OT December 2021/January 2022 by TheAOP

Outer covers spread

VERSION

Journal of the Association of Optometrists

Spotlight Coming together: 100% Optical Page 13

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£9.95

December 2021/January 2022 Volume 61:06

www.optometry.co.uk

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December 2021/January 2022 / Volume 61:06

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Timely triage

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How optometrists are working to deliver the right care to patients at the right time

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Live

2 2 .01 . 2 02 2

Life.

THE ART OF TRIAGE EDITION

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/ www.optometry.co.uk

EXCITING NEWS INSIDE

CPD The role of leadership in delivering safe care

Perspectives Dr Julie-Anne Little on the value of triage

In practice Dr Amit Jinabhai shares his career journey

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FEATURING THE COOPERVISION® BINOCULAR PROGRESSIVE SYSTEM.™

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An evolution in lens design system and ﬁtting approach, the CooperVision® Binocular Progressive System™ utilises different lens designs to optimise vision for all levels of presbyopia.1

ART

LOW ADD.

MEDIUM ADD.

Aspheric centre-near design

PRODUCTION

A CHANGE IS COMING.

CLIENT

GET READY TO TAKE YOUR PRACTICE FURTHER, TO LIVE LIFE AND SEE THE WORLD DIFFERENTLY THIS JANUARY 2022.

LOOK FORWARD TO

Near power

Distance power

For illustrative purposes only.

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HIGH ADD.

Aspheric centre-near design

*98% successful fit with two pairs or fewer when using the fitting guide or OptiExpertTM; 1. CVI data on file, 2020. Prospective, double-masked, bilateral, one-week dispensing study UK with MyDay® daily disposable multifocal; n=104 habitual multifocal contact lens wearers. 2. CVI data on file, 2021. Prospective, subject-masked, randomised, bilateral, two-week dispensing study at five US sites with MyDay® daily disposable multifocal; n=58 habitual multifocal contact lens wearers. 3. CVI data on file 2020. MyDay® daily disposable multifocal spherical power range +8.00 to -12.00DS. Based on Rx option combinations (sph & add) available across all daily disposable soft lenses in multifocal from four main manufacturers in UK, France, Germany and Italy Oct 2020. Cosmetic & Photochromatic CLs not included. Multiple base curve variants not included.

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Welcome

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ART PRODUCTION Cover: Antonio Sortino; This page: Getty/ Anna Minkina

CLIENT

he other day, like many others over the past 18 months, I spent an unhappy hour trying to get an appointment at my local GP practice. Having been turned away from the practice door by a determined – and frankly rather scary-looking – receptionist, I then had to negotiate the online booking system and, when this failed, convince that very same receptionist (this time over the phone) to let me in to see the doctor. All for the sake of ensuring that the prescription which I had been receiving for the past year was rolled over for another month. Not a dramatic story, but one which is depressingly familiar I’m sure. As patients we are increasingly at the mercy of the guardians of the triage systems that have been put in place. That is for very good reasons: triage systems help providers schedule work effectively and sort the urgent from the merely demanding. However, such systems carry with them some patient risk: those who cannot make a good enough case can find themselves denied the care they need. I am not arguing that triage is wrong. But if we are going to rely on triage at this early critical stage in the patient process, we have to take it seriously as a separate and critical discipline. Staff need to be trained and supervised in their new role. And systems need to be put in place to ensure that the judgements made are evidence-based and documented. Plus, if staff are to be undertaking the role and responsibilities associated with triage, it seems reasonable that their work needs to come within the GOC’s framework of regulation. This should be done not by introducing a whole new grade of staff, but by extending regulation to the whole of the optical business, rather than just some of the individuals working for it. That is the route other professions, such as law, have gone down, and that is the solution which the AOP recently called for in our response to the Government’s consultation on changes to regulation in the sector. Consultations like this – and expect more in the months to come – at first glance can seem abstract and far-removed from daily practice, but our responses to government and regulators highlight the views of our members and influence new policy and guidance affecting the sector. Find out about our policy work at: www.aop.org.uk/policy

“If we are going to rely on triage at this early critical stage in the patient process, we have to take it seriously as a separate and critical discipline”

Adam Sampson, AOP chief executive

December 2021/January 2022

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Welcome

DECEMBER 2021/JANUARY 2022

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Contents 53

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13 PRODUCTION CLIENT

07-23 SPOTLIGHT

Spotlight

KNOW YOUR LENSES CAMPAIGN

The news in digest Picture this World Sight Day photo competition OT reports Five trends shaping the High Street The edit Optics in 16 stories 100% Optical ‘Coming together’ for education, product launches and networking Clinical roundup A holistic approach to AMD Industry profile Dem Dx on utilising artificial intelligence, with Dr Mariane Melo AOP affinity partner: Lloyd & Whyte Insurance and finanical planning trends Supplier insight The evolving role of OCT AOP roundup Policy acheivements, the Know your lenses campaign, new menopause resources, and OT’s Jobs board

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“It’s time that there is more in place to protect the public – particularly as the trend for consumers to buy online is set to grow” Adam Sampson, AOP chief executive, PAGE 22

27-33 HIT LIST

The trends, launches and looks OT focuses on... Remote solutions Me and my glasses Optometrist, Alicia Hartman Get the look // Anatomy of a frame With Lizzy Yeowart The shortlist The December/January selection Behind the brand Millmead Optical Group

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35-39 PERSPECTIVES

Voices from optics and beyond Perspectives Dr Julie-Anne Little, Brian Tompkins, Natalie Michaux My vision Photographer, Karren Visser

“CPD is more than just a name change” Natalie Michaux, standards manager and CPD review lead at the General Optical Council PAGE 38

57 98 LAUNCHING ONLINE ON 5 JANUARY

CPD 65-88

Professional development for the eye care practitioner 65 CPD welcome 66 A lens of leadership 70 The power of lenses 74 Building confidence with OCT-A in practice 80 Prescribing prosthetic and coloured contact lenses 84 Cases from the casualty 86 Keratoconus in the community 88 CPD author Q+A: Nick Howard

ONLINE

41-55 IN PRACTICE

Business insight and career development The roundtable Four optometrists discuss their purchase of the Optos Monaco Pre-reg focus Emily Mather and Peter Grant How I got here Academic, Dr Amit Jinabhai Key milestones Setting up a free patient support line What I have learned How a Peer Assisted Learning network informed Optometry Practice Assisted Learning The workhop Triage and miscommunication with the AOP’s Henry Leonard Becoming a business owner Dr Christian French

Cover story

Race against the clock The pandemic put a strain on primary and secondary care, highlighting the importance of patients being seen in the right place at the right time, and enabling optometrists to refine their triage skills. OT explores the art and science of triage.

OT video highlights

A case study with Judith Long on the Optos Daytona Watch the video on

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97-98 END NOTES

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

I could not live without... ”A well-designed triage form,” says optometrist, Anthony Blackman Last word Kishan Devraj’s secret life

December 2021/January 2022

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Contents

CONTENTS

Spotlight, 1 VERSION

Spotlight

REPRO OP

08 OT REPORTS

As 2021 draws to a close, OT reviews five trends shaping businesses on the High Street

17 CLINICAL ROUND-UP

Celebrating Amersham Hospital's AMD clinic and the effect of nutrients on floaters

22 AOP SUPPORT

New AOP resources on the menopause and OT's jobs listing service

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PICTURE THIS ART

‘Going to school’

PRODUCTION

This image of a young child on her way to school in her new clothes was captured by Saiful Islam and has been selected as the winner of the Amateur Photo of the Year in the International Agency for the Prevention of Blindness’ World Sight Day Photo Competition. The annual photo competition aims to highlight the importance of eye health and the social and economic impact of vision loss.

Saiful Islam

CLIENT

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VERSION

FIVE TRENDS SHAPING THE HIGH STREET

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December 2021/January 2022 Volume 61:06 Issn 0268-5485 ABC certificate of circulation 1 January 2020–31 December 2020

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

ART PRODUCTION CLIENT

Senior reporter: Kimberley Young kimberleyyoung@optometry.co.uk Web content and social media executive: Leah Boyle leahboyle@optometry.co.uk Clinical editor: Dr Ian Beasley ianbeasley@optometry.co.uk Clinical editor for multimedia: Ceri Smith-Jaynes cerismithjaynes@optometry.co.uk Video production editor: Laurence Derbyshire laurencederbyshire@optometry.co.uk CET enquiries: 020 7549 2076 CEThelp@optometry.co.uk AOP membership and OT subscription team: subscriptions@aop.org.uk

As 2021 draws to a close, businesses are taking stock of the forces holding sway over UK High Streets – and perhaps setting their sights on the horizon to predict the key trends for the year ahead Over the course of the year, as vaccination rates increased and social restrictions eased, optical practices were among businesses assessing how the ‘new normal’ would affect the way products and services are offered to customers. Consumer habits shifted during the pandemic, with more shoppers supporting local businesses and prioritising a tailored experience. From the impact of coronavirus on the bottom line of High Street businesses to the rising importance of sustainability, OT outlines five key influences on the High Street.

RESILIENCE IN THE FACE OF DECLINING TURNOVER 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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It is no surprise that businesses on the High Street felt the full impact of the pandemic on revenue, as lockdowns caused them to close for spells or restricted the movement of the public. Reviewing the state of the UK’s small and medium-sized enterprises (SME) on the High Street, insurance company AXA found the most common issue reported during the pandemic was falling revenue – with 61% of businesses surveyed reporting a decline in turnover in the 12 months preceding the study. Independents in the optical sector, dentistry and pharmacy saw a 12% decline in turnover. Researchers also reported a “drastic” drop in the number of new practices in the health and pharmaceuticals sector opening on the High Street, recording a fall of around 20,000 in new businesses opening, or a drop of almost 40% year-on-year.

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Despite the challenges, Claudio Gienal, CEO of AXA UK and Ireland, suggested that many businesses adapted, adding that, “as restrictions continue to ease, we believe there will be a growing need for their specialist services within the local communities they serve.” Speaking to OT about the survey findings, AOP Council and Board member, Tushar Majithia, director of Lunettes Opticians, shared that the business saw turnover “significantly” affected at the start of the pandemic, but experienced a strong recovery when practices were able to resume services. Majithia said that pent-up demand led to a moderate increase in turnover in the first half of 2021, as patients began to feel more confident about attending practice, though pointed out: “We have noticed a slight drop off in spending behaviour as supply chain issues have affected consumer confidence.”

CONSIDERING PRIVATISATION

A survey by the Independent Marketing Partnership, exploring optical practice profitability following the pandemic, found a mixed impact on businesses. The survey of 400 independent practices found that 54% saw profit increase since the start of the pandemic, while 42% saw profits decline. Sharing their business plans, the survey found that 7% of respondents planned on “definitely going private” and leaving NHS practice, while another 13% acknowledged they were “seriously considering” moving to private practice within three years. Graham Hutchison, managing director of the partnership, commented: “Most independent opticians appear to have come through the COVID-19 crisis in better shape than might be expected, given the social restrictions and economic impact of the pandemic.” He did caution, however, against “a false sense of security,” highlighting that competition on the High Street and from online retailers “has not gone away.” An OT poll of more than 160 readers found that 55% were considering going private, with another 15% already private. A further 13% were unsure, while 16% said they were not considering the change.

COMMUNITY SPIRIT “Shop local” or “shop small” are oft-used phrases when it comes to the High Street. Of course, competition from online retailers still looms large, but following the pandemic, there has been a noticeable trend in people choosing to visit local businesses. AXA’s Small Business, Big Picture report, which was developed in partnership with the Centre for Economics and Business Research (CEBR), reported a degree of “community-mindedness” from businesses and consumers. Of those surveyed, 42% of SMEs said that their business had seen an increase in customer loyalty during the pandemic, while 39% felt their business had been supported by their local community. Over half of businesses reported that more of their

EXPERIENCE-FOCUS & THE PERSONAL TOUCH Business analysts have noticed that a key consumer trend, currently and for the High Street of the future, is the ‘experiential’ element of shopping. Identifying eight key themes that are expected to shape future retailers, Euromonitor International named experiential approaches as a top trend. Michelle Evans, senior head of global digital consumer research at the organisation, shared that younger consumers in particular “increasingly value ‘doing’ over acquiring.” This is a desire that is expected to translate into demand for experiential retail, with 54% of consumers surveyed sharing their interest in shopping in stores that create engaging experiences. Other reasons for attending physical

stores include convenience and for a personalised service, research found, with 24% of consumers looking for tailored experiences. Looking at the implications of these trends for retailers, Evans explained that while some will continue to cater for impulse purchases, those purchases that lend themselves towards greater levels of consideration could become more ‘experiential’ in focus. In March, a report commissioned by UPS explored the attitudes of 10,000 consumers across UK, France, Germany, Italy, Spain, the Netherlands, Belgium and Poland. The research found that preferences driving the consumer decisions to shop in-store versus online include enjoyment (41%) and more of a personal experience (38%).

visitors were repeat customers in the past year, and 49% noticed that more of their customers were from the local community. Reflecting on his own experiences, Majithia told OT: “We have definitely noticed an increase in loyalty, with patients less likely to shop around during the lockdowns,” agreeing that “there appears to have been an increase in a ‘sense of community’ and desire to shop local.” Barclaycard Payments research from spring 2021 found that almost two thirds (64%) of British people were choosing to shop closer to home. Exploring shifting consumer behaviour, the company said: “This is set to be a lockdown legacy, with nine in 10 (91%) of British people who have been shopping locally throughout the pandemic saying they will keep doing this to support smaller and independent businesses even after all restrictions end.”

SUSTAINABILITY

In the wake of the United Nations Climate Change Conference in November, discussions around sustainability were in the spotlight. A report by The Federation of Small Businesses, published at the beginning of November, revealed that 67% of small businesses had taken steps to reduce energy usage while 64% had increased recycling and 50% had made an effort to eliminate waste wherever possible. Efforts to enhance sustainability reflect evolving customer attitudes. Within the UK, 63% of UPS survey respondents said they would like to see sustainable packaging used by large retailers. Across EU nations, close to half of those surveyed (48%) would like larger retailers to offset the carbon footprint of deliveries, while 30% favoured carbon offsetting for smaller retailers.

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Spotlight, 2

SPOTLIGHT

VERSION

INDUSTRY

Clean air has never been so important

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Is your practice a Safe Air Space?

Norville Opticians has reopened following an extensive refurbishment after joining Hakim Group. The investment in the business, which was established in Gloucester in 1898, included an upgrade to the clinical technology and an overhaul of the interior, while retaining the heritage of the building.

ART

55 Stop the spread of viruses

PRODUCTION

Reduce allergy symptoms all-year-long

Marks and Spencer (M&S) is set to open an optometry service in 55 stores following a successful trial. Delivered by Owl Optical, part of the Scrivens Group, M&S Opticians had launched in 13 locations at the time of writing. The company plans to recruit 500 people to run the service, which will be rolled out by April 2023.

Comply with highest hygiene standards Keep staff safe, healthy and at work Reassure your patients

CLIENT

Promote health and raise productivity

Seven-year findings from CooperVision’s MiSight 1 day contact lens clinical trial have found that, 12 months after treatment cessation, mean axial elongation data has indicated no evidence of rebound effect, “meaning the myopia control gains are retained.” The data also identified a “highly-desired proportional myopia control treatment effect,” with abnormal axial length growth slowing by an average of 50% across all ages tested (8–17).

Reduce sick-leave

Ray-Ban has launched the first ever Non-Fungible Token (NFT) glasses in collaboration with German artist, Oliver Latta, also known as ‘Extraweg.’ The digital artwork featured the brand’s signature aviator frames. Ray-Ban sold the NFT in a charity auction with proceeds donated to the Italian Art Trust.

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

10 www.optometry.co.uk

“We believe that if we want to help people who have difficulty seeing, we must first be able to understand their functional vision” Advanced orthoptist, Caroline Rawse, and SeeAbility Trustee, Professor Rachel Pilling, a consultant paediatric ophthalmologist at Bradford Teaching Hospitals NHS Foundation Trust, developed the Bradford Visual Function box over a decade. The new tool aims to help identify what a child or adult with a learning disability can see.

A survey, funded by Roche UK and developed with the Macular Society and Fight for Sight, found that 80% of people felt losing their sight would be worse than losing their sense of touch, taste, smell and hearing. It also found that, despite valuing their vision, 51% of the 1516 people surveyed admitted to “rarely or never” thinking about their eye health.

Kering Eyewear has completed the acquisition of the Danish luxury eyewear brand, Lindberg, after receiving clearance from antitrust authorities. Announcing the intended deal for 100% of the share capital of Lindberg in July this year, Kering Eyewear suggested the addition of the brand to its portfolio would further reinforce its position in the luxury eyewear market.

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80%

RayBan/Extraweg

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Medical Air Sanitisers

“This is a significant investment not just in the practice itself – it’s also an investment in our patients”

THE EDIT 60 DAYS IN 16 STORIES

Pixabay/St cocoparisienne

SCIENCE & VISION

2.04

Scientists from MIT and Dalhousie University in the US have corrected amblyopia in cats and mice by temporarily anaesthetising the retina of the good eye. Described in eLife, the approach was effective in mature animals past the age where patch therapy is plausible. Scientists hope this will pave the way for a more effective approach to amblyopia treatment.

SECONDS

It has taken a specially developed artificial intelligence system just 2.04 seconds to grade scans for geographic atrophy – a task which takes human graders between 43 and 56 minutes. Konstantinos Balaskas, a consultant ophthalmologist at Moorfields Eye Hospital, who led the development team at Moorfields Clinical Centre and AI Hub, told OT about the technology.

“The device would allow children with amblyopia and/or strabismus to be referred to an eye care specialist as early as two years old” New research published in the Journal of the American Association for Pediatric Ophthalmology and Strabismus highlighted a handheld device that can detect amblyopia. In a study involving 300 children aged between two and six, the device correctly identified all six cases of amblyopia.

Watch the interview online: bit.ly/3wCe0os

PROFESSIONAL SUPPORT

Pixabay/Spencer Davis

COVID-19 vaccinations will become a condition of employment for frontline health and care workers, unless exempt, as of 1 April 2022. This will apply to all healthcare workers regulated by the Care Quality Commission in England and includes hospital optometrists and domiciliary optometrists working in care homes. A survey of 1000 AOP members revealed over half supported mandatory vaccines for healthcare workers, with 37% against and 6% unsure.

The General Optical Council has confirmed that Leonie Milliner will take on the role of chief executive and registrar in January 2022, succeeding Lesley Longstone, who has held the position since 2018. Prior to this move, Milliner has been working as director of education at the regulator.

“We will be ready to expose any serious risks in the implementation process” Adam Sampson, AOP chief executive, sought to reassure members after plans for an apprenticeship in optometry were submitted to the Institute for Apprenticeships and Technical Education in November. Developed by a trailblazer group, the proposal was submitted without consulting sector bodies. A decision on the validity of the proposal is expected in January.

IN PRACTICE “I really enjoyed having the opportunity to meet students from across the globe” Students Ishvinder Bahra and Charis Hedges from Aston University were named the 2021 winners of CooperVision’s Future Ocular Research Creativity Event (FORCE). The pair were awarded for their project Optimisation of blink exercises within the Blinkful app.

Claire Slade, optometrist and head of professional advancement and governance at Hakim Group, told OT how she has used reflective learning throughout her career to help her to reach her goals, sharing advice for taking time to reflect. Watch OT's interview with Slade online: bit.ly/30glbqg

“The small business rates relief saves me a few thousand per year. It means this could be the 'last little bit' that goes into reinvestment for our practice or the next shop fit. Without it, I woiuld need to find it elsewhere” Pam Robertson, owner of Angus Optix, shared her views after Chancellor Rishi Sunak announced a 50% discount in business rates in the Autumn Budget. More reactions on the Budget can be found in OT’s report: bit.ly/3kvOUCR

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100% OPTICALI

Coming together SUBS

100% Optical will return in January, bringing education tailored to the new CPD scheme requirements, along with product launches and networking opportunities. OT hears how to make the most of the show

ART PRODUCTION

After two years of webinars and digital exhibitions, the optical community will reunite at 100% Optical 2022, set to take place on 22–24 January at ExCeL London. The show will have a theme of ‘coming together,’ with event director Nathan Garnett sharing: “It is two years since everyone got together so there is going to be a lot to discuss, a lot to share and learn, and lots of new products to see.”

Geety/ melitas

CLIENT

Professional development The new year marks the beginning of the General Optical Council’s (GOC) new CPD scheme, which replaces CET. As education partner for 100% Optical, the AOP has developed a programme of more than 130 education sessions across 10 areas. Dr Ian Beasley, AOP head of education and OT clinical editor, explained: “100% Optical will be the first opportunity for practitioners to get to grips with the nuances of the new CPD scheme,” adding that the AOP has aligned content to the new framework to support practitioners “as we enter a fresh era of professional development.” The programme will cover key clinical topics “of relevance to practitioners from all modes of practice, alongside seminars with appeal for the wider practice team,” Beasley explained. “Topics include artificial intelligence, dry eye, assistive technology for patients with low vision, paediatric dispensing, management of choroidal naevi and sustainability.” Headline speakers will deliver lectures from the Main Stage, kicking off on 22 January with a session from AOP clinical director, Dr Peter Hampson, and head of clinical negligence, Efa Schmidt, who will discuss the implications of retinal imaging

and what artificial intelligence may mean for clinical decision making. For the first time, the event will also see content streamed live to the Main Stage from two international keynote speakers. The Future Practice Hub returns for a second year, now providing four areas of education, delivered in partnership with exhibitors. The Dispensing Workshop will host peer reviews and workshops, while the Optical Academy will provide an opportunity to gain insights on key topics. On the map At the time of going to press, Media 10 anticipates exhibitor stalls could sell out, which would mark a first for the event. New names at the show include Ocuplan, Occuity, and Mei-Cam, and eyewear brands such as Nathalie Blanc, Düsseldorf Eyewear, and Bonavista Optics. Major suppliers will be showcasing products on their stands, with eyewear brands such as Marcolin and Luxottica also returning to the show.

PLAN, PLAN, PLAN: TIPS FOR A SMOOTH SHOW EXPERIENCE Complete the event registration process ahead of time to receive the electronic visitor badge for the show Be aware of the venue entry requirements regarding COVID-19 Make a schedule of booked CPD sessions Make stand appointments with suppliers early, and schedule these around education With plenty to do – consider attending multiple days of the show.

Garnett shared his expectation that the show would illustrate the closer working of the NHS, secondary care, and optometry. “I think ophthalmology and optometry are going to come closer together, and 100% Optical is the perfect platform to enable networking to take place,” he said. Celsa Vazquez, sales manager for 100% Optical, suggested: “There is just going to be so much to see and do. We are really putting this event on the map.” At the show This year, event organisers are launching an app for delegates to use around the conference in place of a printed guide. Through the app, delegates will be able to network with other attendees, bookmark CPD, post on social media, and make appointments with exhibitors. A number of COVID-19 measures will also be in place throughout the show. On arrival, delegates will be asked to show COVID-19 status, either by showing they have received the vaccines through the NHS app or their vaccination card, or by taking a test the day prior to the event and recording the results with the NHS. For more on these measures, read OT’s article online at bit.ly/3netquX Garnett emphasised: “I think everyone will feel very comfortable and safe within the show.” With the days counting down, Vazquez said: “We cannot wait to see our delegates trying on glasses, trying out equipment, learning and networking. It has been some time, and this show is going to have a ‘welcome back’ feel.” Sponsor centre: trends and launches Johnson & Johnson Vision will spotlight its Acuvue Oasys 1-Day with HydraLuxe Technology products which contain a wetting agent that is similar to parts of naturally occurring tears. Attendees will also be able to find out more about the Acuvue 21 Day Challenge behaviour change programme. Rachel Hiscox, professional education and development manager, UK & Ireland for Johnson & Johnson Vision, said she expects to see continued innovation within the contact lens sector to provide improved levels of comfort and vision: “Patients are living more demanding and increasingly varied lives and therefore want more from their contact lenses.”

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SPOTLIGHT

SPOTLIGHT VERSION REPRO OP SUBS ART PRODUCTION CLIENT

Bausch + Lomb will launch a new contact lens at 100% Optical, offering stand visitors an “exclusive opportunity to experience the lens on eye.” Sharing the trends they expect to see at 100% Optical, a spokesperson highlighted the importance of “building the confidence back amongst eye care professionals; showcasing the great opportunity which exists with contact lenses, not just from a practice building point of view, but more importantly, the huge impact contact lenses can have in benefitting our patients’ lifestyle needs.” Cerium Visual Technologies will display its Intuitive Colorimeter Curve, precision tints and overlays, and share new research developments. Colorimetry will also feature in workshops at the Future Practice Hub. “As the industry emerges from a turbulent and uncertain period, we expect to see practices looking for ways to differentiate themselves in a competitive market,” Kimberley Harrison, managing director of Cerium, told OT. Essilor and Luxottica will be exhibiting together on the EssilorLuxottica stand. The Stellest lens, which will be available from January 2022, will be a highlight on display, and Essilor will also be launching the Myopia Expert 700. The digital solution is designed to detect and monitor the progression of refraction and axial length, and support the patient journey.

MAKING THE MOST OF CPD AT 100% OPTICAL As we return to in-person events, OT asked 100% Optical speakers for their top tips for delegates Ceri Smith-Jaynes, therapeutic optometrist and clinical editor for multimedia at OT, and Dr Andrew Logan, independent prescriber and lecturer: “Take some time after the show to go through your notes and really analyse how you can use that knowledge in your practice. Be honest with yourself about your current skillset and the areas that need the most development. Make a plan and set a date to check-in on that plan later in the year.”

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Tim Precious, Essilor managing director, expects personalisation to be a “major” opportunity for practices in 2022: “As a consumer you want to feel special as you look for unique products and it’s no different for lenses. We now live in an age where we want products specifically designed for us and the optical industry needs to make sure it can adapt and meet those evolving needs.” In the exhibition hall Heidelberg Engineering will launch a new product at the show. Head of UK marketing and education, Emily Malbon, told OT: “The new technology will enhance the Spectralis imaging platform, and it will improve the speed of image acquisition, the quality of the OCT images, reduce image artefacts, offer more ways to visualise and assess the diagnostic data, and offer solutions for imaging traditionally very challenging eyes.” The company will deliver two education sessions on OCT over the event. Altacor will be bringing its Clinitas range of dry eye products and promoting its new AREDS2 ophthalmic vitamin, VisuBright. The company also hopes to launch its new

Richard Edwards, clinical consultant to Optical Consumer Complaints Service: “CET finishes in December 2021 and CPD starts in January 2022. Being at 100% Optical gives registrants a chance to understand more about what the change means for them, as well as a great opportunity to get some points under their belt in the brave new world of CPD.” Ian Davies, managing director of IansEyes Ltd: “Make sure that you are able to engage in the CPD that you want to, but also that you have time to visit the suppliers. Go to at least two lectures or workshops on a topic that is outside your comfort zone. And make sure you are wearing comfortable shoes.”

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Above: Bonavista Optics will make its first appearance at 100% Optical 2022. Left: The Body Doctor will display its compresses, eye drops and lid wipes

brand look, which focuses on the journey of patients with dry eye. Bonavista Optics will be celebrating the international launch of Downton Abbey Eyewear by Bonavista Optics. Bonnie J Ashley, president of the eyewear brand, said: “We have designed and distributed two premier limited edition Downton Abbey sunglass models, along with cases, kits and cleaning supplies. This is followed now by the launch of our first Downton Abbey Ophthalmic line of eyewear.” Positive Impact will have two stands dedicated to its Glasklar product, and its contact lens and dry eye portfolios. The company plans to add a new specialist contact lens to its range at the event. As practices look to differentiate post-pandemic, Nick Atkins, director of marketing and professional services, said: “Two of the biggest business development opportunities are contact lens practice and enhanced dry eye management.”

Emily Andrews, product director at Eyespace Eyewear: “My advice is to simply enjoy learning about all the developments that have been taking place while we have been living behind closed doors.” Professor John Nolan, director of NRCI and principal investigator of the Floater Intervention Study (FLIES), and Dr Emmanuel Ankamah, main researcher of the FLIES trial: “Seek out CPD that represents cutting-edge peer-reviewed science. CPD that builds upon published science and peerreviewed science is much more valuable than whitepaper CPD. Doctors can only make the best decision with the best informed science.”

Spotlight, 5

The Body Doctor will be sharing its Eye Doctor range, with an emphasis on its eye care regime: heat, cleanse and revive, and the stand will display samples of its Dry Eye Support Supplements. Attendees will be able to join the company in celebrating its 10th anniversary on the stand. In the AOP Lounge The AOP Lounge will be waiting to welcome back members at 100% Optical. As in previous years, there will be a dedicated area on the stand hosting a programme of education, including a range of peer reviews, and content

delivered in partnership with Johnson & Johnson Vision. As the leading membership body in the optical sector, individuals from the AOP will be available on the stand for members and non-members alike to meet. Members will be able to request a meeting with individuals from AOP teams to discuss specific issues, through the 100% Optical website. The AOP confirmed it will be working with the exhibition organisers to make the show as safe as possible in light of the COVID-19 protocols in place when the show is held, and ensure the comfort of members is kept in mind.

Announcing the UK launch f h dv &

SPEAKERS' CORNER Peer review: Managing dry eye patients – understanding key aspects Optical Academy, 22 January Dr Debarun Dutta, Aston University lecturer: “The focus of the session will be a comprehensive understanding of dry eye disease treatment and management options. We will discuss the differential diagnosis and treatment options for varying types of dry eye and how we diagnose the different, and perhaps the overlapping, types of dry eye cases.” Look at the vitreous and not through it Optical Academy, 23 January Professor John Nolan, director of the Nutrition Research Centre Ireland and principal investigator of the Floater Intervention Study: “We will examine the impact of vitreous degeneration on the quality of life and visual function of floater sufferers. We will then consider the management options for floaters, focusing on the data of the clinical trial. Delegates at the presentation will learn about the outcomes of our randomised control trial and how targeted nutrition can be employed as a safe management option for floater sufferers.”

Discussion workshop: Eco innovation in frame technology Dispensing Workshop, 23 January Emily Andrews, product director, Eyespace Eyewear: “Our appetite to create new products is infinite, but the planet’s resources aren’t. As a frame manufacturer we have a responsibility to ensure that everyone who buys frames can embrace sustainability measures, no matter their budget or patient demographic. The greatest result we could hope for is that attendees see how easy it is to make positive environmental differences through their frame selection, and decide to act upon what they have learnt.” AOP 100% Optical peer reviews AOP Lounge, multiple sessions across 22, 23, 24 January Ceri Smith-Jaynes, therapeutic optometrist and clinical editor for multimedia at OT: “Participants should come away with a clear understanding of how their skills compare with those of their peers. This means they’ll know what to work on in their professional development plan for the year ahead. We’ll also have a handy crib sheet on optic disc assessment for participants to take away with them.”

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December 2021/January 2022

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SIGHT IMPAIRMENT

Brain implant helps blind woman see

Clinical round-up

REPRO OP

OT’s Selina Powell reviews the latest clinical news and research papers BLIND TENNIS, COOKING CLASSES AND ARTWORK: A HOLISTIC APPROACH TO AMD

SUBS ART PRODUCTION Getty/VioletaStoimenova

CLIENT

An event on 14 October celebrated the pioneering work of Amersham Hospital’s age-related macular degeneration (AMD) clinic since it was established five years ago. Consultant ophthalmologist and joint leader of the Buckinghamshire Healthcare NHS Trust macular, retinal and vitreoretinal service, Mandeep Bindra, explained at the event that when he started his ophthalmology career 18 years ago, patients with AMD were told that they would lose their sight because of limited treatment options. However, the management of AMD has evolved over time. “Now we can prevent patients from losing their eyesight. We have revolutionised the way we are treating patients,” Bindra emphasised. He noted that both patients and staff have had a say in how the service has developed over time. “We say that everyone who comes to work in our macular degeneration service is part of one family… Everyone feels like they can have a say in the service – this is why we improve,” Bindra said. Principal optometrist at the Buckinghamshire Healthcare NHS Trust, Denise Voon, highlighted that the department hoped to empower

“Ultimately we want to make the lives of people with macular degeneration better” patients and their families by increasing their understanding of AMD. Initiatives pioneered by the clinic include cooking classes that outline the role of nutrition in eye health, and visually impaired tennis classes. Staff also started conversations around mental health, and an artwork was commissioned for the clinic that can be appreciated by those living with sight loss. Voon shared that in the five years since the clinic was established there have been more than 50,000 appointments, with 41,000 injections performed. “Ultimately we want to make the lives of people with macular degeneration better,” she highlighted.

CLINICAL

NEWS

Researchers have utilised artificial vision to help a blind woman to see using a brain implant. Writing in The Journal of Clinical Investigation, scientists described how an intracortical microelectrode array was implanted in the visual cortex of a 58-year-old woman who had been blind for the past 16 years. The patient then wore eyeglasses with a miniature video camera. Specialised software encoded the visual data collected by the camera and sent it to electrodes within the implant. The technology enabled the woman to identify lines, shapes and simple letters. Fernandez et al. DOI: 10.1172/JCI151331 IMAGING

Scientists develop automated OCT machine

Scientists from Duke University in the US have developed a fully automated optical coherence tomography (OCT) device. The contactless technology, which was described in Nature Biomedical Engineering, uses robotic positioning to align itself with the eye to be imaged as well as active scanning to locate the patient’s pupil. “Robotic OCT scanners may enable the diagnosis and monitoring of patients with eye conditions in non-specialist clinics,” the authors highlighted. Draelos et al. DOI: 10.1038/s41551-021-00753-6

STUDY INVESTIGATES EFFECT OF SUPPLEMENTS ON FLOATERS A new study published in Translational Vision Science & Technology has highlighted improvements in quality of life among patients with symptomatic vitreous floaters after taking nutritional supplements. The research, which was led by the Nutrition Research Centre Ireland, involved 61 patients who either consumed daily supplements or a placebo for six months. The supplements contained a formulation of antioxidative and antiglycation micronutrients. After six months, there was a significant decrease in vitreous opacity in the group taking supplements. The group that received supplementation reported a significant decrease in their discomfort from

floaters while the control group had no significant change in their symptoms. The authors concluded: “The findings of this study indicate improvements in vision-related quality of life and visual function of patients suffering from vitreous floaters after supplementation.” Professor John Nolan, from the Nutrition Research Centre Ireland, highlighted that the team looks forward to continuing studies in this important area of research. “While we are hopeful that this research will inform eye care, and offer an option to eye care professionals and patients to enhance the health of the vitreous, we strongly advise that patients seek advice from a qualified eye care professional,” he said.

CONTACT LENSES

Risks of substitution examined A new review paper has examined the implications of inappropriate soft contact lens substitution. The research, which was published in Contact Lens and Anterior Eye, highlighted that soft contact lenses prescribed by eye care practitioners are sometimes substituted for alternative lenses in “the mistaken belief that there is essentially no difference between different soft lens types.” Researchers found that almost all forms of soft lens substitution are associated with between one and six potential sources of patient dissatisfaction and adverse events. Efron et al. DOI: 10.1016/j.clae.2021.101515

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INDUSTRY PROFILE

Supporting clinical decisions in triage

SUBS ART PRODUCTION

COVID-19 has accelerated an existing challenge in triage. It gave us an opportunity to try new technologies and ways of working in eye care, which is exciting as it accelerated something that would have happened in the future. It is not positive to think that there is a big backlog of patients that need to be seen for examinations and check-ups. However, it was definitely something that advanced the implementation of new technologies. During the pandemic, we saw COVID-19 Urgent Eyecare Services (CUES) and Minor Eye Conditions Services (MECS) grow in popularity in several regions of the UK, where we are using the competencies of optometrists to help address this large demand and the limited number of ophthalmologists that we have here in the UK and everywhere. Already important for primary care and screening, I think optometrists will be seen as an important part of referrals from primary care to secondary care.

CLIENT

The Government is encouraging optometrists to take more responsibility with triage, recognising red flags, and providing the right referrals at the right times, to the right specialists. But it is not going to happen very fast if we don’t have support from technology. Some optometrists have been working on eye examinations for their whole lives, so they might not be used to assessing acute conditions. Technology can support and enhance their abilities – never replacing clinical judgement – but augmenting their clinical decisions and supporting them with answers to questions, such as, what is the best time to refer these patients? Which patients can I advise and treat here in the High Street? I think triage technologies will be very important to support the transformation of the eye care service.

DEVELOPING A TRIAGE TOOL “We are creating a clinical decision-making support tool for optometrists, nurse practitioners, and other healthcare professionals to support initial assessments, diagnoses and management before the patient sees the ophthalmologist, if they need to see them. Dem Dx tested the platform in paediatric A&E in Moorfields, which has a nurse-led triage. We reduced the time to assessment by around 30%, total waiting time by 10%, and increased the number of investigations ordered or performed by nurses by 65%. We are continuing to develop this platform with machine learning algorithms – a current project ongoing with Moorfields – where we are collecting data from the adult A&E.“

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Dem Dx is creating a decision-making support tool to aid optometrists and other healthcare professionals in initial assessments

“I believe that we are only going to achieve a good feat of technology when we enhance the abilities and skills of the healthcare professionals who know the patients” A big challenge in implementing triage technology is that the referral system is not unified; different services use different platforms. One thing that would help to implement these new technologies would be the implementation of a unique platform that gets referrals from all High Street optometrists, GPs, and primary care services into the hospitals. That would facilitate referrals but also the implementation of technologies that can filter and support clinical decisions. Several technologies are being developed that aren’t available yet in a clinical setting but aim to help triage. Some companies have been working on transferring optical coherence tomography scans into secondary care to provide advice and a second opinion straight away from ophthalmology, so the patient doesn’t need to leave the optometry service and can be treated there. The biggest opportunity in this area is that the new services being developed are giving more autonomy to the optometrist. Right now, we need to support clinical decisions so no-one feels overwhelmed with this change in the role of the primary care service. This is what Dem Dx is trying to address. We are trying to give information, adding technology with the expertise of someone who has the clinical experience and judgement, to identify when a patient’s issue needs referral. I believe that we are only going to achieve a good feat of technology when we enhance the abilities and skills of the healthcare professionals who know the patients.

Dem Dx

REPRO OP

Dr Mariane Melo, chief medical officer at Dem Dx, which is using AI to develop a clinical reasoning tool, tells OT about the benefits that technology can bring to triage

LLOYD & WHYTE

“The pandemic has made people much more aware of how quickly life can change” Lloyd & Whyte managing director, Pete Lishman, highlights trends in insurance and financial planning and shares upcoming tools for AOP members

Getty/ lemono

If 2020 taught us anything, it is that we never know what life will throw at us. While we hope to never see another global pandemic again, the reality is that real crises happen on a smaller, much more frequent basis. Whether it is a flooded home, cyber-attack on a practice, or people being unable to work due to illhealth – doing what we do, we see these on a more regular basis than most people. I think the pandemic has made people much more aware of how quickly life can change in a very dramatic way. The important thing is to actually prepare, as much as possible, so you have less to worry about should disaster strike.

crime is a more recent risk that requires newly developed cover. Half of the practices we have spoken to felt the need for other policies to protect themselves.

Service launches We are working on a few exciting projects, one of which is a Financial Healthcheck, which we have been working on with the AOP. The Financial Healthcheck is a free, anonymous tool that asks AOP members a series of questions around how confident they are about different areas of their finances and insurance. At the end, users are presented with a summary and some analysis of their answers. They then have the option of requesting a personalised Identifying gaps in cover report, which gives recommendations Last year we started offering thorough based on the answers they chose. It takes insurance consultations to AOP member a few minutes and is really easy to use. practices. Although these take just half We just want to help people identify an hour, we are able to establish what where they can improve and point them cover a practice needs, where they might in the right direction. We are looking to be underinsured and give them a better launch this in the New Year. understanding of their insurance cover. We launched the Lloyd & Whyte Since we launched these wellbeing portal in 2020. The Wellbeing consultations, we’ve invited Matters portal gives access to hundreds of optometry healthy recipes, fitness videos For more clinics to have a review. Of and mental health advice. information on the those we have spoken We are able to offer services offered by to, we identified that employers access to the Lloyd & Whyte through 62% were underinsured, portal as an employee its affinity partnership which is easily done when benefit. We can provide with the AOP, visit: www.aop.org.uk/ a practice grows and anonymous trend data to benefits changes quickly. show the areas of wellbeing We also found that many that their people need had gaps in cover; this is where support with the most. This sort they thought they were insured for a risk of information is invaluable given that which would actually be covered by a the cost of sickness-related absence and different policy. presenteeism costs the UK economy £77.5 We find this is common, particularly billion a year. when it comes to the risk of cyber-attacks. Many people believe their business Trends to watch in the year ahead insurance policy would cover it but There is a very real concern about how historically they were developed to protect well people understand their essential physical threats like fire and flood. Cyberinsurance policies. Buying online or

renewing year-on-year without talking to someone can leave homes and businesses worryingly underinsured. On the finance front, 2021 has seen some extremely low mortgage rates thanks to the stamp duty reduction. Even with stamp duty returning, we are continuing to see rates stay low. Sustainability has been a big theme and will continue to be. Investors are now looking to actively invest in socially responsible funds. We have been helping members invest in portfolios across themes such as climate change and human rights. We anticipate that people will continue to focus on their health and wellbeing, particularly employers who want to look after their staff. We talk to members every day about policies like income protection, employee assistance programmes and cash plans. We see that becoming more popular. Three reminders for the new year 1. It is important to remember that you get what you pay for. If something is worth protecting, it is worth doing properly 2. It does not have to be time consuming or expensive to make sure your finances fit what is important to you 3. When you make decisions about anything as important as finances and insurance, you need to be able to trust where the advice is coming from. How qualified are the people you’re talking qualiﬁed to? What values does the company have and how do they demonstrate them? What reassurances do you have that they will act in your best interest? Pete Lishman, managing director at Lloyd & Whyte

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SPOTLIGHT

VERSION SUBS

An essential part of practice ART

From OCT-angiography to the increase in shared care, OT heard from manufacturers about the evolving role of OCT

PRODUCTION CLIENT

Demand for optical coherence tomography (OCT) continues to grow as manufacturers seek to enhance the data the technology can deliver. Speaking to OT, Jacqui Kenyon, HaagStreit OCT product manager, explained: “Interest and demand for OCT increases year-on-year, with a growing number of opticians understanding the true clinical and financial advantages of investing in OCT technology.” Sales have continued to climb through the pandemic. Nicola Bennett, clinical affairs manager for Topcon in the UK and Ireland, said the company had seen a large increase in demand, suggesting that the fact practitioners do not need to get so close to a patient while using some of Topcon’s devices could be a factor, while the devices also enable images to be captured of the back of the eye providing “a lot of key information, very quickly.” Interest in OCT has also grown as the profession responds to the rising patient backlog amplified by the pandemic. Highlighting the challenge, Emily Malbon, head of UK marketing and education for Heidelberg Engineering, explained: “The pressure is now on to work through the backlog and because of this we are seeing NHS eye departments expand, and dedicated ‘diagnostic hubs’ popping up all over the country.” These hubs use a virtual clinical model and a range of diagnostic equipment, with OCT forming an “essential” component, she suggested. Alongside this, the company has seen “more enquiries than ever before” from High Street optometrists who are 20 www.optometry.co.uk

involved with shared care, or are looking to differentiate their clinical offering. She said: “I think this will become more commonplace and the expansion in NHS services has only just begun.” Zeiss has also seen its OCTs making up diagnostic hubs. Claire Martin, Zeiss business development manager, glaucoma and retina, suggested that, as the NHS navigates the patient backlog, “shared care, or at least, the sharing of data between secondary and primary care, has to be the way forward.”

Development of tech Manufacturers are increasing the benefits of OCT by improving OCT IN ease-of-use, enhancing DISCUSSION Quality and connectivity image quality, and For more on the role Improvements in image supporting connectivity of OCT in changing practice routines and quality continue to and data-sharing. the patient experience, enhance the benefits OCT has been evolving read OT’s roundtable of OCT, Bennett shared. since its invention in 1995, discussion with Optos Topcon’s SmartTrack Martin shared, highlighting from page 41. system on its Triton OCT, for that Zeiss’ technology now example, “greatly minimises the has “dedicated scan profiles for risk of artefacts by having different the macula, glaucoma and anterior tracking settings that can help deal segment, allowing for a comprehensive with patients who might struggle to suite of clinical exams.” Recently, Martin said, OCT-Angiography keep fixation during capture, helping to (OCT-A) is “revolutionising the way we see achieve a better image quality,” she said. While the Maestro2 device is a ‘onethe retinal vascular structures.” touch’ automated technology, Bennett Manufacturers all identified OCT-A as emphasised that clinicians can still an important change, with Kenyon calling manually control the device if required, to it “the biggest key development in OCT optimise images in trickier patients. over the last decade.” Optovue recently launched its Solix Describing it as a technology that is product in Europe with enhancements “still, relatively speaking, in its infancy” including a wider field of view for anterior and seeing “a lot of rapid development,” and posterior segment imaging. Malbon said: “The quality, field of view,

December 2021/January 2022

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Getty/Cucurudza

REPRO OP

SUPPLIER INSIGHT

analytics, and speed of image acquisition of OCT-A images has all improved dramatically within recent months.” Mike Papac, vice president, strategic planning and innovation for Optovue, identified OCT-A as one of three key opportunities for the development of OCT, suggesting this technology is being applied more in diagnosis for areas such as early diabetic retinopathy and AMD. He shared: “OCT-A offers a unique view of the ocular blood flow network which research has shown, and continues to uncover, links to early signs of disease.” Quantification is important for this, he said, explaining that the company is working to provide metrics for clinicians to analyse and interpret images in an efficient and decisive way with its AngioAnalytics platform. Practice efficiency, through the merging of technologies and high-speed acquisition, such as of OCT and OCT-A, is another area of opportunity for diagnostic technologies, Papac suggested. He noted, however: “I think where we see that fall down in some of the devices in the market, is that some are very good for scanning healthy patients, for example, using an automated image capture feature. But once there are pathologies present, you need a more advanced device to properly assess these patients,” an area the company said it is focusing on.

This, Papac explained, aims to “make imaging a broader range of patients that have pathologic conditions even easier.” Connectivity is a third area of opportunity going forwards, Papac said, and is an area the company feels it has a renewed strength in, following a merger with Luneau Technologies in 2021. Being able to view images from multiple devices has become “extremely important,” Malbon said. In the past 12 months, Heidelberg Engineering has performed many Heyex 2 software upgrades, which allow for networking of devices within a single practice and multiple locations, “to enable concurrent access to data and simplify data sharing.” Topcon has seen interest grow in the use of referral and vendor neutral data management tools, such as Harmony RS, allowing clinicians to view devices “from multiple modalities” in one place, and allow data sharing with other professionals “in a structured and secure way,” Bennett also identified. Zeiss’ Martin agreed that data analysis tools and the ability to review data away from the device, is “crucial.” This is in addition to data management platforms, such as the Forum software, which enables all patient data from key devices to be viewed on the same screen. She suggested that future developments for OCT will include improved digitalisation for shared care and artificial intelligence. Evolving use Before the pandemic, the use of OCT was focused around pre-screening,

THE ROLE OF OCT IN TRIAGE Malbon, Heidelberg Engineering: “OCT is simply essential for triaging patients, especially if you want to triage in a non-contact manner. This is exactly the model that diagnostic hubs up and down the country are adopting and it is working to move through COVID-19 patient backlogs very effectively.” Kenyon, Haag-Streit: “The introduction and development of artifical intelligence in OCT opens up opportunity to allow patients to be scanned in high volumes,

Bennett suggested, whereas now “it has become normal to have OCT as part of an advanced sight test in many practices.” She continued: “Those that do have OCT are encouraging patients to have the scan as standard because it is going to help them – not only to minimise prolonged proximity to the patient during the test – but also to have a lot of information at their fingertips. Clinicians are able to compare scans over time, monitoring change and referring if need be.” Reflecting on the adoption of the technology, Malbon said: “OCT has become an essential piece of equipment for any practice that is serious about offering clinical services,” adding that the technology is also becoming more familiar to patients. OCT can play an important role as primary care seeks to take on more community-based services. “The optometrist’s role in the early detection of eye disease and timely referral, alongside monitoring patients in the community and reducing pressure on an NHS that is even more overwhelmed than before, is more crucial than ever,” Malbon said. She added that, when choosing diagnostic equipment, optometrists should carefully consider the clinical benefit to the patient and relationship with the hospital eye service. Kenyon suggested hospitals and optometrists are working together more closely, noting, “with the development of artificial intelligence, this will continue to grow.” Optometrists are already

increasing productivity. It will also reduce the number of missed imagingbased diagnoses and will aid clinicians with referrals.” Martin, Zeiss: “The OCT is key to both diagnosing and managing many ophthalmic diseases. For new and stable patients much of this could be done in practice and only referring back into the hospital if there is a need to. The images could be reviewed virtually by clinicians away from the practice.” Papac, Optovue: “I see OCT being recognised as the window into the

Above: Zeiss OCT tools have been important for keeping social distance during the pandemic

becoming involved in glaucoma screening clinics, she pointed out, adding, “we can expect this to expand to include other pathologies, as hospitals look at ways to screen patients in the community, in order to relieve pressure on the NHS. With an ageing population, hospitals are likely to rely more heavily on opticians and GPs, aiming to reduce waiting lists and ensure patients are treated quickly.” Papac suggested that OCT enables primary care to “take more of the heavy lifting” from secondary care in screening and monitoring patients, emphasising the continued importance of connectivity for seamless data sharing. Agreeing that OCT is becoming more important in shared care partnerships, through COVID-19 Urgent Eyecare Services and Minor Eye Conditions Services, Bennett highlighted the role of the technology in the referral process. She said: “It builds on the clinical information that is most commonly available. Increasing the information being sent with the referral aids the ophthalmologist and enables better and more customised patient care.”

body through the eye. Having an OCT available, and more optometrists able to detect disease in its earliest state, is going to be the most beneficial overall to the healthcare systems in terms of reducing the burdens of cost and the progression of diseases.” Bennett, Topcon: “If someone calls the practice with an issue, such as flashes and floaters, or visual distortion, capturing an OCT can provide a lot of information very quickly. That helps the clinician decide what their next steps will be, in combination with the other clinical findings.”

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Spotlight, 8

SPOTLIGHT

AOP reviews manifesto aims

REPRO OP

OT hears about the projects the AOP policy team has been involved in over the past year, and the work being undertaken to plan for the future

SUBS ART PRODUCTION CLIENT

The AOP policy team has contributed to more than 13 consultations over the past year, representing the views and needs of AOP members and making 2021 one of its busiest years. Jacqueline May, AOP policy officer, explained that some of this work has arisen from GOC consultations that relate specifically to the pandemic, while 2021 also saw the Council elections, postponed from 2020, and the meeting of the first Council in the new structure. She added that “meetings of the Policy committee, AOP Council and the sector education forum shifted online and continued to provide the focus for our engagement with membership.” Key activities involved responding to plans and developments in the broader healthcare sector, as the Government set out its plans for the reform of the NHS. This included an NHS England consultation on Integrated Care Systems (ICS), which sought feedback on the next steps proposed in developing the new model in England, and highlighting potential risks and opportunities for optometry in the Department of Health and Social Care’s Health and Care Bill. Education has continued to be an important topic for the AOP’s policy portfolio and for members.

May explained: “We received a large response to our call for comments to support our response to the GOC consultation on its proposed new education framework for independent prescribing.” What’s next?

In 2021 the team undertook a review of the AOP’s policy manifesto, which was published in 2019 to bring together key points from AOP position statements and policy work, in an overview of the association’s policy ‘asks.’ This involved reviewing what the AOP has achieved against each of the ‘asks’ within the manifesto and determining where the organisation’s priorities may lie going forwards. Speaking to OT, the policy team shared that work on some of the biggest issues, including extended services, sight test fees and education, are part of ongoing discussions, with outcomes expected in 2022. A September meeting of the AOP Policy committee, formed of AOP Councillors, discussed areas of the manifesto which could require further work in the future. This included the policy ‘asks’ around learning disabilities and excluded

Tackling illegal supply online A new AOP campaign warned the public of the risks of illegal contact lens sales and urged the Government to act Throughout October and November, the AOP ran a new national campaign highlighting the risks of illegal supply in the UK. The Know your lenses campaign was launched in response to reports from AOP members of a shift in consumer behaviour, with more patients buying prescription contact lenses online. A survey of over 1000 optometrists found that 56% of AOP members saw as many as nine patients in a month experiencing problems as a result of contact lenses purchased online and 55% reported seeing evidence of breaches of the law by suppliers. The AOP highlighted that some websites are run by companies based overseas and fall outside of UK jurisdiction, meaning some products are sold illegally. When asked, almost half (45%) of contact lens wearers were unaware that some online suppliers are unregulated and do not comply with UK safety regulations.

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groups, with the committee discussing ‘extending the scope of the position statement to call for fair treatment of a wider range of groups who do not have equal access to eye healthcare, such as homeless people, and prisoners.’ The meeting covered the position relating to illegal or unsafe practice, and with the GOC launching a consultation on draft protocols in this area, the AOP planned to respond, taking into account the views of the Policy committee. On the association’s goals around driving and vision, the AOP continues to discuss further work required to take forward its proposals for compulsory, regular vision checks for drivers. The review is likely to continue into 2022, looking at the position statements that feed into the manifesto. Whether any of the nine 'asks' will change will depend on the outcome of the review. “The manifesto continues to be a useful document for our members who can use it to see which important issues the AOP has pledged to focus on in its public-facing activities,” May shared. The AOP’s consultation responses can all be found at: www.aop.org.uk/our-voice/ policy/consultations

Through the campaign, the AOP called on the Government to close the loophole enabling suppliers to operate outside of UK safety laws, and suggested that suppliers carry an approved kitemark to make clear to consumers that they are purchasing safe and trustworthy products. The AOP worked with consumer organisation, Which?, and RNIB Connect Radio to promote the campaign. Adam Sampson, chief executive at the AOP, commented: “It’s time that there is more in place to protect the public – particularly as the trend for consumers to buy online is only set to grow. We cannot possibly afford for people to trust unregulated sites over the skills of trained eye care professionals.” At the time of writing, the GOC is considering a draft protocol on illegal practice. The AOP urged the regulator to “clamp down” on suppliers that put consumers at risk.

More information and resources from the campaign can be found on the AOP website: www.aop.org.uk/knowyourlenses

Pixabay/ Edar

VERSION

MEMBER SUPPORT

AOP EXPERT

Commercial

Optometry Today

Sarah Melzack, AOP membership benefits officer

Lucy Miller, deputy editor

What are the AOP’s new menopause resources? These are for any members who are interested in personally preparing for their menopause, as many people don’t know how to ready themselves and a lot of the symptoms can be alleviated by preparing more effectively. We also have workplace content, which is there for employees to look at how they manage menopause in the workplace if it does start to affect them and their ability to practise. From the employer side, if they have staff experiencing symptoms, the resources are there to help them consider how to best cater for employee needs and make adjustments so that they can still carry out their job to the best of their ability. Why did the AOP want to launch these resources? It stemmed from the AOP’s holistic approach of wanting to

cover all aspects of a member’s journey – not just from a professional side, but from a wellbeing side. There has also been quite a lot in the press in recent months about how the treatment of employees suffering from menopausal symptoms has been taken to employment tribunals, with employers being charged for discrimination because they haven’t made suitable adjustments. We want to make sure employers in the optical space are doing what they need to, and we don’t want any employees feeling neglected, or like they have to quit their job. What is next for this support? We would like to do more on this topic if the demand is there. It is an exciting development in the wellbeing space for our members.

More resources can be found at: www.aop.org.uk/menopause

members and make life easier What is OT’s jobs listing service? for them, so we hope this Our jobs listing is a free service offering will help. If members on our website that has been wish to enhance a vacancy, created to allow AOP members there are fee-based options to upload and advertise any available to them through our vacancies that they need to advertising partners, Think. fill in practice. Members can These include pinning their upload and post a listing via the listing to the top of our Jobs ‘Jobs’ section in MyAOP. When board with featured job a member posts a new status, or including role, it will be reviewed it in our weekly and published on our For more newsletter. Jobs board within information on two working days. OT’s jobs listing, All jobs will be live visit www.optometry. What has the response been like? for a month, unless co.uk/jobs We have been really a shorter time period pleased with the is specified. We plan response so far. We will be to run the service for free responding to any feedback we until the end of January 2022. receive about how the service could be improved – please How does this resource support do get in touch to share your AOP members? thoughts. There is a wide range We know that recruitment of vacancies being advertised can be costly and take up a so we would encourage anyone lot of time, especially for a looking for their next challenge busy practice. We are always to take a look. looking at new ways to support

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Spotlight, 9

SPOTLIGHT

Hitlist, 1 VERSION

Available anywhere

REPRO OP

FOCUSES ON... REMOTE SOLUTIONS

SUBS

IbisVision has launched IBISConnect, its new telemedicine platform that connects clinicians with patients in real-time. Tests include visual acuity, visual fields, Amsler and colour tests which can be performed on a laptop or computer. As the platform is interactive, optometrists can see and speak to patients while tracking their test progress, and are able to accurately position their patients remotely. www.ibisvision.co.uk

ART PRODUCTION

Hit list

The trends, launches and looks

CLIENT

Patient engagement

Optimed has highlighted its Captiv8 Connect app, which provides virtual consultation tools and patient education. Recent updates to the platform include the ability to create a unique QR code which patients can scan in-practice to view educational animations on a practicebranded web page. The company plans to roll-out a new e-referral application in early 2022. Currently accessible through iOS and Android devices, the platform is set to be available through a web browser application from early 2022. www.optimed.co.uk

New tools Home monitoring

Mainline Instruments has highlighted the iCare Home2 tonometer, designed for home use by glaucoma patients who need regular intraocular pressure (IOP) monitoring. No air puff or anaesthetic is required for the device, which also hosts an intelligent positioning system for correct alignment and to ensure high-quality measurements. The device features a fully-integrated app for iOS and Android to enable patients to see the results and upload IOP data to their eye care practitioner remotely and safely. www.main-line.co.uk

Advanced Ophthalmic Systems (AOS) has rolled-out AOS 3.1 with tools designed to “bridge the gap between in-clinic and remote care,” and help practitioners manage contact lens and dry eye patients. The solution can assist in measuring the perimeter of contact lenses, rotation angle and the position of toric lenses, using the LARS principle. A new video capture and analysis mode aids eye care professionals in monitoring the movement and centralisation of the lens on the patient’s eye, with practitioners able to control playback speed and capture stills of videos. www.sparca.com

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VERSION

GET THE

REPRO OP

LOOK

Q&A ME & MY GLASSES

Optometrist and lifestyle blogger, Lizzy Yeowart, on the ‘urban cool’ frame offering Strike a pose in these sleek styles.

SUBS ART

Golden Eye

PRODUCTION

‘Pulp’ by Bali Eyewear packs a style punch with its striking black and gold detail. This Parisian brand offers trendy, chic eyewear that is feted by celebrities and models alike. balieyewear.com

CLIENT

Alicia Hartman The optometrist, practice owner, and founder of the Peoples from Barbados eyewear brand, shares her passion for frames

I grew up around eyewear from the age of 13, as my family has one of the oldest optical practices in Barbados – with an incredible history of eye care and ability to communicate the importance of eye health at the root of their values. There was nothing better than being witness to the client receiving the gift of sight, then watching the journey of their eyewear style. I have as many pairs of frames as I have shoes; my two favourite accessories. I am a minimalist with jewellery, so my eyewear, lip colour, and shoes make the statement. I like oversized frames that are lightweight and comfortable. The shape varies with my mood.

Centre of attention

I wanted to create glasses to fit Afro Caribbean faces and to include our rich diversity of visitors. The Peoples from Barbados collection was created as a tribute to the 50th anniversary of Barbados. The vision grew from a bigger purpose to showcase culture and Bajan lifestyle through eyewear. There is so much inspiration of colour, form and texture. My style icons are my practice clients: the Eye Q people. The diversity of my clientele is so special. From fisher folk to aristocrats. The store is an eyewear emporium curated to complement and enhance their features. I love the eyewear stories they have when they go beyond the island.

‘Uppercut’ by LA-based brand Bonnie-Clyde is a design made in geometric acetate with stainless steel detail and round tinted lenses. This unisex style will guarantee second glances. www.bonnieclyde.la

Style chameleon Heart-shaped ‘Queen’ by Catch London is made in colour-change acetate so the frame transforms from crystal pink to purple in sunlight. Not only that, but it is also handmade in West London. catchlondon.net

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Sunglasses

Glamorous in gold

REPRO OP

In its autumn/winter 2021 collection, Barton Perreira has added nine new sunglass and optical frames to its catalogue. Highlights from the new sunglass styles include ‘Magdalena’ (pictured), a butterfly model created from ultra-thin acetate and featuring 24K gold plated Japanese titanium. www.bartonperreira.com

SHORTLIST THE LATEST PRODUCT LAUNCHES

SUBS

Sunglasses

80s heyday ART PRODUCTION

Cutler and Gross launched its autumn/ winter collection for 2021 with frames drawing inspiration from “the melting pot of cultures and personalities of 80s Soho, London.” The 11 new unisex designs reinterpret archive styles from the 50s through to the 70s. Models in the collection include the ‘1391’ rectangle frame (pictured), inspired by Patti Smith and featuring the new ‘Fender Temple’ and vertical vintage oyster pins. www.cutlerandgross.com

CLIENT

Contact lenses

Custom made

Positive Impact highlighted the UK launch of SynergEyes iD, contact lenses which are individually designed to each patient’s ocular measurements. The contact lens design utilises keratometry and horizontal visible iris diameter readings, along with refraction, and also incorporates the patient’s corneal diameter and curvature. SynergEyes iD includes a multifocal element – supported by the proprietary extended depth of focus design from the Brien Holden Vision Institute. www.positiveimpact.co.uk

Frames

Japanese roots

Minamoto, the new brand from Charmant which draws on the company’s Japanese roots, has launched its first collection, with frames made from 99.4% pure Japanese titanium and sides of beta-titanium. The launch collection features 12 styles including four women’s frames, four men’s styles and four unisex models. The flagship frame from the men’s collection, the ‘Akira MN31003’ (pictured), takes inspiration from the past, with anti-slip epoxy used at the nose bridge to replace nose pads. www.minamoto-eyewear.com

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

Equipment

On the go

Grafton Optical has launched the QuickSee handheld autorefractor from PlenOptika. The device combines open view binocular design, wavefront aberrometry, and dynamic measurements to produce clinically accurate autorefraction measurements. The device is suitable for field use and in clinic. The company suggested the technology is as accurate as clinical desktop autorefractors and demonstrates a high level of agreement with subjective refraction. www.graftonoptical.com

Frames Frames

Lightweight and refined

Blackfin has introduced the Aero Wire collection. The frames are made from a 0.7mm sheet of beta-titanium for the nose bridge, while the sides are made from 0.5mm sheets. Styles include the ‘Aero Hayle’ (pictured) which sees titanium wire wrap around the edge of the lens, creating a double bridge and presenting a 'futuristic' and architectural look. www.blackfin.eu

Seasonal hues

William Morris London has released its autumn/ winter collection, with 27 frames in colours symbolising the season: autumn reds, mossy greens, and midnight blues. A standout women’s frame from the collection is the ‘LN50216’ cat’s-eye (pictured) with a colour pop rim combined with tortoiseshell acetate and pin detail. www.williammorris.co.uk

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Hitlist, 3

HIT LIST

VERSION REPRO OP

Q&A BEHIND THE BRAND MILLMEAD OPTICAL GROUP

SUBS

CEO, James Conway, on 75 years in business – and sustainability

ART

MILLMEAD OPTICAL GROUP//

1 PRODUCTION

CLIENT

Conway’s grandfather patented the PIMO machine that could insert a metal core into acetate frames, a more efficient process In October, Millmead launched a range of cases created from a material sourced from recycled plastic bottles and made in the UK Millmead aims to offer a ‘onestop’ service, reducing costs and the environmental impact from a reduced number of shipments.

Clockwise from left: Original Penguin frames by Continental Eyewear; James Conway; Cameo Sustain

Could you tell us about Millmead’s sustainable ambitions? It has been a huge project. Just a few of the changes we have made include LED lighting, recycling our waste and changing our packaging. It's ongoing indefinitely – that’s the way to think about sustainability. When I started to consider sustainability five or six years ago, I thought that you just do X, Y and Z. What I’ve realised is that the whole point is just to keep on going and keep questioning everything you do. What has the company been working on? The Cameo Sustain range of frames is launching in January at 100% Optical and is entirely made from recycled plastic bottles (recycled-PET). On the lenses side, we will be launching a few things at 100% Optical. One project has been in lens waste. All the waste from edged and surfaced lenses goes to landfill or is incinerated. It’s a difficult problem to solve, but something we hope to have a solution to in early 2022. What does it mean for Millmead to be celebrating its 75th anniversary milestone? It is a big milestone. It’s been a bumpy ride at times. I’ve only been involved for 22 years and my memories as a kid are that it was a very different business. Much smaller and fewer employees, but a reasonably successful business. We had a really interesting product when we started with the PIMO machine in 1946 and the business went through so many transitions of ownership over the years. It is nice that its back in the ownership of the two families who founded it.

ANATOMY OF A FRAME OT columnist, Lizzy Yeowart

In a nutshell Manufacturer // Re:Sin Frame // ‘Metis’ Colour // Pink Web // Available via The Exclusive Eyewear Agency: www.instagram. com/the_exclusive_eyewear_ agency/

Made of the highest-quality Italian ecofriendly acetate

Zeiss lenses with 100% UVA and UVB protection

Baltic amber adornments. There are no two identical pieces of amber — so every frame is different

Lightweight and durable pink frames

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Hitlist, 4

HIT LIST

Perspectives, 1

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Perspectives Voices from optics and beyond

SUBS

“I believe that triage has been going on informally for many years in practice”

ART

Dr Julie-Anne Little

PRODUCTION

Getty/sorbetto

CLIENT

riage is important for eye care professionals for many reasons, not only because optometrists are essentially the gateway in primary eye care and the main source of referrals into secondary care, but also because within a general practice there will be certain levels of triage being undertaken every day by both clinical and support staff across the whole team. Triage to me is about profiling risk and emergency, especially in situations where we are trying to profile how soon a patient needs to be seen – that level of urgency or risk is where triage comes into play. This was particularly key during the pandemic when we, as optometrists, were relying on telephone conversations to probe a patient’s need for a face-to-face consultation. In this regard, the pandemic probably helped us hone our skills in triage. However, I do think that the word triage feels like a hospital term and one that is not necessarily used in practice with regards to how staff are trained in filtering patients appropriately when they telephone to make an appointment. As a profession, we are probably slightly behind the curve in using the term triage and formalising what we mean by that in our working lives. Yet I believe that triage has been going on informally for many years in practice; people across the entire practice team are doing it unconsciously day-to-day. Triage is not just about the optometrist referring into secondary care, it is also about the training of support and practice staff as well. When triaging in practice, I think the main concern held by practitioners is about getting

the whole picture. Of course, as clinicians, we want to collect as much clinical information as we can in order to inform our clinical decision-making process. Yet where you are limited by a remote consultation, for example, you are limited to verbal information. Good triage relies on good communication and the assimilation of information across the whole practice team. Therefore, there is a real risk that if that does not occur then there could be gaps in information and things might be missed. In terms of remote consultations, I feel there is a real scope for them to become part of our job and what we do. However, my concern currently is how it fits into General Ophthalmic Services and the requirements of an NHS sight test, as well as the risk indemnity linked to it. While there is great potential, there are also many aspects that need to be thought through. So much of what we do as a profession requires a face-to-face element, so remote consultation for me is a step along the way on the pathway for the patient, but at some point they will probably need to be sitting in the chair in front of you. It so often strikes me when having conversations with colleagues in secondary care that they have little awareness of

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What is your view?

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

AOP Council Read about the topics discussed at the latest AOP Council meeting www.optometry. co.uk

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“Good triage relies on good communication and the assimilation of information across the whole practice team. Therefore, there is a real risk that if that does not occur then there could be gaps in information and things might be missed”

ART

the types of things that the profession is filtering out in practice through effective triage and that they are therefore not seeing. This means that in these situations it can often feel that eye care starts at the hospital door. But 95% of the population are having their eye care needs managed by optometrists in primary care, whether that is just because it’s routine or whether it’s managing conditions that are no longer within other schemes such as Minor Eye Conditions Services (MECS), for example. I think the profession has a long-standing history of really standing up and serving

PRODUCTION CLIENT

“Video consultations are an enhancement not a replacement to the eye care service I provide” Brian Tompkins

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

e responded to COVID-19 by shutting, like everyone did initially. We quickly put in place an emergency email address and diverted our telephone to allow us to be contacted. We announced this through email blasts to our patients and via social media. With the right IT infrastructure in place, we were able to arrange remote access to the practice from the word go. Our clinicians would monitor the emergency email and respond to patients accordingly. In the early days, it was all about reassuring patients and assessing via telephone and WhatsApp calls whether they needed to be seen as an emergency. We later, like many, moved to Zoom. We were much more comfortable doing something to reassure our patients than just leaving them in the lurch or making them go to hospital.

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its communities very well – COVID-19 has helped showcase that, as well as things that have been overlooked in the past. Eye care and primary care professionals manage a wide range of things for their community and for their patients. Even when something is referred to secondary care, for the majority of eye care professionals, it does not feel like the responsibility stops there. Many of my colleagues will want to follow up on those cases; they will want to close the loop of care and have an ongoing relationship with the patients. That continuity of care, I know, is really important for patients and clinicians, who value seeing the progress, and hopefully the good outcome, for patients they have referred. Dr Julie-Anne Little is an optometrist , chairman of the AOP Board, and a senior lecturer in optometry and vision science at Ulster University

I could recount numerous cases of patients who had teleconsultations; we saw them as an emergency and avoided them making a trip to the hospital. The scope and skills of independent prescribing delivered by our optometrist and fellow director, Keyur Patel, worked to give them treatment and relief. During the early days of the pandemic, we did remote consultations, we did home deliveries, and we kept our contact lens solutions and supply going. We tried to be there for our patients in every way that we could, and IT played a massive part in that. If the pandemic had happened 10 years ago, the world would have gone to pot. Remote consultations Having a prior relationship with Advanced Ophthalmic Solutions (AOS), when it developed its remote consultation solution towards the end of 2020, we became a beta tester for the software. Once it was brought to market and we knew it worked, we moved to this for all remote consultations. It’s simple and easy to use. The support team sets up the patient on AOS and it is only the clinician who provides the video call. It took almost no time at all for the clinical team to feel comfortable doing remote consultations. The patient receives a link-coded email with a personal pin and

appointments because of the nature of video calls, enabling us to decide if a patient really does need to be seen in person. With personal protective equipment, including masks, a way of practice life today, remote consultations have other benefits too. During a remote consultation, you do not have to wear a mask, which means you can hear the patient better. It also gives the patient the opportunity to see you; it allows the passion and enthusiasm you have for solving their problem to be seen, which is a real endorsement for you and your practice.

Getty/Jane_Kelly

registration code. The patient is then required to download the app for access. Yes, it relies on a smartphone and sometimes it fails due to user error or the internet connection not being strong enough, but that is rare and, generally, it has been welcomed by patients. Extending remote care Observing the benefits of remote consultations via the AOS platform, we took the decision to extend this service. We began using it not just for emergencies or when a patient requested it, but for pre-screening and triaging a patient before they attended for an appointment. We are a specialist practice and have patients attending from far and wide. Offering a remote consultation and seeing the patient ahead of their appointment enables us to gain massive amounts of beneficial information. Yes, they may have previously shared an email of their history, or we have had a telephone conversation, but to actually see the patient and ask them the questions is so much more interactive and helps you pre-judge what appointment time is needed. We provide these video consultations free of charge – we have never charged for a telemedicine consultation as our patients are private or on a care plan. I appreciate that it is harder depending on a practice’s fee structure. And while we pay a small monthly fee for AOS, it’s a small sum to pay when it allows such a greater level of efficiency of appointments for patients when they do come in. It also means that we have saved

Pre-pandemic Before COVID-19, I had a slight hesitancy about the concept of remote consultations, but there was also not a unique platform available back then, even GPs did not have one. Remote consultation was massively accelerated by the pandemic. While I have a different view now, I also believe that never will or should remote consultations fully replace an eye examination in practice. However, there are just “We tried to be there for some things, such as our patients in every contact lens reviews, that way that we could, and in-person appointments IT played a massive part are not always needed for. in that. If this happened In my practice remote consultations are here to 10 years ago, the world stay. Video consultations would have gone to pot” are an enhancement not a replacement to the eye care service I provide. The enhancement is that you give greater service, and have greater communication, and greater levels of interaction between you and the patient. It takes less time to do a 15-minute remote consultation than it does for the patient to come in, put their shopping down, be late, park the car, and use 30 minutes of clinic time that could have been effectively offered by video consultation. For my practice, remote consultations are money saving, time saving, efficient and set us apart. They also make us appear much more modern and high-tech in a post-COVID era. Brian Tompkins is a contact lens specialist, optometrist and co-director of Tompkins, Knight & Son Optometrists in Northampton. He owns the practice alongside Nicky Tompkins, Keyur Patel and Andrew Oliver. His practice is part of the Hakim Group

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Perspectives, 2

PERSPECTIVES

VERSION REPRO OP

“Enter CPD, the replacement for CET” Natalie Michaux

SUBS ART

PRODUCTION CLIENT

he face of optics is changing. Optical professionals are working in increasingly diverse scopes of practice, the technology at our fingertips is ever-expanding, and our understanding of patient needs is increasing. The initial education of budding optometrists and dispensing opticians is also changing to meet the demands of modern-day practice as part of the Education Strategic Review. It makes sense then, that what the General Optical Council (GOC) expects of registrants, in terms of learning ‘post-qualification,’ should reflect the evolution of the sector. Some registrants have been telling us for a while that CET can feel somewhat like a tick-box exercise, with the same requirements needing to be fulfilled no “CPD is more matter what context they work in. Others have told than just a name us that they’d love to learn change: it represents new things but feel stifled a philosophical by the requirements of shift in what post- the CET scheme, which qualification learning focuses on maintaining should look like” existing skills rather than developing new ones. Enter Continuing Professional Development (CPD), the replacement for CET.

CET online Collect CET points with OT before the end of the cycle www.optometry. co.uk/cet

What’s in a name? CPD is more than just a name change: it represents a philosophical shift in what postqualification learning should look like. It is a framework to make sure that all registrants are maintaining their existing skills, whilst having the flexibility to tailor their learning to current and future practice, career aspirations and professional interests. Meeting the GOC’s requirements should be easier under CPD than CET, because more types of learning can be counted towards the points total (which remain the same as it was under CET).

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Registrants will be able to obtain points for relevant learning that comes from sources outside optics – we’re calling this ‘self-directed CPD.’ The research master’s degree you undertook; the data protection course you went on; the leadership programme you’re part of; the EDI webinar you attended: any and all of these will be eligible to count for CPD points. Registrants will still need to complete CPD in four ‘core domains’ (a minimum of one point in each), and collect at least 18 points from learning delivered by GOC approved providers. But otherwise, you can tailor the scope of your CPD to your own learning needs and goals. The four core domains under CPD also allow a greater variety of learning than the CET competencies, requiring registrants to undertake learning that focuses on ‘soft’ as well as clinical skills. Learning more about professionalism, leadership and communication are vital tools to help the optical professional navigate the complexities of practice and provide safe care to patients. It’s all very well providing excellent clinical care, but if a patient doesn’t feel their needs have been met, or they haven’t really understood what the results of their sight test mean, safety might be negatively impacted. CPD aims to help avoid this. Reflection matters We’re also requiring registrants to do a reflective exercise towards the end of the CPD cycle, looking at what they have learnt, what they plan to learn and how their professional practice has changed. We will give registrants a template that they can use to do this, or they can upload documentation of one they’ve undertaken with their employer or as part of their NHS role. We know reflection can be polarising, but the benefits of it are countless: thinking about what you have done and what you might do differently in the future helps you to continuously improve the care you provide. More information about the move to CPD will be published by the GOC over the next few months, including webinars and guides, so keep an eye out for these and make sure you’re as informed as you can be. Natalie Michaux is standards manager and CPD review lead at the General Optical Council (GOC)

MY VISION

“My vision is like a shattered cashew nut” Karren Visser

Karren Visser

with Sandwell College Department of Photography hen talking about what I do, I try to avoid the designed to give the students a sense of what it phrase ‘taking photographs.’ Instead, I say would be like to be blind or visually impaired. Then ‘making photographs’ in the hope that I am COVID-19 and lockdown came. It was then that the respecting the privacy of those I wish to photograph. project Seeing In Isolation evolved and took on a real For me photography is also about attempting to see presence. We worked virtually. Some of those who my surroundings and appraise what I am seeing. I participated are totally visualise what it is I would blind. Some were living like to photograph and then alone, navigating the I go into a situation with a pandemic by themselves. sense of what is in my mind’s For me the motivation eye and how I would like to behind establishing the convey this. online project was that I had an experience in many Sandwell Visually Rwanda, where I observed Impaired members in a restaurant a mother were quite isolated. I carrying her daughter with thought this would be an autism who was about 12 opportunity for people years old on her back to to share their stories. calm her. I was told that in You will find that none Rwanda, it is considered of their stories are about unacceptable that a mother COVID-19. They are about would carry her daughter of friendship, mental health, that age like a baby. I wished the importance of colour, to convey what I felt and working for charities and saw in the bond between the staying active.There was mother and the daughter. no ‘Poor me, I’m sitting at The mother, if you look at the home during a pandemic.’ tension in her arms, I learned to cry silently. is pressing the daughter There were things where against her. That was the I thought; ‘That may be only space that mattered in me in the future’ or ‘This that moment. is really tough going.’ I was born myopic. “I am inspired by communication – At the same time, there Recently, I was diagnosed the moment where you sense there were moments filled with with degenerative myopia. If I has been a rapport or incredible humour. close my right eye, my vision We all have skills that is black except for a tiny sliver mutual understanding” we can use to contribute like a crescent moon. The way to our society. Photography is what I have as a skill. A I would describe it is that my vision voice. I am inspired by communication – the moment is like a shattered cashew nut. where you sense there has been a rapport or mutual Supported by Multistory, an arts organisation based understanding. When you have those moments, you in West Bromwich, and Sandwell Visually Impaired, I feel that you have a purpose. initially set up photography workshops in collaboration

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

Photographer Karren Visser worked on the Seeing In Isolation project with arts organisation, Multistory, in collaboration with Sandwell Visually Impaired (SVI). Members of SVI shared their stories through short digital films. Find out more through the website: multistory.org.uk/project/seeing-in-isolation

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Perspectives, 3

PERSPECTIVES

In Practice, 1 VERSION REPRO OP

In practice 45 Pre-reg focus

SUBS

Moorfields pre-reg, Emily Mather, on the valuable support she has received during her placement

47 How I got here

The University of Manchester’s Dr Amit Jinabhai on giving back to the city that stoked his ambitions

Business insight and career development

49 Key milestones

Setting up a free service to triage vulnerable patients during the first UK lockdown

53 The workshop

The AOP’s Henry Leonard shares advice on triage and miscommunication

THE ROUNDTABLE ART PRODUCTION

Clarity and precision: a new generation of imaging

CLIENT

Four optometrists tell OT how their worlds have changed since investing in “Monaco” combined optomap® and OCT technology from Optos

The panel Lesley Cree, Lesley Cree Opticians, Nottingham Paul McDonald, Wilson, Wilson & Hancock, East Sussex and Kent

Getty/sorbetto

Dhruve Patel, Optical Studio, Virginia Water Ian Jarvis, Jarvis Optometrist, Dundee.

ith digital imaging technology, the opportunities to bring increased clarity to patients via the use of optomap and optical coherence tomography (OCT) devices have become increasingly important to optometry practices in recent years. A leader in the field, Optos is at the forefront of this progress. OT and Optos co-hosted a roundtable discussion with four practitioners who use Optos devices in their practices and spoke about what they have learnt, and what

advice they would give others considering this investment. Motivation for buying an Optos device

The panel described a differing landscape pre-optomap and OCT, with optometrist Lesley Cree explaining how the standard eye examination in her practice, before having an Optos device, relied on direct ophthalmoscopy. In Scotland, Ian Jarvis described a slightly more advanced imaging process, with every practice given a

digital camera in 2006. “We are the first point of contact for all eye problems,” he said. “We get a lot of flashes and floaters. Before optomap it was a real pain, because you’d spend so much time investigating, and even then you weren’t always sure. optomap makes the decision-making process so much easier; you’re absolutely certain. Although we were already doing quite a different examination in Scotland, the optomap moves it to the next level.”

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Paul McDonald, who practises in East Sussex and Kent, explained that he used an ophthalmoscope and a Hruby lens, attached to a slit lamp, along with a binocular headset. He said the process of photographing fundi, as part of his hospital job, was laborious. “We used a film camera attached to a handheld device with a wide-angle fisheye lens,” he recalled. “We’d get close to the pupil and take pictures as best we could, then get the film developed and three or four weeks later have to phone the patients back because they’d blinked all the way through the pictures.” Meanwhile, in Surrey, Dhruve Patel took over a practice and found that it only had a retinal camera. Having used OCT previously, he explained: “I found myself not enjoying doing the test as much. I lost a lot of engagement, as I couldn’t show patients images.” Optometrists Cree and Patel both described wanting to be ahead of the local competition, rather than just keeping up, as motivation for purchasing the equipment. “We decided to go for more technology

What is the Monaco? Optos’ Monaco is a multi-modal imaging device that combines optomap ultra-widefield technology with spectral domain (SD) OCT. It produces 200-degree, single-capture retinal images and displays a siximage overview including colour, autofluorescence, and OCT of both eyes in as little as 90 seconds.

as it was becoming much more readily available on the High Street,” Cree said. “While we were looking around, we thought that perhaps we should get ahead of the game. That’s when we decided to trial the Monaco, which combines the optomap with the OCT. We loved it.” Coming from a background of using OCT, Patel immediately felt that upgrades were needed to the practice. “One of the first things we thought about was how to improve the services in the practice,” he explained. “OCT was considered, to bring it up to par with what we were doing at our other practices.”

Advice for those looking to invest Ian Jarvis: “There’s always been a myth that technology will be a real expense for the practice. That’s not true; it’s an income generator. If you market these things and place them properly, it will bring income into your practice.” Paul McDonald: “Don’t be fearful of the technology. Know you can get information and help from Optos and other forums.”

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McDonald, looking to purchase an OCT, also had size at the forefront of his mind. “The footprint in the branch was too small to fit an OCT and retinal camera, so we got the Monaco for that reason,” he said, adding that ease of use in being able to take his own images was also a strong factor. Why optomap and OCT was the right choice

McDonald highlighted the practicality that the Monaco offers: “It’s got everything in one position. The patient doesn’t have to move around so much, so from an ergonomic point of view it’s easier.” He added that he feels the device is better quality than others that have a combined OCT and digital format, many of which only have a 45-degree field, and that the ultra-widefield plus OCT component was a major factor in his decision. Jarvis explained that the decision to make the purchase was simple, and that the Monaco “was a nobrainer” due to the floor space that it enabled him to save in his practice.

The impact on patients

Jarvis said that his staff were enthusiastic as soon as the demo device was brought in, and that patients responded well too. McDonald said: “It’s been brilliant. The patients find it a lot easier to stay on one piece of kit. They don’t have to move; we don’t have to type names and dates of birth again. The remote control gives you the chance to zoom into the pupil, and you get a much wider field.” He added: “When we had a digital camera in one of the branches and the Monaco and Daytona in the others, I felt very restricted by the narrower field. It’s a massive step forward.” Having also bought the combined Monaco, Cree said, “I do like to capture an optomap for every patient now. That’s come from realising how much we miss when we don’t have an optomap for everyone. We don’t insist that everybody has a scan, but I really like to see the whole of the retina and there’s no other way of doing that.”

THE ROUNDTABLE

“Everybody has said how beneficial it is for patients and what better healthcare they’re getting. It makes our job so much easier; so much more complete” Lesley Cree

Integrating into practice

Planning the integration of the device into your routine, Cree believes, is vital. “When we first started the receptionists had a script, but now they’ve developed their own ways of explaining it to people,” she said. Cree also has a page on her website that patients are referred to if they’re unsure, and it is made clear that patients can discuss it more when they come into the practice. They are given the option of both optomap and OCT, or just optomap, and

there is split pricing in place for those who choose the latter. Jarvis said that in terms of workflow, he hasn’t had to make huge changes during appointments. The biggest difference, he believes, is that “it improves your clinical decision making, and instantly you know whether things are right or not.” Communicating the value

Cree said: “Patients appreciate that you have invested in something to look after them; that you’re investing in their healthcare. If there is a problem, it’s nice to be able to show them and explain that I’m going to send the images to the hospital. It’s a much slicker procedure.” Patel explained that an increase in patient confidence can have commercial value, too: “Patients are more comfortable because you’ve

Learning curve: tips for success Dhruve Patel: “Most of my learning curve has been in performing it, and being able to monitor patients. We all know what the urgent issues are and what we’re familiar with, so anything that’s urgent, you know to act on it straightaway.” Paul McDonald: “The main thing is tapping into the forums. Both the OCT and Optos forums are really good resources. There’s a real wealth of knowledge; some optometrists out there are really well-versed at both sides of the imaging divide.” Lesley Cree: “When you’re first learning, Optos has a portal with lots of webinars that you can get training from. It’s good when you’re a bit further in too, in order to ask for opinions. Also, there’s a lot of CET across optometry media.”

An analogy for nervous patients Paul McDonald: “I describe the Monaco scan as like looking through the keyhole of a room. That allows us to shine a light on the wallpaper, but with the optomap we can look at the entire room, and then climb inside and look around it. Then for the OCT I say, ‘We’ve seen the wallpaper, but we don’t know where the broken pipe is behind the plasterboard. The OCT slices the wall, and we can see where the broken pipes are.’ That gives them more of a visual idea of why the option is worth pursuing.”

gone through the health side in a lot more detail, with visual stimuli. It’s not just the clinical fee that you’re finding is improving the practice, you find that the dispense value is improved too. Other things feed off having the OCT and optomap.” McDonald referenced research that has suggested patients are more prepared to spend on health than they used to be. “We find that once you explain the benefits of a scan,” he said, “they’re more likely to go ahead. More and more people are now realising that the eye examination has a high rate of detection for other medical conditions, so that’s quite useful to indicate why they should have it.” Further reflections

Patel calls purchasing the Optos device “one of the best decisions we’ve made as a practice team” and says that it has “changed the whole patient experience, and made the eye exams more enjoyable for practitioners.” “If we didn’t have an Optos,” Jarvis said, “we’d feel like our legs had been chopped off. Once you have

that level of technology it really does improve clinical decision-making, and it very much increases patient loyalty – they like to see that you’re ahead of the game and at the forefront of the profession.” McDonald believes one reason his patients love it is “because they don’t have you melting their eye with a slit lamp.” He acknowledges that “it can be a big financial thought process, but I worked on the principle that if I can get two people to pay for it, per day, it does break even. And it’s done significantly more than that – we have about a 90% uptake rate.” Cree is also clear about how much it has helped her in her practice. “I would hate to work without the Optos machine now,” she said. “Everybody has said how beneficial it is for patients and what better healthcare they’re getting. It makes our job so much easier; so much more complete. “You feel like you can confidently diagnose what a problem is, whereas without it you’re fishing in the dark sometimes. I really would not want to be without my Optos machine now. I think it’s great.”

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In Practice, 2

IN PRACTICE

VERSION

PRE-REG FOCUS

REPRO OP

“Treat every opportunity as one to learn”

Education Library.

OT's Education Library contains CET, Skills guides and CPD www.optometry.co.uk/ cet/education-library

Moorfields pre-reg, Emily Mather, on passing Stage 2 and looking ahead to her OSCE exams

SUBS

O ART PRODUCTION CLIENT

nce I was signed off for Stage 1 in early September, I was ready to sit my Stage 2 assessment a month later. Stage 2 was split into different sections, with one part of the assessment carried out remotely. This was nerve-racking, as I was introduced to two entirely new assessors and there was a lot of revision to do. I was both surprised and delighted when I found out I passed. There is now one final hurdle – the Objective Structured Clinical Examinations (OSCEs).

COVID-19 and my pre-reg

The pandemic turned my pre-reg year upside down. I moved to London from my small hometown in West Yorkshire in January with high hopes of living the city life. On my second day at Moorfields, the country went into its third national lockdown. This meant that, after moving to a new place, I was now miles away from my family and it was uncertain when I’d be able to go home again. The support

Peter says…

from everyone at the hospital made the transition easier. I have been lucky enough to have three amazing supervisors assigned to me at Moorfields, who have helped and looked out for me every step of the way. Not only have they offered help in the workplace, and with my assessments and competencies, but they’ve also checked in on me and asked how I’m managing with other aspects – like being away

given a longer contract and time frame in which to complete training. This was helpful as the uncertainty of COVID-19 restrictions was less worrying as we knew we had that extra time. I am now looking ahead to the OSCEs, which I will hopefully sit in January. The final stages

At the time of writing, I had my Stage 2 assessment last week, so I’m giving myself

“Make the most of your placement. Treat every opportunity as one to learn, and say yes to any extra observation sessions in areas you may not usually work” from home. This has been amazing and shows how wonderful the optometry staff are when it comes to looking after their pre-regs. COVID-19 has been a difficult time for everyone, but the staff at Moorfields all came together to look after one another. Due to start times for placements being delayed, pre-regs at Moorfields were The next few months will entail… Preparing for my OSCEs in January. I hope to undertake an OCSE practice course as well as sitting a mock OSCE with my supervisor in the weeks leading up to the exam. This will ensure I get to grips with the format of the OSCEs and have an idea of potential stations that may come up. I will also need

on perfecting the small details. I’m also going to actively try to perfect my communication skills, as these will be vitally important in the OSCEs and beyond. Moorfields offers mock OSCEs before the real thing, so this will be helpful for getting a feel for what the day will really be like.

a little bit of time off to relax before the last leg begins. I aim to revise for the OSCEs by going through the College of Optometrists’ elements of competence and making sure I have a broad range of knowledge surrounding these. I will continue to practise techniques day-to-day in the hospital, and focus to have the correct paperwork completed to practise once qualified. When I’m qualified, I’m most looking forward to… Growing in confidence as a fully-qualified optometrist. Although it may be daunting, I am excited at the prospect of moving around our different practices, working

Say yes

My advice to any pre-regs who have just started the Scheme, or will be starting it soon, is to make the most of your placement. Treat every opportunity as one to learn, and say yes to any extra observation sessions in areas you may not usually work. I have been incredibly lucky to do my pre-reg in such a supportive environment, and I think it’s so important to spend time getting to know your team and how people work, and where to go for help. Working these things out at the start of your pre-reg will really help you settle in and get into good habits for the rest of the year. with new people and patients, and developing my skills and ability as a clinician on my own. I also hope to gain further qualifications in the not-toodistant future.

Peter Grant is a pre-registration optometrist at Julian Davies Opticians in St Mellons, South Wales

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In Practice, 3

IN PRACTICE

VERSION REPRO OP

keratoconus were fitted with customised, aberrationcontrolling soft contact lenses. The results showed that such bespoke soft lenses were limited in their ability to correct higher-order aberrations, due to their inevitable movement during regular blinking.

SUBS

HOW I GOT HERE

ART

“My ambition was always to teach” University of Manchester lecturer, Dr Amit Jinabhai, on giving back to the city that trained him and being recognised for his inclusive teaching methods

PRODUCTION

My school work experience was at Boots Opticians. I

CLIENT

really enjoyed seeing how healthcare and retail can work together to serve the local community. Afterwards I was offered a Saturday job, which felt very significant for a 15-year-old. I have never looked back. While studying, I enjoyed helping my peers with our homework problems.

I grew in confidence by being able to explain things to my classmates. At this early stage, I realised I took pleasure in helping others learn. I graduated from UMIST in 2004, and then from the University of Manchester, with my postgraduate degree, in 2012. My pre-registration year was with Vision Express.

I worked in its flagship Trafford Centre practice, where I was supported by some exemplary clinicians. Afterwards, my first fulltime job was as a resident optometrist for Vision Express in Birkenhead. This was a big step for me,

as I worked two days of the week without another optometrist in the practice. Being the primary clinician helped develop my patient management skills and overall confidence. When I worked in the field of refractive surgery, I would collect clinical data on postoperative LASIK patients.

I was already working in the capacity of a research optometrist, so I realised that

“I consider it my privilege to be able to pass on everything I know to the next generation of optometrists” if I collected and analysed data from my own research studies, I would be able to gain a PhD. I secured a postgraduate position at the University of Manchester. As part of my PhD, I programmed predictions of how optical quality changes if eyes with different grades of

I then moved into postdoctoral research.

Although Aston University was my employer, I was based in Farnham. While there, I worked on research projects ranging from toric contact lens studies to toric intraocular lens studies. My ambition was always to teach at the University of Manchester. I wanted to

give something back to the city that gave me so much joy as an undergraduate and as a postgraduate. My favourite thing about working at a university is that ‘lightbulb moment,’ when a student understands something they were previously struggling to comprehend and it all suddenly clicks into place for them. That moment on the student’s face is priceless. Having been a runner-up for the AOP Awards Lecturer of the Year accolade twice previously, it was a fabulous surprise to win in 2017. I am

still the only winner from the University of Manchester. I’ll always be extremely proud of this achievement. It helped to validate my credentials as an optometry lecturer on a national scale. Last year I designed a module to support students who come to us without a maths A-level. I didn’t study

maths at A-level, so I can

“My Plan B?” My alternative career option was to read for a degree in pharmacy. However, I am very grateful that I achieved the A-level grades that allowed me to study my first choice of optometry.

relate to how intimidating many maths-based subjects can appear to our students. I wanted to develop this module so all my students appreciate that the practice of optometry is underpinned by numbers. The feedback I received was phenomenal. Students were positive about how it helped support them in other areas of the first-year course. This was extremely satisfying, as I was keen to ensure that there was more of a level playing-field for optometry students who do not have A-level maths. In September 2021 I was honoured to receive a Teaching Excellence Award from my university, for demonstrating excellence in educational leadership and inclusive teaching. These are

university-wide awards, and are highly-regarded across all our faculties. I consider it my privilege to be able to pass on everything I know to the next generation of optometrists. I hope that my students will go on to do something extraordinary with this knowledge, which will have a positive impact on patient care. Get in touch Share your career journey with OT. Email lucymiller@ optometry.co.uk

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KEY MILESTONES SUBS ART

“It was my way of contributing in the pandemic” Optometrist, Robert Longhurst, on setting up a free patient support line to relieve pressure on hospital eye departments during COVID-19

PRODUCTION

01 When the pandemic

hit, I was working in eye casualty at the Royal Berkshire Hospital in Reading.

CLIENT

Patients were presenting with problems that could have been dealt with by an optometrist, particularly one with independent prescribing. I thought it would be useful if they were signposted better. I had the idea to set up a free of charge service, like 111 but for eyes, which I called eye.support.

I bought an 0800 number, then found a UK company that could answer the phone 24 hours a day.

There is a small monthly fee, alongside a small charge per call. There are 15 handlers available, and I spoke to them about the questions they need to ask and red flags that suggest the patient needs to go to hospital.

I marketed through social media, including Facebook adverts. A friend

made an animation, with cartoon characters: if you

have a problem with your eye but don’t know where to go, you can call this free phone service 24/7. We shared it on social media, and I think that's where the response came from. I asked some patients to send pictures, and then I was able to use AOS software to look

lights and floaters, which need to be seen to rule out retinal tears. Patients can be seen the same or next day, at an opticians instead of at the hospital. Between clinics, I’m able to read messages and decide if I need to respond straightaway. If I don’t, I’ll respond in the evening. We tell patients they’ll be contacted within 12 hours, so they’re not left worrying for too long. The service works across the whole of the UK. It was quite busy at the start of the pandemic, as people were nervous about going out. I hope that it kept a lot of people out of the hospital, so they could concentrate on more serious cases and free up staff to deal with the pandemic. We’ve helped about 50 or 60 patients with the line so far.

05 A lot of patients have offered positive feedback.

There was one woman who phoned a few times about

“A lot of the patients were isolating because of underlying health conditions. They didn’t want to go out to their doctors or to their opticians” at the eye more in detail. As a result, AOS ran an advert about the service on its social media platforms.

Calls started coming through within a week.

I’m notified and I’m able to listen. I want to know exactly what the situation is in case it’s urgent, so I can call straight back if needed. Otherwise, I can take some time working out where they can go before I contact them. A lot of calls are for flashing

the same issue, because things were changing. She was grateful that the information was readily available, and for not having to go out. A lot of callers were isolating because of underlying health conditions. It was useful for them to have that access on the phone that wasn’t going to cost them.

I probably will keep the service going. It’s good to

be able to signpost patients

How eye.support works “Callers receive a pre-recorded message, checking their condition isn’t anything serious. If they do have concerning symptoms, the line advises they call 111 or go to their optician. Others speak to a call handler, who takes as much detail as possible. That is then sent to me in an email. I either call or email the patient back with advice on where to go, using the Look After Your Eyes service to find a local optician, with an independent prescribing optometrist if necessary. I can offer reassurance that there is someone available to help. I often call the opticians to make sure they’re happy to accept the patient, and then come back with the options on where the patient can go, the cost, and what the NHS services would be if they didn’t want to pay.”

to the right place. I think it’s worth continuing. It doesn’t cost me much to run, because I’m only charged per phone call. It's only a few pounds each time. That’s the cost of a coffee, so if I can help someone, that small cost doesn’t really matter. It was my way of contributing during the pandemic. There are so many stories of people going out of their way to help and support each other. I saw how hard all of my colleagues were working in the hospital, so I wanted to do something to help too.

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In Practice, 5

IN PRACTICE

VERSION REPRO OP SUBS

WHAT I HAVE LEARNED

ART

“OPAL has been designed to help practice teams” NHS Education for Scotland tells OT how its Peer Assisted Learning network informed the launch of Optometry Practice Assisted Learning

PRODUCTION Pictured is Steven Whittaker

CLIENT

What is the Peer Assisted Learning (PAL) network? Rebecca Daly (RB), PAL lead NHS Education for Scotland: The PAL Network

was developed by NHS Education for Scotland (NES) in 2015, addressing the need for eye care practitioners to engage in regular peer discussions, reviewing cases and learning from each other’s experiences. NES provides cases for the group to discuss, with each pack having a theme. Cases are based around real patient scenarios. The PAL network also supports peer review sessions. Facilitators receive training via NES’s Turas Learn and utilise our facilitator notes specific to each pack. There are currently approximately 30 active PAL groups that meet regularly throughout Scotland and as engagement has increased over the years, we have developed packs for general and independent prescribing optometrists, dispensing and contact lens opticians.

We continually evaluate and look for improvements, one example being the launch of Journal Club packs to support evidence-based practice. What is involved in the new Optometry Practice Assisted Learning (OPAL)? Madeline Harvey-Brown (MHB), OPAL lead NHS Education for Scotland:

We all appreciate that eye care in community practices is delivered by practice teams, not just registered practitioners. When defining clinical risks in our practices, we must address everyone working in the system. OPAL has been designed to support practice teams. It uses the same approach as PAL and provides training materials to be undertaken as a team activity with all members of the practice. What do you hope OPAL will provide? MHB: We aim for OPAL to

support the delivery of safe and effective patient care and enhance teamwork in

community practice. We recently launched our first two OPAL training packs, both of which are COVID-19 themed, and we have already had interest from 40 practices throughout Scotland. OPAL is available to any optometry practice in Scotland and can be applied for via NES’s Turas Learn. What learnings from PAL are you applying to OPAL? MHB: From PAL we have

learned that sessions with the same groups build relationships, trust, and create a safe, non-judgemental environment that encourages free discussion and learning. We aim to continue this small group learning approach with OPAL, while recognising the diversity of the practice team. What is it like being a PAL facilitator? Steven Whittaker (SW), Independent prescriber optometrist and PAL facilitator: I facilitate the

sessions in Ninewells Hospital, Dundee and I’ve used those facilities and the opportunity that PAL offers to ensure that all the local optometrists have access to CET. In our group we utilise the PAL packs provided, or the practitioners bring a case that meets the discussion theme for the evening. We discuss the patient presentations, options, and clinical management plan. As the facilitator, I just need to keep one step ahead, and so in advance of each evening I research around the topic. I take a lot of pleasure from that process, and I find that I learn and retain a lot by that, and by the range of topics and experiences that fellow delegates bring with them.

How has the scheme had to adapt to COVID-19? SW: COVID-19 had a big

impact on these sessions, so we swapped to virtual meetings. Initially, there was some reticence in speaking to the camera, but that soon eased, and now we all log in, chat away, and it’s very natural. In fact, it has broadened the appeal to practitioners, as there is now no travelling involved, and we all get home from work, have our dinner, get a comfy seat, and just enjoy the professional craic that flows. We also opted to change the format slightly, from patient-based topics to the new PAL Journal Club packs. Has anything surprised you from the experience? SW: I have ceased to be

surprised by the general level of intellect, experience, knowledge, and generosity of my professional colleagues in these discussions. The past few Journal Club discussions have been around Scottish-based papers on the primary to secondary care interactions regarding glaucoma. As COVID-19 has caused particular problems in keeping up with glaucoma patient followups and reviews, in Tayside community optometry has been asked to step up to help keep this vital service going, alleviating the waiting list pressure on the hospital eye service, so these papers have provided invaluable local knowledge and networking. Share your story Get in touch if you would like to share your experience with OT kimberleyyoung@optometry.co.uk

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THE WORKSHOP

Team triage SUBS

OT poses a monthly scenario from a practitioner. This month, the AOP’s Henry Leonard looks at what to expect if a patient is wrongly triaged because of a miscommunication

The scenario ART PRODUCTION

Vincent, independent practice owner “A patient has complained that we did not see them quickly enough after they told us they had noticed new floaters, resulting in them being admitted to hospital with a retinal detachment two days later. Our receptionist says the optometrist was consulted and recommended an appointment in one to two weeks, but the optometrist says they were only told the patient had symptoms of dry eye. How should I proceed?”

The advice CLIENT

Henry Leonard, head of clinical and regulatory at the AOP

Getty/Aleksei Morozov

ll optometry practices should have a written protocol setting out how they deal with complaints. As the practice owner, you should acknowledge receipt of the complaint promptly, and let the complainant know how long it is likely to take for you to investigate and respond. To properly investigate, you should provide the members of staff involved with copies of any relevant information and ask them to draft a written statement about the incident. If the practitioner is an AOP member, they should be advised to contact the AOP for advice and support with their statement. Once your investigation is complete you can decide what action is necessary, before drafting a response

to the complainant, with assistance from the AOP’s legal and regulatory team. Patient expectation

It is important that anyone seeking advice from your practice receives accurate information. When a patient contacts your practice with symptoms, they will expect to receive advice on whether an appointment is necessary, and if so: Which professional they need to see Where the appointment should take place How quickly this needs to be arranged. Unregistered staff members should not be expected to offer clinical advice and should be trained to consult a registered practitioner where necessary, who can assess the situation and offer appropriate advice. In a busy practice, it is not always possible for patients to speak to a registered practitioner straightaway, so

there needs to be a system in place to ensure that all relevant information is passed on promptly, and that any advice given by the practitioner is relayed accurately back to the patient. Practices should ensure that practitioners have sufficient time to review the information and offer appropriate advice. If more information is needed to reach a decision, the practitioner should ensure the patient is contacted again. If there are times when a registered practitioner is not available to offer advice within an appropriate timeframe, you should have a protocol in place. This should include making patients aware that there are no registered practitioners available to offer advice on their symptoms and advising patients to contact another provider, such as their GP, for advice. It is important that staff are made aware of this protocol through regular training, and are reminded about it whenever a registered practitioner is set to be unavailable.

“Once you have completed your investigation, you can then decide what action is necessary, before drafting a suitable response to the complainant” be seen and reduces the risk of miscommunication. The form also serves as a record of symptoms the patient presented with, and what advice was given, which is important for the patient’s ongoing care. The information may be crucial in defending the actions of the practice and/or practitioner in the event of a complaint. You should use incidents like this as an opportunity to improve the care your practice offers. If you have chosen to put additional measures in place, such as triage forms or arranging regular staff training, you can explain this in your response to the complainant. Should the complaint escalate, these actions may be viewed in a positive light by an investigatory body.

Next steps

If the investigation shows there was a breakdown in communication between the receptionist and the optometrist, you should consider how similar incidents can be prevented in the future. Many practices use a triage form that a member of staff can complete whilst speaking to a patient, before presenting it to a registered practitioner for advice. This ensures sufficient information is gathered at the outset, which helps the practitioner decide how urgently the patient needs to

Further advice

The AOP has published guidance on dealing with complaints on its website, which includes template acknowledgement letters and complaints procedures for practice owners in each part of the UK (bit.ly/3xAnhOp). If you have received a complaint, contact the AOP’s clinical and regulatory team for advice and support on regulation@aop.org.uk Member support For more clinical and professional support visit www.aop.org.uk/ advice-and-support/clinical

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In Practice, 7

IN PRACTICE

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ptometrist Dr Christian French made the decision to open a practice focusing solely on the clinical side of optometry at the end of 2020. French explained that the idea “was born during the pandemic,” after he bought equipment in order to carry out research at the University of Hertfordshire, where he is a senior lecturer. Whilst buying equipment, he realised setting up his own practice was a real possibility. Then, his locum hours were cut, and a location fell into his lap when his brother moved out of a cottage owned by their parents. The coincidence seemed too good to ignore. “Within a couple of months,” French said, “I’d got all the kit and was ready to go.” French knew he would focus purely on eye exams, after identifying earlier in his career that “selling wasn’t for me.”

Setting up the business

Commiting to the practice was exciting, if nerveracking. He explained how following AOP guidance on starting a new business was his first step. He then made a spreadsheet of overheads to determine setup and running costs. Crunching the numbers allowed him to confirm that going down the NHS route would not be sustainable without selling glasses, and from that he calculated a private charge. He could then work out how many patients he needed to see to break even. French already owned the essentials: trial lenses and frame, retinoscope and ophthalmoscope, and sourced the rest via Optical Marketplace and eBay.

BECOMING A BUSINESS OWNER

Opening a clinically focused practice Consulting optometrist, Dr Christian French, opened his Leicester practice, which does not sell glasses, in December 2020 He then organised his logo and branding, settling on a traditional look and feel in the manner of an old-style brass plate practice.

its crooked walls and wood panelling, fits the aesthetic he wanted – something French is determined to retain as the business grows.

Decisions for the long-term

Finding a balance

For the moment, French has made the decision not to take a salary because “trying to pay myself would strangle it before it’s off the ground.” He added: “As long as it can pay its way, I’m happy for the first few years. Once it’s grown, I can think about paying myself a wage.” Borrowing the building has been “a huge help in terms of premises, because renting would be a huge overhead, especially if I was only using it part time.” For those who might be worried about securing a space, he believes “it’s about thinking outside the box. It may be that there’s a dentist or hairdresser that has a spare room you might be able to pay a small amount for while you’re getting started.” The cottage, with

French works at Kettering General Hospital in eye casualty and paediatrics, alongside the practice and his academic work. Was he nervous about balancing practice ownership with his other commitments? The answer is yes. He planned carefully, though, working “on an appointment only basis, because I didn’t want to cut a day out of my salary and then have one patient booking in.” For now, he’s focusing on evening and weekend appointments. In order to keep a working relationship with other local practices, and to heighten the chance of referrals, French reached out to explain his aims. “I made a point of introducing myself and explaining the business model,” he said. “I’ve had referrals from clinicians across the network. It has been really encouraging.”

“You don’t have a sit-down lesson on what you need to do to open a business”

He added: “The model allows me to take the time and investigate things, particularly binocular vision cases, and I will send the patient and a report back to their original optometrist afterwards.” This was also important in ensuring that his patients would have a positive dispensing experience elsewhere. “I need to trust that my patients can be dispensed to the same standard as I’ve examined them at,” French said. “I spend ages going through things. I want that to be carried through wherever they go to get glasses.” The other local practices, he emphasised, need to trust his refractions too: “There’s got to be trust on both sides.” Looking ahead

French does not anticipate the practice becoming his full-time job – he values the variety he currently has. “I like the academic environment, lecturing and research,” he said. “The hospital offers a different slant; it’s clinically challenging. The practice I see as pure optometry.” What would he say to other prospective practice owners who might want to avoid selling glasses? “You don’t have a lesson on how to open a business. It’s about speaking to other practice owners and building a network. It’s a new skill.” But, he added: “It’s so rewarding. It’s what you’ve trained to do. I’m really pleased that my practice has worked as a model, because it does show that it’s possible. The public are a lot more on board than you might expect.”

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The strain of the pandemic on primary and secondary care has brought to the fore the importance of seeing patients in the right place at the right time. OT talks with eye care professionals about how they have honed the art of triage

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uring the early months of the pandemic, when routine eye care appointments were suspended and practices operated on a skeleton staff, across the country optometrists faced a daily conundrum. Often sitting in a room with only a phone for company, eye care professionals mulled over whether the patient they had just spoken to needed to be in practice or whether they could safely wait at home. “It was balancing the risk of someone having a significant problem with their eyes and the general risk of seeing someone face-to-face with a transmissible disease in the community,” optometrist and AOP clinical adviser, Kevin Wallace, shared with OT. More than a year later, restrictions on the provision of eye care have eased but many practices are still working through a backlog of routine appointments. While statistics for England have not yet been released, data from Northern Ireland reveals that the number of General Ophthalmic Services sight tests performed in the year following the pandemic dropped by 34%. Wallace shared that triage skills refined during the pandemic are still being applied following the recommencement of routine appointments. “From speaking to other practices, I know most people are busy because we have a backlog of routine tests to get through. We are still having to be fairly choosy about how we appoint people,” he said. Wallace emphasised that triage processes within optometry practices have improved during the pandemic. “It would be good if that could have happened without a devastating worldwide event, but we have become much more used to deciding, 58 www.optometry.co.uk

“IT'S A CYCLE OF AUDIT, CHANGING THE SYSTEM AND THEN AUDITING IT AGAIN” Kevin Wallace

one, if a patient requires to be seen and, two, how urgently they need to be seen,” Wallace shared.

PRIORITISING TRAINING At Wallace’s Edinburgh practice, all staff receive training in triage as a priority when they start, while a triage form with key questions is used by staff appointing patients. The questions on the form have been adapted and honed over the decade since the resource was introduced. “It’s a cycle of audit, changing the system and then auditing it again to see if it needs to be tweaked further. This ensures that the process becomes more efficient with time and that the important things are prioritised and less important issues do not take up valuable emergency appointments,” Wallace said. He emphasised that a hallmark of an effective triage system is that it is led by the non-clinical staff. “If your triage system requires someone

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to knock on your door every time a patient phones, it doesn’t work. It’s not effective. You should be able to work out 99% of them by asking straightforward questions,” Wallace highlighted. During the pandemic, when only emergency cases were seen in secondary care, independent prescribing optometrist Stanley Keys worked in casualty clinics at Raigmore Hospital in Inverness as well as for a triage line staffed by optometrists and ophthalmic nurses. “We were helping the nurses to do the triaging and to keep it as tight as possible – only seeing patients who we really thought needed to be seen,” he said. Keys’ experience on the triage line prompted him to develop a triage training course for ophthalmic nurses and a triage guide. “The COVID-19 pandemic, and the work that we did with our nurses locally, made me feel as though there is an area where training would be beneficial and worth developing,” Keys shared. After a successful pilot over the summer, the first courses in October and November were fully subscribed, while an NHS trust in England has commissioned a bespoke course for a group of 14 nurses. The guide covers the key principles of triage, how to take a clear history from a patient, an overview of the

main emergency eye conditions, and the red flag signs and symptoms. There is also a section on effective communication in the triage process. Since publication, the guide has been sent to 60 practices in all four nations of the UK. Keys has also received interest from optometry practices in Australia. “It’s quite a nice thought that something you have produced is going to the other side of the world to help a practice,” he noted. Keys shared that the content of the triage guide provides useful guidance for all staff who encounter emergency eye conditions. “It will be equally useful for ophthalmic nurses working in hospital as it will be for staff in optometry practices and even GP clinics,” he said.

A TEAM EFFORT Like Wallace, Keys emphasised the importance of the whole practice team understanding the importance of triage. “You can have the best clinicians in the world with the best knowledge and experience, but actually if you don’t have a good front of house team booking the appropriate patients in, controlling the diary and ensuring

“THE HEART OF IT IS REALLY THE PATIENT – MAKING SURE THAT THOSE WHO REALLY NEED THE URGENT CARE ARE SEEN AS A PRIORITY” Stanley Keys that high priority cases are getting through, then it is almost irrelevant if you have super clinicians,” he said. Working in a hospital environment, Keys knows first-hand the importance of patients being directed to receive care in the appropriate environment at the right time. He added that in each casualty clinic, there might be one patient with complex needs who requires input from a range of disciplines. “They can be time-consuming but these are the patients who need to be thoroughly investigated,” Keys shared with OT. “You don’t want to have your diary clogged up with cases that don’t need to be seen that day. The heart of it is really the patient – their needs and making sure that those who really need the urgent care are seen as a priority,” he said.

SHARED CARE As the pandemic has exacerbated pressure on secondary care and waiting lists for elective care have

grown to record levels, more NHS trusts are exploring the potential for primary care to take on services traditionally offered in hospital. Optometrist, Optometry Scotland member and co-owner of McFarlane and Nicol’s Ltd, Richard Spruce, is involved in a shared care scheme that has been rolled out in the Forth Valley. Five practices in the area introduced glaucoma clinics in October as part of measures to ease the hospital backlog. “These clinics are a great way for us to support our local hospital eye service while helping to keep NHS waiting lists down,” Spruce emphasised. Speaking with OT shortly before the launch of the glaucoma clinic at his practice, Spruce shared that he had received positive feedback on a similar shared care system in the past. “The patients who I saw in our Selkirk practice were very happy not to have to go to the hospital,” he said. “It is a nice service – to see them on their doorstep rather than the patient

STANLEY’S FIVE GOLDEN RULES FOR EFFECTIVE TRIAGE

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Make sure that all staff members are aware of the main eye care emergencies – particularly the red flag signs and symptoms Have an effective way of recording the information that you receive from patients Make sure that there is clear communication in order to reach the appropriate decision Ensure that you have the ability to see emergency patients. Your clinic diary should be flexible and responsive Clearly communicate the arrangements that have been made back to the patient.

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having to trek over to hospital.” Through the new initiative, Spruce has blocked out one morning each week to see six patients from the hospital eye service. In advance of their first meeting, Spruce is sent the last clinic letter for each patient setting out key information about their history and management through the electronic patient record software, OpenEyes. He then performs tests set out in the

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TIMES ROUND THE EARTH Travelling time avoided:

2 YEARS 10 MONTHS OF LIFE Travel expenses saved:

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standard operating procedure and records them on OpenEyes. If he has any concerns about patients seen through the service, Spruce can flag these with the hospital eye service. “Most of the cases are stable – the consultants are fairly happy with their eye pressure and they are not expecting things to go haywire,” he said. Spruce shared that on some of the records he has seen patients were told a year or 18 months ago that they needed to be seen within six months. “These patients have not been seen and they need to be. If we don’t see them there will be more pressure on the hospital and it just snowballs,” he shared with OT. As well as easing hospital waiting lists, the shared scheme has potential to foster strong relationships between community optometry and ophthalmology. Spruce shared that his practice has built up a good relationship with the hospital over time, but the shared care initiative will strengthen this. “You do get to know the consultants more. They are not just a name, they become a face and a person. They get to know us and trust us – they know we are reliable and give them good data,” he said. Spruce noted that having standard operating procedures meant that the service could be rolled out to other areas in the future. “This is something that could be easily expanded going forward – they have the foundations there,” he said.

CALCULATING THE VALUE OF HIGH STREET OPTOMETRY While most optometrists would agree that more patients receiving eye care on the High Street is a good thing, the data illustrating why this is the case can be challenging to pin down. Economist and academic at the University of Aberdeen, Professor Alexandros Zangelidis, has been exploring the evidence-base that supports the value of High Street optometry.

“YOU DO GET TO KNOW THE CONSULTANTS MORE...THEY GET TO KNOW US AND TRUST US” Richard Spruce His research, Community Eye Care and GP or Hospital Referrals in Scotland: A Tale of Two Stories, analysed the relationship between High Street eye examinations and referrals to a GP practice or hospital using health board data collected between 2011 and 2018 in Scotland. “The findings of this paper highlight the effectiveness of community eye care services delivered by optometrists,” Zangelidis said. His research found that a 5% increase in primary examinations within optometry practices was associated with a 10% drop in referrals. “Eye conditions are treated at the community level and not referred to a GP or hospital,” he shared. Conversely, an increase in supplementary examinations were linked to an increase in referrals. Zangelidis highlighted that this finding supports the preventative role of High Street optometry, as supplementary examinations often detect previously undiagnosed, asymptomatic conditions. “In the absence of those eye examinations, what we anticipate is that these health conditions would remain undiagnosed for a longer period of time. Early detection of these health conditions through a supplementary eye examination can potentially save NHS resources in the long-term,” he said. Zangelidis noted that while there are differences in the provision of eye care in Scotland, other UK nations can learn lessons from the Scottish system.

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“What we have seen is that even when eye examinations resumed, priority was given to emergency cases and many examinations were further delayed,” he shared. Some patients remained reluctant to have their eyes tested even when their vision became worse, Zangelidis added. “The fact that we saw fewer referrals across the NHS does not suggest that people’s health has improved, what that suggests is that there are cases that have not been seen. We need to be very careful when considering any future restrictions on healthcare services.”

REMOTE CONSULTATIONS

Previous research by Zangelidis investigated the impact of accessible eye care on rates of hypertension in Scotland. He found that as the uptake of eye examinations increased following 2006 reforms that made a comprehensive eye examination free of charge, more cases of hypertension were detected. “That provides evidence that an eye examination is not only about your sight but about your general health. If those cases are not detected on time, they can lead to a deterioration of the patient’s health, which makes treatment more expensive and more complicated,” Zangelidis observed. He noted that a larger proportion of individuals from affluent households took up the offer of free eye examinations following the 2006 reforms in Scotland. Zangelidis shared that in the future he would like to see a range of interventions piloted

“IT’S BEEN HUGELY BENEFICIAL TO BE ABLE TO TRIAGE PATIENTS REMOTELY” Dr Gordon Hay

that aim to increase the number of people who are getting their eyes tested – particularly from lower socioeconomic groups. “There is mounting evidence that people should be strongly encouraged to have their eyes tested on a regular basis. This is important for the individual and from a public health perspective,” he said. Zangelidis observed that during the pandemic there has been a significant disruption to healthcare, including the temporary suspension of eye care at the beginning of the pandemic.

One way that optical professionals have worked to streamline their triage process and use resources effectively during the pandemic is to use digital solutions. Moorfield Eye Hospital introduced its online accident and emergency (A&E) service within 48 hours of the first lockdown in March 2020. Since then, the service has accounted for more than 26,000 consultations – with only 22% of patients requiring a face-to-face A&E appointment. On average, each patient avoided a journey of 41 kilometres and travel costs of £25.07, while the carbon dioxide emissions saved over the course of a year is equivalent to 185 one-way flights from London to New York. Service director for Moorfields Eye Hospital A&E/Urgent Care, Dr Gordon Hay, highlighted that optometrists have been involved in offering the service since the beginning of the pandemic. “At present we have five optometrists working in the emergency department, either seeing patients face-to-face or on the virtual platform,” he said. Hay noted that many Moorfields Eye Hospital patients live some distance from London. “These patients did not want to leave

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home during the worst part of the pandemic, and we were keen to reduce the need for them to come to London when the infection rate was so high,” he said. “Ultimately, given that so many people have risk factors for COVID-19 or are immunosuppressed, it’s been hugely beneficial to be able to triage patients remotely and get the right care from the right team at the right time,” Hay emphasised. As well as benefitting patients, the service enabled staff who were shielding or unable to work with patients face-to-face to continue working. “We had staff on maternity leave who wanted to contribute, and staff who were stuck in other parts of Europe unable to get back due to airline difficulties,” he elaborated. Hay shared that the range of conditions that clinicians have seen through the Attend Anywhere platform has included corneal abrasions, relapses of uveitis, visual loss and pain. “Virtually everything that would be presented to face-to-face A&E also has a presence on the platform,” he said.

REFERRAL TIPS The pandemic has heightened the need for hospital referrals to be carefully considered by optometrists. Hay shared that a direct dial line for community optometrists looking to receive advice and guidance has been established by Moorfields Eye Hospital. “I think one of the main problems we’ve had in the past is how difficult it has been for optometrists to get advice from their local eye unit. Since the start of the pandemic, many units have made it far easier for optometrists to seek advice and guidance from their local unit,” Hay shared with OT. Community optometrists in the Moorfields catchment area interested in the direct dial line can make contact with systems partnership 62 www.optometry.co.uk

“WE NEED TO BE VERY CAREFUL WHEN CONSIDERING ANY FUTURE RESTRICTIONS ON HEALTHCARE” Alexandros Zangelidis

manager, Zain Mohammed, to learn more. Hay encouraged optometrists to collect a full history and background information from the patient before contacting the hospital. “My top tip for optometrists is to get all of the information together before you pick up the phone so that you can give us a clear and concise narrative when you speak to the ophthalmologist,” he said. Hay emphasised that the “overwhelming majority” of optometrists are fully aware of what is and what is not a same-day emergency. “There’s always a difference between what ophthalmologists think is a same-day emergency versus what optometrists think is a same-day emergency, but having made it so easy for community optometrists to get advice and guidance, we’re now seeing more appropriate referrals into specialist clinics and a reduction in the number of unnecessary referrals to A&E,” he shared.

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FROM OPTOMETRY TO OPHTHALMOLOGY Dr Elizabeth Hill is someone who has a unique perspective on triage, with experience both receiving cases for triage as an ophthalmologist and referring patients to hospital as a High Street optometrist. She currently works as a consultant ophthalmologist and urgent care lead at County Durham and Darlington NHS Foundation Trust. Hill initially trained as an optometrist before starting a medical degree at the age of 25, funding her training through locum work as an optometrist. Part of Hill’s job is to triage new referrals coming in from GPs and optometrists and appoint those patients appropriately. When asked for her tips on referrals, Hill shared that when she receives a referral from an optometrist, she needs enough information to make a clinical decision that is safe. She values legible, succinct referrals with relevant medical and ophthalmic history, as well as what the optometrist has found during the examination. “What I need to be able to do as an ophthalmologist is look at your referral and decide when to see the patient,” Hill shared. “Look at the referral and think ‘Can the ophthalmologist triage this? Is there enough information there to make a decision without calling the patient?’,” she added. As a former optometrist, Hill has an appreciation for the challenges

“YOU ONLY GET CONFIDENCE BY KNOWING WHAT HAS HAPPENED TO YOUR CASE” Dr Elizabeth Hill that her colleagues working in the community face when they are deciding whether to refer a patient to hospital. She shared that as an ophthalmologist working in urgent care, she sees pathology all day, every day. “I think sometimes ophthalmologists don’t appreciate that optometrists see ‘normal’ most of the time with a scattering of pathology,” Hill observed. In contrast to practices that may only have one optometrist working, Hill shared that she works in a department where there are usually three or four consultant ophthalmologists working at the same time. “You can pop next door and ask someone if you are unsure,” Hill shared. She has access to the latest technology working in hospital and the ability to bring patients back into the clinic for a follow up examination. “I have said to juniors that they have to understand what it is like for optometrists at the front line,” she shared with OT. Hill noted that a further challenge for many optometrists is a lack

ELIZABETH’S REFERRAL CHECKLIST Legible? Brief? Could use a bullet point list Date, patient and optometrist details, visual acuity Relevant medical and ophthalmic history Reason for the visit – routine or because of a problem?

of feedback from the hospital eye service. This is something that she is endeavouring to establish within her own unit. “It would be nice to be able to feedback to optometrists and say ‘Yes, that was a really good spot’ and ‘That wasn’t something to worry about’,” she said. “Otherwise people just do the same thing again and again. You only get confidence by knowing what has happened to your case and getting feedback,” Hill emphasised. Reflecting on what she wished she had known as an optometrist, she shared that not all pathology is an emergency. “Just because you identify something in a patient’s eye, the alarm bells don’t need to ring. It is much better that people are seen at the right place at the right time with the right people there,” Hill shared. “For example, if you pick up a macular-off detached retina at 6pm one evening, it might not be worth sending that to A&E because the vitreoretinal surgeon may not be there. Maybe speak to ophthalmology and they may see the patient the next day,” she elaborated. She cautioned optometrists against telling patients how soon they should receive an appointment within the hospital eye service. “Sometimes an optometrist will feel that something needs to be seen urgently and an ophthalmologist may disagree,” Hill said. “Once the patient has been told that they have a sight-threatening emergency condition and the ophthalmology department say they will not see it for a month – that creates a lot of panic,” she added. In the past, she has seen children who were told by their optometrist that they had a tumour when they did not.

“In terms of diagnosis, you can put ‘This could be x’ but it can be risky for an optometrist to make a definitive diagnosis and then tell the patient what is going to happen,” Hill shared. Optometrists should consider what action they would like the hospital eye service to take with the patient. For example, many units have long waiting lists for patients with suspect glaucoma. “If you have someone in front of you with normal vision, normal fields, normal pressures and their OCT scan makes you think ‘Oh well it could be predicting glaucoma in seven years,’ consider whether that referral needs to be in the hospital eye service,” Hill shared. “I am not suggesting that optometrists take risks and sit on pathology, but my question is what are you wanting the hospital eye service to see the patient for?” she said.

A REWARDING ROLE Working as an ophthalmologist, Hill shared that a rewarding part of her job is providing patients with a high standard of care. “I love my job and I love working with the patients,” she shared. She also enjoys the challenges of operating. For example, when performing cataract surgery, the anterior chamber is only around 2.3mm in size. “It is a beautiful operation. You operate and 15 to 20 minutes later you have made a big difference to someone’s life,” Hill shared. The pandemic has meant that she is seeing patients with more advanced cataracts than in the past. Hill recounted performing a successful operation on a patient who had waited for 18 months to have surgery due to the pandemic. “I said ‘It is a very dense cataract. Technically it is very difficult and there is higher risk of a problem, but I will do my best.’ He said ‘Love, I can just about see my fingers in front of my eyeball. Whatever you do is better than this’.”

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IN THIS ISSUE PRESCRIBING PROSTHETIC AND COLOURED CONTACT LENSES

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LEARNING OUTCOMES

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Practitioners will understand the importance of leadership in delivering collaborative care Practitioners will recognise the role of leadership in delivering safe care.

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THE POWER OF LENSES

Practitioners will have insight on the types and use of prosthetic contact lenses Practitioners will be able to advise patients on different prosthetic contact lens options.

CASES FROM THE CASUALTY CLINIC

OT II 1 61:06 CLIENT

OT ART 2 61:06

LEARNING OUTCOMES

Practitioners will understand the effects of frame fitting parameters on lens power Practitioners will be able to explain to patients about non-tolerance due to lens compensation issues.

Practitioners will be able to assess a range of clinical cases and determine management within their scope of practice.

KERATOCONUS IN THE COMMUNITY BUILDING CONFIDENCE WITH OCT-A IN PRACTICE

OT II 2 61:06 LEARNING OUTCOMES

OT ART 3 61:06 LEARNING OUTCOMES

Practitioners will have an understanding of the clinical applications of OCT-A.

Practitioners will be able to identify and manage contact lens complications in patients with keratoconus Practitioners will be able to explain the causes and management of contact lens complications to patients with keratoconus.

EXAM QUESTIONS, REFERENCES & DECLARING CPD POINTS MCQs for OT’s CPD exams appear online at www.optometry.co.uk. Exams in this issue will be live from 5 January to 25 March, 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. Certificates will be available to download in your MyAOP.

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A LENS ON LEADERSHIP Dr Helen J Court PhD

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When considering the words ‘leadership’ and ‘optometry’ in the same sentence, what comes to mind? This is an important question because the answer could impact how the challenges and improvements in the clinical environment are approached by practitioners. This article will explore leadership in healthcare, and specifically optometry, with a look at how this may change in the future.

DEFINING LEADERSHIP: THE PAST TO THE PRESENT

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It is difficult to find a consensus about the definition of ‘leadership.’1 An internet search engine will produce a plethora of definitions, models and frameworks; this is perhaps unsurprising since the theory of leadership has developed considerably over the last few decades.2 It is helpful to look back at this development to enable understanding of the language of leadership when applied to healthcare today. Broadly speaking, leadership theory has moved from defining leadership as a set of traits, intrinsic to an individual, towards a collective leadership process.2 Figure 1 shows a simple timeline outlining the development of theory, which is not exhaustive but shows the direction of this trend. 1840 to late 1900s: leadership – about a person Original theories of leadership promoted the idea of a hierarchical structure, one in which there is a defined leader ‘at the top.’ One of the first well known leadership theories was the ‘Great Man Theory’ (1840 onwards).3 This theory encapsulates the idea that some people are ‘born to lead,’ that leadership belongs exclusively to the individual.4 This developed into the ‘trait theory,’ which sought to identify the innate traits which good leaders possessed.4 By the mid-1900s these theories were superseded, not least because there was little empirical evidence to support them.2 Leadership theories then sought to identify the personal behaviours which characterised leadership. However, without reference to the context of the leadership task, reducing

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leadership to a list of behaviours was challenging. In response to this challenge, ‘situation and contingency theories’ emerged which described successful leadership as a combination of behaviour, environment, personality and ability to influence.5 1980s to present: leadership – about a process The mid-1980s marked a significant shift in thinking about leadership from an individual role (hierarchal) towards a more inclusive collective approach.2 The focus was no longer on one individual or role. ‘Leaderfollower theories’ described leadership as a process owned by all the individuals. Over time, these theories began to incorporate a moral dimension, known as transformational leadership.5 The focus has since been upon both leaders and followers working towards a common goal, while supporting one another to higher levels of ethical behaviour and motivation. More recently, there has been a movement to incorporate systems thinking into leadership theory. This approach acknowledges that we all work in complex systems, with healthcare being a good example. A complex system has been defined as ‘one in which even knowing everything there is to know about the system is not sufficient to predict precisely what will happen.’6 When challenges occur within complex systems it would be ineffective to devolve all responsibility to one person in a leadership role (traditional hierarchal approach); this is because no one individual can understand all the complexity within the system. Rather, effective improvement requires a collective approach in which all members of the team take ownership and work together to overcome challenges.7

LEADERSHIP IN HEALTHCARE Based upon the previous few paragraphs, it is perhaps unsurprising to discover that the prevailing leadership approach across the NHS today is one which encompasses a systems and collective approach. When describing healthcare, Braithwaite9 suggested that ‘no

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1840 onwards Great man theory

1910–1948 Trait theory

1950–1970 Behavioural theory

Mid 1960s–1900 Situational and contingency theory

Leadership – centred on the individual ‘leader’ Promotes a hierarchical structure

1990 onwards Leader-follower theories

1985–2010 Transformational theory

2010s –present Systems/ collective leadership

Leadership – centred on the process Promotes a shared collective structure

Figure 1 Simplified historical timeline of leadership theories8

other system is more complex: not banking, education, manufacturing, or the military.’ Clinicians in optometry practice work within this complex system, one in which there is a constant interplay of people, technology and processes. It is the very nature of this complex environment which demands a more collective leadership approach. This approach, adopted by the NHS, has been well summarised by The King’s Fund: ‘The NHS needs people to think of themselves as leaders not because they are personally exceptional, senior or inspirational to others, but because they can see what needs doing and can work with others to do it.’10 In other words, every person in the healthcare team needs to see themselves as part of the leadership process. Within optometry, and the wider NHS, there is an acute awareness of the complex challenges arising from an ageing population, workforce, financial pressures and latterly the COVID-19 pandemic. To overcome these challenges, every member of the team needs the leadership skills to enable them to be actively involved in planning, delivery and improvement.11 To enable clinicians to develop leadership skills and behaviours, several leadership frameworks have been developed over the last few years. Despite differences in wording and context, the overall core principle of a collective leadership approach is common to all. The medical leadership competency framework (MLCF) and the clinical leadership competency framework (CLCF) provide helpful examples to explain the leadership behaviours encouraged by these frameworks.

THE MLCF AND CLCF The value of a collective leadership approach has been recognised within medicine for some time. In 2008, the NHS Institute for Innovation and Improvement and the Academy of Medical Royal Colleges developed the MLCF.12 The MLCF identifies the leadership competencies which all doctors should develop and has since been embedded into both undergraduate and postgraduate training for medics. This framework quickly attracted the attention of other clinical groups, giving rise to the CLCF,13 which allowed application of the competencies in a wide variety of clinical settings. The CLCF groups leadership behaviours in five core domains: demonstrating personal qualities, working with others, managing services, improving services, and setting direction (see Figure 2, page 68). These are the behaviours which can empower a clinician to be part of the leadership process to enable successful delivery of the service. To help explore this framework further, it is interesting to consider how it could apply to optometry practice. Domains one and two – an optometry perspective ‘Demonstrating personal qualities’ (domain one) and ‘working with others’ (domain two) include competencies that most clinicians would believe are essential when working in optometry practice. Indeed, these competencies map well onto the professional standards set by the General Optical Council (GOC).14 However, it would be interesting to consider how much time and attention is given to developing these

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The five leadership domains

M se ana r vi gin ce g s

ART

g in ov ces r p vi Im ser

Delivering the service

g rkin s Wo other with

SUBS

S dir etting ec t ion

Demonstrating personal qualities

1. Demonstrating personal qualities 1.1 Developing self-awareness 1.2 Managing yourself 1.3 Continuing personal development 1.4 Acting with integrity 2. Working with others 2.1 Developing networks 2.2 Building and maintaining relationships 2.3 Encouraging contribution 2.4 Working within teams 3. Managing services 3.1 Planning

3.2 Managing resources 3.3 Managing people 3.4 Managing performance 4. Improving services 4.1 Ensuring patient safety 4.2 Critically evaluating 4.3 Encouraging improvement and innovation 4.4 Facilitating transformation 5. Setting direction 5.1 Identifying the contexts for change 5.2 Applying knowledge and evidence 5.3 Making decisions 5.4 Evaluating impact

Figure 2 Clinical leadership competency framework13 PRODUCTION CLIENT

behaviours in everyday practice. Practitioners work in increasingly demanding and busy environments, and as such, it should not be a surprise when communication with others in the team becomes strained and challenging. Perhaps you can think of colleagues who have been challenging to work with and communicate with in the past. How did you deal with that situation? Time spent developing personal qualities, such as selfawareness, can reap huge benefits in such situations. For example, self-awareness of team members promotes better communication, allows people to understand themselves and their working relationships better and is a predictor of higher functioning teams.15 Understanding that every individual has their own ‘mental model’ with which they perceive events, can help build empathy and understanding between individuals. There are many useful tools, models and resources available to help individuals and teams, including: emotional intelligence,16 ladder of inference,17 Johari window18 and transactional analysis.19 Domains three to five – an optometry perspective While most people working in optometry practice may see the value in developing personal qualities and team working, the relevance of the proceeding domains ‘managing services’ (domain three), ‘improving services’ (domain four) and ‘setting direction’ (domain five) may be less obvious to some. However, these three areas for development are all fundamental to ensure that the practice team can continue to improve and provide effective patient care. As previously noted, optometry practice is a complex and demanding environment. In the last few years, across the UK, there has been a growing number

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of optometrists and dispensing opticians assuming extended roles and responsibilities,20,21 for example, therapeutic prescribing rights, specialist contact lens fitting, myopia control and low vision schemes. Furthermore, there has been rapid development in technology allowing unprecedented imaging of the eye. Alongside this, the elderly population is growing, placing greater demand upon services. The picture has been even further complicated by the COVID-19 pandemic. As a result of all of these factors, the environments in which we work in are constantly changing. Within this context, two possible approaches to overcoming the inevitable resulting challenges may be either ‘work harder’ in the existing practice systems, or ‘work together’ to make improvements. The ‘work harder’ approach is undesirable, potentially leading to high levels of stress within the team, reduced staff wellbeing and potential risks to patient safety.22 Unfortunately, without an alternative, this can be the default position to turn to. However, the alternative approach, requires all staff to have the tools to empower them to work together to make improvements. This gets to the nub of collective leadership, and hopefully helps contextualise the King’s Fund quote about leadership referred to earlier:10 ‘The NHS needs people to think of themselves as leaders not because they are personally exceptional, senior or inspirational to others, but because they can see what needs doing and can work with others to do it.’ Domains three, four and five of the CLCF, identify behaviours which empower individuals within the team to engage in this type of working. However, it is important to remember that the success of any team to work together and overcome challenges will be

CPD 1, 2

COMMUNICATION

dependent upon the behaviours developed in the first two domains (personal qualities and team working). For example, if a culture of mistrust and blame exist within a team, people will be less likely to speak up and proactively offer ideas for improvement.23 When this happens, key opportunities for learning and improvement are lost. Conversely, in high performing teams there is a culture where people can speak up without fear of punishment and high levels of trust.23 For this reason, as previously mentioned, it is important not to overlook the development of personal qualities and team working skills to enable individuals to partake in effective improvements. There are many tools to help support individuals and teams to engage in this type of work, for example, the model for improvement, process mapping and fishbone diagramming. Discussing these tools is beyond the scope of this article, but excellent online resources are available on the Institute for Healthcare Improvement website24 and via NHS Education for Scotland (NES) Quality Improvement Zone.25 Finally, although the CLCF is written for ‘clinicians,’ it is apparent that all the domains discussed are applicable to all members of a practice team.

LEADERSHIP DEVELOPMENT IN OPTOMETRY – LOOKING TO THE FUTURE

Although there are benefits to developing leadership among clinicians, to date, optometry has lacked a consistent approach. However, the potential to integrate leadership further into training and standards can be visualised by looking at the approach of our colleagues working in other disciplines. For example, the General Medical Council recognises that leadership and management is essential for every doctor,26 and as such, leadership is part of the core training for all medical trainees. In nursing, the Nursing Midwifery Council identify leadership as a core competency for all students and registered nurses.27 The General Pharmaceutical Council include leadership as one of their standards for all pharmacy professionals.28 Although we are not quite at the same stage of some of the other professions, there are some encouraging developments within optometry. At a UK regulatory level, in 2019, the GOC’s education strategic review (ESR) recommended an increased emphasis upon

clinical leadership within the education and training for optical professionals.29 This approach will enable all clinicians to understand the value and benefits of leadership from the start of their clinical journey. At a national level, in 2017, the Scottish Government published a review of eyecare services in which leadership was identified as a recommended area for training all registered optometrists working in Scotland.30 In line with this, for the past few years, NES has been developing a range of leadership resources for those working in optometry practice. Notably, in 2021, there is now a mandatory requirement that all optometrists and ophthalmic medical practitioners in Scotland will be required to complete an eLearning module entitled ‘Developing Personal Leadership in Optometric Practice.’ This training is supported by a range of leadership webinars and discussion workshops delivered by NES. In Wales, the Welsh Clinical Leadership Training Fellowship (WCLTF) (previously a programme for doctors, dentists, pharmacists) was opened up to include optometrists in 2020.31 The focus of this programme is to empower clinicians to lead developments and improvements in the delivery of patient care. Alongside these developments, there is an increasing range of leadership courses available to those in optometry practice, for example: Leadership and Management Programme for Optometry by NES,32 Leadership Skills for Optical Professionals by Wales Optometry Postgraduate Education Centre (WOPEC),33 and a new management and leadership course delivered by the Association of British Dispensing Opticians (ABDO) launching in 2021.34

CONCLUSION This article has introduced the concept of leadership within optometry and outlined the importance of leadership development. The environment of eyecare delivery is becoming increasingly complex and challenging. However, as the profession continues to focus upon leadership development this will help all clinicians to become actively involved with overcoming challenges, making improvements and delivering safe and effective care.

Dr Helen Court is an experienced optometrist and is active in research and teaching. She currently works for NHS Education for Scotland as a senior

postgraduate tutor in optometry, in addition to holding honorary lecturer and fellow posts at both Cardiff University and Edinburgh University, respectively.

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THE POWER OF LENSES

REPRO OP

Mark Hickton BSc (Hons), Cert Ed, FBDO, FHEA

Using case studies, this article outlines the importance of lens power compensation during the dispensing process to avoid patient non-tolerance. IN BRIEF

SUBS

INTRODUCTION ART PRODUCTION CLIENT

In ophthalmic practice, practitioners deal with lenses every day in various forms and appliances. The power of a lens is generally considered to be a measure of the ‘strength’ of the lens required in order to correct a patient’s refractive error in line with their prescription. This article will remind practitioners how these powers are quantified and how lens powers may require changing when considering the fit of a spectacle frame. Lenses in ophthalmic practice are quantified by the power (F), measured in dioptres (D). More specifically, the labelled power relates to the back vertex power (BVP or Fv’). In other professions, such as photography, lenses may be compared by considering their focal length (f). For thin lenses in air (a theoretical lens in which the thickness is ignored), the dioptric power of the lens is the reciprocal of the focal length in metres; however, this relationship does not really describe how the lens affects incident light. It is important to consider how the dioptric strength impacts the vergence of light passing through the lens. Vergence (L), also measured in dioptres, directly relates to the curvature of a light wavefront.1,2 Imagine dropping a stone into a still pond and the concentric circular ripples that will emanate outwards. The dioptric curvature of these ripples is the reciprocal of the radius of curvature. The further out these ripples travel, the flatter their curvature becomes. Under the wave-theory of light, consider light as a transverse wave where the ‘ripples’ in the pond would represent the wavefronts (and the peaks of the transverse wave). By considering a ray diagram of light (see Figure 1) it can be seen that wavefronts are perpendicular to the rays of light. As with the curvature of the pond ripples, the vergence at a specific point is the reciprocal of the distance from the considered point to the source or focus. Figure 1 Parallel rays of light with zero vergence and flat wavefronts (dotted)

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CPD

POINT

Light emitted by a source will diverge outwards (see Figure 2) and will possess negative vergence. The further light travels from a source, the more the wavefronts flatten and the more the numerical value of vergence of the wavefronts approaches to zero. Parallel rays of light coming from infinity will have flat wavefronts (see Figure 1) and a vergence of zero. When light is incident on a lens, the refractive influence of the lens affects the vergence of the emergent light, with the lens adding its power to the incident vergence (L’=L+F). If a lens were quantified based on the emergent vergence, it is clear that this would vary for different positions of the source producing the incident light. Therefore, to help standardise the dioptric measurement of spectacle lenses, the labelled power, or BVP, is based on the emergent vergence value of light at the back surface of the lens when light from infinity (parallel rays) is incident on the lens.3 The power of any lens is influenced by the surface radii of curvature, refractive index and lens thickness, but is generally constant after surfacing and manufacture. While the spectacle lens power to be dispensed will generally be the same as the patient’s prescription, individual patients with the same prescription can experience different corrective effects with the same lens depending on the fitting of the spectacles.

CASE STUDY 1 A 42-year-old hyperopic patient had a sight test with the trial frame sitting at a VD* of 10mm. The following prescription was found: R +9.50 / -2.00 x 100 L +8.00DS *Note that although the terminology ‘vertex distance (VD)’ is more up to date, BVD continues to be used. They have chosen a plastic fixed-pad bridge frame with single vision lenses for distance, which sits at a VD of 15mm. Upon collection of the spectacles, the patient complains that their distance vision is not as sharp as they were expecting from the sight test, although they feel that their reading is a little better. The spectacles were checked and found to be made up to the patient’s prescription and dispensed with correct lens centration. Although, in this example, the BVP of the spectacle lenses is the same as that of the trial frame, there is a

CPD 2, 1

DISPENSING significant change in VD. Recalling visual optics theory, the far point of the eye is the point at which incident light must be converging towards (for a hyperopic patient) or appear to be diverging from (for a myopic patient) in order that the eye’s refractive system can focus the image on the macula. To provide optimal correction, the second principle focal point of the lens should coincide with the eye’s far point in order to ensure a sharp image is formed on the retina,2,4 as shown in Figure 3a. It can be seen from Figure 3b that increasing the VD will move the second principle focal point of the lens away from the far point so that the image now falls short of the retina. From the earlier discussion on vergences, it is clear that with the spectacles in the position in Figure 3b, light is converging too much, that is to say, the vergence incident on the cornea is more positive with the spectacles in the new position. It follows that if the lens power were made less positive, this would bring the image back on to the retina. Modifying the VD will change the effective power of a lens system. Moving spectacles away from the cornea, by increasing the VD, will make the lenses effectively more positive, whereas decreasing the VD will make the lenses effectively more negative. Early presbyopic patients can take advantage of this by moving distance spectacles down their nose to make them effectively more positive; however, the distance prescription needs to be significant to create appreciable optical changes. Generally, if spectacles are not fitted correctly in relation to the VD, visual problems may arise. As seen in Table 1 (see page 72), the stronger the prescription, the more likely vertex changes will impact on the dispensing considerations. Under British Standards BS2738-A1, all prescriptions with at least one meridian of +/–5D or more must have the VD recorded at the time of the sight test;5 however, this may not be possible with paediatric prescriptions determined from retinoscopy only.6 If a pair of spectacles fit at a different VD to that of the sight test, the practitioner should alter the dispensed power to compensate. It is important that any changes in the dispensed power are noted in the patient’s record to justify the dispenser’s actions. The following formula can be utilised to determine the new powers to be dispensed, where distance, d, is the change in VD (converted to metres), with d having a positive value if the spectacles fit closer to the eye and a negative value if the VD increases:

Fnew =

F ( 1–dF)

Note, for astigmatic lens powers, the powers of the principal meridians should be worked out individually using this formula and then converted back into spherocylindrical form for ordering. In this case study, the lenses should be dispensed with the following powers after compensation, rounded to the nearest 0.25D: R +9.00 / -1.75 x 100 L +7.75 DS This is a significant difference compared to the original prescription at a VD of 10mm.

Light source

Focus

Diverging light

Converging light

(negative vergence)

(positive vergence)

Figure 2 Vergence relating to light rays and wavefronts (dotted) F

Vertex distance Hyperopic far point

Correcting spectacle lens

Second focal length of lens

Increased vertex distance Hyperopic far point

Second focal length of lens d

Figure 3 (a) A correcting spectacle lens fitted at the same vertex distance as the trial frame from the sight test where the second principle focal point of the lens coincides with the eye’s far point; (b) As the vertex distance changes, the second principle focal point changes

CASE STUDY 2 A patient has arrived at the clinic with spectacles made to the following prescription in lenses with a refractive index of 1.6: R +8.50 DS L +7.00 DS They are complaining that their vision is a ‘bit blurry’ when looking into the distance. After verifying that the lens powers match with the prescription and the centration is correct, the fit of the frame is assessed. Although the frame is sitting at the correct VD, it is observed that the frame is fitting with a pantoscopic angle of 25°. The patient reluctantly states at this point that they may have sat on their glasses and the vision has been a problem since then. The labelled power of a spectacle lens (BVP) assumes that incident light is travelling parallel to the optical axis of the lens. If the lens is tilted in relation to the patient’s direction of gaze, then the incident light will strike the lens obliquely. Consider a spherical prescription with a convex positive lens, as in Figure 4 (see page 72), where it can be seen that the light forms a point focus when incident light is parallel to the optical axis (assuming the lens is free from aberrations).

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Table 1 Examples of dispensing compensation based on initial prescribed powers. *In practice, these values would normally be rounded to the nearest 0.25D step

REPRO OP

Prescription

Ideal compensated powers for a VD increase of 5mm*

Difference between dispensed power and prescribed power

+5.00D

+4.87D

-0.12D

+10.00D

+9.52D

-0.48D

+15.00D

+13.95D

-1.05D

SUBS ART PRODUCTION CLIENT

In a real-world environment, adults tend to have an average viewing angle of around 10° below the primary gaze. As such, most adult frames are fitted with a pantoscopic angle (note that pantoscopic angle is often informally referred to as pantoscopic tilt in practice) of around 8 to 10° to ensure that the wearer’s average gaze angle is along the optical axis of the lens.7,8 For young children, spectacles have a pantoscopic angle close to zero, as their shorter height means that the average gaze angle is more at eye level. The application of pantoscopic angle also offers other advantages to the adult wearer:7,9 oblique astigmatism decreases when looking downwards; lens reflections can be reduced; and it prevents the wearer from looking underneath the lens. Progressive addition lens (PAL) wearers in particular can benefit from effectively wider near zones when the pantoscopic angle is increased as this brings the lower portion of the lens closer to the eye providing a ‘keyhole’ effect. Although there are many benefits to pantoscopic angle, practitioners have to be mindful about the impact on the patient’s vision. As a lens is tilted, thereby increasing the pantoscopic angle (see Figure 5), an astigmatic error, known as central oblique astigmatism, is induced along the primary gaze position.2,7 To determine the refractive power experienced by the patient in this case study, the following formula can be utilised to calculate the effective sphere and cylinder (where θ is the pantoscopic angle):

(

Fsph = F x 1 +

(

sin2 θ 2n

)

Fcyl = F x tan2 θ

In this case study, using the above equations, the patient will experience a prescription of: R +8.97 /+1.84 × 180 L +7.39 / +1.52 × 180 As pantoscopic angle is created by rotation of the lens about a horizontal axis of 180°, the unwanted astigmatism induced will, as in this example. also have this axis direction. It is important to note at this stage that the pantoscopic angle must be measured with the patient wearing the spectacles and viewing a target at eye level, that is to say, the primary gaze position, as shown in Figure 5. Pantoscopic angle cannot be measured without the patient and there is often confusion between pantoscopic angle and angle of side, which is specifically a frame measurement (see Figure 6); however, it is usually very close to the pantoscopic angle, and altering the angle of side will directly alter the pantoscopic angle of the frame.

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It is clear from this case study that the 25° pantoscopic angle has an undesirable impact on the experienced power, with a significant degree of unwanted astigmatic error present. This type of effect can also be induced when the face form angle, sometimes informally referred to as the ‘wrap’ of the spectacles, is increased, although the resulting astigmatic error will have an axis of 90° in this scenario.2,7 The scope of this article has considered relatively simple scenarios. Most patients will have prescriptions involving some cylindrical correction and the majority of spectacle frames will be fitted with a combination of ‘tilt’ and ‘wrap.’ With all these parameters, calculating the experienced refractive power requires a combination of mathematical models. While this is rarely worked out in practice, modern free-form surfaced lenses can be manufactured using software that utilises complex mathematical algorithms. The resulting lenses are, therefore, compensated to take into account fitting parameters, such as pantoscopic angle and face form angle, to provide the desired refractive power when viewing in the primary gaze position.10,11 Compensation for frame fitting parameters, such as pantoscopic angle, is increasingly common with modern bespoke PAL designs, but is also available in advanced single vision lenses.12 Care must be taken when checking compensated lenses as they are typically supplied with

Pantoscopic tilt applied Figure 4 (Top) Laser optics showing a lens with zero pantoscopic tilt forming a point focus; (Bottom) A tilted lens producing astigmatic image formation

CPD 2, 2

DISPENSING a verification power as well as the patient’s prescription and it is against this verification power that the spectacles should be measured on the focimeter.10 Although this compensation aims to deliver optimal visual performance, in the author’s experience, some patients may not tolerate a change from an uncompensated to a compensated lens design. While the rationale of a compensated lens is to provide the best optical correction based on the frame fit, dispensing such lenses requires the frame fitting to be precisely matched to the ordered fitting parameters at the point of collection (see Figure 7). Some patients may change their natural posture when moving from a sitting to a standing position, which can mean that the compensation in the spherical and cylindrical powers, typically taken while the patient is seated, may be suboptimal when the patient stands. It is also suggested that while compensation provides optimal vision along the primary gaze, it may cause larger deviations from the prescription for different viewing positions across the lens.7 If bespoke lenses are ordered without any fitting parameters, then some manufacturers will make assumptions on the fit of the frame when working out the surfaced power compensation, which may not conform to the individual patient’s measurements. It is assumed that trial frames are worn with a pantoscopic angle of zero during the refraction of a patient7 and lens compensation assumes this when formulating the compensated powers of a lens; however, if the trial frame is itself is fitted with a pantoscopic angle, the compensation applied to the spectacle lenses will be inaccurate. Although the focus of this article is on the power of lenses, it should also be noted that significant pantoscopic and face form angles also induce prismatic effects and some manufacturers will compensate lenses to mitigate for these unwanted prismatic effects. The differences in prescribed power and verification

Patient’s primary gaze

Pantoscopic angle

a Optic

l axis

of th

e len

Spectacle frame front

Figure 5 Pantoscopic angle

Angle of side

Figure 6 Angle of side is often mistaken for pantoscopic angle

power can also have implications for management of intolerances. Imagine a scenario where a patient has purchased spectacles elsewhere using your prescription and they come into your practice with the glasses claiming that they cannot see clearly. You measure the spectacles on the focimeter and note that the measured power does not match with the prescribed power. In such situations, it can be very easy to dismiss the fault as an incorrectly made-up pair of spectacles, when in fact the lenses are compensated for fitting. The author suggests some form of engraving on lenses (similar to those on PALs) should perhaps be added by the lens manufacturers to indicate the lens powers have been compensated, but as this is not current practice, the practitioner should ask if the patient has been provided with any other information on their lenses or contact the practice where the dispensing took place.

CONCLUSION

Figure 7 Measuring pantoscopic tilt with the patient wearing the spectacles and viewing a target at eye-level. Note that the vertical angle measured here will be equal to the pantoscopic angle in Figure 5

In summary, it is clear that ordering a spectacle lens to a patient’s prescription does not necessarily mean that the patient will experience the ideal power to correct their vision. Elements of the spectacle fitting, especially with more complex prescriptions, can certainly change the perceived vergence emerging from the spectacle lens. With more bespoke lens designs emerging on the market, striving to achieve the best optical performance for the user, it is important that practitioners are aware of the impact that spectacle frame fitting has on lens performance for both dispensing and diagnostic troubleshooting.

Mark Hickton qualified as a dispensing optician in 2006 and is currently a lecturer at Bradford College where he teaches ophthalmic lenses, optics, ophthalmic dispensing practical workshops, alongside ophthalmic business and retail skills.

Prior to this he completed a degree in physics with astrophysics at the University of Kent. Alongside his teaching commitments, Hickton continues to work in practice.

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BUILDING CONFIDENCE WITH OCT-A IN PRACTICE

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Alison Edwards MCOptom, DipTp(IP), Prof Cert Med Ret, Prof Cert Glauc, Prof Cert Paed Eye Care

CPD

This article explores the clinical applications of OCT-A through a series of illustrative case studies. IN BRIEF

ART

INTRODUCTION

PRODUCTION

Optical coherence tomography angiography (OCT-A) has been available since 2014. As with most innovations, it was initially used mainly in research settings, but with improved knowledge and understanding of its capabilities, it is now routinely used in hospital eye departments and increasingly in optometry practices. This article will discuss the benefits and limitations of OCT-A, aim to build practitioners’ confidence in using this technology in everyday practice and illustrate its clinical applications with case studies. The vascular network of the eye is altered by many ocular and systemic conditions. OCT-A is particularly useful in monitoring patients with macular degeneration, genetic macular conditions, diabetic retinopathy, retinal vein occlusion, glaucoma and uveitis. Further research

POINT

CLIENT

is looking at how OCT-A can play a vital role in neuro-ophthalmology. OCT-A is a non-invasive method of imaging the vascular structure of the retina using OCT without obscuration from leaking vessels. An OCT creates cross-sectional images of the ocular tissue by analysing phase differences in the light scattering properties of different structures in the tissue. The movement between scans in a static eye are due to red blood corpuscles moving through the blood vessels. An OCT-A detects changes in light scattering between a series of scans taken in quick succession while each scan is stabilised in the same location. Image stabilisation between B-scans is usually achieved using an initial image which uses the retinal blood vessels to match position. The vessels are then identified as the locations at which motion contrast can be detected through the repeat stabilised B-scans.

Vitreous

Water absorption (1/cm)

2.5

1.5

SS OCT

SD OCT

0.5

24mm

0 700

800

900

1000

1100

Wavelength (nm) Figure 1 Graph showing absorption spectrum of water

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1200

1300

1400

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DIAGNOSTICS, INSTRUMENTATION, OCT

At least two images must be captured at each B-scan location in order to detect blood flow, although most instruments do more than two. Each manufacturer has its own algorithm and some are more sensitive to blood flow than others. A study comparing four different commercially available OCT-A devices looked at images of the superficial and deep capillary plexus along with vessel density.1 These were independently graded and ranked in order based on their performance. It was concluded that there was no statistically significant difference between the devices and each provided their own strengths. OCT-A can be performed with either spectral-domain or swept-source techniques. Spectral-domain OCT uses a shorter wavelength of light (840nm) compared to the average of swept-source OCT (1050nm). Figure 1 shows the absorption spectrum of water (which is analogous to the vitreous), which shows good transmittance for wavelengths below ~900nm and between ~11001000nm. Longer wavelengths from swept-source OCT appear less likely to produce flow artefacts when imaging the choriocapillaris underneath drusen than the shorter wavelengths from spectral-domain OCT.2

Figure 2 (Top) OCT-A 6x6mm macula and disc scan; (bottom) swept-source OCT B-scan and fundus image

OCT-A VERSUS FUNDUS FLUORESCEIN ANGIOGRAPHY/INDOCYANINE GREEN The current gold standard method of imaging the vascular structure of the retina is fundus fluorescein angiography (FFA), which is an invasive imaging technique requiring the injection of fluorescein dye into the blood stream usually via an antecubital vein. The fundus is illuminated with a specific excitation wavelength of blue light which allows the progression of the dye fluorescence around the retinal circulation to be captured in a series of still photographs. Images are captured every two seconds for the first 30 to 40 seconds, then after a few minutes to check for any late leakage. Indocyanine green (ICG) is another imaging modality used to view the choroidal vasculature. It involves injecting ICG dye into the bloodstream and a series of images captured over 10 to 15 minutes. Some patients have complications associated with the injection of fluorescein sodium and indocyanine green, including nausea and vomiting. There are a few reports of acute anaphylaxis, therefore, a detailed allergy history is extremely important.3 In comparison, OCT-A is a quick, non-invasive procedure that minimises footprint and personnel down to one operator. There is no angiographic dye required so this reduces the risk to the patient. OCT-A has another advantage over FFA as it allows visualisation of retinal layers including the outer retina, choriocapillaris and the radial peripapillary network. Some abnormal structures such as microaneurysms in

Figure 3 (a) Motion artefacts; (b) Areas of reduced visualisation following removal of artefact

diabetic retinopathy are predominantly found in the deep vascular plexus, making them easier to see and localise with OCT-A rather than FFA. It also allows detailed examination of the foveal avascular zone (FAZ) and areas of non-perfusion. There is evidence to suggest that the FAZ is enlarged in diabetic patients even before diabetic eye disease develops and capillary drop out can be a marker of early diabetic retinopathy prior to clinical signs.4,5 The main disadvantage of OCT-A over FFA and ICG is that it cannot show leakage of fluid and it is less sensitive to structures with very low blood flow such as microaneurysms and polyps.

OCT-A INTERPRETATION AND ARTEFACTS It is important to consider that artefacts can occur with any imaging system and OCT-A is no different. The challenge is to identify them when interpreting scans. All OCT-A systems suffer from artefacts as outlined below:

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Figure 4 (a, b) Normal eye; (c, d) ERM causing segmentation errors

CLIENT

● Projection artefacts result in vessels appearing in more than one layer. Light passes through superficial vessels to deeper layers, which fluctuates over time because of the flow of red blood cells in the vessels. The structures beneath are illuminated by this fluctuating light and the OCT-A interprets this change in light intensity between repeat scans as blood flow, so it appears that the superficial vessels are also present in deeper layers which may cause false positives ● Motion artefacts are very common and are caused by eye movements. They are seen as white horizontal lines. Most OCT-A systems now have the ability to remove the lines, but this can lead to reduced visualisation (see Figure 3)6 ● Segmentation errors can occur in diseased eyes with distorted structures such as macular oedema and proliferative diabetic retinopathy, which may cause vessels to be located in the wrong layer. Again, segmentation errors can be manually corrected but this can still prove difficult in diseased eyes. Figure 4a and Figure 4b illustrate a healthy eye, whereas an epiretinal membrane (ERM) on the retinal surface is shown in Figure 4c and Figure 4d. The black patches captured on the OCT-A is the space under the ERM. The fluorescent blood vessels are in the incorrect layer.6 When interpreting an OCT-A report it is sensible to have a methodical approach. A helpful guide was compiled in 2020 detailing a five-step process to OCT-A interpretation, which is summarised below:7 ● Step one involves choosing the correct scan size for the area of retina being imaged

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● Step two is to look at the en-face OCT-A images. Most systems provide ‘slabs’ such as those seen in Figures 5 and 6; these display the superficial capillary plexus, the deep capillary plexus, the outer retina and the choriocapillaris. It is important to know what each projection should look like in a normal eye so you can spot something that is abnormal. This does not necessary mean that everything new you see should be referred as it is always important to consider alongside symptoms and visual acuities ● Step three is to take note of the segmentation lines. As discussed earlier, proper segmentation lines help to ensure correct identification of retinal boundaries and many OCT-A systems allow for correction if errors occur ● Step four: the OCT B-Scan has a function which allows the interpreter to visualise flow in the outer retina layers. In Figure 5, the B-scan is colour-coded to identify flow above and below the retinal pigment epithelium (RPE) ● Step five involves looking at the en-face intensity image as this helps to determine whether low blood flow is real or shadowing from pathology. Comparing OCT-A with other forms of imaging is very important when learning to interpret the findings, and, as with all novel imaging modalities, it should be seen as an addition to the expanding tool kit of the optometrist.

CASE ONE – NEOVASCULAR AGE-RELATED MACULAR DEGENERATION (AMD)

An 80-year-old patient attended the practice in April 2020 presenting with a five-week history of distortion in her right eye along with reduced vision. She had been very reluctant to seek help due to COVID-19 and the national lockdown restrictions in place at that time. Her visual acuity (VA) was surprisingly good at 6/7.6 and N6 at 35cm in both eyes. The OCT-A report is shown in Figure 5. In a normal retina, the outer retina slab should be empty but in this report there appears to be a knot of vessels temporal to the fovea. This area of hyper-reflectivity is a choroidal neovascular membrane (CNVM). The OCT-A B-scan in the bottom left of the report shows the location of blood flow, colour coded red for vessels above the RPE and purple for the choroidal circulation beneath. There is an increase in blood flow which corresponds to the CNVM. This patient was referred via the local fast track macular service and offered Avastin, anti-VEGF intravitreal treatment off-licence as there was evidence of wet AMD, but she did not meet NICE guidelines for one of the approved treatments, such as Lucentis. Under the Royal College of Ophthalmologists’ COVID-19 guidance it states that ‘New wet AMD cases may be confirmed by OCT

CPD 3, 2

DIAGNOSTICS, INSTRUMENTATION, OCT

Angiography (Superficial)

Angiography (Deep)

OCT B-Scan

Angiography (Outer retina)

Angiography (Choriocapillaris)

Composite Angiography

Fundus

Figure 5 Default OCT-A report displaying a CNVM

Overlay

Display

Overlay

Line Angio B

OS(L)

Figure 6 OCT-A report of a patient with CSCR

and OCT-A. Fundus fluorescein angiography is not mandated if wet AMD is confirmed by OCT and OCT-A.’8 A study carried out in 2019 looked at the diagnostic accuracy of OCT-A in identifying occult and classic CNVM in wet AMD versus FFA. The results of the study found that FFA detected CNV in 70 of 90 eyes (77.7%) compared to OCTA which

identified CNV in 69 eyes (76.7%).9 Another study found the sensitivity and specificity for CNV detection with OCT-A to be similar to that of FFA.10 With the demand on hospital eye services and limited capacity, it will become increasingly important for practitioners to be confident in using and interpreting OCT-A in the community.

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OD(R)

RNFL Circular Tomogram/Thickness

Colour photo

RNFL Thickness Map

SUBS

GCL++ Macula 6Sector Grid

ART

Average thickness RNFL(µm) Total thickness 46 Superior 44 Interior 39

SuperPixel-200 (Disc:RNFL/Macula:GCL++)

GCL+ Macula 6Sector Grid

Disc topography Margin Disc Cup

PRODUCTION

Horizontal tomogram

Rim area (mm2) Disc area (mm2) Linear CDR Vertical CDR Cup volume (mm3)

0.34 2.92 0.94 0.97 0.75

CLIENT

Figure 7 OCT glaucoma report

CASE TWO – CENTRAL SEROUS CHORIORETINOPATHY (CSCR) A 75-year-old patient presented to practice under the minor eye conditions service (MECS) in March 2019. His main complaints were of metamorphopsia and blurred vison in his left eye for two weeks with his VA measuring 6/12 (N8 at 40cm) in this eye. It was noted in the history that he had been prescribed a steroidal nasal spray by his GP which he had taken for a number of years but was otherwise fit and healthy. The scans were emailed to the local medical retina consultant and it was suggested that the patient should be referred for a non-urgent FFA as OCT-A did not show any signs of choroidal neovascularisation. The OCT-A image in Figure 6 includes features commonly seen in CSCR. The angio B function displays a thickened choroid along with absence of drusen or haemorrhages and the outer retina slab is empty indicating no choroidal activity. As in this case, the OCT-A was used alongside the gold-standard FFA imaging to confirm there was no evidence of a CNVM. Based on the results of the FFA, the patient was offered treatment for CSCR including photodynamic therapy, macular micropulse laser and mineralocorticoid antagonists such as spironolactone or eplerenone. The decision was made to monitor his condition under the medical retina

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virtual clinic on a three to six monthly basis. There are a number of studies looking at how OCT-A can be used to diagnose CNVMs associated with CSCR, with one study reporting a high sensitivity and specificity (100%) of OCT-A detecting this feature.11 Another study analysed findings from OCT-A imaging compared to those captured with multimodal imaging. The report found that the OCT-A was able to detect an abnormal choroidal vessel pattern at the choriocapillaris and abnormal flow in all cases although it did also result in some false positives; this reiterates the need for OCT-A to be used in conjunction with other imaging modalities alongside knowledge of OCT-A interpretation.12

CASE THREE – GLAUCOMA A 53-year-old patient had been diagnosed with end stage primary open angle glaucoma (POAG) with severe visual field loss in both eyes. Figure 7 shows the OCT glaucoma report for the patient’s right eye. The top centre of the picture is the retinal nerve fibre layer (RNFL) thickness map (also shown by the RNFL circular tomogram) indicating loss (cool colours – blue) superiorly, temporally and inferiorly. The report also looks at ganglion cell loss at the macula, which is indicated by the sectors in red in the bottom left of the report.

CPD 3, 3

DIAGNOSTICS, INSTRUMENTATION, OCT

OD(R) Angiography (Nerve head)

Angiography (Vitreous)

OCT B-Scan

Angiography (RPC)

Angiography (Choroid/Disc)

Density map

Fundus

Figure 8 OCT-A glaucoma report

The disc-centred OCT-A image in Figure 8 helps to monitor and manage the condition in order to preserve remaining vision. The first three slabs at the top of the report capture increasing numbers of vessels starting from the vitreous, to ensure that vessels protruding from the optic nerve head are scanned; this is of particular concern when examining patients with proliferative diabetic retinopathy and retinal vein occlusion. New blood vessels can grow on the disc surface and into the vitreous as they try to feed the retina. As with the macula-centred OCT-A, the OCT B-scan in the bottom left of the report looks at blood flow to the optic nerve head which is severely reduced in this case; this is also denoted on the density map with blue indicating areas of no, or very low, blood flow. A review article looked at several studies of disc-centred OCT-A and found that although there were some limitations from flow artefacts, it clearly

shows changes in the optic nerve microvasculature and peripapillary network.13 There is much debate over which parameters are best to detect glaucomatous change – vessel density, peripapillary microvasculature and macular microvasculature. Further research is required in this area, but many studies have concluded that OCT-A should be used in conjunction with OCT to improve early detection and monitoring of this condition.14–16

CONCLUSION

The future of OCT-A is promising and exciting for the world of optometry. There is still a lot to learn and clinicians require appropriate training and education on OCT-A interpretation. This article has provided an overview to build confidence in understanding the concept of OCT-A and how it can be used in everyday optometric practice to guide clinical decision making.

Alison Edwards graduated from the University of Bradford in 2014 and completed her pre-registration year in Limavady, Northern Ireland. Since qualifying, Edwards has completed the

College of Optometrists’ professional certificates in medical retina, glaucoma and paediatric eye care, along with her independent prescribing qualification. She worked at BBR Optometry and Hereford County Hospital until recently relocating to York. She now works at York Teaching Hospital in the glaucoma team as an advanced specialist practitioner, including working within the ophthalmology research team.

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PRESCRIBING PROSTHETIC AND COLOURED CONTACT LENSES Dr Melanie Frogozo OD, FAAO, FSLS

SUBS

This article will allow practitioners to understand current coloured and therapeutic contact lens options and learn how to implement these into practice. IN BRIEF

ART

INTRODUCTION

PRODUCTION CLIENT

Coloured contact lenses have an important role as prosthetics for diseased and traumatised eyes. Prosthetic lenses improve the cosmetic appearance of patients who have ocular disfigurement or asymmetry. Additionally, these lenses can relieve patients who have visual discomfort such as diplopia1 or photosensitivity.2 Several types of prosthetic contact lenses are available, each with their own unique features and limitations. This article first describes the various types of coloured contact lenses that are available. Then, cases are used to illustrate the uses for these types of lenses. The peculiarities of prosthetic contact lens evaluation are discussed with an emphasis on patient history and ocular evaluation. Lastly, special considerations for the care and use of these lenses are presented.

LENS TYPES

Translucent soft tinted lenses Translucent tinted lenses have a homogenous colour throughout the tinted portion of the lens that overlaps the iris thereby enhancing the natural tones of the eye (see Figure 1). These lenses are commonly used to augment natural eye colour or to cover mild disfigurements. An additional central feature can be added such as a second translucent tint or a black pupil (see Figure 2).The centre can also be left transparent giving a clear pupillary zone. Computer-generated soft lenses Computer-generated lenses are available in a variety of common iris colour patterns and diameters. These lenses have good reproducibility and are less expensive than hand-painted lenses. Computer-generated lenses achieve their desired iris appearance by layering several different colour patterns by dot-matrix printing (see Figure 3). An iris colouration pattern without an opaque underprint provides partial iris occlusion whereby some of the patient’s natural eye features will be visible. In order to achieve full iris occlusion, an opaque underprint may be specified underneath the coloured iris print. The final perceived iris colour will vary depending on the colour

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CPD

POINT

of the opaque underprint (see Figure 4). An opaque backing will mask the natural colour of the eye and any underlying irregularities. Some manufacturers offer diagnostic fitting sets that include iris enhancements such as a limbal ring or pupillary frill. Pre-set designs with a variety of iris colourations and opaque underprints are also available. Computer-generated lenses can be made with either a clear or black pupil. Hand-painted soft contact lenses Hand-painted prosthetic contact lenses offer the most customised appearance providing complete control of parameters such as overall diameter, base curve, iris diameter, pupil size and iris colour. More intricate ocular details can also be added such as iris flecks and coronas, limbal rings and blood vessels. Additionally, the artistry can easily be decentred to improve symmetry with the fellow eye, for instance, to cosmetically corrected

Figure 1 Examples of translucent coloured contact lenses

VERSION REPRO OP

a hand-painted lens may be indicated. For patients who have visual challenges, the quality and quantity of the visual discomfort will guide lens selection. For example, if the patient has only mild to moderate photosensitivity, a translucent tinted lens may be sufficient to alleviate symptoms. However, if the patient has severe sensitivity to light, a lens with an opaque backing may be indicated.

COLOUR MATCHING SUBS

Figure 5 (Top) Dark brown-eyed patient with central corneal scar of the right eye from Peters’ anomaly. (Bottom) A brown translucent coloured lens that effectively masks the central corneal scar ART PRODUCTION CLIENT

Figure 6 (Top) Patient with significant corneal arcus of the right eye. (Bottom) The same patient fitted into a dot-matrix computer-generated brown prosthetic lens to mask his peripheral corneal opacity

such as dryness or intraocular pressure changes. It is also important to discover any other underlying ocular condition that may impact the fit. For instance, if a patient also has a compromised corneal endothelium, the wearing schedule of the contact lens may need to be altered and/or topical hyperosmotic solutions may need to be prescribed in order to decrease consequential corneal oedema. Globe anatomy should also be considered – if, for example, the patient has a small shrunken globe from phthisis bulbi, a rigid scleral prosthetic cover shell may be indicated instead of a soft contact lens. Being aware of any underlying medical and ocular concerns will help guide patient management.

PROSTHETIC LENS TYPE SELECTION Determining the patient’s cosmetic and visual goal will guide lens selection. If the aim is to mask a mild corneal opacity, a translucent tinted lens or a computer-generated lens without an opaque underprint may allow for a satisfactory appearance. However, if the patient has severe scarring, a computer-generated lens with an underprint or

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Consistent good quality lighting will help determine the patient’s natural iris colour for matching. Evaluating the patient in both indoor and outdoor lighting will help to determine their true eye colour under most lighting conditions. Similarly, having the patient wear white or black clothing and performing evaluations in a room with similar neutral colours will allow for better colour matching. Having access to a diagnostic lens fitting set with a variety of tinted and coloured prosthetic lenses will also help to streamline the colour matching process. A fitting set with light, medium and dark-coloured lenses will provide a good start in finding the desired colour match. Colour matching for a hand-painted lens requires a good quality photo of both the affected and natural eye. In such cases, providing the laboratory with a printed photo verified to best represent the true colour is preferred since digital images will have different perceived colours on uncalibrated computer monitors. Depending on the patient’s goals, all prosthetic lens types may allow for successful cosmetic appearance. Nevertheless, there are more colour matching options when fitting patients with darker brown eyes. In lighter eyes, such as blue or green eyes, the colour matching choices are more limited. For example, a translucent tinted lens on a light-coloured eye may not have enough pigment to effectively mask dense corneal scars. In certain cases, fitting both eyes with a coloured contact lens will help the patient achieve a successful colour match.

CONTACT LENS PARAMETERS

The first parameter that should be considered when prescribing coloured prosthetics is the contact lens diameter, which will be determined by the size of the deformity that needs to be masked. If the irregularity being masked is confined to cornea or the iris, the lens should ideally cover 1.5mm past the limbus. In some cases, contact lenses do not centre perfectly when working with patients with larger ocular disfigurements. In these cases, the iris paint can be decentred on the contact lens in order to achieve a good cosmetic appearance. For this, a larger diameter lens (16mm to 18mm) may be necessary to allow enough space for proper decentration. In such situations, a prism-ballasted or truncated contact lens may be used create consistent orientation. Next, the base curve should be determined in order to achieve a comfortable and well-fitted lens. The patient’s corneal shape may be too irregular to measure accurate keratometry readings so diagnostic fitting of a clear lens with a known base curve may be necessary to determine

CPD 4, 2

CONTACT LENSES the best fit. Having a few diagnostic lenses on hand with known flat and steep base curves will help with efficiency of the fitting process. Finally, if the eye being fitted has visual potential, the power of the lens should be addressed. A subjective refraction or retinoscopy over a trial lens will help determine this. Note that the patient should be educated on the changes of visual perception through the coloured contact lens. Again, tints will change colour perception and/or may alter the patient’s peripheral vison. Before starting the process, be aware that every laboratory has different returns policies. If a prosthetic contact lens is not returnable it is advantageous to fit a clear version of the same lens in the desired base curve and diameter to first confirm proper fit. Make sure that patients are able to manipulate the contact lens to perform lens application and removal. Consider dispensing the clear lens and allowing the patient to wear it for a few days before ordering the final prosthetic lens. Clear contact lenses from many labs are returnable but the tinted prosthetic version is a final order.

Figure 7 (Top) A patient with opacified corneal transplant of the right eye. (Bottom) The same patient fitted with a hand painted soft lens for the damaged eye

CARE OF PROSTHETIC CONTACT LENSES Since silicone hydrogel material cannot be tinted or painted, prosthetic contact lenses are limited to traditional hydrogel materials. Prosthetic lenses are typically prescribed for annual replacement. Advise patients that tinted and hand-painted contact lenses gradually fade over a time. If the colour fades, translucent and hand-painted lenses can be sent back to the manufacturer or artist to be retinted or painted if needed. Computer-generated lenses are less likely to fade but should still be replaced annually. Consult with the laboratories for recommended contact lens care products since some solutions can accelerate the contact lens fading process.

PROTECTION For safety and protection, consider prescribing impactresistant eyewear in monocular prosthetic lens patients. In addition to protection, glasses worn over the contact lens can further enhance the cosmesis (see Figure 8). A light or graduated tint can help to blend the appearance of the contact lens with the fellow eye. In addition, the power of spectacle lenses can be used to alter the perceived size of a disfigured eye. For example, a patient who has a smaller eye appearance may benefit from a plus-powered spectacle lens to provide better symmetry in size between the two eyes.

CONCLUSION A range of coloured contact lenses exist that serve prosthetic and therapeutic roles. Patients all have different

Figure 8 (Top) Patient with right eye corneal scar from trauma. (Middle) The same patient fitted with a prosthetic contact lens. (Bottom) With spectacles to help blend cosmetic appearance of the prosthetic lens in the right eye with his fellow eye

end goals and expectations for their visual performance and cosmesis. Having good knowledge of the available products and their uses enables practitioners to guide their patients through the process to an acceptable outcome. In many cases the end result is positively life altering for the patient. As such, fitting these types of lenses, while challenging, is also highly rewarding.

Dr Melanie Frogozo completed a residency in cornea and contact lenses at the University of Houston College of Optometry. After residency, she joined the University of Iowa Department of

Ophthalmology and Visual Sciences. She is the owner of Alamo Eye Care and the director of the Contact Lens Institute of San Antonio, Texas. She is a diplomate of the cornea, contact lens and refractive technologies section of the American Academy of Optometry, a fellow of the Scleral Lens Education Society and a member of the contact lens section of the American Optometric Association and the Texas Optometric Association.

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CASES FROM THE CASUALTY CLINIC

CPD

Alan Hawrami BSc (Hons), MCOptom, Prof Cert Glauc, DipTP(IP)

POINT

SUBS

This article features a series of eye casualty cases. Readers are invited to review the images and access additional resources where necessary to answer the questions. IN BRIEF

IMAGE A

IMAGE B

ART PRODUCTION CLIENT

A 52-year-old male patient reports a one-week history of unilateral red eye and significant discomfort. He has tried lubricants, but it has made no improvement. 01 What is the most likely diagnosis? a) Inflamed pinguecula b) Inflamed pterygium c) Scleritis d) Uveitis 02 What type of medication would this patient require? a) Topical steroids b) Topical antibiotics c) Topical antivirals d) Oral non-steroidal anti-inflammatories 03 At what point would surgery typically be advised in these patients? a) Never b) As early as possible c) When the lesion is close to the pupillary margin d) When the lesion has covered the entire pupil

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04 What is the common term for the clinical sign in the image? a) Vitritis b) Shafer’s sign c) Anterior uveitis d) Weiss floaters 05 What would be the least likely symptom related to this finding? a) Opaque shadow/curtain across vision b) Photopsia c) Pain d) Floaters 06 This patient has not had any eye issues previously. If they were seen under a Minor Eye Conditions Service, what should the next course of action be? a) Emergency referral b) Routine referral c) Soon referral d) No referral necessary

II 1 IMAGE C

IMAGE D

A 38-year-old female patient attends with a five-day history of headaches and dizziness. Clinical examination reveals the above finding in both eyes.

A 30-year-old male patient attends eye casualty due to right eye pain and photophobia for two days. He mentions he has been run-down and unwell for the past week.

07 Which of the following conditions would be considered as part of your differential diagnosis? a) Retinal detachment b) Hypertension c) Open-angle glaucoma d) None of these options

10 What is the most likely diagnosis? a) Corneal abrasion b) Herpes simplex keratitis c) Contact lens-related ulcer d) Vortex keratopathy

08 What are the potential systemic risks associated with this finding? a) Heart attack b) Stroke c) Aortic aneurysm d) All of these options 09 If this patient was seen under a Minor Eye Conditions Service, what would the most appropriate course of action be? a) Emergency referral b) Urgent referral c) Soon referral d) No referral

11 Which of the following signs is least characteristic of this condition? a) Poor tear film b) Dendritic pattern c) Reduced corneal sensation d) Lesion stains with fluorescein 12 What would be the most appropriate treatment? a) Topical antiviral b) Topical antibiotic c) Topical lubricants d) Topical steroids

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 the hospital eye service 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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KERATOCONUS IN THE COMMUNITY

CPD

POINT

Nick Howard FBDO (Hons) CL, FBCLA SUBS

This article features a series of keratoconus cases. Readers are invited to review the images and access additional resources where necessary to answer the questions. IN BRIEF

IMAGE A

IMAGE B

ART PRODUCTION CLIENT

A 78-year-old female patient with keratoconus has been wearing polymethylmethacrylate (PMMA) corneal contact lenses since 1965 and was successfully refitted with a rigid gas permeable (RGP) material over 25 years ago.

A 69-year-old patient with advanced keratoconus wears RGP corneal contact lenses all waking hours and presents complaining of a significant reduction in vision and debilitating glare at night.

01 What condition best describes the corneal appearance on lens removal? a) Normal appearance b) Hurricane keratopathy c) Neurotrophic keratitis d) Vortex keratosis

04 From the image shown, what is the likely reason for the symptoms? a) Scratched and deposited contact lens surface b) Horizontal crack across the centre of the contact lens c) Anterior subcapsular cataract d) All of these options

02 The patient is asymptomatic, achieves visual acuity of 6/7.5 and wears contact lenses for 16 hours every day. Which consideration is most appropriate? a) Cease lens wear for two weeks and review in six months b) Continue without treatment or actions c) Fit a low powered soft contact lens as a piggy-back d) Refer to an ophthalmologist

05 What should be the immediate course of action? a) Discuss referral for potential cataract extraction b) Replace the contact lens c) Give advice on appropriate contact lens management and cleaning routines d) All of these options

03 Which of the following statements is true? a) Some corneal staining is inevitable in all keratoconus patients wearing RGP corneal lenses b) Intervention is not required if the patient is asymptomatic c) Friction generated by RGP contact lens materials will often cause this type of stain d) This type of corneal stain may be seen without contact lens wear

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06 What advice and guidance may be appropriate and acceptable for this patient going forward? a) Always wear up-to-date spectacles for a minimum of two hours at the end of the day b) Keep a new pair of replicate contact lenses in case of loss or damage c) Refer for a penetrating keratoplasty d) Explain that following cataract surgery only reading spectacles will be required

II 2 IMAGE C

IMAGE D

A 50-year-old female patient with a moderate, stable level of keratoconus is successfully wearing a piggy-back contact lens system. The patient becomes aware of a significant drop in visual acuity after about seven hours of wear.

A 35-year-old female patient attends for a contact lens check-up. She reports successful, full-time contact lens wear following a surgical procedure four years ago for advanced keratoconus.

07 What can be observed in the image? a) Linguatula serrata b) Protein and lipid adherence on the RGP contact lens surface c) Demodex folliculorum colonisation on the soft lens surface d) Strands of mucus between the lens surfaces

10 Which of the following observations is correct? a) The patient has had a full thickness keratoplasty and is wearing a fluting soft contact lens b) The patient has had a surgical procedure to fit intrastromal rings and is wearing a well ventilated corneoscleral contact lens c) The patient is wearing a mini-scleral contact lens following corneal transplantation d) The patient is wearing a reverse piggy-back combination causing the soft lens to flute away from the ocular surface on the horizontal meridian

08 What action may have an immediate beneficial effect? a) Oral ivermectin b) RGP removal and irrigation c) Storing the soft lenses in 3% hydrogen peroxide d) Cleaning with terpinen-4-ol 09 What action would be least appropriate to explore in the short to medium term? a) Refit with scleral contact lenses b) Refer to ophthalmology for collagen crosslinking c) Full dry eye assessment and management review d) Change of contact lens materials

11 What action would be most appropriate in this case? a) No action is required as the patient is asymptomatic b) Refit with a flat-fitting hybrid contact lens c) Discontinue contact lens wear and use spectacles d) Refit with an oblate mini-scleral contact lens with a toric periphery 12 What is the most likely reason for the contact lens demonstrating this appearance? a) High level of scleral toricity b) Steepening of the peripheral cornea at host/donor junction following the surgical procedure c) The contact lens is inside out d) The contact lens base curve is too flat

IMAGE INTERPRETATION

ANTERIOR SEGMENT, CONTACT LENSES, PATHOLOGY

Nick Howard qualified in 1984 and subsequently completed advanced contact lens training. Having been involved in a broad variety of training and research settings, his specialty contact lens work is currently divided between two NHS Lancashire hospitals, where he fits an extensive range of contact lenses for the more challenging ocular conditions.

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CPD AUTHOR SPOTLIGHT

REPRO OP

“NEVER SAY ‘NO’ TO PROGRESSIVE, CONSTRUCTIVE OPPORTUNITIES”

SUBS

Nick Howard

NICK’S 10-SECOND CHALLENGE

CONTACT LENS OPTICIAN

Kindle or hardback? Hardback Face-to-face or Teams? Face-to-face Tea or coffee? Coffee Cats or dogs? Dogs Early bird or night owl? Early bird Staycation or vacation? Vacation Savoury or sweet? Savoury Bake off or Masterchef? Neither.

ART

Tell us about your role… Day-to-day, I fit specialty contact lenses, primarily in secondary care settings for challenging ocular conditions. My current work also includes writing, and delivering lectures, workshops and presentations in hospitals and at conferences in the UK and overseas. What is the most memorable moment of your career? Spending a day in deepest China with the President of the Hong Kong Cornea and Contact Lens Society. A truly momentous, breathtaking, exciting, entertaining, enjoyable and wholly unforgettable day.

PRODUCTION CLIENT

What is the most important change that you have witnessed in optometry during your career? The introduction and full acceptance of advanced technology and improved instrumentation, providing a far greater understanding and awareness of both complex, and low grade, sub clinical ocular conditions. For example, the computerised digital imagery from corneal topography (videokeratoscopy), is now the backbone, the fundamental and essential tool in my contact lens clinic, consigning the cumbersome, dated and largely ineffective keratometer to the annals of 19th century history.

Who inspires you? Great leaders in adversity: Nelson, Nightingale, Churchill, Mandela. Tell OT about one of your hobbies... I paint. I regularly copy and improvise Claude Monet’s work and have a particular affinity with Monet’s Japanese Bridge Over a Pond of Water Lillies. What are you reading or watching at the moment? Three men in a boat (Jerome K Jerome). What advice would you give newly-qualified optometrists? Never say ‘no’ to progressive, constructive opportunities for personal or professional development. If the answer is always ‘yes,’ the world is yours.

OT CET exams will close at midnight on 28 December. To support practitioners, OT has a range of exams available covering all practitioner types and competencies: n Infection control and prevention – 2021 update n Casualty cases n Ancillary tests in practice

n The treatment of children with amblyopia n Communication essentials: cultural competence in practice.

The current CET cycle closes on 31 December. Take an exam at www.optometry.co.uk/cet

CPDs COMING UP IN FEBRUARY/MARCH n The missing piece of the glaucoma puzzle? Preeti Singla n Acanthamoeba keratitis: clinician and patient perspectives Carnt et al n Non-arteritic anterior ischaemic optic neuropathy Tham Nguyen n Single vision lenses: are your standards up to standard? Jim Cox n The painful red eye Jaspreet Sajjan n Diabetic retinopathy or not? David Bundy.

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LIVE CET

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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Marketplace Services and products for the practitioner

SUBS

A WELL-DESIGNED TRIAGE FORM

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Anthony Blackman, optometrist at Leightons Opticians and director of training and development for Insight Optical Training, on how a simple triage form has empowered staff and increased efficiency that the optical assistant or receptionist can circle the answer. This speeds up the completion of the form and reduces ambiguity. Using the form has definitely made them more confident in speaking to patients – they don’t go into panic mode. Now they go through a calm introduction and explain that they will ask a few questions. They don’t have to remember what to ask, as it is written down for them. Using the form makes speaking to patients much easier for them, and they feel more confident and competent. I have also run training sessions with them to ensure that this is the case. The form was developed at the start of 2020, so out of coincidence it was ready in time for the COVID-19

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good triage form is essential for a number of reasons. I use a template that I designed and have since altered, based on feedback from colleagues. I gave it out free as a download when I presented at SightCare’s online conference, so I know of over 25 independent optical practices that have it already. The feedback so far has been great. Practitioners have told me that the form is simple and quick to use, that the prompts included mean they don’t forget to ask obvious questions, and that their reception staff are now feeling more confident in handling queries from patients.

Upskilling reception staff

All calls to the practice go via the reception team, so when we are busy it is very useful for them to be able to gather the necessary information to start the triage process. Most of the questions have simple answers so

“Support staff may not be qualified to diagnose, but ours have been well trained in how to handle patients presenting with problems” pandemic. It has been tweaked a little since then; it is a live document that can be amended based on feedback. It made things much easier for everyone during the pandemic. It meant that most patients could be dealt with without the need for them to physically visit the practice. We continue to receive calls daily that require triaging, but having the

reception team able to undertake the first part of the process has made things much easier. They can pass the details on to a professional colleague for the rest of the process.

Prioritising patients

The form has also been very helpful in cutting down chair time. We ask some patients to send a photo of their eye to confirm the signs and symptoms that they have reported. We might follow it up with a call or even email them some PDF leaflets, for example one on conjunctivitis or subconjunctival haemorrhage. The majority of patients have not needed to be seen urgently by the hospital, so it has saved their time too. Having the right information at the beginning helps the clinician to manage the situation. All the major signs and symptoms are checked, so the process is consistent. What we don’t want is the clinician to have to call the patient to run through the questions again. The form helps us to avoid this. Within the practice we have different titles, but we are all a team trying to deliver an excellent service to all of our patients. Support staff may not be qualified to diagnose, but ours have been well trained in how to handle patients presenting with problems. This way the patient can be dealt with efficiently and without delay. We never want to say, ‘I’m sorry but I can’t help you.’ The form means that patients feel like someone has listened and acknowledged their problem from the very beginning.

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Secret Life

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My secret life

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MY T SECRE ... S LI F E A PRODUCTION CLIENT

Locum optometrist, Kishan Devraj, on a lockdown project that saw him create a chatbot for Moorfields Eye Hospital

“You can go from an idea to reality with technology. I didn’t always know how, but I knew that I could learn” 98 www.optometry.co.uk

or over 10 years, I have been building websites. Before I started optometry, even during my A-levels, I found the technology interesting. Even back then, I thought ‘there is no limit to what you can build.’ I think what excited me is that you can go from an idea to reality with technology. I didn’t always know how, but I knew that I could learn. Programming is very creative – but you can get carried away, creating things that people don’t need. Just because you build something, it doesn’t mean that it has a value. The reason I believe that my experience in optometry helps is that people come to you to solve a problem. I took that idea with me into technology. It was lockdown that really accelerated my knowledge. During lockdown, I thought: ‘What can I do that I enjoy?’ I didn’t just want to build websites and apps. I wanted to build tools with artificial intelligence. I saw on Twitter that Mariya [Moosajee, Moorfields Eye Hospital clinician scientist] had launched a website for people with genetic eye problems. I messaged her, we had a call and I showed her what I could do. She thought that a chatbot would make the information on the website much more accessible. Gene Vision launched a chatbot and an Alexa app. If you have a genetic eye condition, or you have someone in the family who has a genetic eye condition, you can have

a conversation with this chatbot. What we found is that a lot of people want to know the current research. We are also finding that people want information on support. You can ask the chatbot questions like ‘Can I drive? What employment support is available?’ It is an artificial assistant – it’s not real, but we can make it pretty accurate. We had one person during testing who thought it was an actual human on the other side. The work I did on Gene Vision has resulted in a part-time job at University College London contributing to research that will help with the monitoring and managing of eye disease through technology. I’ve also developed a simple way that any optical practice can incorporate a chatbot on their website for free within minutes. This enables practices to improve their communication, engagement and bookings. All practices have to do is go to the website www. autoconversation.com and it allows them to generate a piece of code which can then be copied and pasted onto their website. As a locum in North West London, work dropped off at the start of lockdown. I think it was a blessing because it allowed me to focus on my skills in technology. I could easily have complained that there was no work but, considering the opportunities I have now, I wouldn’t have it any other way.

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Journal of the Association of Optometrists

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December 2021/January 2022 Volume 61:06

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December 2021/January 2022 / Volume 61:06

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Timely triage

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How optometrists are working to deliver the right care to patients at the right time

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EXCITING NEWS INSIDE

CPD The role of leadership in delivering safe care

Perspectives Dr Julie-Anne Little on the value of triage

In practice Dr Amit Jinabhai shares his career journey

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