Hospital between 1985 and 1990. Orr completed his vitreoretinal fellowship at Moorfields Eye Hospital in 1993.

Anwar Zaman is a consultant vitreoretinal surgeon at Nottingham University Hospital. He was appointed in 1999 after completing general ophthalmology training and

research in London, Southampton and Nottingham, along with vitreoretinal fellowship training in Manchester and at Moorfields Eye Hospital.

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PRACTICAL TIPS FOR THE IDENTIFICATION OF DRY EYE

SUBS

Megan Zabell BOptom, MClinOptom

1

CPD

IN BRIEF This article provides the practitioner with simple tips to identify patients suffering from dry eye in a clinical setting

POINT

ART PRODUCTION

Ocular Surface Society (TFOS) in the International Dry Eye Workshop II (DEWS II): ‘Dry eye is a multifactorial disease of the ocular surface characterised by a loss of homeostasis of the tear film and accompanied by ocular symptoms in which tear film instability and hyperosmolarity, ocular surface inflammation and damage, and neurosensory abnormalities play aetiological roles.’7 This means that in order to be classified as dry eye, a patient must have both signs and symptoms of the condition.

Similar conditions that have either signs without symptoms or vice versa, may not strictly be classified as dry eye, but often have overlapping management strategies with a few key differences and will be discussed in forthcoming articles.

CLIENT Getty

INTRODUCTION Dry eye has been described as a modern global epidemic.1 The last decade has shown increasing interest in dry eye research and product development globally,2,3 due to the high prevalence and impact (both on patients’ quality of life and on a larger economical scale) of the condition.4 In the last two years, the impact of the COVID-19 pandemic is likely to have seen a rise in the incidence of dry eye, given the increase of screen time, both due to working from home and social isolation resulting from home confinement, and the emergence of a condition referred to as mask-associated dry eye (MADE).5,6 As such, this article will focus primarily on the identification of dry eye in a clinical setting, including practical tips to detect dry eye sufferers.

It is important to acknowledge the updated definition of dry eye, released by the Tear Film &

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TIP #1: BE FAMILIAR WITH THE COMMON RISK FACTORS Before discussing how to identify dry eye in individual patients, it is good to understand the demographics of the dry eye population and risk factors that may predispose a patient to suffering from the condition. Some risk factors are inherent to the patient, hence non-modifiable, whereas others may be mitigated through changes in behaviour or habits.8 The following are non-modifiable risk factors (or those inherent to an individual) that have strong evidence associated.

Sex, gender and age It is well known that dry eye is more commonly observed among the older population – the prevalence increases linearly with age and this is particularly noticeable after age 50.8 The increased prevalence with age is thought to be due to a natural reduction in the tear volume produced, as well as age-related atrophy

CPD 3, 1

COMMUNICATION, DIAGNOSTICS, DRY EYE

or keratinisation of the meibomian glands, meaning that the dry eye experienced with age can be aqueousdeficient (ADDE), evaporative (EDE), or mixed.9 As the prevalence of dry eye increases with age it is known that females tend to be affected more than males.8 In terms of sex,* this is linked to the differences in expression of the sex steroids such as androgens and estrogens.10 Further evidence of this has been shown in the increased incidence of dry eye in males (usually elderly) who experience andropause, or are in an androgen-depleted state.11 It is interesting to know that gender** has also been linked to dry eye prevalence, with women being at higher risk of dry eye. This association is more complex but is thought to be related to a number of factors including access to care and gendered behaviours such as seeking care.10 Although age is one of the most consistently reported risk factors for dry eye, with prevalence increasing linearly with age, the TFOS DEWS II epidemiology report highlights a surprisingly high prevalence in the younger cohort of school-aged children.8 Among this cohort, female sex and gender appear to be more affected compared to males,12 and although digital device use is postulated as a contributing factor, more studies need to be completed.8 Ethnicity It has been consistently reported, from the original TFOS DEWS report in 2007 through to DEWS II in 2017, and in current research, that people of Asian ethnicity are more likely to suffer from dry eye compared to their Caucasian counterparts.8,13,14 As with other dry eye factors, this gap becomes more apparent in older populations. The reason that Asian patients are more likely to suffer dry eye is thought to be linked to higher levels of eyelid tension, which in turn affects meibomian gland function and leads to EDE more often than ADDE.14 Systemic conditions – Sjögren syndrome (SS) and connective tissue disorders Connective tissue disorders are a group of systemic auto-inflammatory diseases including rheumatoid

arthritis, systemic lupus erythematosus and SS.15 Patients with mixed connective tissue disorders often have concurrent SS,16 an auto-immune condition that affects the exocrine glands and causes severe dryness of the eyes and mouth, among other symptoms.17 The relationship between dry eye and SS is clear, with reduced tear production causing ADDE; however, further investigation is ongoing into the pathophysiological pathways and how much EDE is also associated with SS.9 Of note is that SS, like dry eye, occurs more commonly in those of female sex compared to male.9 The modifiable risks strongly associated with dry eye should be taken into account not only when identifying dry eye cases, but also when counselling patients who have been diagnosed.

As this article focuses on the identification of dry eye, so will the discussion of modifiable risk factors for dry eye.

Computer use Particularly relevant for many patients in current times is that the use of visual display units (VDUs), such as the screens of computers, laptops, tablets and other mobile devices, has been associated with dry eye symptoms.8 There are several factors hypothesised to contribute to the dry eye symptoms caused by VDU use, including reduced blink frequency and an increased proportion of incomplete blinks, which leads to excessive evaporation of the tear film, resulting in dry eye.18,19 As working from home, as well as home confinement due to the COVID-19 pandemic has led to a rise in screen time,5,6 it is highly likely that many patients presenting will have this risk factor in their history.

Various medications and medical treatments As mentioned in the non-modifiable risk factor section, dry eye appears to be more prevalent in ageing females. While this is partially due to factors such as age-related atrophy of the lacrimal and meibomian glands, and the sex steroids expressed by females, it has also been shown that hormone replacement therapy (HRT), in particular oestrogen supplementation alone, has been linked to dry eye.20 HRT has decreased in popularity over the last few

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decades as various studies have suggested links between different HRT combinations and certain cancers.21 Other medications that have been strongly correlated with dry eye disease (DED) include antihistamines, antidepressants, anxiolytics and isotretinoin.8 Isotretinoin, taken orally as a therapy for severe acne, and as a chemotherapy agent, is expressed in the lacrimal gland and contributes to atrophy of the meibomian glands, leading to EDE.22 Antihistamines are thought to be related to dry eye due to their antimuscarinic activity reducing tear flow and production.23 While the link between anxiolytics, antidepressants and dry eye depends on the drug or class of drug, benzodiazepines are thought to be linked to dry eye through a combination of binding to the muscarinic receptors of the lacrimal system and reducing tear outflow, along with possible immunemodulated side effects due to their antigenic nature.22 Allogenic hematopoietic stem cell transplantation is a procedure to treat a number of haematological malignancies as well as other life-threatening haematological diseases.24 As the procedure has improved over time since its inception, the survival rate has increased, as has the number of recipients living with some of the more serious side effects such as graft versus host disease.8 The eye is a common target site of graft versus host disease, with more than 50% of recipients developing DED six to 24 months after transplantation.24 Environmental factors The environment in which a patient lives and works can have an impact on dry eye. It has been shown that consistent exposure to very low humidity increases rates of dry eye,8 while conversely, a moist environment is healthier in terms of dry eye;25 this may be of importance for patients who work in ‘clean rooms’ or similar environments. There have been several studies highlighting that air pollution, in particular the level of particulate matter in the outdoor environment, can also affect dry eye in the population, although further research is needed to find out the precise level of impact.26

TIP #2: ASK THE RIGHT QUESTIONS IN HISTORY

While understanding that a person is at higher risk of dry eye can make it easier to spot those who could possibly be sufferers, an important requirement for diagnosis is the presence of key symptoms.7 There are many ways to identify symptoms of dry eye in

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a clinical setting with the simplest being through routine questioning as a regular part of history-taking.

The symptoms of dry eye can be non-specific and inconsistent, but many of the common symptoms should be familiar given their prevalence in the community, including ocular discomfort, grittiness, burning, foreign body sensation and watery eyes or epiphora.27 It can become easy to incorporate questioning or probing of these symptoms into the general eye examination in the ocular history section.

However, it is recommended that dry eye symptoms, if present, should be quantified in clinical records, in a similar matter to the way ocular surface signs are recorded.28

TIP #3: PICK A SYMPTOM QUESTIONNAIRE AND USE IT ROUTINELY

This can be done using any of a number of available dry eye questionnaires, four of which will be discussed in the following paragraphs. While each questionnaire has separate benefits and drawbacks, the same questionnaire should be used for consistency, as the results of each are not interchangeable. For simplicity, the questionnaires listed are those that were found to have sufficient patient-reported outcomes and include questions on health-related quality of life in a recent review.29 One of the benefits of a dry eye questionnaire is that it can be administered by support staff prior to the eye examination, or self-administered by the patient, as long as there is ample opportunity for the patient to ask questions when needed.

Ocular surface disease index (OSDI) The OSDI was developed in 1997, and while early iterations of the form involved 40 items, subsequent studies facilitated the reduction to a 12-item questionnaire.30 The items assess three different categories that may be affected by the presence of dry eye symptoms: ocular symptoms, vision-related functions or limitation, environmental triggers, and their frequency over the week before taking the questionnaire.8 The OSDI is one of the most commonly-used questionnaires in dry eye research;28 however, some of its limitations include no questions relating to the psychological and social aspects that dry eye may have on a sufferer’s life.8 While it can be used to measure the symptoms of dry eye, it should not be a reliable indicator as to the impact that dry eye is having on a patient’s quality of life.8 The OSDI has been validated in eight languages.29

CPD 3, 2

COMMUNICATION, DIAGNOSTICS, DRY EYE

Impact of dry eye on everyday life (IDEEL) IDEEL was developed in 2003 with the aim to more comprehensively cover the aspects of a patient’s life that may be impacted by dry eye symptoms.31 It also aims to investigate both satisfaction with, and bother caused by, any current dry eye treatment and covers the period of the two weeks preceding the questionnaire being completed.29,31 Although it is very comprehensive, the length of the IDEEL questionnaire often prevents it being used in an everyday clinical setting, given that it includes 57 items and can take up to 30 minutes to complete.8 IDEEL has only been validated in English so far.29 25-item National Eye Institute’s Visual Function Questionnaire (NEI VFQ-25) The NEI VFQ-25 was developed in 2001 and assesses a patient’s health-related quality of life without any set time frame, unlike many other tests which usually refer to one to two weeks before the questionnaire is being completed.29 As the NEI VFQ-25 was not developed specifically to assess dry eye symptoms, there is no designated cut-off in the symptom score for dry eye, but it has been found that patients with moderate dry eye had a lower ocular pain score than those with mild dry eye (where a low score indicates better function).8,29 The NEI VFQ-25 has been validated in more than 50 languages, but needs further validation and testing in dry eye-specific cohorts.8 Dry eye-related quality-of-life score (DEQS) The DEQS is a 15-item questionnaire that was developed in Japan in 2013, in order to assess the impact of dry eye symptoms on everyday life in the week preceding the survey being taken.8,29 Although the questionnaire was specifically developed in order to meet the criteria defined by the Japanese Eye Society and could be used in everyday clinical practice to evaluate how dry eye affects the daily life of patients, it has not been validated in languages other than Japanese, or in a population outside of Japan.8,29

CONCLUSION

The first step in the journey of managing dry eye is of course, to identify sufferers. Some patients may come armed with a complaint that makes it quite obvious that dry eye is at least part of their problem, but not every case will be as straightforward.

Knowing that older patients, women and females, and those of Asian ethnicity are at higher risk of dry eye is a good start, but it is also important to bear in mind that dry eye sufferers are also likely to be the younger cohort with plenty of exposure to digital screens, those whose occupation or lifestyle involves a low-humidity environment, or when the particulate matter in the ambient air increases. Certain health conditions or medications could also pre-dispose a patient to having dry eye, including connective tissue disorders, SS, or those taking antihistamines, anxiolytics, anti-depressive mediations, HRT, or isotretinoin. It wouldn’t be dry eye without symptoms and confirming the presence of these could be as simple as routine questioning during a patient history. However, it may be more suitable to use a validated dry eye questionnaire as they can be used to monitor the effect of treatments and can also be administered by support staff. There are plenty of high-quality questionnaires available and consistency in which type is used is important.

FOOTNOTES

* In this article, the term sex is used to differentiate the biological differences between female and male ** In this article, gender refers to a person’s selfrepresentation in society as a man or a woman.

In order to correlate with currently available studies only these two genders are being considered, although the author acknowledges that gender is considered by many to exist outside of this binary.

Megan Zabell graduated as a therapeutically endorsed optometrist from the University of Melbourne before beginning work in a private optometry practice alongside teaching pre-clinical optometry skills at her alma mater. Zabell’s passion in diagnosing and treating dry eye,

as well as driving awareness of contact lenses led her to join Alcon’s professional affairs team in 2018. She has also recently completed her master’s degree in clinical optometry, again at the University of Melbourne.

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BIFOCAL LENSES: ARE YOUR STANDARDS UP TO STANDARD?

SUBS

1

Jim Cox FBDO

CPD

POINT

ART

IN BRIEF This article provides an overview of the standards that relate to bifocal and trifocal spectacle lenses.

INTRODUCTION PRODUCTION CLIENT

In a previous article (OT, February/March 2022), the interpretation and application of ISO tolerances for single vision lenses were covered. This article will consider the tolerances that apply to bifocal and trifocal lenses.

In ISO terminology, bifocals and trifocals are termed ‘multifocal’ lenses; this can be confusing as in practice progressive lenses are often referred to as multifocals.

In ISO terminology, progressive and degressive lenses are referred to as ‘power variation lenses.’

BS EN ISO 21987:2017 is the current standard that should be used when checking glazed and mounted spectacle lenses.1,2 While this standard should be used for checking all mounted spectacles, care should be taken to ensure that the correct table is used for the lenses being tested.

Of course, bifocal and trifocal lenses are, as the name suggests, lenses with two or three focal powers, respectively. Traditionally a bifocal would have a distance prescription in the top portion of the lens and a near prescription in the lower segment. However, it is fairly common to see an intermediate/near bifocal. In this instance, for verification purposes, the intermediate portion should be treated as the distance power, with the difference in sphere power between the intermediate and the near portions used to verify the add power.

A trifocal has the addition of a small segment above the near portion that carries an intermediate power, which is typically 50% or 60% of the near addition power. For example, a trifocal with a 50% intermediate power, in a lens with a +2.50D near add would be expected to have an add of +1.25D

D B to D = 10mm B

Seg top to B = 5mm

D

B to D = 10mm

CC

Seg top to B = 5mm

N to seg top = 5mm

N to seg top = 5mm

N

N to B = 1.25mm

B to D = 1.25mm

Figure 1 Reference points for verification of bifocal lenses where B is the point of rotational symmetry, D is the verification point for the distance power and N is the verification point for the near power

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T

N

N to B = 1.25mm

B to D = 1.25mm

Figure 2 Reference points for verification of trifocal lenses where B is the point of rotational symmetry, D is the verification point for the distance power, T is the verification point for the intermediate power and N is the verification point for the near power

CPD 4, 1

DISPENSING

Table 1 Tolerance of principal powers and absolute cylinder for glazed and mounted spectacles for single vision and multifocal lenses

Power of principle meridian with higher absolute back vertex power

Tolerance on the back vertex power of each principal meridian

≥0.00 and ≤3.00

Tolerance on the absolute cylinder power ≥0.00 and ≤0.75

>0.75 and ≤4.00

>4.00 and ≤6.00

>6.00

±0.12

±0.09

±0.12

±0.18

-

>3.00 and ≤6.00

±0.12

±0.12

±0.12

±0.18

±0.25

>6.00 and ≤9.00

±0.12

±0.12

±0.18

±0.18

±0.25

>9.00 and ≤12.00

±0.18

±0.12

±0.18

±0.25

±0.25

>12.00 and ≤20.00

±0.25

±0.18

±0.25

±0.25

±0.25

>20.00

±0.37

±0.25

±0.25

±0.37

±0.37

in the intermediate section. BS EN 21987:2017 section 6.2 details that ‘the distance portion of multifocal lenses shall be verified with the back surface of the lens against the focimeter’s lens support’, which is the same as for single vision lenses. However, the approach changes when it comes to the verification of the add.

The standard also states in section 6.4.2 that ‘the surface on which the segment is located shall be chosen as the reference surface.’ From these two statements, it is clear that the distance power should be checked on the back surface and the add power on the surface which carries the segment. Most commonly the segment is the front surface, although for some bifocals it can be on the back surface; this means that for the majority of bifocal or trifocal lenses they should be turned over and measured from back to front. To be clear, the distance power should be verified as normal from the backside of the lens, that is to say, with the front of the frame facing the practitioner, but when working out the add power, both portions of the lens should be measured on the side that carries the segment and the difference between the distance

and near spheres on this side used to calculate the add power.

BIFOCALS As well as advising which surface to measure from, ISO guidance also provides details of the point on the front or back surface where the powers should be measured. Figure 1 sets out three specific reference points on the bifocal lens. These reference points tell us where the powers of the lens should be measured: • N is the near reference point. If not identified by the manufacturer, then a point 5mm down from the centre of the segment top should be used • B is the point of rotational symmetry; this is found by measuring the distance vertically from N to the segment top and then by the same distance again up the lens, and out by half the inset of the segment (inset is usually between 2 and 2.5mm, so 1 to 1.25mm). D is found by measuring the distance NB again from B towards D • D is the distance reference point where the distance power should be verified on the back surface of the lens.

Table 2 Tolerance of cylinder axis for glazed and mounted lenses

Absolute cylindrical power (D)

<0.12

≥0.12 and ≤0.25

>0.25 and ≤0.50

>0.50 and ≤0.75

>0.75 and ≤1.50

>1.50 and ≤02.50

>2.50

Tolerance on the direction of the cylinder axis (°)

No requirement

±16

±9

±6

±4

±3

±2

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If a manufacturer of a bifocal stated that the optical centre of the near segment was 11 mm from the segment top (for a round 22mm bifocal) then N would be positioned 11 mm down from the top centre of the segment. If this same bifocal had an inset of 2mm then B would be 11mm above the top centre of the segment and displaced 1mm out. D would then be found 11mm above and 1mm out from B. D is 22mm above and 2 mm out from N. The measured power should be verified using Table 1 of BS EN 21987:2017. For example, a pair of spectacles have been ordered with powers of: R -3.50/-1.25 x 45 Add 2.50 L -3.75/-2.50 x 50 Add 2.50 The first step is to find the principal meridian with the highest absolute power in each lens. In this case, it is -4.75D along 135 in the right lens and -6.25D along 140 in the left lens; this means that the second row in Table 1 should be used for the right lens and the third row for the left lens. Once the highest principal power for each lens has been identified, the next step is to check the power in each meridian.

For the right lens, powers of -3.50D and -4.75D would be expected, and for the left lens, -3.75D and -6.25D. For all of these powers, there is a tolerance of ±0.12D. The cylindrical powers are 1.25D in the right lens and 2.50D in the left; the standard details a tolerance of ±0.12D for the right lens but ±0.18D for the left.

Remember this is for the cylindrical power, where the difference between the measured principal powers is taken into account. Consider, for example, the following scenario for the right lens: • The first principal power measures -3.61D versus the ordered power of -3.50D, which is within the ±0.12D tolerance and, therefore, passes this aspect of the standard • The second principal power measures -4.63D versus the ordered power of -4.75, which is also within the ±0.12D tolerance and, therefore, passes this aspect of the standard • For the cylinder power, the difference between the measured principal powers of -3.61D and -4.63D is

Table 3 Tolerances – addition power or variation power

Value of the addition power or variation power (D)

≤4.00

>4.00

Tolerance

±0.12

±0.18

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1.02D versus an ordered cylinder power of 1.25D and, therefore, fails the standard.

In short, it is possible for each principal meridian to pass and the cylinder to fail, and vice versa, highlighting why a three-point check is important.

Next, the axis tolerance, which is detailed in Table 2, needs to be considered. The standard specifies that for a lens with a cylindrical power of >0.75D and ≤1.50D, a 4° tolerance applies in either direction of the ordered axis position, whereas for a cylindrical power of 2.50D, the tolerance is 3° either side; this means that for the example given, the axis for the right lens can be anywhere between 41° and 49°, and for the left lens, between 47° and 53°.

Once it has been confirmed that the distance prescription at point D is correct, the add power can now be checked. As outlined previously, most bifocal/ trifocal lenses will have the add power on the front surface of the lens and so the front surface of the lens should be placed on the focimeter mount. If the lens is a rear surface bifocal, then the rear surface should be placed on the focimeter mount. Sometimes, the manufacturer will nominate on which surface the addition power should be checked so, if in doubt, it is worth checking with the lab.

The first step is to locate point N, which if not provided by the manufacturer, should be a point 5mm down from the centre of the segment top. At this point, the sphere power for highest principal meridian should be recorded. Then, the lens should be moved to point D (still on the same surface) and the sphere power recorded in the same meridian. The sphere power at D should be subtracted from the sphere power at N to arrive at the add power.

Consider another example where a pair of spectacles have been ordered as a C28 bifocal lens in CR39, with segment heights at 15mm from lower rim and powers of: R +2.50/-1.50 x 35 Add 2.25 OC 32 L +2.75/-1.50 x 40 Add 2.25 OC 32 As before, step one is to measure the principal powers at point D on the rear surface of the lens. For the right lens, powers of +2.50D and +1.00D would be expected, and for the left lens, +2.75D and +1.25D. For all of these powers, there is a tolerance of ±0.12D. In this example, the measured principal powers were: • R +2.58D and +0.99D both of which are within ±0.12D and so pass this aspect of the standard • L +2.74D and +1.30D both of which are within ±0.12D and so also pass the standard in this regard.

CPD 4, 2

DISPENSING

Table 4 Tolerance of prism power for glazed and mounted single vision appliances. Tolerance values in prism dioptres (∆)

Highest ordered prism component

Tolerance (prism dioptres at the ordered centration points) Horizontal component

Vertical component

Powers ≥0.00 to ≤3.37D

Powers >3.37D

Powers ≥0.00 to ≤5.00D

Powers >5.00D

≥0.00 to ≤2.00

± 0.67

±(0.2 x S)

±0.50

±(0.1 x S)

>2.00 to ≤10.00

±1.00

±[0.33 + (0.2 x S)]

±0.75

±[0.25 + (0.1 x S)]

>10.00

±1.25

±[0.58 + (0.2 x S)]

±1.00

±[0.50 + (0.1 x S)]

Note 1: Tolerances are determined by the highest absolute principal power of the pair of lenses Note 2: (0.2 x S) corresponds to the prismatic effect of 2mm displacement, while (0.1 x S) corresponds to the prismatic effect of 1mm displacement

For step two, the cylinder should be verified. In this example, the expected powers are 1.50D for both the right lens and left lens with a corresponding tolerance of ±0.12D. The difference between the principal power meridians is 1.59D and 1.44D for the right and left lenses, respectively, so both lenses meet the standard for the absolute cylinder power.

The axes were found to be R x 37 and L x 42 so both are within the 4° tolerance limits and, therefore, pass the standard.

The final step is to check the add power. As this is a front surface bifocal, the lenses should be turned over, placing the segment over the focimeter aperture at position N. Find the highest power in the segment, move the lens from position N to position D, on the same surface, and measure the power in the same meridian. Then subtract the power at D from the power at N. The expected add power in the example given is +2.25D, and from Table 3, the tolerance given is ±0.12D. If the measured power is +4.89D along 35 at position N and then +2.50D along 35 at position D (remember that the front vertex power is being measured so it should not be the same as the earlier rear surface measurement from step 1) then subtracting 2.50 from 4.89 gives an add power of 2.39D. As the expected add is 2.25D, this is outside the tolerance of ±0.12D.

TRIFOCALS Trifocals should be treated like bifocals except for there being two add powers to verify, with the intermediate add often specified as a percentage of the near add.

Points N, B, and D will still need to be considered as with the bifocal example. For the intermediate add, the position of measurement should be in line with B and at the vertical midpoint of the intermediate section (see Figure 2). Both additions should be checked to the tolerances as before.

Consider the example of a front surface segment D35 trifocal with a 14mm upper intermediate portion (D1435) and an intermediate add that is 60% of a near add power of +2.25D. The expected intermediate add power should, therefore, be +2.25D x 0.6 = +1.35D. The distance powers and near add should be checked as in the previous example. Then, to verify the intermediate add, turn the lens over as with the near add and measure the power at point D then moving the lens to point T. The difference in spherical values at these points will be the add power for the intermediate portion of the lens. As with bifocals, the tolerance for an add of this power is ±0.12D, so measures between +1.23D and +1.47D will pass the standard.

PRISM Prism for bifocals and trifocals should be checked in the same way as with single vision lenses. Before placing the spectacles on a focimeter, the distance

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CPD 4, 3 VERSION REPRO OP SUBS

“IT IS POSSIBLE FOR A PAIR OF LENSES TO FAIL INDIVIDUAL PRISM TOLERANCES BUT PASS WHEN THE COMBINED PRISM IS CONSIDERED”

ART PRODUCTION CLIENT

centration points should be marked on the lenses and any prism found at this point should be checked against the tolerances. For most bifocals or trifocals this will be all that is needed as any prism in the distance portion will be mirrored in the near segment.

However, for prism-controlled bifocals the amount of prism in the distance and near sections will vary; therefore, the prism tolerance will need to be checked twice, once at the distance centration point, and again at N, using the highest principal powers in each respective portion of the lens.

Consider the following example: R -7.50 1.00Δ IN Add 2.50 OC 33 L -8.00 1.50Δ IN Add 2.50 OC 33 The measured prescription at the distance centration point is: R -7.49 1.12Δ IN L -8.01 1.59Δ IN Referring to the prism tolerances (see Table 4), the highest ordered prism component is 1.50Δ so the tolerance is ±(0.2 x S) where S is the highest absolute principal power of the pair of lenses. In this case, S is equal to 8.00, so the tolerance is ± (0.2 x 8) = 1.6Δ.

This means the prism tolerance range in this example is from 0 to 3.10Δ IN. Although 1.50Δ – 1.60Δ would result in 0.10Δ OUT, a reverse in base direction cannot be passed. Individually each lens will pass, but what happens when the combined (relative) prism is considered? The combined prism ordered horizontally in this example is 2.5Δ IN so the tolerance is found in the second row of Table 4 which is: ± [0.33 + (0.2 x S)] ± [0.33 + (0.2 x 8)] = ±1.93Δ The tolerance range in this example is 0.57Δ IN to 4.43Δ IN, against a measured horizontal prism of R 1.12Δ IN + L 1.59Δ IN = 2.71Δ IN, so this lens

passes the standard. It is possible for a pair of lenses to fail individual prism tolerances but pass when the combined prism is considered. This is seen most commonly in progressive lenses with thinning prism.

It is important to remember that it is the combined prism value that takes priority when checking.

POSITIONING

As well as ensuring that the power and axis values are within tolerance, the position of the segments should also be checked. Vertically, the segment top positions should be within ±1mm of the ordered position. Any difference between the two should be no more than 1mm relative to any ordered difference. If, for example, segment heights were ordered at 18mm and 20mm from the lower tangent for the right and left lenses, respectively, and were received at 19mm in both, this would not pass. Although each segment individually is within 1mm of its ordered position, there was an ordered separation of 2mm. Therefore, the minimum acceptable difference between the two lenses is 1mm.

Horizontally, the midpoint of the segment top should be ±1mm from the ordered monocular centration point. Importantly, the horizontal position of both segments should appear symmetrical and balanced unless unequal monocular centration distances or geometrical insets are ordered. In this case, unless it was ordered that way, if it looks wrong, it probably is.

CONCLUSION This article provides a refresher on how the standards for the verification of bifocals and trifocals should be applied in practice ensuring that practitioners meet their obligation to patients when supplying optical appliances.

Jim Cox is a dispensing optician and has worked in both multiple and independent practice as well as the manufacturing industry. During his career, he has been a store manager, area

manager and business owner. Currently he works as vice president of business support for Eyoto Group Ltd.

84 www.optometry.co.uk

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VERSION REPRO OP

RETINAL CASES IN SECONDARY CARE Sharita Jhummun BSc (Hons), MCOptom, DipTP (IP), Prof Cert Med Ret and Sonal Amin BSc (Hons), MCOptom

SUBS

IN BRIEF This article presents a range of retinal abnormalities seen within the hospital eye service. Readers are invited to review the images and use additional resources where necessary to answer the questions.

IMAGE A

1

CPD

POINT

IMAGE B

ART PRODUCTION CLIENT

A 76-year-old female patient was referred to the hospital eye service (HES) due to reduced vision in her right eye. Optical coherence tomography (OCT) revealed an incidental finding in her left eye. Visual acuities were: R 0.68 pinhole (PH) 0.60; L 0.02 pinhole no improvement (PHNI).

01 Which of the following best describes the OCT shown for the left eye? a) Diabetic macular oedema b) Central serous chorioretinopathy c) Macular telangiectasia type 2 d) Central retinal vein occlusion with macular oedema 02 What treatment would be considered for this patient? a) Laser treatment b) Intravitreal injection c) Course of topical steroids d) No treatment available 03 Which other ocular finding can be associated with this condition? a) Choroidal neovascular membrane b) Bullous keratopathy c) Cataract d) Uveitis

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A 70-year-old female patient was referred to the HES by her optometrist for cataract surgery due to a steady decline in her general vision. Visual acuities were recorded as R 6/24 PHNI; L 6/15 PHNI. 04 What is the most likely diagnosis? a) Cystoid macular oedema b) Branch retinal vein occlusion with intraretinal fluid cysts c) Late-onset Stargardt disease d) Pigment epithelial detachment 05 After diagnosis at the hospital, which of the following would this patient benefit from? a) Signposting to RNIB resources b) Low vision clinic c) Genetic testing and counselling d) All of these options 06 The patient has experienced a slight deterioration in vision over the last two years, but OCT remains stable. When should the patient next be reviewed? a) One day b) One week c) One month d) Six months

II1 IMAGE C

IMAGE D

A 55-year-old male patient was seen at the local diabetic eye screening programme (DESP) complaining of reduced vision in his right eye for the past few months. His visual acuity was recorded as 6/12 in this eye.

07 What features of diabetic retinopathy can be seen in the image? a) Pre-retinal haemorrhage b) New vessels on the disc c) No diabetic retinopathy d) Small exudates within the macular area 08 According to England DESP grading definitions for referable disease, what would be the grade in this case? a) R2M1 b) R0M0 c) R3AM1 d) R1M0 09 What would be the timescale for referral from the DESP to the HES? a) Same day b) Two weeks c) 13 weeks d) Six months

A 65-year-old male patient has returned to the HES four weeks after being treated with an intravitreal injection to his left eye.

10 What is the most likely condition that the patient is being treated for? a) Geographic atrophy b) Choroidal neovascular membrane c) Branch retinal vein occlusion d) Proliferative diabetic retinopathy 11 Given the findings in the image, what is the most likely side effect that has occurred from the intravitreal injection? a) Anterior uveitis b) Retinal vasculitis c) Increased intraocular pressure d) Endophthalmitis 12 What is the most likely management? a) Start course of topical antibiotics b) Continue with loading course of intravitreal injection c) Fundus fluorescein angiography d) Start course of oral steroids

Sharita Jhummun is the clinical lead for orthoptic and optometry services at Central Middlesex Hospital. Her clinical specialities include diabetic retinopathy,

IMAGE INTERPRETATION

OCT, PATHOLOGY, RETINA

corneal and macular services.

Sonal Amin is a specialist optometrist at Central Middlesex Hospital.

Her clinical specialities include macular and post-operative cataract services.

Amin is also a visiting clinical tutor at City, University of London.

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VERSION REPRO OP

ALL ABOUT THE EYELIDS Alan Hawrami BSc (Hons), MCOptom, Prof Cert Glauc, DipTP (IP)

1

CPD

POINT

SUBS

This article features a series of clinical cases centred around abnormalities of the eyelids. Readers are invited to review the images and access additional resources where necessary to answer the questions.

IN BRIEF

ART

IMAGE A

IMAGE B

PRODUCTION CLIENT

A 65-year-old female patient attended for a routine sight test.

During the examination, the finding in the image is noted.

A 75-year-old male patient attended as he has been experiencing a constant watery eye for the past two years.

01 What is the most likely diagnosis? a) Cyst of Moll b) Cyst of Zeis c) Hordeolum d) Chalazion

04 What is the most likely cause of the symptoms? a) Entropion b) Ectropion c) Blepharitis d) Dermatochalasis

02 Where does this finding originate from? a) Apocrine sweat gland b) Sebaceous gland c) Eyelash root d) Epidermis

05 A referral is made to ophthalmology. What relief can be provided to the patient while they wait for an appointment? a) Regular daytime topical lubrication b) Nightly topical paraffin-based ointment c) Taping the eyelid shut at night d) All of these options

03 If the patient is asymptomatic and unconcerned by the lesion, what would the most appropriate management be? a) No further management required b) Routine referral to ophthalmology for biopsy c) Treat with topical antibiotics d) Refer urgently to eye casualty

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06 What is the most likely management option to be offered by the ophthalmology department to resolve the issue? a) Long-term bandage contact lens b) Eye shield c) Eyelid surgery d) No treatment required

II2 IMAGE C

IMAGE D

A 50-year-old female patient attended with concerns over a lesion on her eyelid.

A 62-year-old patient attended for a sight test complaining of intermittent watering and some soreness of the right eye.

07 Which of the following questions would be useful to aid in the management of this patient? a) How long has the lesion been present? b) Has the lesion ever bled? c) Are there any similar skin lesions on other parts of the body? d) All of these options

10 Which of the following signs is likely to raise suspicion towards a malignant lesion? a) Bulbar conjunctival redness b) Lid ulceration c) Increased tear prism height d) None of these options

08 The lesion in the image is diagnosed as a benign eyelid papilloma. Which of the following features is not typically present in this condition? a) Soft to touch b) Pedunculated c) Ulceration d) Flesh-coloured 09 What is not typically a sign of suspect lesion malignancy? a) Hair growing from the lesion b) Madarosis c) Bleeding d) Change in lesion colour

11 What other condition can cause a similar finding to the image above? a) Meibomian gland dysfunction with gland dropout b) Entropion c) Pyogenic granuloma d) Verruca vulgaris 12 Which of the following is not a type of malignant lesion? a) Squamous cell carcinoma b) Melanoma c) Sebaceous carcinoma d) Seborrhoeic keratosis

IMAGE INTERPRETATION

PATHOLOGY

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. Hawrami is also undertaking a master’s degree in advanced clinical optometry and ophthalmology at University College London.

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CPD EXIT VERSION

CPD AUTHOR SPOTLIGHT

“I’D LIKE TO SEE THE EXPANSION

REPRO OP

OF THE SCOPE OF PRACTICE”

MEGAN’S 10-SECOND CHALLENGE

Megan Zabell SUBS

OPTOMETRIST

ART

Why did you become an optometrist?

I wanted to study a course that was not available in the university of my hometown of Darwin, Australia, in order to try and push myself out of my comfort zone. I knew I wanted to study something medicine-adjacent, but had no true interest in becoming an MD. It was a science summer school, held in Melbourne, that I attended in year 11 that helped me decide on optometry.

PRODUCTION

What is the biggest challenge that you have faced in your career to date?

Reconciling the reality of optometry as being in a unique position where we’re a mix of retail and healthcare, compared to the pure clinical healthcare model that we were taught at university. I now appreciate that it’s important to understand the retail/business side of optometry, although it was a steep learning curve after graduation.

CLIENT

If you could change one thing about optometry, what would it be and why?

In Australia, I’d like to see the expansion of the scope of practice of optometrists, to allow us to better serve our patients and reduce the waiting time for certain ophthalmological services. This comes with a caveat: it

Face-to-face or Teams? Face-to-face Tea or coffee? Coffee Cats or dogs? Dogs Early bird or night owl? Night owl Staycation or vacation? Vacation Savoury or sweet? Sweet Bake off or Masterchef? Bake off. would need to come with change to both the training and assessment of optometrists, perhaps, to ensure patient safety is protected.

Who inspires you?

My parents, my late grandmother, and my partner. They all have different positive qualities that I try to emulate and develop in myself – patience, storytelling abilities, kindness and an easy-going attitude.

Tell OT about one of your hobbies: I have an oddball collection of hobbies. If I were to pick one it would be my love of learning languages – currently I’m learning Telugu, Spanish and Auslan (or Australian sign language).

What are you watching at the moment?

I’m re-watching Offspring, an Australian TV show.

OT currently has a wide range of CPD available online covering all domains n Charles Bonnet syndrome and the patient in practice n Cataract surgery: discussing refractive outcomes with patients

n A day with the orthoptist in urgent care n Scleral lens fitting: where should we start? n INTERACTIVE: Myopia: putting the evidencebase into pratice.

LIVE CPD

The CPD articles are available at www.optometry.co.uk/CPD

CPDS COMING UP IN OCTOBER/NOVEMBER n How HeadSmart are you?

Dr Deborah Armstrong n Communication in optometry Lorcan Butler n Adverse effects of periocular aesthetic treatments Sonali Nagendran, Mohammad Javed Ali, Murat Dogru, Raman Malhotra n Myopia management in clinical practice Prashant Shah and Yashita Shah.

90 www.optometry.co.uk

Dr Ian Beasley is the clinical editor for OT and head of education for the AOP. He began his career as an optical technician and later went on to train as a dispensing optician before 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. He is a visiting lecturer at Aston University, 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 CPD article?

Email the clinical editor ianbeasley@optometry.co.uk

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91OPTAUG22147.pgs 02.08.2022 15:11

Jobs VERSION REPRO OP

Jobs

www.optometry.co.uk/jobs

SUBS

MY CAREER ADVICE

ART

“WHILST WORK EXPERIENCE IS DESIRABLE, ATTITUDE IS FAR MORE IMPORTANT” Managing partner at Haine & Smith, Angela Davey, explains why attitude is everything for new recruits at the optical group

PRODUCTION

What is the one piece of advice that you would give to someone who wants to work for Haine & Smith?

Patient care, and being a team player, must be at the heart of all they do.

CLIENT

When you are shortlisting candidates, what is the first thing that you look for?

Enthusiasm, with flexibility as a second. They must also have a passion for working with people. Whilst work experience is desirable, attitude is far more important.

How important is the cover letter in applications that you receive?

Very. You can get a feel for a person with the cover letter.

We are always surprised by the number of letters that haven’t been spell checked or read through before sending. We would definitely recommend doing this, along with checking the spelling in the CV itself.

Always start by introducing yourself, and tell us why we should employ you.

I would be looking for an engaging and enthusiastic introduction. Let us know why you are the most suitable candidate, and give examples of your successes and what you enjoy

most. This will help to show your engagement and commitment. Finish your covering letter with the key points discussed.

How important is employee wellbeing at Haine & Smith?

Employee wellbeing is a key focus for us at Haine & Smith. Our priority is to provide excellent patient care and customer service. In order to do that, we need happy and healthy employees. We have an employee assistance programme, offering counselling, tips and advice around wellbeing. We also have a professional HR team that supports managers and staff with their wellbeing through dayto-day advice, wellness action plans, training, and occupational health referrals where required.

How important is sustainability for those working at Haine & Smith?

Haine & Smith Opticians is becoming ever more aware of how sustainable we are and what we do – or could do – to become more eco-friendly. Our teams are taking steps to try to reduce their waste in practice, with initiatives like our contact lens recycling scheme through TerraCycle, where patients can return their contact lens packaging

“Our teams are taking steps to try to reduce their waste in practice, with initiatives like our contact lens recycling scheme”

What is your favourite interview question?

Behavioural questions are always the best – asking about specific situations and examples will always tell you a lot about a person. My favourite is “Tell me about a time when you gave excellent patient care.” This paints a real picture of how someone deals with people.

for recycling, and down to the small things like reducing the amount of paperwork we are producing.

The business is investing in new equipment to reduce our energy usage both in practice and in Kennet Optical, our group laboratory, and we are always looking at ways that we can further reduce our carbon footprint.

We have also set up our Sight For All campaign. Working alongside Alabaré, a local charity that helps homeless and vulnerable people across the county, we are offering free eye examinations to all of its residents. We have asked our patients to donate their old spectacles to be refurbished and then reused for the Alabaré residents that require them. The donated pairs that are too old or broken to be refurbished, are handed over to the local Lions club for recycling through its charity. So far, we’ve saved more than 2000 pairs going to landfills by reusing or recycling them.

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ICLW VERSION REPRO OP

Marketplace Services and products for the practitioner

SUBS

A CONTACT LENS RECYCLING SCHEME Bhavin Shah explains why children are the most reliable users of his practice’s JJV contact lens recycling scheme

ART

T

PRODUCTION CLIENT

he contact lens recycling scheme that we use is facilitated by Johnson & Johnson Vision (JJV). We started pre-pandemic, in February 2019.

Before we set up in the practice, JJV had either sent an email, or I saw the scheme mentioned in Optometry Today.

I contacted them, and they put me into their partnership programme. The setup process itself was very easy.

It was the first scheme of its kind that I’d heard about. They were providing the boxes for free, and arranging the collection, so we didn’t have to do anything other than order the boxes as and when we needed them, and of course arrange for collection when the box was full of lenses.

Whenever we fill a box, we just email TerraCycle, JJV’s partner in the programme. On the website, there’s a form that you fill out, and they email through a UPS label and arrange for them to come and pick it up. Because we collect a high volume of lenses from patients, they’ve arranged for one box for free for us. We fill a box at least once every two months, maybe more often.

The feelgood factor

The patients love it. Something like 80% of our daily soft lens wearers are children, and they’re really into environmental, social and corporate governance, and sustainability. I think it’s something that has been promoted a lot in schools, so they’re very aware of the issue of sustainability and the plastic pollution problem. They are good at being organised, saving their lenses and bringing them in when they come for appointments. It’s their future. We’re

I COULD NOT LIVE .

WITHOUT..

“We’re protecting the planet for children, and I think they’re aware of that” protecting the planet for children, and I think they’re aware of that.

In terms of getting the message out to patients, we initially sent an email.

We see our contact lens wearers quite frequently, at least every six months, so we also speak to them about the scheme then. We remind them every time.

During the consultation, they’ll have to take their lenses out at some point, and I’ve got a recycling bin, like a miniature wheelie bin, in my consulting room. I tell them to put the lenses in there, and then I add it to the bigger bin later. Parents, even though they’ve been told before, will say, “Oh, I didn’t know you did that.” Hopefully the message will start to stick with them.

I think it is a question of just reminding people all the time. Adults forget; the kids have better intentions.

I think they’re a bit more committed

to saving them. I had one child who had three different containers, and he’d separated the plastic part, the foils, and the lenses. Children feel like it gives them a sense of responsibility, I think.

You have to make it easy for an adult.

If they’re collecting their lenses at home, if they’ve got a box to drop them in right there, it gets done. If it’s not there, then in that extra time it gets forgotten.

I think patients do realise that, with contact lenses, they are generating lots of plastic waste. Although actually, the plastic waste generated by dailies is less than by monthlies, because of the use of the solutions. Some of the solution bottles can’t be recycled. Patients know, when they are generating this waste, that they can be doing something about it. I think it helps raise people’s awareness, too. It’s an easy feelgood factor for people.

A sustainability ecosystem We’re trying to be environmentally conscious where we can, and look at areas where we can make an impact.

The JJV contact lens recycling scheme is one of the key things that we’re doing in practice in terms of sustainability.

We’ve also gone paperless over the last few years. We changed all our light bulbs to LED about four years ago, and that brought down our electricity bill by at least 50%, maybe more. We’ve also got a couple of frame ranges that are eco-friendly. Patients are looking for that, as well. With all of those things combined, it feels like we’re doing something, at least.

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Secret Life

LAST WORD VERSION

My secret life

REPRO OP

MY T SECRE ...

S LI F E A

SUBS

J

ART PRODUCTION CLIENT

Optometrist, Anthony Josephson, discusses a children’s book he dedicated to his two daughters

ust before lockdown in 2020 I found a note on my phone that I had written and then forgotten about. After I read it, another few lines came to mind. Those were the opening lines of The Happy Zoo. In June, I began sending the manuscript to various publishers.

The Happy Zoo is a rhyming picture book that takes you on a tour of some of the animals in a fictional zoo. The book touches on conservation and the need to protect animals and their habitats.

It was a special moment when the book turned up on my doorstep for me to approve the final illustrations.

That copy is now in my daughter’s room with tattered corners. I have achieved many business milestones, but having something like this, that can be handed down to my kids and that can be read to their kids, is lovely.

The book was written before my youngest child was born. She will happily eat the pages – I am not entirely sure what she thinks of the words just yet. My three-year-old loves it and will grab The Happy Zoo from the bookshelf saying ‘Daddy’s book.’ I have a whole repertoire of voices that I use when reading to my

“Children get such joy from words and pictures. They can see a picture of an animal or read a few words and go on an adventure in their head” 98 www.optometry.co.uk

Do you have a personal passion to share with readers?

Get in touch with selinapowell@ optometry.co.uk

children. You can definitely approach bigger topics with children’s books. The feedback I’ve had from parents is that they have realised that sometimes we take the environment for granted. It is not only about making sure that these animals and their habitats survive, but also ensuring that future generations have the chance to see these wonderful creatures.

I’ve always had a fairly creative streak. It is nice to shut the door on the real world and create an environment that exists on a page.

When my daughter arrived, I was inspired by reading all of these amazing stories for children. I would make up my own little stories and songs. There wasn’t a point where I decided to have a book published – it was originally going to be something that I printed at home and stapled together.

Children get such joy from words and pictures.

They can see a picture of an animal or read a few words and go on an adventure in their head. It is really lovely to create that spark.

The more passionate a child becomes about an animal the more likely they are to want to look after the environment. As they get a bit older, if they realise that their pals are in danger, they are more likely to engage with activities to help protect wildlife.

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