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THE EDUCATION, REGULATION AND REFORM EDITION

GOC fitness to practise waiting times examined The exhilarating role of a hospital optometrist 100% Optical 2024 education programme revealed

December 2023/January 2024 Volume 63:06

STEPPING UP How education and regulation are evolving to support optometrists

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Elaine is very aware of her crucial role in ensuring the population of Stranraer maintain their eye health as the nearest hospital is 70 miles away. ‘I work closely with consultant ophthalmologists so I can offer emergency are locally’, she says, ‘and now I’m pursuing the NESGAT (NHS Education for Scotland Glaucoma Award Training) qualification so I can offer even more essential support to people in this remote area’. Elaine Hawthorn, Specsavers Stranraer

Sabina was part of a pilot with her local health board which reduced waiting times from two years to three months. ‘New glaucoma patients are referred to the Cardiff cluster of Specsavers practices that I am responsible for,’ says Sabina. ‘I have set up an inter-store referral scheme and I’m training my colleagues so we can care for even more people in our community.’

Specsavers believes in the Sp life changing power of better sight and hearing. Our optometrists are serving communities and optimising patient outcomes. Working with us, you’ll see the difference you can make daily – alongside investment in you, technology and services. You’ll join talented people focused on clinical excellence and patient care.

Sabina Arshad, Specsavers Llanishen

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Adam Sampson

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OUR BEST FOOT FORWARD

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One of the key assets at the AOP, which we should celebrate more, is our Council, writes Adam Sampson

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Adam Sampson, AOP chief executive

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The AOP represents the voice of over 14,000 qualified optometrists and dispensing opticians in the UK. Daily its works to protect, promote and represent the profession. The membership renewal period is now live. Turn to page 88 to read more about the renewals process and the importance of checking your grade.

As CEO of the AOP, my fundamental responsibility is running the AOP’s business and trying to translate our strategy into effective action. In doing so, my key reference point is the AOP’s Board. As directors, they are ultimately responsible for how the AOP operates. The challenge of running the AOP is, in truth, not managing the business itself, but ensuring that what the organisation does is in the best interest of our members and, by extension, of the profession. Over the years we have developed robust ways for making sure that what we are saying and doing is what our members agree needs to be said and done. This year’s member survey, for example, not only validated what we have been doing to support members, but gave us some important pointers about areas where we could further develop. Equally important is the need for me and the AOP executive team to be able to test out our interim conclusions or the lines we propose to take with optometrists themselves. That is where our Council is so valuable. Take the last meeting, where two important issues were discussed: the GOC’s review of individual practitioner standards, and remote refraction. Both are subjects that require careful thinking, balancing the needs of patients, optometrists, and the financial underpinnings of the sector. Remote refraction is not a topic for the future but very much for the present. Councillors used our meeting to provide evidence that this method of examination has moved from theory into practice in more than a few businesses. But, with the GOC now committed to updating its guidance on whether refraction can be delegated, setting the rules around how such techniques are to be used is an urgent necessity. Much of the heavy policy lifting will be done by the AOP executive. That is what we are paid for and what members expect. But we are exquisitely aware that we do not have all the answers. And while – yes – it is my job to lead the AOP, I am committed to leading it in the direction agreed by our members. The sessions with Council are at the heart of that. 0

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EDITOR’S PICKS -

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INSIDE THE JOURNAL

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10 / FEATURE PRODUCTION

Great expectations As a new approach to optometry education launches, OT talks with students and lecturers about their aspirations for the future of the profession

14 mins to read CLIENT

CPD 48-66

OT asked attendees at this autumn’s party conferences what eye care can expect from the coming year

FOR OPTOMETRISTS, SPECIALTY OPTOMETRISTS, DISPENSING OPTICIANS AND CONTACT LENS OPTICIANS

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48 Eyelid health:

management of itchy, sticky and swollen lids 52 Ethical considerations of myopia management 58 The clinical characteristics of Stargardt disease 62 Real-time lens design: advances in lens manufacturing and why they matter

Don’t forget, OT now runs bimonthly Clinical interpretation exams and interactive CPD Videos online: www.optometry.co.uk/cpd

_ WORDS: LUCY MILLER

26 / LIFE IN PRACTICE

31 / LIFE IN PRACTICE

44 / IN FOCUS

Life as a locum

A day in the life

Inside party conferences

Thaksha Sritharan shares why she decided to become a locum

Practice owner Deven Lakhani on his daily rituals that end with family time

OT speaks to the organisations present at this year’s party conferences

4 mins to read

6 mins to read

71 / WHAT’S HAPPENING

77 / WHAT’S HAPPENING

88 / AOP ON THE GROUND

Latest launches

Trend watch

An explainer on…

OT looks at the latest eyewear, lenses, solutions and equipment

Lizzy Yeowart shares her party-perfect frame selection for the festive season

The AOP’s Suzanne Page on reviewing your membership grade

3 mins to read

2 mins to read

5 mins to read

December 2023/January 2024 OT www.optometry.co.uk 5

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Editors Picks, 3

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Optometry Schools Council chair, Professor Joy Myint

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s, nc he r u a l n i catio bout the u d e a ry s on omet lecturer professi t p o d _ f the s an ch to proa student future o p a ith the new LL As a OT talks w tions for P OW E A N I L a SE K IN S aspir O R D S: D JE N P HO

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Education, regulation and reform _

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handwritten recipe for spaghetti bolognese, bright wristbands fading as the week progresses, the lone oven glove left on the pavement by parents balancing tea towels, crockery and their sadness outside university halls. This summer, the same rituals of student life came to pass, but with a significant difference for many optometry students beginning their degrees. From September 2023, eight UK universities began offering a master of optometry programme. This milestone marks the culmination of years of work by universities and the General Optical Council (GOC) to ensure that the education and training of optometrists remains fit-for-purpose. The updated education and training requirements (ETR) will see professional placements incorporated into degree schemes, with the pre-registration year that

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ÒWe do have a set of learning

outcomes that better reflect what optometrists and dispensing opticians need to do in practice Professor Joy Myint has been a fixture of optometry training for decades ceasing to exist in its current form for students on a Masters course. rofessor Joy Myint is chair of the Optometry Schools Council (OSC). She was responsible for developing both the

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first and the revised integrated Master of Optometry courses at the University of Hertfordshire, and is now working on designing the Master of Optometry programme at Cardiff University. Each programme is an exercise in fitting together a jigsaw of GOC and university requirements, while making sure that every element of the course is relevant to students. “The students keep me motivated. They are the future of the profession,” she said. “I am now at the stage in my life where retirement is closer than being newly-qualified. I have my degree, I have my GOC registration and now I am helping others to achieve those milestones. It is their time now,” Myint said. She believes that the ETR has helped to update an educational framework that had become outdated. “I agree that something needed to change. We do have a set of learning outcomes that better reflect what optometrists and

COVER FEATURE, 2 Alex Lloyd Jenkins

Professor Joy Myint is pictured at the University of Cardiff

dispensing opticians need to do in practice,” Myint shared. However, she emphasised that academics were doing what they could within the previous framework to give students the right mix of skills and knowledge. “There is nothing wrong with the existing degrees at all,” she said. “I think it was more that the core competencies and requirements that we had to work towards were quite limited. If institutions had stuck rigidly to only what the GOC required, then I think the optometrist possibly would not have skills that were fit for purpose. However, we have all moved with the times,” Myint explained. Myint uses teaching students about optical coherence tomography as an example of technology that is already taught by most universities but was not a previous GOC requirement. “We have introduced new techniques that don’t necessarily fit into a core competency because as educators we want to ensure that we

are developing optometrists who are practice-ready,” she said. The new learning outcomes give educators the flexibility to move with developments in practice and technology, rather than focusing on ensuring that every core competency is evidenced. “We are able to respond to developments in technology because it is no longer concentrating on specific clinical techniques, it is being able to perform an eye examination that is appropriate to the patient that is in front of you,” Myint explained. “If artificial intelligence (AI) or other emerging technology comes to the fore, we can ensure that our students are introduced to that at an appropriate time,” she said. A key aspect of the updated framework is an overhaul of how professional placements are provided. Rather than a two-stage process, where students complete a pre-registration period that is usually

separate to their university study, all clinical placements will be integrated into their university programme. The OSC has been meeting with employers from a range of settings to discuss how these placements might work. “We need to make sure that we are working together. With the traditional model, it was very easy to do a degree then you go out on placement, and you had nothing to do with the university,” Myint said. “Now it is all integrated we need to make sure that we are singing from the same hymn sheet – that the employers know when the students go on placement what level they are at, what they can and cannot do,” she shared with OT. Myint highlighted that the placements will not be as big a change as some people fear. “Students will go out in practice, they will test under supervision, they will learn from their supervisor. ►

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That fundamental experience is still very similar,” she said. Asked whether commercial pressures on placements are a concern, Myint observed that there have been instances of this under the previous framework. “We have raised this with the GOC previously. The big change, for some universities, will be that they will still be our students. As universities we have responsibility for those students, so we need to look out for the signs of commercial pressures. That is why the relationships we are building with the employers are key so we can have these discussions now,” she said. In terms of how the changes to education will shape the future of optometry, Myint highlights that there are broader factors at play. “Education is a small part of what happens within the profession. It is an important piece – it is the cornerstone – but what we do is the starting point,” she said. ill Holmes, immediate past chair of the OSC and a senior optometry lecturer at the University of Manchester, also believes that factors beyond education will shape the future of the profession. He points to political questions about what roles optometrists will be assigned within the NHS and funding of professional placements relative to other healthcare professions as examples. “If you were to ask me, ‘What does the perfect optometry programme look like?’ my answer would be to go back further and sort

Will Holmes

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out some of the bigger structural issues within the profession. Education swims in all of that.” A key focus for Holmes, who is an AOP Councillor, is championing the idea that the education of optometrists should be evidence-based. He shared that there can be a temptation for educators to teach others based on their own preferences or experiences of learning. “I know how easy it is to slip into intuitive ways of doing things. But this does not always fit in with the health education literature – we need to use educational approaches that are evidenced, not simply what has worked for us,” he said. Asked why the education of optometry students should be based in evidence, Holmes highlighted that this approach helps to maintain the integrity of the university. “There is an expectation that we should take an evidence-based approach for our students as well as our patients,” he said. “It would be hypocritical to highlight to students that you must look at the evidence for a particular ocular intervention but not apply the same sort of thinking to our educational practice,” Holmes emphasised. Rupal Lovell-Patel is the academic lead for vision sciences at the University of Central Lancashire (UCLan), which launched its new Master of Optometry course in September. Students studying on the course are registered dispensing opticians or contact lens opticians, who continue to work in practice alongside their study. Lovell-Patel shared that the main change to the course has been aligning the learning outcomes of each module to the new GOC outcomes. “I think the underpinning knowledge will still remain. What does show up in the new outcomes is a focus on the behaviour of the clinician,” she said. Lovell-Patel added that there is a greater emphasis on communication and leadership skills as well as lifelong learning. While academics

Academic lead for vision sciences, Rupal Lovell-Patel, has overseen the launch of the Master of Optometry course at the University of Central Lancashire

attempted to instil these attributes under the previous framework, students had less incentive to prioritise them because they were not assessed by the GOC. “Sometimes when they are in that assessment mode, they forget that there is a human being there and the holistic approach you need to take,” LovellPatel said. She hopes that graduates of the new programme will be strong communicators, who provide evidence-based, patient-centred care. Lovell-Patel, who has worked in

COVER FEATURE, 3

academia for 25 years, shared with OT that watching students develop over the course of their study is what motivates her in her job. “We want to make a difference in someone’s life who will then go on to make a difference in many other lives,” she said.

Mark Newton

The student view

“We want to make a

difference in someone’s life who will then go on to make a difference in many other lives Rupal Lovell-Patel

Chris Sunderland, a student on UCLan’s Master of Optometry programme, began working in optics 11 years ago as an optical assistant. He is now a qualified dispensing optician and has a clear idea of the type of optometrist he would like to become. “Where I work, many of the optometrists will have patients who only want to see them because that optometrist has done right by them,” he said. “That is my aspiration as an optometrist. I want people to think, ‘He did a really good job. I will go back to him’,” Sunderland shared. He has found being able to call on the expertise of practice-based educators – an element of the hybridlearning model at UCLan – a valuable part of the programme. “You have not just that knowledge base but a wealth of experience that goes with it. It is less of a textbook answer, but someone saying ‘This is the reality of the situation and what happens in practice’.” Sarah Owen, also a qualified dispensing optician, had some uncertainty entering the course about how the programme would unfold – and how she would manage full-time work alongside study. “I was a little apprehensive – I knew the course was changing. I didn’t know what to expect until I was there,” she said. “We are just about two months in, and I am starting to find my feet with my routine. When you get home and you are tired, you think ‘I would rather be on the sofa watching telly’ but then you remind yourself of why you are doing it,” she said. She looks to her mentor – who has done independent prescribing and a medical retina qualification – for inspiration. “No day looks the ►

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that.’ If I can do that with my mum, same for her. Some days she is doing then maybe I can do that with other routine testing. Other days she is patients,” Poojara shared. doing foreign body removal. She is able to do so much,” Owen said. n the background to changes to “To be able to help patients and the education of optometrists, ease the burden on the hospitals, I the GOC has been taking a think that makes sense. I want to be fresh look at the legislation able to do that when I qualify.” that underpins optometry, the Fellow UCLan student and Opticians Act 1989. dispensing optician, Deepali Poojara, A four-month consultation in supports the emphasis on developing 2022 received 353 responses on the well-rounded clinicians in the new need for change in a range of areas GOC framework. “I have worked in – including business regulation, practice for five years. I can delegation of refraction and see how important it is the sale and the fitting of to communicate with contact lenses. patients,” she said. Following the Poojara also consultation, the believes that GOC decided to an emphasis on call for legislative understanding change that would how optometry ensure mandatory practices operate business regulation as businesses for optical businesses. Deepali Poojara is important. “At At present, it is the end of the day, estimated that around only most optometrists do work half of optical businesses are in community practices. The regulated in the UK. optometrist has Regarding the delegation of a vital role in refraction, the optical regulator helping that business to grow.” decided against pushing for Poojara explained that her legislative change that would permit mother, who has dry eye disease and dispensing opticians to refract. glaucoma, was part of her motivation Optometrist, Azzam Shweiki, for studying optometry. “For me, is the chair of Kensington, Chelsea, understanding more about those Westminster Hammersmith and conditions sparked my interest,” she Fulham Local Optical Committee said. “When I was able to explain (LOC). Shweiki explained that his the condition to her, she told me ‘No LOC made a submission on the call one has ever explained it to me like for evidence to ensure that the

“We do identify refractive error,

but the minute you divorce that from the health check you really do risk damaging the health of the nation Professor James Wolffsohn

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GOC had an understanding of what is happening in practice. “What optometrists see and experience in practice is essential feedback. The voice of people who are dealing with these issues on the ground is the voice that should be the loudest,” he said. Shweiki believes that mandatory regulation of optical businesses could place a disproportionate strain on independent practices. “We need the small independents that exist in places where the big companies would not want to establish a practice. If we make it

COVER FEATURE, 4

“What does

show up in the new outcomes is a focus on the behaviour of the clinician

Mark Newton

Rupal Lovell-Patel

hard to open a practice in a small village, we are denying those people that live in the village the right to eye care within their own community.” Optometrist Mark Waine contributed to the Bexley, Bromley and Greenwich LOC submission alongside his colleague, dispensing optician Lesley Reid. Waine and Reid work in a practice that is located within a dental surgery, where the dental nurses need to be registered and complete continuing education. The LOC called for optical assistants to be registered with the GOC as part of its submission. “An element of professionalism should be engrained in that career. You would have a minimum standard required to perform the job across the whole of the UK, rather than variation from place to place,” Waine said. Optometrist David Knight, of Northumberland, Tyne and Wear LOC, surveyed the group’s 150 members before submitting its response. “We got about 60 replies which is a significant chunk of the footprint. We were very pleased with that,” he said. Knight highlighted that despite the high response rate, he would have

liked to see more young optometrists making submissions on the call for evidence. “Who is it going to affect the most? It is going to be the newly qualified optometrists and the younger people within the profession. They are the people who probably have the quietest voice,” he said. Knight, who has a degree in computing alongside optometry, emphasised the need for regulatory change to keep up with developments in AI technology. “Automation is coming. It is a rarity now but it will be commonplace in 10 years’ time. My personal view is that regulation is going to struggle because the rate of change is way faster than regulatory mechanisms are adapting,” he said. Looking ahead, Knight believes that teleoptometry will play a key role. “That is the future, but it should be done with patient safety as a priority rather than commercial interests.” Professor James Wolffsohn, who compiled a submission on behalf of Aston University, shared his view that some mandatory regulation of optical businesses is particularly important now professional placements are built into university courses. “We are making a commitment to students to provide them with

the required Clinical Learning in Practice. Industry, of course, have their own aspirations of what they want the students to do during this time. That has got to be very carefully balanced,” he said. Wolffsohn emphasised the risks of separating refraction from the eye health check. “We are a health profession. As part of that we do identify refractive error, but the minute you divorce that from the health check you really do risk damaging the health of the nation.” Wolffsohn would also like to see professionals who have trained in countries where optometry is advanced – such as Canada, the US, Australia and New Zealand – face fewer hurdles before they can practise in the UK. “It would help mobility. By making it difficult for other nations, essentially we are making it difficult for our own optometrists. That exchange of ideas and practice is both good for the profession and good for patients.” 0

Selina Powell OT features editor. Get in touch by email: selinapowell@optometry.co.uk

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Behind the cover _

Rupal Lovell-Patel is photographed at the bottom of a stairwell

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THE STORY BEHIND THE COVER STORY

LOCATIONS: PRESTON, CARDIFF

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A search for fresh perspectives saw contributors climb stairwells and gaze through a glass orb

CLIENT

To some readers, regulation may seem a dry topic – conjuring images of dusty textbooks and serious people making decisions in far-flung rooms. But regulation can be about imagining possibilities as well as imposing boundaries. Its effects can be found close to home, on High Streets and university campuses, as well as in the halls of Westminster. In order to showcase this sense of the big picture, photographers, Mark Newton and Alex Lloyd Jenkins, took a creative approach for this edition’s photoshoots. Optometry Schools Council chair, Professor Joy Myint, was photographed at Cardiff University’s optometry building and surrounding campus. Myint posed with spectacles and below staircases as photographer Alex Lloyd Jenkins experimented with different ways of framing his subject. “It was pleasant – Alex was very friendly. I am not keen on having my photo taken and he did put me at ease,” Myint shared. In Preston, Rupal Lovell-Patel patiently sat on steps and held a glass orb and mirror to capture her reflection. “There was some bemusement from students walking through the student centre and one staff member stopped to ask me if I was ok whilst I was sat on the stairs in the building.”

THANKS Optometrists Rupal Lovell-Patel, Professor Joy Myint Photographers Mark Newton, Alex Lloyd Jenkins Art director Grant Pearce

18 www.optometry.co.uk OT December 2023/January 2024

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Rupal Lovell-Patell outside the UCLan student centre

Cover Feature Behind the scenes, 1

Professor Joy Myint

Photographer Mark Newton took a creative approach

Professor Joy Myint in front of Cardiff University

A bird’s eye view

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Life In Practice, 1

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LIFE IN PRACTICE

Career paths and personal development EDITED BY: LUCY MILLER

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A CONVERSATION ABOUT…

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Promoting the Easy Eye Care Pathway to patients and practices

This issue’s must reads...

ONLINE EXCLUSIVE

24 29 31

YOU HAD ME A DAY IN AT HOSPITAL THE LIFE

How a childhood lazy eye sparked an interest in optometry for Henry Leonard

Birmingham and Midland Eye Centre’s Paramjit Ghataore shares a valuable moment

Read more about what’s happening on the ground at www.optometry.co.uk/life-in-practice

Why myopia is the focus for Enfield practice owner Deven Lakhani

“THERE IS A GROSS INEQUALITY”

Around 70,000 people on benefits are set to lose automatic entitlement to free eye care and dental care in Northern Ireland www.optometry.co.uk/benefits

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HOW I GOT HERE

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HOW I GOT HERE

“I TRULY BELIEVE I HAVE THE BEST JOB IN OPTICS” Henry Leonard, AOP head of clinical and regulatory, on how his interest in optometry was sparked by the diagnosis of lazy eye as a child 24 www.optometry.co.uk OT December 2023/January 2024

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optometrists, who could show me the ropes. After joining the AOP, I also spent some time as a trustee of the Optical Benevolent Fund, which is jointly funded by the AOP and the College of Optometrists. It offers assistance to optometrists who find themselves in a time of need.

My interest in eyes goes back to early childhood, when an optometrist spotted signs of a lazy eye at the age of three and referred me into the hospital eye service. I remember my grandparents taking me out of school for regular trips to the hospital eye department for checkups, which I loved, even though I had to wear spectacles and an eyepatch.

I gradually progressed to professional adviser and am now head of clinical and regulatory at the AOP. I truly believe I have the best job

On a visit to the opticians at the age of 17, my optometrist mentioned that my A-level subjects were ideal for optometry. In the absence of any original thoughts of my own, I decided this might be better than nothing, so off I went to study optometry at Aston University. During my final year at Aston, Essilor ran a competition open to optometry students throughout Europe. I wanted to submit my dissertation, but the judging panel needed six hard copies and, having only a few pounds left in my bank account, I could only just afford to make enough photocopies. Fortunately, I ended up winning second prize, which included a trip to Paris to be presented with an award at the Silmo exhibition, so it was all worth it in the end.

in optics. Working alongside the legal team to support other practitioners who are going through what is often the most difficult time

“Working alongside the legal team to support other practitioners who are going through what is often the most difficult time in their professional career is a huge honour” in their professional career is a huge honour. Working for the AOP means I’ve found myself doing things I never imagined, like being interviewed live on BBC News as part of the AOP’s campaigning, or giving presentations to MPs at the Houses of Parliament.

I was extremely lucky to have fantastic support during my pre-registration training, which I completed at Specsavers Opticians in High Wycombe. My supervisor, Heena Thaker, and contact lens optician, Bharat Gandhi, were a huge inspiration to me, and gave me a strong foundation for my career in optometry.

Outside of the AOP, I’ve started a domiciliary company with my wife, who is also an optometrist, offering home visits to patients in my local area who can’t get to a High Street practice unaccompanied. The idea for this

After I qualified, I worked for multiples, small groups and independent practices, and I feel very privileged to have practised alongside some exceptional practitioners over the years. A standout moment in my early career was a trip to Tibet with a group of other optometrists to help set up an optometry clinic in the remote town of Yushu on behalf of Rokpa International, a medical charity. Most of the patients we saw hadn’t previously had any access to eye care, and being able to give people back their vision, and sometimes their livelihood, simply by providing them with a pair of spectacles, was a truly rewarding experience. Around this time, I also became a member of my Local Optical Committee, which got me interested in a side of optometry I hadn’t known existed.

When the AOP advertised for a clinical and regulatory officer, I was intrigued enough to apply. Working in the AOP’s legal and regulatory team was a steep learning curve at first, but again I was lucky to find myself working alongside a brilliant team of solicitors, barristers and

service came after I experienced difficulty finding a domiciliary provider in my area, who could visit my elderly grandmother when she was no longer able to get to a High Street optician. This new role fits well around my other commitments, and gives me insight into being a general ophthalmic services contractor, as well as a performer. I’d like to say I’ve worked hard to get where I am, but the truth is I’ve mostly just been incredibly lucky to work alongside inspirational people, who have been generous enough to share their time and knowledge. 0

NAME: Henry Leonard

ROLE: Optometrist and AOP head of clinical and regulatory

LOCATION: Buckinghamshire

Any regrets? I’ve never really had a Plan B, but since qualifying I’ve developed an interest in computers and software development. There’s nothing I enjoy more than spending a couple of hours writing a piece of code to do something I probably could have accomplished by hand in a matter of minutes.

December 2023/January 2024 OT www.optometry.co.uk 25

91OPTNOV23122.pgs 29.11.2023 15:10

Life In Practice, 2

Life in practice _

Life In Practice, 3

VERSION

Life in practice _ My biggest challenge as a locum is... Getting to know each practice, their systems, and the little things, like where they keep the records. What is their system for post-checks? I like to go in early, to get ahead of it and ask as many questions as possible.

LIFE AS A LOCUM

REPRO OP

“EVERY DAY IS A NEW JOURNEY ”

SUBS

Newly-qualified optometrist, Thaksha Sritharan, on her early decision to locum and how she found herself fitting contact lenses on a film set Before I started locuming... I worked at

ART PRODUCTION CLIENT

Manchester Royal Eye Hospital, where I had completed my pre-reg, for three months. I was in that transition period, and was gaining more confidence. It was great to have very knowledgeable colleagues around to ask any questions while I was starting to become more independent. At weekends, I shadowed my colleagues at their practices. It was really helpful to gain some confidence and build my routine. I worked at the hospital and shadowed at the weekend until February 2023. My next experience was untraditional, in the sense that I was working in the TV and film sector. We were putting prosthetic contact lenses in the actor’s eyes, which was fun. That was a completely different experience. When the film and TV season finished, I went into full-time locuming.

As a locum, I have adapted my day by... Doing lots of research. If I’m working in a different area, I would look up their referral pathways. London is quite different to Kent, which could be very different to Berkshire. My biggest worry is knowing where to refer people. You’ll refer someone, but you won’t know what happens to them afterwards, which is the downside of locuming. I’ve adapted by asking lots of questions. Practices can make life easier for locums by... Being organised. I’m really impressed with some practices. They’ll have a printout with information on what to do, where to refer, what the system is. They go through everything you need to know, in one little cheat sheet. That’s really helpful.

“Anywhere you go, a routine sight test is going to be a routine sight test, and you’ll know how to do it”

When I started locuming, I wish I had known...

My favourite thing about being a locum is...

That anywhere you go, a routine sight test is going to be a routine sight test, and you’ll know how to do it. The biggest challenge is knowing how to use the systems. Once you get your head around that, you stop feeling like you’re in over your head.

That I can work at different settings. Every day is a new journey, a new experience, and a new adventure. I like that I’m getting to know different people, in different areas.

I made the decision to become a locum because... Of the flexibility. For someone in my situation, with family overseas, your annual leave doesn’t always work. This way, I can bulk up my days and then take longer breaks. It has helped me to become more organised, too.

On my first day of locuming... I was nervous. But I told myself that I had got this. I was like, ‘You know the system. You’ve done it before.’ It’s just about getting yourself into a routine. I also wanted to prove myself, especially coming from a hospital setting, which is completely different from routine sight testing. But after two or three sights tests, I got into the flow of it.

BLACK YELLOW MAGENTA CYAN

NAME:

My advice for people who are new to locuming is... Be brave. It takes that extra step to go out

ROLE:

of your comfort zone, and that’s what locuming is. It’s being comfortable with not being comfortable. It’s not just the work that can be different. It’s the fact that you may not have a steady income. You need to be comfortable with that. My biggest advice is to remember that you can do the sight test – you’re just in a different setting.

Thaksha Sritharan Locum optometrist

LOCATION:

West London

My last word on locuming is... Know what you’re worth. Don’t let people bring you down. You are the clinician, so set boundaries based on that. 0 Read more in our Life as a locum series on our website: www.optometry.co.uk

91OPTNOV23123.pgs 29.11.2023 12:22

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Life In Practice, 4

VERSION

Life in practice _ YOU HAD ME AT HOSPITAL

REPRO OP

“I BELIEVE I HAVE SERVED AS A POSITIVE ROLE MODEL” Every edition, OT poses a series of questions to a hospital optometrist. This time: Paramjit Ghataore, deputy head of optometry at Birmingham and Midland Eye Centre

O··································································································································································································· SUBS

When and why did you decide to become a hospital optometrist?

ART PRODUCTION CLIENT

When I applied for the deputy head of optometry role, in 2018, I knew I wanted to dedicate the remainder of my career to the hospital eye service. Over the past five years I have been responsible for the day-to-day running of the optometry department. In the absence of my department head, I am trusted with all departmental activities, including the development of local protocols and polices. I also serve as an advocate for the optometry team on our trust’s emergency department board, offering solutions to enhance our service. Our trust allocates monthly half days for training and development. I facilitate these programmes by organising external speakers, continuing professional development activities and peer reviews for colleagues, to enhance our professional growth.

What is the most surprising case you have seen in the hospital setting? A patient presented with a two-day history of a foreign body sensation after removing her soft lenses in one eye. Anticipating giant papillary conjunctivitis, I was surprised to see a fully intact insect leg stuck on her corneal epithelium.

What is the biggest challenge facing hospital optometry, and how can this be resolved? The growing demand for eye care services and the strain on resources to meet demand. We are addressing this by implementing telephone consultations in some of our low vision followup clinics, to streamline care and reduce backlogs.

What is your biggest recent success? My youngest son started secondary school when I turned 50, which prompted me to embark on my postgraduate training journey. I focused on independent prescribing, glaucoma, and medical retina. This initiated my involvement in urgent care clinics. I steadfastly believe in the importance of ongoing education and the continuous development of our clinical competencies. I regard this as the trajectory that will shape optometry’s future. I am the proud mother of four sons, with my second eldest qualifying as an optometrist in 2023. My youngest has also demonstrated an interest in pursuing optometry. I believe I have served as a positive role model and an ardent advocate for our profession.

NAME:

Paramjit Ghataore

ROLE:

Deputy head of optometry at Birmingham and Midland Eye Centre

LOCATION:

Birmingham

What would you say to High Street optometrists about working in a hospital? A hospital environment offers a diverse range of enriching clinical experiences, professional growth, and the satisfaction of making a meaningful impact on patients’ lives. It is an incredibly rewarding career. 0 Read more in our You had me at hospital series on our website: www.optometry.co.uk/you-had-me-at-hospital

One valuable moment A 12-year-old girl was referred for a cosmetic lens fitting due to scarring and no perception of light in one eye, following an injury she sustained at the age of nine. She spent the appointment looking down at the floor with her shoulders slumped. The lens I fitted was a perfect match and I encouraged her to have a look at herself in the mirror. Her face lit up, and she couldn’t stop smiling and looking at herself. She walked out of my room with her head held high. It was an immensely gratifying moment. She went to the canteen and bought me a can of Coke and a packet of crisps to say thank you.

December 2023/January 2024 OT www.optometry.co.uk 29

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VERSION REPRO OP

done and why, as this influences the way I test. I am so glad I made the decision to do my pre-reg in a hospital, and I am so grateful Moorfields Eye Hospital selected me. I can’t imagine going through this anywhere else.

Gaining momentum PRE-REG FOCUS

SUBS ART PRODUCTION CLIENT

The most important thing I have learnt is to keep pushing through those more difficult weeks, where it feels like you’ll never know enough or feel confident enough to qualify. Learning is a slow process sometimes, especially when there is so much to take in. Focus on the little victories, like remembering to check something before your supervisor tells you to, and soon those little habits will add up to make one good sight test. It has been challenging for me to get ready Lizzie Shaw explains how her workload is ramping up for my visits, as I’ve always been a last-minute studier. The content is all suddenly relevant to four months into her pre-registration placement my day-to-day life, which has raised the stakes. ..................................................... ···········O Having competencies in my head as I work has helped – you never know which patients will At the time of writing I have been at Moorfields NAME: Lizzie Shaw walk in. Even if you have already seen a patient for four months, so I am much more settled in with systemic disease, for example, keep the the routine than I was earlier in my placement. ROLE: Pre-registration competency in mind when seeing the next There is a weekly timetable where we rotate core optometrist at patient to consolidate the knowledge. Keeping clinics: refraction, contact lenses, dispensing, Moorfields Eye that in mind has been very important for me paediatrics, and visual display unit exams for Hospital when revising. staff members. LOCATION: Starting full-time work has been challenging Now that we have gained experience, we are London for me. When I get home, revision is the last thing starting to have very busy days. We have also I want to do. So, if I know I have a topic I want to started doing low vision appointments, which cover, I won’t change into comfy clothes or start increases our scope of practice to include a relaxing until I’ve done it. greater variety of patients. The best part of the hospital placement is The support within the hospital is fantastic. that I have seen a lot of interesting patients and Every single member of the department, from pathologies. Conditions I thought I might only pre-regs to seniors, both seek guidance and ever encounter in textbooks, such as thyroid provide advice. This has been invaluable to me eye disease, retinitis pigmentosa, and Terrien’s so far. It is so encouraging to know someone is marginal degeneration, are now just another always willing to go over something with me. day at the office. It has really boosted my The learning opportunities are never-ending. confidence in my refractions to know that If there is a slow day in clinic, we are encouraged I can handle the more unusual cases that may to observe other parts of the hospital. This present themselves. 0 access to the first-hand knowledge of secondary care clinicians has not only been helpful when preparing for visits, but when testing the Read more from OT’s Pre-reg focus contributors online: patients. It is good to know exactly what has been www.optometry.co.uk/prereg-focus

“THE LEARNING OPPORTUNITIES ARE NEVER ENDING”

HAYLEY SAYS The person who has helped me most is… my supervisor. Before pre-reg, when I was working as an optical assistant, we would discuss cases, which prepared me for a range of pathologies. My knowledge has developed with his support. My biggest learning so far is… realising how quickly time goes. I now appreciate the importance of staying on top of my logbook and keeping a note of cases to use for competencies. ;,......................................................... ....

30 www.optometry.co.uk OT December 2023/January 2024

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Before I started pre-reg I wish I’d known… not to put pressure on myself. I quickly realised pre-reg is about building upon foundations learnt at university. Hayley Smith is a pre-reg optometrist at Peter Ivins Eyecare, Bearsden

A DAY IN THE LIFE OF A BUSINESS OWNER

06:00 I get up just before 6am and do a 10-minute stretch, to get the body moving before I shower and get ready.

06:45 I get to work at about quarter to seven. The morning is my critical time, because that’s when I get all my business-orientated work done. The first hour I work on marketing projects. I enjoy a freshly made cup of brewed coffee to kickstart my day.

08:45 The team arrives between 8.30am and 8.45am, and we spend 20 minutes catching up on what the day holds. Everyone is pumped and ready to go. I think that chat in the morning helps, because it gets us into the day. We know what we’re expecting.

“MYOPIA IS OUR FASTEST GROWING SECTOR” Owner of Enfield’s Hammond Opticians, Deven Lakhani, walks OT through his working day

09:30 Appointments will be booked from 9.30am. We left General Ophthalmic Services (GOS) just over two years ago. It has enabled us to see fewer appointments, and spend a lot longer with patients. My appointments will be either 30 minutes or an hour, depending on who I’m seeing.

and it’s got to the stage where my team knows exactly how I like to work.

16:00 We reserve the final appointments of the day for myopia management, because parents want to bring children in after school. Myopia is our fastest growing sector within the business. With each of these children, I see in them who I was 40 years ago. Because I really enjoy that aspect of my work, I end the day on a high.

17:30

NAME:

Deven Lakhani

ROLE:

Owner of Hammond Opticians

LOCATION: Enfield

13:00 Much to the frustration of my children, who are teenagers, I have the same lunch every day: a homemade salad, very healthy and absolutely delicious. After half an hour I’m ready to go back.

15:30 I start preparing for the following day’s clinic in the afternoon, making sure I know what’s going on and who’s booked in. I’ve run this business now for 23 years,

My fantasy practice... The practice is in the mould that I would like it to be, barring a few minor changes. We are tenants in someone else’s building, which is quite old, so we are restricted. If I could do anything, I would make structural changes to make the work area even better. My wildest ambition is to

I typically finish clinic at 5pm, so I’ll try and leave about 5.15pm. If the day has gone well, I will have pre-planned the next day so I can start fresh in the morning again.

18:00 As a family, we listen to a lot of music. We don’t play instruments, but there’s always music on in the background, rather than the TV. I love reading, so in the evening that’s my escapism. Our kids are now teenagers, but if they’ve got a day where they don’t have homework, we will play board games.

19:00 Most of our mid-week dinners are really straightforward. Trying to eat healthily, stir fry is something To unwind, I read... we would usually Michael Connelly have at least once a crime novels week. Read about Deven’s day in more detail on the OT website: www.optometry.co.uk/a-dayin-the-life

have a continuing legacy in what we’ve built. The practice dates back to 1932. I’m only the third owner in 90 years. The practice has changed, substantially, but we are still well known in the area for clinical and business expertise, and great customer service. I would love that legacy to continue, with a likeminded practitioner, who can drive it for the next 30 years, like I’ve done.

December 2023/January 2024 OT www.optometry.co.uk 31

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Life In Practice, 5

Life in practice _

References: 1. Lindblad AS et al, and AREDS Research Group. Arch Ophthalmol. 2009;127(9):1168-1174. 2. Sunness JS et al. Ophthalmology. 2007;114(2):271-277. 3. Fleckenstein et al. Ophthalmology. 2018;125(3):369-390. doi:10.1016/j.ophtha.2017.08.038.

UK-GA-2300060 I November 2023

Visit geographicatrophy.uk to discover more about GA or scan the QR code

Apellis

•••••

•••••• VERSION

• ♦• ♦ ♦• • • • • ♦ • • • • • ♦

• •••• •• •• •• • •• •••• ;

....• ...·~~-· ♦

♦

•

SUBS

•• •• ·~~~ •• •• •••• • • • • ••• • • • • • • • ••••

ART

••••••••••••••••••• ••••••••••••••••••• IP AND ME

PRODUCTION

REVIEWING OR MANAGING A STAINED CORNEAL LESION

CLIENT

OT presents a clinical scenario to three of its resident IP optometrists. Here, the trio discuss potential management of a stained corneal lesion

....................................................................................................................................................................................

The scenario:

OT’s panel says...

A patient presents at practice with a small, stained lesion on their cornea. They are unable to provide a detailed history, and you have questions over whether this might be a dendritic lesion. Would you assume it was herpetic, or potentially review in 24 hours in the hope that you will be able to make a clearer decision at that point?

Ceri Smith-Jaynes: It’s tricky when

THE AOP PANEL

REPRO OP

• • •

you can’t get a clear history from a patient. In my area, these sorts of cases often present though the COVID-19 Urgent Eyecare Service (CUES) where, with patient permission, I can look at the summary care record from the GP. That can often yield answers you can’t get otherwise. I could ask if there is a family member I may call, who might know more. OT recently featured a CPD Video in which Moorfields consultant, Harry Petrushkin, describes his

decision-making process for uveitis. I think it applies nicely here too. He was taught to ask three things: what is the threat, what is the pace, and whether the patient is immunocompromised. In this case, the threat is greatest if the lesion is on the visual axis or if the person is a contact lens wearer, because the differential diagnoses include Acanthamoeba keratitis and microbial keratitis. The pace? Well, if it is herpes simplex keratitis (HSK), it’ll be apparent by tomorrow. Some years ago, I treated what I thought was a small corneal erosion but it was definitely an epithelial dendrite by the next day. Is the patient immunocompromised? Are they on chemotherapy or steroids, had a transplant or having medication to suppress an autoimmune disease such as rheumatoid arthritis? Or are they generally really run down?

Kevin Wallace

Ceri Smith-Jaynes

Ankur Trivedi

OCCUPATION: AOP clinical adviser YEARS IP-QUALIFIED: 11 years

OCCUPATION: Clinical multimedia editor YEARS IP-QUALIFIED: Five years

OCCUPATION: AOP IP Councillor YEARS IP-QUALIFIED: Nine years

34 www.optometry.co.uk OT December 2023/January 2024

BLACK YELLOW MAGENTA CYAN

Getty/GeorgePeters

Kevin Wallace: I agree with Ceri. If

I’m suspicious then I would treat with antiviral drops, but without that suspicion it would be entirely reasonable to monitor the patient closely. I often say to people, ‘I’m going to book you in for an appointment for three days’ time, but I want to know sooner than that if it’s worse.’ In the early stages of many conditions there might not be a lot to see so a decision might seem reasonable, but a few days later it might look significantly different, making the diagnosis clear. If a patient has had this sort of thing before, they are often very good at recognising the feeling. That doesn’t mean that I would definitely treat it – I saw someone recently who had had HSK a number of times over the years and thought it had happened again, but after

Life In Practice, 7

examination I wasn’t convinced so only gave her lubricants. When I reviewed her a few days later she was feeling fine and there was nothing to see. However, if the feeling is familiar and I am suspicious, that would again be something I would treat with antiviral drops. It is especially important, as Ceri said, to be suspicious when a contact lens wearer presents with a corneal problem. My general rule is that it is microbial keratitis until we have proved it is not, as those can very easily go wrong.

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Ankur Trivedi: I think there is a lot to

be said for ‘watch and wait,’ with an appropriate follow-up period and full red-flag advice issued to the patient. As Ceri has touched on, a lesion will be more apparent by the next day. It can be tricky to watch and wait sometimes, but with experience I have found that things can become much clearer with a bit of time. Each case has to be judged on its own merits and this is one of the parts of the job that means that we are always learning and developing in our role or roles. This is a great example of where it is useful to know

“The threat is greatest if the lesion is on the visual axis or if the person is a contact lens wearer”

Enjoy the flexibility of wireless connectivity

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The other possibilities include a foreign body (I would evert the lids to see if I could find one), abrasion (in which case, usually the patient would be able to describe a recent incident of trauma), or corneal erosion – which usually means sudden watering and pain on waking, with redness. These are similar symptoms to HSK. Looking at the other cornea for signs of dystrophy and dry eye would help. If the patient has had a few incidents of a sore, red eye in the past, but it’s a bit less painful this time, that could be a clue to HSK, because the cornea can become less sensitive on recurrence. I’m going to assume we’ve checked both fundi and anterior chambers and they are normal. So, my answer to the question is: ‘it depends.’ If they are not pregnant or breastfeeding, they are in a risk category for HSK, and the lesion has a suspicious look to it (epithelial defect which stains with fluorescein, with bulbous, rounded ends rather than a thin scratch), I think I would give topical 0.15% ganciclovir gel, five times a day. It’s usually well-tolerated and unlikely to do harm. The gel will cushion the cornea while it heals too. If I don’t give it and there’s a raging ulcer on the visual axis the next day, I’ll be kicking myself.

VX•=l•r.t)!I VSXlink

Ceri Smith-Jaynes your limitations. Bringing in input from colleagues can be helpful when discussing management approaches. Red flag guidance issued to the patient is paramount, and needs to be robust. Scenarios like this being discussed at IP peer reviews have always been great sessions, where I have taken a lot away. 0 If you are unsure about how to manage a scenario in practice, contact the AOP’s regulation team: regulation@aop.org.uk

emr network

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

OPHTHALMIC INSTRUMENTS

December 2023/January 2024 OTwww.optometry.co.uk 35

91OPTNOV23127.pgs 28.11.2023 14:28

VERSION

~ REPRO OP

-~-

SUBS ART PRODUCTION

A CONVERSATION ABOUT...

CLIENT

PROMOTING THE EASY EYE CARE PATHWAY TO PATIENTS With Trevor Hunter, eye care pathway co‑ordinator at SeeAbility, and Trang Dinh, learning disability and autism specialist prescribing adviser at South East London ICS

............................................................................................................................................................................................................................................

Developing the Easy Eye Care Pathway Trevor Hunter (TH): The Easy Eye Care Pathway

was conceived in 2013. LOCSU, SeeAbility, the Royal College of Ophthalmologists and Mencap got together to find a way for patients with learning disabilities to be seen in practices. These patients need an individualised sight test: extra time, multiple appointments, or the use of non-standard testing equipment. They need a clinician who is able to understand their needs and deliver a sight test that will not contain lots of jargon. The clinician needs to report back to the GP, so they have it on record that the patient has had a sight test, what the results were, and whether they were referred. The service was refreshed in 2020, and now includes autistic people and those of all ages with a learning disability.

The benefits of accessing this patient base

Trang Dinh (TD): Trevor’s team and I have been

working together, and it’s been a wonderful

36 www.optometry.co.uk OT December 2023/January 2024

BLACK YELLOW MAGENTA CYAN

step forward. I’m a pharmacist by background and for the Integrated Care System I cover South East London, leading in learning disability and autism. I also work in a GP practice, so I see both sides of the coin. Those with learning disabilities have an annual health check. This is where we’re promoting the pathway. If clinicians understand how it can help their patients, that’s where it will be most effective. Patients use their GPs as a point of access for everything – both emotional and physical care. If we get our clinicians to understand the pathway and use it, it’s going to catch those patients who might not otherwise understand. TH: About 75% of people with learning

disabilities have an annual health check. If it is brought up that they need an annual sight test, and that it can be facilitated easily through a referral programme to a single point of access, that is the key to getting these people involved.

Life In Practice, 8

It has to be a smooth journey, whether it is from the GP, the borough learning disability team, or the hospital, into an accredited optical practice. We’ve learned a lot from just giving out a leaflet to a patient or putting up posters in a GP’s practice. It doesn’t do enough to get these people involved, and it’s so important they’re involved. Lots of diagnostic overshadowing takes place with this group. Often, their behaviour is attributed to their learning disability, whereas it could be attributed to the fact that they just need a pair of glasses so that they can see clearly.

Engaging optometrists TH: South East London has many

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“These patients are vulnerable; they might not be able to reach out like others can”

pathways into primary care practices. If you take the Minor Eye Conditions Service (MECS) pathway, there are around 40 practices signed up. If they’re signed up to MECS and done the training, it’s not a huge step Trang Dinh, learning disability to do the WOPEC training for people and autism specialist prescribing with learning disabilities and get adviser at South East London ICB signed up on this pathway as well. Many practices are seeing these patients anyway, it’s just that they haven’t been recognised for the work. We’ve had over 20 practices express an interest so far. There are 16 with a clinician who has done the WOPEC training and attended a CPD event about the the programme, and are now accredited and offering the service. The practice team also needs to be aware. We’re proposing that we go around and talk to practice teams, and perhaps suggest that they have a learning disability champion within the team as the first port of call. TD: The pathway is great, but it is only when we use it that it will become even greater. That’s why it’s important that we make those connections with practices. We are encouraging optometrists to reach out, and have that communication in place. 0 Read the full conversation with Trevor and Trang on the OT website: www.optometry.co.uk/easyeyecare

NAME:

Getty/Annika McFarlane

ROLE: Eye care pathway co-ordinator at SeeAbility

Legacies were meant to live on...

See Clearly, Treat Optimally:

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Trang Dinh

ROLE: Learning disability and autism specialist prescribing adviser at South East London ICB and clinical pharmacist in a GP practice

LOCATION: London

Trevor Hunter

Th w m dmo t m idi ™ dv c d Topog ph & comp t D ,nalyser.

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

LOCATION: London OPHTHALMIC

INSTRUMENTS

December 2023/January 2024 OT www.optometry.co.uk 37

91OPTNOV23128.pgs 29.11.2023 16:17

VERSION REPRO OP SUBS ART PRODUCTION

EDUCATION ROLLS OUT

CLIENT

OT takes a look at the education programme and what to expect in eyewear and lenses

lans for 100% Optical 2024, taking place on 24–26 February, are coming in thick and fast. Details of the education programme have been released in batches throughout the last few months, with well over 100 hours of CPD sessions scheduled across the hubs of the show. AOP members can access a priority booking slot for the programme on January 3, 2024, with ABDO bookings between January 11–12 and sessions opening to all other delegates on January 13. This booking process was rolled out for the first time at the 2023 show and enables delegates to book onto the education programme in advance of the event, while also ensuring a proportion of seats in the sessions are available for attendees at the show on a first-come, first-served basis. The content at the show has been curated to meet the needs of all practitioner types, and to fulfil the requirements of the continuing professional development scheme. Dr Ian Beasley, head of education for the AOP and OT clinical editor, shared that myopia, collaborative working, and artificial intelligence, have emerged as key themes in the education planned for the 2024 show.

38 www.optometry.co.uk OT December 2023 /January 2024

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The delivery of the contemporary programme of education at 100% Optical keeps pace with the needs of practitioners in the face of changing technology and regulations Dr Ian Beasley, head of education for the AOP and OT clinical editor “The delivery of the contemporary programme of education at 100% Optical keeps pace with the needs of practitioners in the face of changing technology and regulations,” he told OT. 2024 marks the last year of this CPD cycle, and 100% Optical offers an avenue to attend peer reviews, develop knowledge in key areas, and tick off those final domains. Beasley recommended delegates take the time to review the personal

development plan they set out at the beginning of the cycle, “to ensure they are on track, to see whether it needs to be more nuanced, or if they have since identified any additional topics to focus on,” and make the most of the sessions on offer at the show. “100% Optical also provides delegates with an opportunity to make the connections they might need for the reflective exercise, which registrants will need to complete in the latter half of 2024,” he added.

Key topics On the Main Stage, the AOP will be delivering a session exploring common reasons for clinical negligence claims in The Wheel of Misfortune, and Dr Mario Giardini, from the University of Strathclyde, will explore the impact of digital technologies in task shifting ophthalmology from secondary care to the community. Tim Cole from Heidelberg Engineering UK will discuss artificial intelligence in Do androids dream of electric eyes? ‘Myopia’ will be the name of the game on the second day of the show, with two sessions dedicated to myopia management taking over the Main Stage, while glaucoma is also a key topic, appearing multiple times across the agenda. The Future Practice Hubs will be sponsored by SpaMedica and Newmedica, with four rooms covering skills and learning in the areas of consulting, diagnostics, dispensing, and industry hot topics. The Optical Academy will be sponsored by Sense Medical | Canon, with sessions including independent prescribing, referral decisionmaking, and sight and homelessness. A hub of peer-learning, the Dispensing Workshop will host peer reviews and discussion workshops on topics including myopia management, assistive technology for people with low vision, and supporting patients with additional needs. For the first time, 100% Ophthalmology will run as a co-located event, sponsored by Birmingham Optical, Zeiss and Haag-Streit UK.

What to expect in eyewear and lenses Caledonian Optical will be showcasing its new laboratory through the magic of virtual reality technology at 100% Optical. The manufacturer moved into the new site, located near Aberdeen International Airport, earlier this year, tripling its capacity. EssilorLuxottica is welcoming delegates to its stand where eye care professionals will be able to learn about new launches for 2024, including the

AOP LOUNGE The AOP Lounge will return to 100% Optical with a suite of education in partnership with industry experts. On the Saturday, the AOP has partnered with CooperVision for a series of sessions, while Sunday brings the team from Johnson & Johnson Vision to the stand, and Monday sees a partnership with Optos. Ava Williams, AOP events manager, said: “We look forward to creating an environment for further engagement with members and continue the AOP’s education provision in the final year of cycle.”

ES edger range, innovations such as the VS and VR optometry range, and new equipment from distribution partners including ESW, SB Sistemi, Medmont and Takagi. Paul Cumber, Essilor instruments director, said: “It’s an exciting time for instruments and the team will be on hand to discuss what benefits the new kit can bring to an optical practice.” Mokki Eyewear, which was new to the show in 2023, makes a return, bringing its modular Mokki Click & Change set for children’s sunglasses. Mac Eyewear will increase its floor space at 100% Optical by 25%, with more space to showcase its collections of Specs By Prue, J F Rey, and Struktur. Also featuring will be Coco Song, CCS, Ronit Furst, Francois Pinton, and bespoke iGreen and O-Six. “We are very excited for you to meet our new sales team members as we have recruited some amazing and very experienced staff in 2023,” Sara Walker of MAC Eyewear said. “We will also be unveiling additions to our bespoke O-Six collection, which is bold acetate, but where the patient can choose their shape, colour and size, whilst achieving the bold look for 2024,” she said. Eyespace will join the show with frames from across its brands. This includes a newly introduced high fashion edit: Cocoa Mint Studio. The range includes oversized silhouettes with unique lamination techniques, exaggerated shapes and sculpted sides. The models all come with biodegradable lenses as standard. 0 Have you been attending 100% Optical since 2014? Get in touch with OT to share your stories from past shows at newsdesk@optometry.co.uk

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Feature 1 100% Optical, 1

100% Optical

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THE LONG WAIT The notification of a GOC investigation is a moment that many optometrists dread. But what if the process drags out for years? OT examines fitness to practise waiting times _ WORDS: SELINA POWELL

40 www.optometry.co.uk

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hen the letter came from the General Optical Council (GOC), his first reaction was disbelief. “You never think it will happen to you,” the optometrist shared with OT. “You freeze and you are in a state of shock. It is the only thing you think about. I didn’t sleep much for the first few weeks,” he said. During the initial period of facing an investigation, the optometrist, who OT has agreed not to name, clung on to one thought that provided him relief. The GOC had advised him that his case would be resolved within 18 months. “There was a countdown in my life – like I was in prison. I would think ‘There are this many months until freedom.’ But then it kept on going,” he shared with OT. The optometrist would not receive an outcome on his case until seven years after the letter first arrived on his doorstep. He is not the only one who has faced an extended wait to have his fitness to practise case heard. It is an issue that has seen the GOC repeatedly reprimanded by the body responsible for its oversight, the Professional Standards Authority (PSA). Although the GOC has made improvements on timeliness in recent years, its latest annual report shows that there were 78 cases on the regulator’s books that have been open for more than a year. The mental health effects of extended fitness to practise proceedings are documented within research. A 2016 BMJ Open article explored what doctors found most stressful about the complaints process through a series of qualitative surveys. Prolonged duration was cited as one of the most stressful components of the complaints process, alongside a variety of factors including the unpredictability of procedures and poor communication. “Complaints seriously impact on doctors’ psychological wellbeing... To improve procedures, doctors propose they are simplified, time limited and more transparent,” the authors highlighted.

Getty/Wragg

More than a number The optometrist who experienced a seven-year wait for his case to be heard told OT that it was the state of uncertainty that was the most challenging aspect of the ordeal. “If you know what is happening and when your case is going to happen,

ÒAtjustthea number time, I was probably to the GOC. They have to appreciate that behind the number there is also a person Optometrist who faced a seven-year wait then you can work towards that. But when you don’t know, it is like there is no light at the end of the tunnel,” he said. To deal with the stress of facing a GOC investigation, the optometrist took up running and discussed his worries with his network of family and friends. He would like people working at the GOC to have a greater understanding of the impact that long waiting times can have on registrants facing fitness to practise hearings. “At the time, I was probably just a number to the GOC. They have to appreciate that behind the number there is also a person,” he said. The optometrist, who continues to practise, believes that his experience of waiting seven years to have his case heard has seen him change from the person he was when he first graduated. “To be treated like you don’t actually matter by the GOC, the same people who are your governing body, that is a real kick in the teeth,” he shared. “I don’t know whether I have the same passion for the job that I did have,” the optometrist said.

Life on pause Another optometrist, who OT has agreed not to name, waited close to three years for his case to be heard, and found the uncertainty challenging also. “You are not in control of it. You wake up and feel fine for about 10 seconds and then it hits you: This is still going on,” he said. The optometrist shared that people can be left in limbo as they wait for their case to be heard. “People can’t really move on with their lives. You could take a chance and change your career, but then maybe three years later you will be told that you can be an optometrist again,” he said. The optometrists emphasised that long fitness to practise waiting times are an issue that is ►

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In Focus, 1

In focus _

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“

The support from the AOP was unbelievable. If I hadn’t had that support I’m not sure where I would have been Optometrist who faced a three-year wait relevant to everyone within the profession. “All optometrists need to worry about it because at the end of the day, you can’t be perfect all the time,” he said. “Whether it is personal lapse or a professional lapse, don’t think you are immune to it,” he shared. During the process, the optometrist valued being able to talk with his family and friends, as well as guidance from the AOP legal team. “The support from the AOP was unbelievable. If I hadn’t had that support I’m not sure where I would have been,” he said.

The AOP view Solicitor, Nan Mousley, who works within the professional discipline team at the AOP, is responsible for guiding members through the fitness to practise process. She said that the impact of facing a fitness to practise investigation can vary depending on whether an optometrist is subject to an interim order while they wait for their case to be heard. “If they are made subject to an interim order, which means that their practice is curtailed in some way or is conditional, that has an immediate and concerning impact for the practitioner,”

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Mousley shared with OT. Optometrists may struggle to find work while they are subject to conditions. There is an administrative and sometimes financial burden of being subject to regular supervision. “That can have the effect of making someone feel like they are serving a punishment before they have been found guilty,” she said. For optometrists who are not restricted in their practice, the impact will vary between individuals. Some optometrists will be advised that they are at risk of suspension or erasure if the facts against them are proven. “There is the exhaustion of thinking ‘I have to go through this.’ They have to make provision financially for their family and for their expenses,” Mousley highlighted. Optometrists who are suspended will need to apply to rejoin the NHS Performers List, meaning the period they are unable to provide NHS sight tests is often longer than the suspension period. “There is always a sting in the tail – it is not necessarily limited to the immediate impact of the GOC investigation,” Mousley said. She sees her role as supporting members with realistic advice. “You have to look after people

BY THE NUMBERS Median number of weeks taken to conclude fitness to practise proceedings General Medical Council

40 General Optical Council

OCJ 63 General Dental Council

83 General Pharmaceutical Council

94 Nursing and Midwifery Council

96 Source: Professional Standards Authority annual report, 2022–2023

and be sympathetic to their position. You want to ensure that process works as well as it can for them,” she said. While Mousley appreciates that some members may feel a lack of support from the GOC, she highlighted that the statutory duty of the optical regulator is to protect the public. “Their role is not to support the registrant – it is fair, timely prosecuting,” she said.

Getty/Skynesher

Work in progress Reflecting on how the fitness to practise process could be improved, Mousley would like to see more stringent criteria applied to when an investigation is opened against a practitioner. “I think the acceptance criteria could be more rigorous. They should think about the impact of opening a fitness to practise investigation.” She also highlighted the disproportionate impact of lengthy fitness to practise waiting times for student optometrists and those in their pre-registration period. “These cases are not huge in number, but the delays can be devastating for them,” Mousley shared with OT. The PSA monitors the performance of different healthcare regulators

across a range of criteria – including the timeliness of fitness to practise investigations. This year was the first time since 2013–2014 that the GOC met the PSA’s expectations in this area. “We have been critical of the time it has taken the GOC to progress cases through its fitness to practise system for a number of years,” the authority highlighted in its periodic review of the optical regulator. “However, the GOC has maintained the improvements in timeliness we saw last year, and its performance now compares favourably against the other regulators,” the PSA noted.

The GOC responds A GOC spokesperson highlighted that the regulator has made improvements across fitness to practise processes, including reducing the number of open older cases and bringing down end-to-end timeliness. “We recognise that involvement in fitness to practise cases can impact an individual’s wellbeing. It is extremely important that, where appropriate, cases are closed or progressed at pace and any undue stress is prevented,” the spokesperson said. Turning to challenges the GOC faced in reaching timely decisions, the regulator shared that an increase in the number of cases involving health allegations had affected timeliness. “Significant work in recent years has also been conducted to bring down the backlog of cases arising from the COVID-19 pandemic, particularly in digitising physical files and evidence,” the spokesperson stated. The GOC spokesperson emphasised that the regulator would continue to make improvements across its fitness to practise processes in the coming years. “Retaining the confidence of the optical professions and supporting them to deliver high standards of care is vital to ensuring public protection, and fitness to practise is an important part of this,” the spokesperson concluded. 0

Selina Powell OT features editor. Get in touch by email: selinapowell@optometry.co.uk

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LOOKING FORWARD TO 2024

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OT asked attendees at this autumn’s party conferences what eye care can expect from the coming year _ WORDS: LUCY MILLER

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ey stakeholders in the eye care sector had different yet complementary aims when attending this year’s party conferences. For Specsavers, the main objective was highlighting to decision makers how community optometry can help to reduce GP waiting times and relieve pressure on busy hospitals. “We wanted to show MPs that we can do even more to contribute to public health and the prevention agenda,” Giles Edmonds, Specsavers clinical services director, told OT. “We also wanted to make a clear ask of the Government to make access to care more equitable and show exactly how this can be done at very low cost.” Edmonds called the engagement from MPs “tremendous,” noting that Specsavers had in-depth conversations with more than 100 MPs, party peers and commissioners across the Conservative and Labour conferences. Royal National Institute of Blind People (RNIB) attended the three main conferences – Liberal Democrat, Conservative and Labour – with a focus on vision rehabilitation in mind. Emphasising the Eleanor Thompson, importance of accessible b RNIB director of voting for blind and partially campaigns, with sighted people ahead of a Keir Starmer general election was also key for RNIB, as was developing conversations with candidates and party members who might hold sway in future policy. Cate Vallis, interim campaigns and public affairs manager at RNIB, noted that reducing waiting lists is priority across all parties. “Clearly, key to any strategy to reducing waiting lists has to be co-signed with ophthalmology,” she said. “From an RNIB perspective, we’ve got a whole strategy around that that we’re keen to engage with the Government on,” she added.

AOP priorities AOP policy director, Carolyn Ruston, noted a ‘buzz’ across the Labour conference specifically, adding that many healthcare-focused fringe events were standing room only. “There was a common thread of the need to develop a long-term plan to address the AOP policy director, challenges currently facing the Carolyn Ruston

UK, with a strong ‘fit for the future’ narrative,” she said. For the AOP, the need for different conversations to be had when speaking to MPs from across different parties was front of mind. “Health is obviously a key political battleground,” Adam Sampson, AOP chief executive, told OT. He noted that the Conservative Party appeared to be most focused on secondary care waiting lists, whilst Labour had a greater emphasis on taking pressure off GPs.

“Prevention was a big theme this year, in terms of addressing the growing public health need Carolyn Ruston, AOP policy director “You have different conversations,” he said. “With Conservatives, you say, ‘if you make this change now, if you give us an extended services contract, if you give us IT connectivity, if you give us more work in glaucoma or cataract, we can make a dent in waiting lists immediately.’ “With Labour, the conversations are more about a strategy for eye care, changes in regulation, the way the private sector is involved in the NHS generally. It’s a broader structural conversation.”

Eyes on 2024 Alongside waiting lists – an issue that was highlighted at the Conservative conference via banners hanging from the ceiling – prevention was also a key topic of conversation. “Prevention was a big theme this year, in terms of addressing the growing public health need, but also linked to addressing avoidable health issues caused by the NHS backlog and waiting times,” Ruston said. “Mental health and wellbeing was another big theme, along with the need to utilise new and emerging technologies and address IT connectivity issues to improve care delivery.” Edmonds also noted the importance of technology, highlighting his belief that analytics in patient care will be a focus for primary care and prevention. He also spoke about increased equity in healthcare, which Specsavers will continue focusing on in 2024. Conservative Minister for Homelessness, Felicity Buchan, and Preet Gill, Shadow Minister for ►

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In Focus WEHD, 1

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In Focus WEHD, 2

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BY THE NUMBERS REPRO OP

Some vital statistics from party conference season

29 SUBS

Sessions attended by AOP staff during the three party conferences

700 ART

Visits to the RNIB stand across all three conferences MP Steve Barclay on the Specsavers stand

PRODUCTION CLIENT

Primary Care and Public Health, spoke at a Specsavers fringe event on improving equitable access to care, Edmonds shared. The event included people with lived experience of homelessness, who “gave powerful examples of the range of unnecessary administrative obstacles disadvantaged people face in accessing healthcare,” Edmonds said. He added that Specsavers will “continue to advocate for changes to the GOS contract for homeless people and ending care home pre-visit voluntary notifications” in 2024. We also know that a general election will be coming, and with it, potentially, a new government. What changes do those in the industry foresee if that does end up being the case? Ruston told OT: “Given the discussions at conference, I would expect to see a new focus on investment in healthcare, including those areas where there is current underinvestment, such as eye care. I would also expect to see a focus on public health and reducing health inequalities, a strategy for a consistent roll out of new healthcare technologies, a real focus and narrative around individual driven care, and a plan to tackle the growing mental health crisis in the UK.” Vallis emphasised the importance of not assuming the outcome of a general election, and that “RNIB continues to engage with all political parties on an equal footing.” “It is within the interests of blind and partially sighted people to make sure we have good relationships across all political parties,” she said. After speaking at the Labour conference to MP Marsha de Cordova, the architect of the National

100

Parliamentarians had their eyes checked on the Specsavers stand

£1.1 billion

The amount Labour would add to the NHS budget, according to MP Wes Streeting

Eye Health Strategy Bill, Edmonds emphasised that “it is clear she is considering the next steps for her campaign” and “needs the support of a united sector to secure the highest level of engagement.” Sampson emphasised that “the point is not just what a national eye care strategy says, but how you sell the strategy.” He added: “There’s got to be an economic case or an unarguable human case, preferably both. It’s not enough for us to develop the right suite of policies. We’ve got to develop the right suite of arguments to justify those policies being prioritised. “We have to find simple language and say, ‘we understand the problems of healthcare generally, we can be part of the solution.” 0

Lucy Miller OT deputy editor. Get in touch by email: lucymiller@optometry.co.uk

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91OPTNOV23133.pgs 29.11.2023 15:20

e.ve\id& EyelashCleanse • Tear-less Formula

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~ I'

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CPD

FOR OPTOMETRISTS, SPECIALTY OPTOMETRISTS, DISPENSING OPTICIANS AND CONTACT LENS OPTICIANS EXAMS CLOSE: 1 MARCH 2024

SUBS

Eyelid health: management of itchy, sticky and swollen lids

CPD POINT

ART

This article outlines the clinical presentation and management of itchy, sticky and swollen eyelids. 0 Dr Sandeep Dhallu PhD, BSc (Hons), MCOptom, FBCLA, FHEA ............................................................................................

Itchy, flaky or sticky lids

PRODUCTION

Introduction

CLIENT

The fragile cornea is directly exposed to the outside environment, and therefore, at risk of injury, infection and irritation, all of which can affect visual acuity (VA).1 The lacrimal functional unit is comprised of the ocular surface, including the cornea, tarsus, conjunctiva, and the eyelids, which consist of the eyelashes, the glands of Zeis and Moll, the meibomian glands, as well as the connecting sensory and motor nerves and associated vascular and lymphatic supply.2 The healthy eyelid is made up of fine skin on the outer surface and conjunctiva on the inner surface. Between these layers are the muscles, which are involved in eyelid movement, including the blink reflex, as well as glands. The tear film is found between the eyelid and the ocular surface; it protects, lubricates and nourishes the anterior eye and consists of aqueous as well as lipids from the sebaceous secretions of the meibomian glands.3-6 The eyelids have an important role in maintaining the health of the ocular surface by facilitating lubrication as well as providing protection to an otherwise exposed cornea, in order to optimise VA. Eyelid disease can involve the anterior (lash follicles) or posterior lid margin (meibomian glands). Practitioners encounter eyelid disorders on a regular basis, with patients often presenting with

Twitchy lids

Drooping lids

Swollen and/or painful

Lumps and bumps

FIGURE 1 The five main categories of eyelid disorders most often encountered in optometric practice. This article will cover two of these five categories, outlined in yellow

meibomian gland dysfunction (MGD), blepharitis and dry eye. Many of these disorders are affected by inflammatory mediators. Lid hygiene, which incorporates eyelid cleansing and massage, is a well-accepted treatment for many of these disorders and may form part of a broader regime of care that includes other management options.

Eyelid disorders Eyelid disorders can be characterised by a number of different signs and symptoms, which broadly fit into five main categories as shown in Figure 1. There are many different eyelid disorders on a wide spectrum ranging from those which are relatively minor and easily managed by the patient themselves, to others which are more severe, such as

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TYPE OF EYELID PROBLEM

malignancies which require specialist treatment. Although this article will touch briefly on the latter, the focus of this piece is to provide an update on the group of disorders that are generally benign and self-limiting, and encountered more frequently in High Street practice.

Itchy, flaky or sticky eyelids Conjunctivitis Conjunctivitis can occur as a result of bacterial infection of the conjunctiva (bacterial conjunctivitis) and would usually cause conjunctival hyperaemia, a purulent or mucopurulent discharge and crusting of the lids which may have to be bathed open, particularly in the mornings. The tarsal conjunctiva may show a mild papillary reaction, but the cornea is usually not involved. Normally, this condition can be managed

CPD 1, 1

48 Eyelid health: management of itchy, sticky and swollen lids

58 The clinical characteristics of Stargardt disease

52 Ethical considerations of myopia management

62 Real-time lens design: advances in lens manufacturing and why they matter

by cleaning the eyelids with sterile wipes, or cotton wool dipped in cooled boiled water and does not require pharmacological intervention; however, in some cases topical antibiotics may be required. If there is corneal involvement or if the infection fails to improve, onward referral is recommended so that swabs can be taken, and treatment attempted with other antibiotics.7 It is possible for the microorganism Chlamydia trachomatis to infect the conjunctiva (chlamydial conjunctivitis), and this may cause similar symptoms of gritty eyes, sticky mucopurulent discharge as well as oedema and ptosis of the upper lid. There may be large follicles present and corneal involvement, such as epithelial keratitis, subepithelial infiltrates, marginal infiltrates or superior pannus. In these cases, patients should be advised to cease contact lens wear where applicable and referred urgently in order for lab testing to confirm diagnosis, so that treatment with systemic antibiotics can be started.8 Certain substances may also cause a chemical irritation of the eye and surrounding region (conjunctivitis medicamentosa); this could be from the use of some drugs and/or preservatives or it may occur from certain cosmetics that are applied to the lids or lashes. Symptoms can include ocular irritation, stinging and/or burning, photophobia, ocular redness, lid swelling and blurred vision. There may be diffuse punctate staining of the cornea and conjunctiva, tear film instability and possibly corneal oedema. Management usually involves identifying the offending drug, preservative or cosmetic and stopping its use; this may require a referral back to the original prescriber if a certain drug or medication is suspected to be causing symptoms, so that a suitable alternative can be provided. Cold compresses and preservative-free ocular lubricants may also be advised to provide symptomatic relief.9

Finally, adenovirus can cause an infection of the conjunctiva (viral, non-herpetic conjunctivitis) and patients usually present with symptoms of grittiness and watering with conjunctival hyperaemia, follicles on the palpebral conjunctiva, pseudomembranes, and possible corneal involvement. The condition is usually self-limiting and should resolve within two weeks. Antiviral and antibacterial agents are ineffective. However, lubricating agents can be given to relieve symptoms. As the condition is highly contagious, patients should be advised to avoid cross contamination. In cases where there is corneal involvement, onward referral is advised.10

PLEASE NOTE

OT CPD exams will be closed from midnight on 28 December until 2 January.

WHAT YOU NEED TO KNOW C-105861 LEARNING OUTCOMES 0 Practitioners will identify the

information they need to obtain from patients to guide management of lid disorders 0 Practitioners will consolidate their skills in managing patients with itchy, sticky and swollen lids relative to their scope of practice.

-~ "

·-·

Anterior blepharitis Anterior blepharitis is a chronic inflammation of the eyelid margin that usually involves the anterior lid margin and eyelashes. It can range from being quite mild and self-limiting to chronic and more severe, with lid margin hypertrophy, scarring and trichiasis. It is a fairly common condition and quite often associated with staphylococcal infection or Demodex mite infestation (see Figure 2, page 51).11-14 Patients with certain dermatological conditions such as seborrheic dermatitis, rosacea and eczema may be more prone to the condition.15 Typical symptoms include a burning or foreign body sensation, itchiness, tearing and dry eye. Patients may also complain of eyelid stickiness.16 Treatment requires commitment from the patient in terms of adhering to a consistent, thorough and long-term eyelid hygiene regime.17,18 There is overlap with other common eyelid pathologies, for instance, MGD, dry eye and blepharitis can present together in the same patient.

MGD MGD can be defined as a chronic abnormality of the meibomian glands characterised by terminal duct

,..

...

@8@ obstruction and/or qualitative or quantitative changes in the glandular secretion. It may result in an altered tear film, ocular inflammation and ocular surface disease.19 The clinical manifestations of MGD can vary considerably and arise from a decreased quality or quantity of meibum to the ocular surface, usually due to blocked meibomian glands. Such obstruction can lead to dilation of the ducts, as well as a change in the lipid composition of the meibum giving it a waxier characteristic.20 The standard treatment is eyelid maintenance which includes application of a sustained and reliable form of heat in order to melt the meibum, followed by massage and cleansing in order to facilitate its release.21-23 MGD often coexists with other conditions such

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as anterior blepharitis and dry eye disease (DED). It is also thought to be affected by factors such as contact lens use, Demodex mite infestation, as well as hormonal conditions such as menopause and androgen deficiency. Other conditions such as rosacea, psoriasis, atopy and hypertension may also contribute. Research indicates that MGD seems to be much more prominent among Asian populations compared to Caucasians, with figures of up to 60% in Asian populations versus a much lower prevalence of between 3% and 20% in populations which are predominantly Caucasian.24

DED PRODUCTION CLIENT

DED is a common ocular complaint encountered by practitioners worldwide25 with a prevalence of as much as 50% of the adult population.26 It is defined as ‘a multifactorial disease of the tears and ocular surface that results in symptoms of discomfort, visual disturbance, and tear film instability with potential damage to the ocular surface’. It is accompanied by increased osmolarity of the tear film and inflammation of the ocular surface.2 If early disease remains untreated, DED may become a chronic inflammatory condition that ultimately leads to permanent damage to the ocular surface. DED can also impact on a person’s quality of life as symptoms can affect many everyday tasks. In addition, there may be a significant economic impact for both the individual as well as the wider economy.27 DED disease can be classified as aqueous deficient, evaporative or mixed.28 In the aqueous-deficient form there is a decrease in tear production while the latter form is characterised by a decrease in tear film stability.2 MGD is the leading cause of evaporative DED, but it can also occur as a result of other eyelid-related issues such as blink anomalies.28 The aqueousdeficient form can be classified as either Sjögren syndrome or non-Sjögren syndrome. While 10% of patients will have aqueous-deficient DED, more than 80% have evaporative DED, or a

Eyelid symptoms

Possible cause

Sticky, red, itchy and watery

Conjunctivitis

Sticky, crusty lashes, itchy, dry, red or irritated eyes

TABLE 1

Summary of the main symptoms and causes of itchy, flaky or sticky eyelids

combination of both.29 Patients with DED can present with symptoms of eye irritation of varying degrees of severity and persistence, ocular fatigue and blurred vision.30 Ocular lubricants can provide some degree of relief, as can eyelid cleansing regimes. For instance, it was found that in patients with aqueous-deficient Sjögren syndrome, the addition of an eyelid hygiene regimen decreased corneal epithelial permeability more than tear lubricants over a period of two weeks.12 More recently, heat and light therapies have been developed for use with the condition. Intense pulsed light therapy (IPL) has been used fo many years in dermatology and recently has become available as a treatment option for DED. IPL involves the use of flashes of visible and infrared light around the eyelids, which are absorbed by the tissues and generate heat. During the procedure, the eyes are protected with opaque goggles. Toyos et al were the first to describe a clear treatment protocol for IPL in DED in 2005.31 IPL therapy has been found to be associated with significantly reduced ocular surface disease index (OSDI) and standard patient evaluation of eye dryness (SPEED) scores, and significantly increased invasive and non-invasive tear breakup times.32 The mechanisms by which IPL has an effect in the relief of DED symptoms are still partly unclear and proposed theories include a reduction in inflammatory mediators, eradication of bacterial overgrowth like Demodex, as well as the melting of meibum.33 While IPL is considered a safe and effective treatment for patients with evaporative DED,34 there are limitations in its use, including the cost. As such, lid hygiene measures remain the mainstay in the treatment of evaporative DED.

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Blepharitis, MGD or DED

Swollen lids Cellulitis Cellulitis is a bacterial infection of either the periorbital tissues which lie anterior to the orbital septum (preseptal cellulitis), or of the tissues which lie posterior, that is to say, within the orbit (orbital cellulitis). Orbital cellulitis is the more severe of the two and can be both sight as well as life threatening. It can sometimes be difficult to differentiate between the two, especially in children.

Preseptal cellulitis Preseptal cellulitis can occur following an insect bite, dacryocystitis, hordeolum, impetigo, trauma or upper respiratory tract infection. It often presents as acute swollen, red and tender lids, along with fever, malaise and irritability in children. There may also be ptosis, but usually no proptosis. Ocular motility, colour vision and pupil responses tend to be normal, and VA is usually unaffected. When this occurs in children, an emergency same day referral to an ophthalmologist or accident and emergency (A&E) department is warranted. In adults with preseptal cellulitis, it may be possible to start systemic treatment with flucloxacillin or co-amoxiclav first.35

Orbital cellulitis Orbital cellulitis can occur following acute sinusitis, trauma, including orbital fracture, dacryocystitis, preseptal cellulitis, a dental abscess, in those that are immunocompromised, or patients with diabetes. It usually presents as a sudden and painful unilateral swelling of the conjunctiva and lids, along with pain on eye movement, blurred vision, diplopia, fever and a high temperature, as well as severe malaise. There is usually ptosis and proptosis, restricted extraocular motility, impaired colour vision and abnormal pupil reactions;

this requires an emergency same day referral to an ophthalmologist or A&E department, whether it occurs in children or adults.35

Allergy Allergic conjunctivitis is the commonest but also mildest form of ocular allergic disease. Exposure to an allergen (acute allergic) prompts an immediate response that may include lid swelling, itching, conjunctival hyperaemia and possibly a mild watery or mucoid discharge.36 It can occur due to seasonal allergens (seasonal allergic conjunctivitis (SAC)) like grass pollen whereby symptoms present at particular times of the year, or it can occur due to non-seasonal allergens such as dust mites or animal dander, in which symptoms tend to linger all year round (perennial allergic conjunctivitis (PAC)).37 There is usually no corneal involvement and no papillae, and it can be managed quite easily using ocular lubricants and/or topical anti-histamines, cool compresses, advising the patient not to rub their eyes and to avoid the offending allergen.38 In cases of recurrent allergy, a prophylactic topical mast cell stabiliser such as sodium cromoglicate 2% (POM) may be prescribed.38 Other forms of ocular allergic disease include atopic keratoconjunctivitis (AKC) and vernal keratoconjunctivitis (VKC), which can produce more severe adverse reactions including vision loss. Unlike SAC and PAC, the cornea can be affected with VKC, and punctate keratitis, epithelial micro-erosions and ulcers are all signs of corneal involvement in this condition. Initial management can involve use of mast cell stabilisers alongside careful monitoring for any sight-threatening complications, which would require rapid onward referral. AKC is strongly associated with staphylococcal lid margin disease,

FIGURE 2 A patient with chronic blepharitis, associated with staphylococcal bacterial infection presenting with conjunctival hyperaemia, purulent or mucopurulent discharge and crusting of the lashes

and so lid hygiene and treatment of any staphylococcal blepharitis is also a key part of its management. Allergic eye disease affects a large proportion of the world’s population and is often linked with other atopic conditions such as asthma, eczema and food allergies. The surfaces of the body (skin, mucous membranes) provide a physical barrier against foreign substances and infections and are reinforced by secretions. The eyelids act as a barrier not only to ocular injury, but also to allergens and so lid hygiene measures can help keep allergens away from the lid margin thereby limiting exposure.

Maintaining eyelid health Good lid hygiene requires continuing commitment to the prescribed management plan which usually involves lid warming, cleansing and massage. In general, long-term patient compliance with this is poor.39 Educating patients on the importance of healthy eyelids and a stable tear film can help to improve compliance, as could regular encouragement at every appointment

Eyelid symptoms

Possible cause

Swelling after contact with a substance that the patient is allergic to

Allergic reaction

Red, hot, painful and swollen

Cellulitis

TABLE 2

Summary of the main symptoms and causes of swollen eyelids

to continue with the prescribed regime. There are several products and devices available, which are designed to deliver sustained and consistent heat40 and many eyelid cleansing products available including gels, wipes and foams, which may help to support compliance.

Conclusion Given the prevalence of eyelid disorders and the frequency with which they present in practice, a thorough inspection of the eyelids is essential in every ocular health assessment. Early identification and treatment are beneficial in preventing progression. Many eyelid disorders such as blepharitis, MGD and DED cannot be easily and quickly remedied and require a life-long commitment to good eyelid hygiene by the patient. Practitioners can help with this by educating patients so that they understand their disorder, as this is likely to increase acceptance and compliance with eyelid cleaning and massage. 0

To read this article online, access the references and take the exam, visit: www.optometry.co.uk/cpd

Dr Sandeep Dhallu works as a lecturer in the optometry department at the University of Hertfordshire having previously worked as a research fellow in optometry

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Ethical considerations of myopia management This article explores ethical considerations when seeing young patients with myopia in practice and answers common questions for practitioners to ensure safe and effective myopia management.

ART

0 Yasmin Whayeb BSc (Hons), MCOptom, AFHEA

Why is myopia management needed?

CPD POINT

PRODUCTION CLIENT

also correlates with increasing degrees of myopia, with posterior subcapsular opacities having the strongest association.9 It is important to note there is no safe level of myopia; although high myopia carries the greatest risk, lower levels also significantly increase the likelihood of ocular complications. The psychological impacts of myopia are a further consideration. Financial, cosmetic and practical implications of myopia can negatively impact a person’s quality of life;10 this is particularly evident for high myopes, who often endure wearing unsightly, thick spectacles or face the greater cost of cosmetically appealing alternatives. Research suggests that 25% of high myopes are likely to suffer with anxiety and depression disorders,10 and the negative impact of high myopia on an individual’s quality of life is comparable with that of keratoconus.11 Globally, uncorrected refractive error constitutes the leading cause of vision impairment and the second worldwide cause of blindness after cataract.1,12 Economic impacts accompany this, where lost

Additional to the inconvenience ····························································································O of needing optical correction, having myopia carries a multitude Introduction of consequences. Research has The dramatically increasing global shown myopia to increase the risk of prevalence of childhood myopia is various ocular pathologies,4 the most well established, with half of the world’s population expected to be common being myopic maculopathy; myopic by the year 2050.1 Due to myopia of 5D or more carries a 60fold increased risk of developing the serious clinical and economic myopic maculopathy.5 Through consequences of myopia, the World Health Organization (WHO) has progressive stretching of blood declared myopia to be a major vessels, geographic atrophy, choroidal public health concern.2 Advances in neovascularisation, posterior staphyloma, and other pathological knowledge from animal models along changes, this irreversible and often with a growing body of evidence bilateral macular disease can have from human clinical trials has devastating effects on a person’s led to a number of optical myopia eyesight.6 Similarly, glaucomatous management interventions to become available in the UK market. With these optic neuropathies have a strong interventions becoming increasingly association with myopia, where accessible to eye care practitioners its prevalence among myopes with to employ in clinical practice, safe refractive error of 8D or more can and effective management of young be as high as 50%.7 Additionally, myopic patients is imperative. compared to a non-myopic eye, the The swift implementation of optical risk of retinal detachment increases myopia interventions in community four-fold in an eye with spherical practice, paired with the lack of a equivalent of -1.00 to -3.00D, and 10standardised approach to manage fold in levels greater than -3.00D.8 young myopes, carries various ethical The likelihood of developing cataracts considerations. The evidence base supporting optical intervention Child’s age (years) Cut-off point for age-normal hyperopia methods is extensive and everSix +0.75D or less growing; however, practising myopia management may feel daunting Seven to eight +0.50D or less for practitioners with little or no previous experience in the field. Nine to 10 +0.25D or less This article aims to answer common 11 Emmetropia questions to provide reassurance that the world of myopia management is TABLE 1 Classification of age-normal hyperopia relative to a child’s age within a practitioner’s competency.

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CPD 2, 1

MYOPIA, PAEDIATRICS, PROFESSIONAL GUIDANCE 6

productivity due to uncorrected refractive error has been estimated at $202 billion per annum.13,14 Further, healthcare providers, such as the NHS, are faced with the ramifications of the growing prevalence and degrees of myopia. The increasing awareness of the repercussions of myopia on an individual and global scale has seen many eye care practitioners across the world become more clinically active in the area of myopia management.15 Accompanying the ever-expanding evidence base and availability of myopia interventions comes the increased responsibility of the practitioner to inform young patients with myopia and their parents/guardians of their options.

Do I have to discuss myopia management? Consider how you would feel if you were diagnosed with a progressive health condition, yet your healthcare practitioner did not inform you of preventative therapies which may reduce the extent of its deterioration. Further, what if you could have changed your lifestyle to possibly prevent the onset or severity of this condition in the first place? With this in mind, in the context of myopia, there is rationale for eye care practitioners to inform patients of their management options. The Age-Related Eye Disease Study Research Group (AREDS) found six years of taking dietary supplements (antioxidants plus zinc) reduces the risk of developing advanced macular degeneration by 25%.16 From this, advising a patient to take such supplements and/or alter their eating habits often forms a standard part of managing patients with age-related macular degeneration (AMD) in clinical practice. So, how is myopia control different? Research suggests that slowing a patient’s myopia progression by 1D reduces the likelihood of them developing myopic maculopathy by

40%, independent of their level of myopia or race.17 Despite six-year data being relatively sparse, existing research suggests a reduction of at least 1D of myopia progression may be possible over this time.18-20 Aside from the pathological associations, consider how a reduction in myopia progression would impact a patient’s quality of life financially, cosmetically, and practically, even in childhood. The College of Optometrists advises practitioners that they should be able to have a conversation about myopia management even if they feel it is not within their scope of practice or is unavailable in their work setting.21 That being said, it is crucial for practitioners to feel confident when having these discussions to ensure patients and parents are not being under- or over-sold.

When should I discuss myopia management? It is well established that the sooner we intervene in a child’s myopia progression, the better the outcome.3 Therefore, close monitoring before the onset of myopia will aid a practitioner in identifying children at risk and give opportunities to begin conversations about myopia at an early stage. Often, a significant hurdle when recommending myopia management is educating the parents and patients of the importance of preventative techniques and the long-term benefits they may bring, particularly when increased monetary cost is involved. Planting the seed at an early stage may enable practitioners to reinforce this message to patients and parents over time. There are several factors a practitioner can evaluate when identifying children at risk, some of which are identifiable through a child’s history and lifestyle. The presence of parental myopia significantly increases the risk of myopia; when quantified, the

WHAT YOU NEED TO KNOW C-106268 LEARNING OUTCOMES 0 Practitioners will be able to

explain the benefits and limitations of myopia management to patients and their parents to enable informed consent 0 Practitioners will recognise the importance of good record keeping when offering myopia management advice to patients and their parents.

.,~ .,

@) {~~t,@ prevalence of myopia in children with two myopic parents is 30 to 40%, 20 to 25% with one myopic parent, and <10% with no myopic parents.22-24 The visual demands associated with educational and recreational near work have been evidenced to increase the likelihood of childhood myopia, with the greatest risk being in children who conduct near work at close working distances (<20cm) for continuous periods of time (>45 minutes).25 The mechanisms behind this are unclear; however the increased accommodative demand associated with near work may play a part.26 Increased time outdoors appears to do the opposite; the greater light intensity of outdoor environments may provide a shielding effect against myopia onset and progression.27 Children who spend less than 90 minutes per day

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outdoors during daylight hours have a greater risk of developing myopia. Once again, the relationship between outdoor time and myopia isn’t fully understood. As you would expect, measuring a child’s refractive error and eye growth offers vital information when identifying children who would benefit from myopia management. However, these factors are helpful even prior to a child becoming myopic. Future myopic eyes experience significantly more axial growth up to three years prior to onset, with the fastest axial growth occurring the year before myopia manifests.28 Lower hyperopia (as measured under cycloplegia) than age-normal (see Table 1) can indicate the risk of myopia development as a child, and children who become myopic show less hyperopic refractions up to four years before myopia onset compared to emmetropes.28 Further, axial elongation during emmetropisation occurs most rapidly in children aged six to 10 years and slows in older children. Therefore, the younger a child is at the age of onset, the faster their myopia progression will be regardless of their ethnicity, sex, parental myopia and reading behaviours.29-31 Establishing what is ‘normal’ for a child of a particular age is an extremely useful tool to determine the likelihood of a young patient becoming myopic, particularly if paired with familial and behavioural risk factors. These at-risk children are often termed ‘pre-myopes,’ which the International Myopia Institute (IMI) defines as: ‘A refractive state of an eye close to emmetropia in children where a combination of baseline refraction, age, and other quantifiable risk factors provide a sufficient likelihood of the future development of myopia to merit preventative interventions.’32 Therefore, introducing the topic of myopia management to pre-myopes is arguably just as important as that

of children with established myopia. This does not mean that a practitioner should prescribe an optical intervention for a child who is not yet myopic; however, informing the patient and parents of the expected ametropia, the management options that child may have in the future, along with appropriate lifestyle advice, is worthwhile.

How do I choose the right myopia management method? Behavioural intervention alone cannot be considered a sufficient myopia management method for progressing myopes. Evidence suggests increased time outdoors is mostly effective in slowing the myopic shift in refractive error and onset of myopia in pre-myopic patients.33,34 In myopic eyes, epidemiology reports have shown conflicting results with some concluding that time outdoors does not reduce refractive progression,27 whereas others suggest it does.35,36 Nevertheless, children should be encouraged to make such lifestyle changes; however, the likelihood of strict compliance to 90 minutes of daily outdoor time and taking regular breaks from near work is unlikely to be maintained over several years throughout childhood and adolescence. Therefore, taking into account scope of practice and treatment availability, additional

Clinical tests for myopia management • History taking • Visual acuities • Refraction (subjective and/or objective) • Accommodative and binocular vision assessment • Anterior and posterior ocular health assessment • Axial length measurement (every six months) • Cycloplegic refraction (annually or on indication)

• Dilated fundus examination (annually or on indication)

FIGURE 1 The clinical tests recommended for myopia management by the International Myopia Institute (adapted from the IMI – Clinical Management Guidelines Report)3

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intervention options should be explored. Myopia management cannot have a ‘one-size-fits-all’ approach. Despite several optical intervention methods being accessible to practitioners to prescribe, the management should be tailored to each child’s myopic prescription, lifestyle, compliance with spectacle/contact lens wear, financial budget and patient/ parent preference. Additionally, the intervention techniques offered should have evidenced efficacy through clinical trials and peerreviewed academic literature; this is not to say this guarantees the chosen approach will work for a specific child, however, it gives practitioners a solid foundation to support their recommendation. It is easy to misinterpret the efficacy of interventions when only considering the reported reduction in progression in percentage terms. Naturally, when comparing two intervention types, seeing a higher percentage efficacy of one over the other suggests a greater effect, and therefore, the better option. However, this may not be true when considering the absolute treatment effect. It is, therefore, advisable to review the differences in reported efficacy of axial length in millimetres, and refractive progression in dioptres, rather than as a percentage.

CPD 2, 2

MYOPIA, PAEDIATRICS, PROFESSIONAL GUIDANCE 6

“BEFORE BEGINNING MYOPIA MANGEMENT, PATIENTS AND THEIR PARENTS SHOULD BE FULLY INFORMED OF THE POSSIBLE BENEFITS, EFFICACY, RISKS, NECESSARY COMPLIANCE AND COMMITMENT IT ENTAILS” It is also worth acknowledging that clinical trials may be done in different populations with variable inclusion criteria, making it difficult to do a head-to-head comparison of efficacy. Where possible, interventions licensed for myopia control and those with an indication for myopia management should be a practitioner’s first choice. Although licensed for general use in the UK, standard multifocal contact lenses and orthokeratology lenses which are not specifically marketed for myopia management would be considered off-label interventions. If an on-label approach does not meet a patient’s clinical needs, off-label options can be offered if supported by sufficient evidence of their benefit to young myopes. Furthermore, practitioners should consider their scope of practice when forming a management plan. If a suitable option is not accessible in a practitioner’s work setting or within their realm of expertise, referring a patient to a local service or practitioner who can offer alternative options should be explored,37 providing the receiving practitioner agrees to this.

How should I monitor myopia progression and when do I stop? It is important to perform appropriate tests to sufficiently monitor a child’s myopic progression. Due to the associated pathological risks, axial length is a key metric when monitoring pre-myopic and myopic children, and therefore, is the preferred way to assess progression of myopia. Unfortunately, this may not be straightforward for many practitioners as the required instrumentation generally isn’t routinely accessible in optometric practice. Alternatively, it is possible to estimate axial length

through cycloplegic autorefraction and keratometry.38 Cycloplegic autorefraction is also an effective and objective way to measure refractive progression independent to what is prescribed in a child’s optical correction. The IMI recommends the clinical tests detailed in Figure 1 as best practice when monitoring myopia.3 For children undergoing myopia management, a recall of no greater than six months is also recommended. The recommended duration of treatment is less clear. Myopia tends to slow through the teenage years and adulthood,39,40 with the average age of stabilisation at around 15.6 years of age.41 By the age of 24 years, 95% of myopes have stabilised; however, progression at an older age is still possible.41 At present, a clinically significant rebound effect has only been observed after ceasing higher dose atropine42 although some evidence suggests this may be true for orthokeratology in children.43 With this in mind, it is advisable to wait until the patient’s late teens or early twenties to stop myopia management, followed by close monitoring to ensure no sudden progression on cessation of the intervention occurs.

Is it safe to fit children with contact lenses? Contact lenses are advantageous for young patients who do not like wearing spectacles or feel inconvenienced by them, such as when playing sports. Despite this, a recent worldwide survey found that practitioners consider the minimum age required to fit children with contact lenses to be around three years older than that of spectacles (9.8 to 6.4 years of age, respectively).15 Additionally, practitioners prescribe children with single vision spectacles

over four times more often than single vision soft contact lenses.15 The risk of adverse ocular events is very low across different contact lens modalities, with daily disposables being the safest option.44 Safe contact lens wear requires necessary compliance, which is often a concern for practitioners and parents when recommending contact lenses to a child. When researched, children and adolescents have been found to be as safe as adults in soft contact lens wear,45-47 and contact lens related corneal infiltrative events in eight to 11 year olds may actually be lower.45 The risk-to-benefit ratio of childhood myopia management contact lens wear has also been investigated; the lifetime risk of childhood contact lens wear is significantly less than the lifetime risk of vision impairment with axial lengths >26mm and myopia of >6.00D.48 In lower levels of myopia, the lifetime risk of childhood daily disposable wear is significantly less than myopia-associated vision impairment in axial lengths of <26mm and <3.00D myopia.48 Parental supervision of a child applying, removing, and (if applicable) cleaning their contact lenses should be encouraged. Ideally, a child should at least be able to safely remove their contact lenses in case an issue arises in the absence of a supervising adult. Research indicates that children report high satisfaction with soft contact lens handling and parents infrequently need to intervene, particularly after the first month of wear.49

Is it necessary to obtain informed consent? Before beginning myopia management, patients and their parents should be fully informed of the possible benefits, efficacy,

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risks, necessary compliance and commitment it entails. Managing expectations is vital; it is important for parents to recognise that no myopia intervention will permanently stop or reverse their child’s myopia progression, and there is no way to predict how their child’s eyes will respond to a particular intervention. How often the child should be using a specific intervention must also be understood, as well as the longterm commitment that myopia management requires. The frequency of follow-ups should be advised to ensure this is feasible, particularly when several appointments may be required (for example, during orthokeratology fitting).3 As myopia management is not covered under the NHS at present, the financial cost of optical myopia interventions and follow-up appointments may be a significant obstacle for some families. The greater cost of myopia management is a problem many practitioners recognise across the world,15 and must be advised when discussing myopia management. Despite this, it is important for practitioners to not assume that someone cannot afford the associated costs. Unfortunately, there is no easy solution for this; hopefully with the increased uptake of myopia management, costs may decrease over time. Patients and parents must be made aware of any associated risks, such as contact lens complications. Myopia management contact lenses provide no greater risk of adverse events than single vision/standard multifocal contact lenses, so the standard contact lens safety procedure is sufficient. It should also be advised that it is not possible to state a specific time to stop myopia management but is expected once the eye growth and myopia progression has stabilised. With this,

the possibility of a rebound effect is a risk to be discussed; although there is no clear evidence for young myopes to expect accelerated eye growth on cessation, parents should be aware that there is no guarantee this will not occur. Much like any clinical advice, a combination of verbal education and written material is advisable. Furthermore, meticulous record keeping is crucial. All aspects of the discussion and recommendation should be documented in the patients record, even if the patient and parents decide not to go ahead. If the child and parents wish to proceed, practitioners have the option to ask the parents to sign a consent form. Additional to providing clear evidence of informed consent, a form helps practitioners to reinforce the information provided to prevent any misunderstanding. The Association of Optometrists (AOP) and British Contact Lens Association (BCLA) provide downloadable consent forms for their members.

How can I keep up to date? The GOC standard of practice 5.3 states that practitioners should ‘Be aware of current good practice, taking into account relevant developments in clinical research, and apply this to the care you provide’. With myopia management forming a fundamental part of optometric and ophthalmological research, developments in this research are frequent; this includes ‘debunking’ outdated approaches previously thought to control a child’s refractive error progression. For example, undercorrecting a child’s myopia was thought to be an effective method of myopia control several years ago; however, more recent research shows undercorrection to be ineffective,50 or even detrimental51,52 to myopia progression. Despite

this, more than one in 10 eye care practitioners worldwide still undercorrect their young myopic patients,15 demonstrating the importance of keeping up to date with advances in research. There are various resources about myopia management for eye care practitioners, such as: • The IMI offers free, open-access white papers containing the latest literature reviews and clinical guidance for myopia management3 • The World Council of Optometry provides webinars, articles, and approaches to apply a standard of care to manage myopia. These are available in different languages and are free to access • The AOP offers legal advice, CPD articles and events, myopia management guidance and a downloadable myopia management patient information leaflet and consent form to its members37 • The College of Optometrists provides clinical guidance,21 patient resources, and CPD articles and events about myopia management to its members • The BCLA provides professional resources including a myopia management factsheet and consent form for its members to download.

Acknowledgement The author would like to thank Professor Nicola Logan for reviewing this article. 0

To read this article online, access the references and take the exam, visit: www.optometry.co.uk/cpd

Yasmin Whayeb

is a PhD student at Aston University. Research interests include the progression and management of myopia, and the choroidal response to myopia intervention methods.

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The clinical characteristics of Stargardt disease

This article outlines the clinical characteristics of Stargardt disease, including the key signs, symptoms and patient management options.

ART

0 Emily Eraneva-Dibb BA (Hons), and Dr Jasleen Jolly BSc (Hons), MSc, DPhil ............................................................................................

Introduction PRODUCTION CLIENT

Stargardt disease (STGD) is one of the most common inherited retinal dystrophies (IRD), characterised by bilateral, central visual field loss that progresses to the periphery over time.1 Reference to STGD can be seen in the medical literature towards the end of the 19th century, although it is Karl Stargardt who is credited with the first comprehensive clinical description of the condition in 1909.2–4 Other synonymous terms for STGD include Stargardt macular dystrophy, juvenile macular dystrophy and fundus flavimaculatus.5 STGD is a rare disease, with much of the literature reporting an incidence of one in 10,000.3,6 However, a recent epidemiological study of the UK population suggests that STGD is rarer than previously thought, reporting an annual incidence of 0.110 to 0.128 in 100,000.3

Pathophysiology This article will discuss cases of STGD caused by the recessive inheritance of two mutated copies of the ABCA4 gene, classified as STGD1 (OMIM 248200) and referred to throughout this article as ‘STGD.’7 However, some cases of STGD are caused by mutations in ELOVL4 (STGD3, OMIM 605512) or PROM1 (STGD4, OMIM 604365), typically inherited in an autosomal dominant manner.7,8 ABCA4 is a large gene, located on the short

arm of chromosome 1 (1p13-p22) and encodes a membrane protein known as adenosine triphosphate binding cassette transporter 4, or ‘Rim Protein’ (RmP).5,9,10 Over 1200 causative mutations of the ABCA4 gene have been identified thus far, producing a highly heterogenous patient group.1,2,11 Missense mutations are typically associated with milder, adult-onset, foveal-sparing disease, while null mutations are associated with more severe, early-onset disease.9 The RmP localises to the curved rim of membranous discs in the outer segment of rod photoreceptor cells and is crucially involved in retinoid metabolism as part of the visual cycle.10,12 Wild-type RmP is thought to facilitate the transportation of both 11-cis-retinal and all-trans-retinal in the form of their Schiff bases with phosphatidylethanolamine, N-retinylidene -phosphatidylethanolamine (N-RPE), out of the disc lumen and into the cytoplasm of rod photoreceptor cells.9,13 Dysfunction in RmP results in the accumulation of excess N-RPE within membranous discs, which are shed and taken up by cells of the retinal pigment epithelium (RPE).9,10 N-RPE and all-trans-retinal combine to form A2PE, which is hydrolysed to A2E in the lysosomes of RPE cells. A2E and other molecules form lipofuscin, a toxic compound that ultimately results in

the death of RPE cells.9,13 The macula is the first region to be affected in STGD due to its high density of rod photoreceptors.9,14

Symptoms The majority of STGD patients present with progressive visual impairment beginning in the first or second decade of life.9 Many patients with early STGD report objects appearing distorted or wavy, photophobia and nyctalopia.5 As the disease progresses, patients develop bilateral central visual field loss and impaired colour vision.5,7 The speed of visual deterioration is affected by multiple factors, including the causative mutation, age of onset and environmental factors, for example, exposure to cigarette smoke. As a result, the disease course varies significantly between patients, even those within the same family. In some cases of STGD, patients report Charles Bonnet syndrome, in which they experience visual hallucinations.5

Diagnosis The diagnostic triad of STGD includes progressive macular degeneration, the presence of fundus flecks and peripapillary sparing.2,8 Multimodal imaging is necessary to investigate and provide a clinical diagnosis for suspected cases of STGD. For patients presenting with early disease, the retinal examination and

“A RECENT EPIDEMIOLOGICAL STUDY OF THE UK POPULATION SUGGESTS THAT STGD IS RARER THAN PREVIOUSLY THOUGHT”

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best corrected visual acuity (BCVA) are likely to present as normal.15–17 Pupil responses and the anterior segment are also likely to be unremarkable, although early visual deficits in STGD may present as a reduction in contrast sensitivity prior to measurable loss in BCVA.16,18 Specialist tests to confirm a clinical diagnosis of STGD include fundus autofluorescence; fluorescein angiography; optical coherence tomography (OCT); visual field tests; microperimetry; and electroretinography.9,15,19–22 Degeneration of the macula begins with deterioration of the RPE, followed by loss of the photoreceptorattributable ellipsoid zone.2 Atrophic lesions may have a characteristic ‘beaten bronze’ appearance with visible choroidal vessels due to progressive degeneration of the choriocapillaris and underlying choroidal layers.2,5 More recently, adaptive optics scanning laser ophthalmoscopy (AOSLO) may be able to reveal disorganisation of the photoreceptor mosaic prior to clinically detectable RPE loss.9,20,21 On fundus autofluoresence imaging, STGD patients with early disease often present with homogenous central hyperfluorescence, thought to relate to the accumulation of lipofuscin; this is followed by heterogeneous hyperfluorescence and progresses to central hypofluorescence in advanced disease, suggesting a progression from material accumulation to RPE cell death and resorption.23,24 Clinicians may also use OCT to monitor loss of normal retinal architecture in the macula and beyond, including thinning of the outer retinal layers, disruption of the ellipsoid zone and thickening of the external limiting membrane.2 Yellow-white ‘flecks’ seen on fundoscopy in STGD patients are thought to be deposits of excess lipofuscin in swollen RPE cells.2,8,25,26 These flecks appear as subretinal and intraretinal hyper-reflective foci on OCT and are associated with increased disease severity, as measured by

central macular thickness, VA and duration of disease.27 Flecks may be visualised using fundus autofluorescence before they are apparent on funduscopy.8,23,28 However, it should be noted that up to one-third of paediatric STGD patients do not have visible flecks at presentation, or may present with finer yellowish-white ‘dots’ within the central macula.17 Peripapillary sparing of the retina is considered the third hallmark of STGD; however, it is not a universal sign. Peripapillary atrophy has been reported in STGD patients with multiple mutations within the ABCA4 gene and may be associated with more severe disease.26,29,30 Another important sign of STGD is the dark choroid or ‘silent choroid’ sign, which is seen on fluorescein angiography in over 60% of confirmed STGD cases.8,26,31 The dark choroid sign occurs due to lipofuscin deposits in the RPE that block normal choroidal autofluorescence. The dark choroid sign (or a dark peripapillary choroid ring in cases where diffuse fleck hyperfluorescence has obscured the dark choroid) can be a useful auxiliary test for distinguishing STGD cases from masquerade diseases, including pattern dystrophy and Batten disease.26,32

Classification Several methods for classifying patients with STGD disease have been proposed. In 1976, Gerald Fishman developed a four-tier classification system of STGD patients based on fundoscopy.2,33 However, fundus appearance has been shown to poorly correlate with retinal function, prompting the development of further classifications such as those based on fundus autofluorescence (FAF) and electrophysiology, as summarised in Table 1 (see page 60).7,8,28

Patient management A STGD diagnosis is a life-changing event for patients and their families. Care must be taken to explore the

WHAT YOU NEED TO KNOW C-106227 LEARNING OUTCOMES

Practitioners will be able to outline the key characteristics of Stargardt disease to patients Practitioners will recognise the key clinical characteristics of Stargardt disease.

possibilities for help and disease management when delivering a diagnosis of STGD, as the manner of delivery can have a lasting impact on a patient’s ability to navigate life with an IRD.34 After diagnosis, many STGD patients present with a rapidly progressive disease course. For patients diagnosed before 20 years old, visual decline typically progresses from a BCVA of 6/12 towards a final acuity of 6/60 to 6/120 over an average follow-up of seven years.35 The same decline occurs over an average of 22 years and 29 years for patients diagnosed between 21–40 years and 41–60 years, respectively.35 There are currently no approved therapies for the treatment of STGD. However, to minimise disease progression, it is recommended that patients protect their eyes from the sun and avoid both smoking and second-hand smoke. Patients are also widely recommended to avoid excess vitamin A intake, although there is little evidence to suggest this has a deleterious effect on disease progression.9

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Referral to the local low vision service is also essential to reduce the visual burden of STGD and can be supplemented by referral to a local rehabilitation team for at-home support and/or mobility training. An increasing number of electronic visual aids are now available to support near-vision activities, including reading.36 Patients’ quality of life can also be improved by developing a preferred retinal locus (PRL), a ‘pseudo-fovea’ that can help maintain fixation stability and aid in activities that require high-acuity vision.37 Microperimetry can be used to highlight potential PRLs by identifying a well-preserved area of the retina. Techniques to assist with using PRLs, such as verbal coaching, can be delivered at a low vision clinic.37 It is also important for patients with advanced STGD to be monitored for choroidal neovascular membranes (CNVM), a rare complication that arises from the growth of abnormal blood vessels into the retina that leak and aggravate vision loss.38 A CNVM can be detected on fluorescein angiography or OCT and may be treated with intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections.9,38 Genetic testing of STGD patients and their families can help identify causative mutations, providing a more accurate diagnosis and prognosis.15 However, genetic testing can produce a vast amount of information, some of which may be distressing for the individual.15 It is therefore essential to provide counselling to patients and their families prior to obtaining consent for genetic testing.15

Therapeutic intervention There are currently many trials exploring a range of therapy modalities designed to limit, prevent or even reverse progression of STGD. Research into novel STGD therapies has been extensively reviewed,39 but will be briefly discussed here.

Early-onset STGD Fundus Grading System

ERG

Heidelberg FAF grading system

Genotype group

Grade 1: Normal fundus Grade 2: Macular and/or peripheral flecks without central atrophy Grade 3: Posterior atrophy 3a: Central atrophy without flecks 3b: Central atrophy with macular and/ or peripheral flecks 3c: Paracentral atrophy with macular and/or peripheral flecks, without central atrophy Grade 4: Multiple extensive atrophic changes of the RPE, extending beyond the vascular arcades

Group 1: Abnormal pattern ERG (PERG) P50 with normal fullfield ERG Group 2: Abnormal PERG P50 with cone ERG abnormality Group 3: Abnormal PERG P50 with generalised cone and rod dysfunction

Type 1: Localised low FAF signal at the fovea surrounded by a homogeneous background with or without perifoveal foci of high or low signal Type 2: Localised low FAF signal at the macula surrounded by a heterogeneous background and widespread foci of high or low FAF signal extending anterior to the vascular arcades Type 3: Multiple areas of low FAF signal at posterior pole with heterogeneous background and/or foci of high or low signal

Genotype A: Two or more deleterious variants Genotype B: One deleterious variant and ≥1 missense or in-frame insertion or deletion Genotype C: Two or more missense or inframe insertion or deletion variants

TABLE 1 Classification of STGD. Adapted from Coussa et al8 and Huang et al28

Gene therapy

Gene therapy is particularly suited to restoring expression of the wild-type protein in monogenic diseases such as STGD. • Viral vectors: delivery of wild-type ABCA4 using an equine infectious anaemia viral (EIAV) vector at three dose levels, of which the highest dose was 6 x 105 transduction units delivered via subretinal injection, was recently reported to be safe and well-tolerated in 22 STGD patients at the three-year follow-up of a phase I/IIa clinical trial. However, no significant changes in visual function were reported39 • Non-viral gene therapy: non-viral modes of gene transduction offer

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both a larger packaging capacity and lower immunogenicity than viral methods.40 A 2020 paper reported that self-assembling nanoparticles carrying the wild-type ABCA4 gene achieved wild-type RmP expression that was maintained for at least eight months and resulted in a 35% reduction in A2E accumulation in ABCA4-knockout mice.40 Furthermore, a 2023 study reported a 32±5% increase in newly generated RmP in retinal organoid models of severe STGD following an eight-week washout regimen with QR-1011, an antisense oligonucleotide at 3μM.41 It is thought that the STGD phenotype occurs once RmP activity falls below 30–40%, with

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mouse models reporting a decrease in lipofuscin production following a 10% restoration of wild-type RmP.41 However, these therapies have yet to be translated into human studies.

Stem cell therapies A significant concern with stem cell transplants is the growth of teratomas from a single undifferentiated cell.42 However, two phase I clinical trials have confirmed a lack of tumour formation following subretinal injection of human embryonic stem cells in suspension at long-term followup.42,43 However, neither trial reported a significant change in visual function, perhaps due to a lack of integration of the stem cells into the circuitry of the eye.

Small molecule therapy • Inhibition of RBP4: fenretinide, A1120 and STG-001 are small molecules that inhibit the interaction between retinol and its major transport protein in the plasma, retinolbinding protein 4 (RBP4).44 These small molecules thus aim to reduce the delivery of retinol to the retina and potentially reduce lipofuscin accumulation.28 Fenretinide was entered into a phase II trial for patients with age-related macular degeneration, which reported a dosedependent decrease in serum levels of RBP4 in addition to a significant reduction in the growth of geographic atrophy and the onset of CNVM45 • Removing existing lipofuscin deposits: ‘Remofuscin’ is a tetrahydropyridoether that was granted orphan drug designation for STGD in the US and Europe after its promising ability to remove existing lipofuscin deposits in monkeys, putatively via the generation of superoxide ions within lipofuscin granules.46,47 Remofuscin taken orally has since entered a phase II clinical trial for the treatment of STGD • Inhibition of RPE-65: emixustat hydrochloride (ACU-4429) is a novel

“A SIGNIFICANT CONCERN WITH STEM CELL TRANSPLANTS IS THE GROWTH OF TERATOMAS FROM A SINGLE UNDIFFERENTIATED CELL” RPE-65 inhibitor that has entered a phase III clinical trial to investigate its safety and efficacy as a therapy for STGD. Inhibition of RPE-65 prevents the isomerization of all-trans-retinyl ester to 11-cis-retinol, thereby inhibiting the production of toxic byproducts such as A2E48 • The TEASE study has been the first to report a statistically significant reduction in disease progression in STGD patients following oral administration of C20-D3-retinyl acetate, a selectively deuterated vitamin A supplement. A 2022 abstract from this study reported a reduction in the progression of atrophic lesions in STGD patients aged between eight and 70 years old, although no changes in BCVA were observed.49 Deuterated vitamin A acts to slow the formation of vitamin A dimers, thought to play an active role in retinal degeneration, by fourto-five-fold.50

Patient signposting Following a diagnosis of STGD, the patient’s healthcare professional should make a referral to a low vision specialist.5 Where appropriate, the healthcare professional should complete a certificate of vision impairment (CVI) so that the patient can be needs-assessed for various benefits, including tax allowances and free transport.5 The local council should also assign children a qualified teacher of children and young people with vision impairment (QTVI) to assist both at home and in school.5 Other organisations to signpost for STGD patients include:5 • RNIB Sight Loss Advice Service and online shop • Stargardt’s Connected

• Macular Society • Gene Vision • Gene Alliance UK.

Conclusion Although rare, STGD disease is an important cause of vision loss in young people. The variable and often subtle signs of early STGD contribute to delayed diagnosis and unnecessary tests endured by many patients, highlighting a need for clinicians to maintain a high suspicion of STGD. Although there are currently no licensed treatments for STGD, the healthcare team can assist a patient with their diagnosis by recommending lifestyle changes, discussing low vision aids and support to use PRLs. Given the multitude of clinical trials investigating novel therapies for STGD, there is potential for young STGD patients to benefit from treatment in the future. 0

To read this article online, access the references and take the exam, visit: www.optometry.co.uk/cpd

Emily Eraneva-Dibb is a medical student. Her third-year project explored changes in the contrast sensitivity function of those with STGD and choroideremia.

Dr Jasleen Jolly is an associate professor of vision and eye research at Anglia Ruskin University. She has worked on several gene therapy trials.

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Real-time lens design: advances in lens manufacturing and why they matter

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Computer numerical control (CNC) surfacing of ophthalmic lenses began in the early 2000s and helped create a new industry in lens design software. This article considers how these advances may translate to better lenses for patients.

1 CPD

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Eluned Creighton-Sims FBDO ART

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Introduction

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Industry 1.0 and 2.0 Lenses have been used to correct refractive error since the late 13th century and crafting them was a laborious task done entirely by hand.3 The first evidence for a mechanical machine capable of grinding lenses is in a sketch from around 1500 by Da Vinci4 although there is no evidence that it was ever made.

Number of new launches

PRODUCTION

There are many overlaps in the roles of optometrists and dispensing opticians, for example, supplying and fitting spectacles, which is within the scope of practice for both roles. In March 2016, the GOC began an education strategic review, publishing a new framework for approved qualifications; this states that both optometrists and dispensing opticians must be able to ‘evaluate optical products and advancement in technology of ophthalmic lenses and frame manufacture in order to provide patients with the most appropriate optical appliances.’1 In the late 1990s, the advent of freeform manufacturing facilitated a revolution in ophthalmic lens designs. The impact of this can be seen in Figure 1, which shows the number of ophthalmic lens designs launched from 2001 to 2010.2 As the number of laboratories using freeform generators (see Figure 2) increased, so too did the number of new launches. This article explores the advances in ophthalmic lens design and the impact these developments have on the wearer.

40 21

30 24

20 6

0 2

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Top 5 ■

Others ■

FIGURE 1 Ophthalmic lens design launches from the top five suppliers (Carl Zeiss Vision, Essilor, Hoya Vision Care, Rodenstock and Seiko) and others

By the early 1600s, hand lathes came in to use (see Figure 3); these were soon abandoned to be replaced with devices which involved the movement of ‘laps’ against a stationary lens – the forerunner of conventional surfacing. As knowledge of refraction and the visual system improved, so too did innovation in lens design and manufacturing. This synergy is evident in the correction of astigmatism, a condition first described by Thomas Young in 1801 leading to the first cylindrical lens

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40 15

being produced by George Airy in 1825.5 It is also evident in the development of the first commercial progressive powered lens in the 1950s, which was made possible in part by the development of a new manufacturing process.6

Industry 3.0 The development of freeform manufacturing in ophthalmic lenses – like the invention of anti-reflective coatings in 19357 and CR39 in 19408 – paved the way for other industrial

CPD 4, 1

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A freeform lens is defined as: ‘A lens in which at least one surface is a freeform surface.’ Although it is possible to manufacture simple surfaces (such as those manufactured using conventional methods) with freeform generators, the standards make it clear that this would not be classified as a freeform lens.

The life of a lens

FIGURE 2 A freeform generator. Image courtesy of Norville 2020

applications. In the 1940s, numerically controlled automation (via coded punched paper tape) was used to manufacture helicopter blades.9 The technology evolved and during the 1980s and 1990s began to incorporate CNC automation10 with generators powered by software that was coded with design information. In the optical industry, this production method was first used in precision optics before being adapted for the manufacturing of glass moulds for ophthalmic lenses.11 Since the launch of the first freeform lens in 1997,12 there have been many innovations in freeform machinery, and like other industries, we are now moving towards the next industrial revolution: industry 4.0.

Prior to surfacing, a lens will be in its semi-finished form (often referred to as the ‘blank’); this is a thick, hockey puckshaped block of material which has its front surface (the base curve) already ‘worked.’ For very high prescriptions requiring steep curves, the thickness may not be adequate, so the laboratory has to consider alternatives, such as using a different material, or in extreme cases, have bespoke semi-finished lenses made. The semi-finished lens goes through various processes to create the required finished lens (see Figure 4, page 64) – two of these processes differ significantly depending on the method of manufacturing.

Generating/Surfacing Conventional process The cutting tool is limited to movement in two planes: the

C-106369 LEARNING OUTCOMES 0 Practitioners will be able to

explain to patients about the relative merits of conventional and freeform lens designs 0 Practitioners will recognise the relative merits of conventional and freeform lens designs.

-~ ®@

horizontal and vertical, enabling the machine to generate symmetrical surfaces (spherical or toroidal). After surfacing, the lens will have a surface roughness of 0.03 to 0.1mm visible on the lens as generator marks;13 these are curved and run parallel to each other. An additional process – fining – is required to smooth the surface.

Freeform process The cutting tool can move in all planes enabling it to generate symmetrical and non-symmetrical surfaces (atoric, aspheric and progressive powered). The surface roughness after generating is 0.0003mm,13 demonstrating the increased accuracy compared to conventional methods. There is no need for a fining process, therefore, freeform is sometimes referred to as cut-to-polish.

Freeform versus conventional The accepted terms relating to freeform manufacturing are detailed in ISO: 18476:2017. It includes definitions for a freeform lens, a freeform surface, freeform surfacing and freeform technology. A freeform surface is defined as: ‘A continuously smooth, nonsymmetrical, surface which has been produced using freeform technology. This does not include conventional casting/moulded front surface progressive-power surfaces.’

WHAT YOU NEED TO KNOW

Polishing Conventional process FIGURE 3 Lathe by Andrea Frati, 18th century. The lens is attached to a vertical boxwood plate which rotates when the handle is turned. The grinding tool lowers to remove unwanted material. Image courtesy of Robert Woods4

This is performed using rigid lap tools with a soft pad attached. The curvature of the lap tool must exactly match the lens surface so the laboratory must hold large stocks for many different prescription combinations.

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Conventional processing

SUBS

Protects the front surface of the lens and improves adhesion

BLOCKING

Ensures correct mounting postion

CRIBBING

Reduces diameter to reduce amount of cutting required

GENERATING

Removal of material to produce required curvatures

Free form is capable of moving in all planes

FINING

Smoothing the surface prior to polishing

Not required in free form process

POLISHING

Removal of microscopic material to increase transparency

DE-BLOCKING/DE-TAPING

Removal of the blocking ring and tape prior to cleaning

ART

TAPING

PRODUCTION CLIENT

FIGURE 4 The production steps involved in conventional and freeform manufacturing

Freeform process

Real-time lens design

This is performed using flexible tools which can polish an extensive range of prescriptions. Rigid tools cannot polish a freeform surface. These differences mean that freeform lenses are made much more accurately than by conventional methods and they are quicker to produce. As well as negating the need for a fining process, freeform generators work a surface around 30% faster than conventional ones. Additional processes such as slab-off can increase that production time by a factor of around 12 regardless of the type of generator. A laboratory may choose to use their freeform equipment for simple, symmetrical surfaces to reduce production time and waste, with freeform being more environmentally friendly than conventional methods.

Lens design software (LDS) provides the generators with instructions on how to work the surface. In conventional surfacing, the limitations in how the tool can move means the complexity of the

Conventional progressives

Freeform progressives

Fixed corridor

Variable corridor lengths

Fixed inset

Variable insets

Limited fitting heights

Larger range of fitting heights

Limited diameter availability

Thickness optimisation

Requires large stocks of semi-finished blanks

Aberration control Blank size up to 90mm Stock minimisation

TABLE 1 The main differences between conventional and freeform progressive designs

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calculations contained in the software are relatively simple. Freeform generators use software that is far more sophisticated, and in some cases extremely flexible, with the ability to quickly change the parameters (for example, introduce a new progression length or alter a degression rate). The instructions for the generator are created using a series of ‘target’ maps of the desired design (see Figure 5). The software runs a series of calculations using the parameters provided, such as prescription, frame size and shape, and centration measurements and creates theoretical maps of the surface. The target and theoretical maps are compared and then the software will perform further calculations to work out how the lens should be surfaced to give a result which best matches the ‘template’ for the given parameters. It will then deliver this unique set of instructions to the generator. This means that every freeform lens is designed in ‘real time’, with the surface geometry uniquely designed during the calculation phase. Any manufacturer producing freeform lenses requires a team of lens designers and software engineers to build and maintain this system. Lens design software will calculate a lens to 0.01D, although whether this can be achieved in the final lens depends upon the type of machinery, the frequency of machine maintenance and standards of quality control procedures in place. However,

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2.5

FIGURE 5 Target map showing magnitude and distribution of oblique cylinder in a plano/+2.00 Addition lens for a specific design. Image courtesy of IOT Lenses

provided a laboratory has a strict maintenance schedule and adequate means to perform regular additional quality checks (see Figures 6 and 7), then the accuracy will consistently be better than that achieved by conventional manufacturing methods.

Manufacturing and progressive lens designs It is no surprise that the first generation of freeform lenses were progressives and even the earliest designs demonstrated an improvement on their conventional counterparts. Freeform completely changed the landscape of progressive lens solutions. Table 1 shows the potential advantages of these types of designs. A conventionally manufactured progressive is one with the design on the front surface of the semi-finished blank, which is created using a specific mould containing the addition and the design. The distance prescription is then surfaced on to the rear. A freeform manufactured progressive commonly has a spherical front surface with both the design and elements of the prescription surfaced on to the rear. The positioning of the progressive surface is important – the further it is from the eye, the more likely that the wearer will notice a reduction in field of view, resulting in a ‘keyhole’ effect; this is one of the ways in which the early freeform designs improved performance.

A key problem with conventional progressives is the lack of flexibility due to the design being pre-made on the front surface; this is an issue in terms of availability but also regarding the final performance. For example, a conventional progressive cannot be adapted to place the position of the near zone in a more suitable position when considering the distance centration and frame fit, that is to say, it is an off-the-shelf lens. Today’s freeform progressives are very different to the early designs with many more ways to improve wearer satisfaction. One development has been in the ability to manufacture with a variable base curve on the front surface or with dual surfacing techniques, working both sides of the lens; these processes provide additional benefits relating to width of field,15 magnification16 and aberration control.17

Aberration control Today, freeform progressives have varying levels of optimisation – the lens may be a basic offering with improved accuracy, or it can be enhanced with consideration of many additional parameters, including position of wear, binocular viewing behaviour and ametropia. The most common optimisation is the use of merit functions to reduce or eliminate oblique aberrations which we see as compensated or ‘as worn’ powers. In conventional surfacing, consideration for oblique aberrations is done by choosing an optimal base curve. However, there will be an optimal curve for each aberration, including oblique astigmatism, mean power error, tangential error, or root-mean-squareerror, so the solution will always be a compromise. Even a spherical semifinished lens as used in freeform manufacturing is a compromise for

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FIGURE 6 Incorrectly manufactured lenses with accompanying error maps showing surface topography for errors caused by: (top) improper calibration producing central dot error; (bottom) a non-optimal parameter feeding macro in the calculation software leading to ring error. These would pass inspection according to ISO 8980-2 yet result in poor visual performance.15 Image courtesy of IOT Lenses

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progressive lenses as a steeper curve is optimal for near compared to distance due to the change in prescription. Base curve selection can be done by referring to lens caster charts (see Table 2) or by using ‘rules-ofthumb’ such as Vogel’s Rule; this is a very approximate way of reducing aberrations but deviating from these ideals can lead to significant reduction in visual quality when viewing away from the centre of the lens. Pre-1987, the American Prescription Standards (ANSI Z80.1) stipulated the level of acceptable aberrations in the periphery to discourage opticians and laboratories from departing from the recommended base curve,19 – a flatter base curve is sometimes used to produce less bulbous and slightly thinner lenses, at the expense of optical quality. This standard was removed as larger frames became more fashionable and the steeper curves led to frequent mounting problems. The merit functions in freeform manufacturing enable laboratories to deviate slightly from the optimum curve when necessary, without sacrificing the optics, such as with high wrap sports frames. However, the calculations are finite – if resources are used to correct

Power range (D)

Base curve (D)

+8.00 to +4.75

10.00

+2.25 to +4.50

8.00

+2.00 to -2.00

6.00

-2.25 to -4.00

4.00

-4.25 to -7.00

2.50

-7.25 to -12.00

0.50

TABLE 2 Typical base curve selection chart. Note the corrected curve theory fails at high plus powers where aspherics are essential18

base curve induced errors, there are fewer resources available to improve the performance. Think back to the ‘template’ and theoretical map – poor base curve means these are further apart. Base curve selection remains an important part of optimising image quality and is the foundation on which the software can build. Entrylevel freeform will provide improved accuracy, while mid-range delivers accuracy and image optimisation through methods like aberration control. In the top tier of freeform design and manufacturing, this optimisation is even more advanced and as well as considering more personalisation data, by utilising the newer variable curve semi-finished lenses or using dual surfacing techniques, it is possible to free up some of the design resources and ensure that the software is being used to its full potential to deliver the best possible clarity and performance for every wearer.

Conclusion

FIGURE 7 Quality control checks performed

after surfacing using a Focovision SPV-3 from Automation and Robotics. Image courtesy of Optimum Rx Lens Specialists

Freeform surfacing has continued to improve over the past 25 years providing increased accuracy, even in its simplest form, compared to conventionally manufactured lenses. However, the lenses which have the highest optical value to our patients will be those which are designed and produced to give the most natural vision possible through optimisation and personalisation. Nevertheless, conventional

manufacturing still has its place as there are some prescription/material combinations that freeform cannot produce. For the time being, both will continue to play an important role in meeting our patients’ needs. A wider view of the manufacturing process enables practitioners to better understand the constraints as well as the possibilities when they are seeking the best ophthalmic lens solution for patients. As we move into the fourth industrial revolution, we can expect an increase in automation and improved quality control processes, which will lead to higher rates of satisfaction for wearers. Of course, with NHS England working to an 80% reduction in its carbon footprint by 2039,20 sustainability of lens production is a challenge that many manufacturers and ophthalmic technology companies are actively working to solve.

Acknowledgement The author would like to thank Optimum Rx Lens Specialists, Norville 2020 and Waterside Laboratories for their support with this article. 0

To read this article online, access the references and take the exam, visit: www.optometry.co.uk/cpd

Eluned ‘Lil’ Creighton-Sims is a dispensing optician and UK manager for IOT Lenses, supporting freeform laboratories in developing their own lens designs.

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What's Happening, 1

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WHAT’S HAPPENING Your need to know industry insights

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This issue’s must reads...

Lizzy Yeowart picks out festive frames

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BEHIND THE BRAND Ocumetra on supporting myopia management

MINTEL SHARES FIVE CONSUMER TRENDS HEADING INTO 2024

Simon Moriarty, Mintel’s director of trends, EMEA, identified the key trends to watch in the year ahead www.optometry.co.uk/industry/high-street/2023/11/15/ five-consumer-trends-heading-into-2024

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