Journal of the Association of Optometrists years
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October/November 2020 Volume 60:08
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Shortlist Creative combos Page 30
October/November 2020 / Volume 60:08 LEARNING & DEVELOPMENT
Your future in focus Adapting education to build a resilient profession
/ www.optometry.co.uk
CET Binocular vision and myopia management
Perspectives Reinventing the role of optometry in society
In practice Meeting the need for contact lens comfort
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aking the long view is a fundamental part of running a successful business. But in the last seven months, strategic planning has never been more under strain as businesses scramble to react to the Government’s latest guidelines and restrictions. And yet, the need to prepare for 2021 and beyond remains a priority for the AOP and the members we are committed to support and protect. A clear example is the work by the General Optical Council (GOC) on its Education Strategic Review. The AOP recognises this is a project of real long-term significance. The review seeks to redraw the lines defining the education of optometrists and dispensing opticians, reflecting how these roles have changed to respond to the needs of an ageing population, evolving local healthcare services, and technological change (see OT’s cover story on pages 8 and 59). In response, the AOP will continue to demand that the GOC’s proposals are robust in the delivery of programmes for future optical professionals to make sure they are best placed to safely deliver an enhanced and expanding range of patient care. The way the AOP supports members through its 2021 education programme in the final year of the CET cycle will call for creativity. Members can expect the majority of education to be delivered online, offering interactive CET points via webinars, online peer discussions, legal content and tailored sessions for key sections of the membership including locums and students. To complement this, our flagship event, 100% Optical, will return, delivering three days of live face-to-face education on 8–10 May. OT is an essential part of the AOP’s education toolkit, offering CET content and so much more. Members will continue to receive their print edition on a bi-monthly basis in 2021, coupled with access to daily news and analysis online. Through OT, our education programme, and all our supporting communications, the AOP is committed to giving members the critical insights and support needed to be ready for whatever the future brings.
“Through OT, our education programme, and all our supporting communications, the AOP is committed to giving members critical insight and support”
Henrietta Alderman, AOP chief executive
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The news in digest Picture this esigns for Moorfields’ new clinical D and education centre revealed OT reports Five ways the Education Strategic Review could change optics The audit The month in 16 stories Health and wellbeing The rise in redundancies Clinical roundup How the retina can reveal signs of cognitive impairment in patients with type 2 diabetes Suppliers respond Frame, equipment and lens suppliers are finding new ways to communicate with practices AOP roundup Supporting a DOCET video, a locum vacancies list, and work on racism
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“We are now beginning to see the real fallout from an economic and social shut down that has lasted for most of this year” Simon Coombs, Working Minds PAGE 15
27-33 HIT LIST
The trends, launches and looks OT focuses on... Remote consultation tools Me and my glasses British Formula E driver, Alexander Sims Get the look Bold and brave eyewear The shortlist This edition’s selection Behind the brand Topcon
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37-41 PERSPECTIVES
Voices from optics and beyond Perspectives Richard Edwards, Leonie Milliner My vision Elizabeth Manuel, retired judge
“My pre-reg was due to begin the first week in August – however, COVID-19 led to it being postponed by a month” Peter Grant, PAGE 47
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CET 67-91 Education and training for the eye care practitioner
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67 CET welcome 68 Is binocular vision a critical component of myopia management? 73 Advances in the management of central retinal vein occlusion 78 Helping parents understand their child’s myopia – a ‘dual purpose’ approach 84 Gaining insight: patient perspectives of the cataract journey 88 Specialist spectacle dispensing 90 External eye pathology In this edition of OT, practitioners can test a range of competencies: OPTOMETRISTS // 4 THERAPEUTIC OPTOMETRISTS // 1 DISPENSING OPTICIANS // 5 CONTACT LENS OPTICIANS // 2
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Business insight and career development The roundtable OT talks contact lens discomfort with practitioners Pre-reg focus Peter Grant and and Luke McRoy-Jones The workshop Managing a redundancy scenario How do I...? Make an online CET claim in England How I got here With OT’s clinical editor, Dr Ian Beasley What I have learned How optometrists have responded to the pressures of the pandemic AOP AGM notice How to attend the annual meeting In conversation OT discovers how engaging with contact lens patients is a good way to help protect business
ONLINE
Cover story
The long view Changing the way optometrists learn is key in ensuring that the profession remains resilient through current and future challenges. OT speaks to practitioners about the road ahead PLUS: a timeline of the GOC’s Education Strategic Review to date, and what training do optometrists in other countries receive? PAGE 59–64
OT video highlights
A roundtable on contact lens discomfort Watch the video on
www.optometry.co.uk Contact the OT team with your experiences, observations and lessons from practice today: newsdesk@optometry.co.uk Follow us on Twitter @OptometryToday
98 SECRET LIFE
Secret life Roshni Kanabar’s bespoke scrapbooks
Like us on Facebook OptometryTodayJournal Follow us on Instagram @optometry_today
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CONTENTS
CONTENTS
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Assessing the impact of the GOC's Education Strategic Review for the profession
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How signs from the retina can show cognitive impairment in patients
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The launch of the association's new antiracism and equality team
Moving home
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The latest designs for a new, purpose-built centre for eye care, research and education at St Pancras Hospital in London have been unveiled. Oriel, a joint initiative between Moorfields Eye Hospital NHS Foundation Trust, UCL Institute of Ophthalmology and Moorfields Eye Charity, would see services move from Islington to Camden’s Knowledge Quarter.
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FIVE WAYS THE EDUCATION STRATEGIC REVIEW COULD CHANGE OPTICAL EDUCATION October/November 2020/Volume 60:08 Issn 0268-5485 ABC certificate of circulation 1 January 2019 – 31 December 2019
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Editor: John White johnwhite@optometry.co.uk Interim deputy editor: Lucy Miller lucymiller@optometry.co.uk Assistant editor: Selina Powell selinapowell@optometry.co.uk
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Senior reporter: Kimberley Young kimberleyyoung@optometry.co.uk Web content and social media executive: Leah Boyle leahboyle@optometry.co.uk Clinical editor: Dr Ian Beasley ianbeasley@optometry.co.uk Clinical editor for multimedia: Ceri Smith-Jaynes cerismithjaynes@optometry.co.uk Video production editor: Laurence Derbyshire laurencederbyshire@optometry.co.uk CET enquiries: 020 7549 2076 CEThelp@optometry.co.uk AOP membership and OT subscription team: AOP, 2 Woodbridge Street, London, EC1R 0DG subscriptions@aop.org.uk
An optometrist’s first day in their first job as a qualified practitioner is a significant milestone Undergraduate study and the pre-registration year prepare optometrists to assess the patient sitting in the chair before them rather than considering a hypothetical clinical scenario. This is not Patient A but Doris; who comes with stories about her grandchildren and her tradition of swimming on the coldest day of the year. For optometrists who have the right training and experience, the first day on the job may seem less daunting. But how can optical education adapt as the sector evolves, technology advances and clinical
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care shifts from the hospital to the community? Since the end of 2016, the General Optical Council (GOC) has been undertaking a review of education and training with the aim of ensuring that optometrists now and in the future have the right skills when they enter the world of work. The optical regulator is now reaching the final stages of its consultations on planned changes to the education of optometrists and dispensing opticians. Below OT summarises how optical education could change following the Education Strategic Review.
GOODBYE TO PRE-REG
Advertising: Richard Ellacott 020 3771 7242 richard.ellacott@thinkpublishing.co.uk Advertising production: aop@ccmediagroup.co.uk Senior designer: Grant Pearce Account director: Anna Vassallo Executive director: Jackie Scully Published bimonthly for the Association of Optometrists by Think Capital House, 25 Chapel Street, London NW1 5DH Printed by Acorn Web, Normanton Ind Estate, Loscoe Close, Normanton, West Yorkshire, WF6 1TW All rights in and relating to this publication are expressly reserved. No part of this publication may be reproduced in any form or by any process without written permission from the AOP or the publisher.
8 www.optometry.co.uk
At present, optometrists generally complete three years of study followed by a pre-registration year. The GOC is proposing that clinical experience is integrated within the course. The optical regulator has indicated that the change is partly informed by research the GOC conducted in 2018 that found that 60% of newly qualified optometrists felt
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professional experience there was not enough would need to be offered clinical experience within across more than one their course. sector and more than Under the new model, one practice setting. education providers The Association of would need to provide British Dispensing 1600 hours (48 weeks) Opticians has of professional questioned and clinical whether there experience is enough to students evidence to over the support the course HOURS overhaul of of their of professional and dispensing studies. clinical experience optician Educators education. would have While the 2018 the flexibility research found that to decide how this experience is offered – so most newly qualified optometrists thought it is possible that some there was insufficient providers would choose clinical experience, 70% to offer it in a single of dispensing opticians block, resembling the thought it was set at current pre-registration about the right level. year. Clinical and
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SINGLE PROVIDER RESPONSIBLE FROM FIRST DAY AT UNI TO GRADUATION Under the planned changes, a single institution would be responsible for an optical student’s journey to qualification. Described by the GOC as a ‘single point of accountability’ (SPA), the education provider would need to be legally incorporated and offer either an academic award or a regulated qualification. This means the qualification would be overseen by an independent body. Universities that already offer optometry qualifications would have three options to transition to the new system. They could either ‘teach out’ existing qualifications while developing a new
qualification at a timeframe agreed by the GOC, or they could adapt an existing qualification so it meets the new requirements. The third option would be to teach out an existing qualification while partnering with another organisation to develop a new qualification for approval. Under the phased approach, early adopters could begin to recruit students for a September 2022 start. However, it is envisaged that the two models would run side-by-side for some time. The GOC anticipates that the Scheme for Registration may need to be operational until 2030.
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A flexible approach The Education Strategic Review signals a change in direction by the optical regulator from a more detailed competency-based approach, with defined inputs, to one driven by high-level outcomes evidenced through quality assurance. This shift in focus could create flexibility so that education providers can adapt to changing technology and service delivery. Each education provider will decide how to educate and train students so they have the required knowledge, skills and behaviours in seven key areas. The proposed learning outcomes fall into the following categories: personcentred care, communication, lifelong learning, ethics and standards,
bibonline.co.uk New start Refits Package deals risk, clinical practice and leadership and management. Professional bodies, including the AOP, have raised concerns about how consistency will be maintained across different education providers under the planned model and the implications that this could have for patient safety. The optical regulator has the power to check that learning outcomes are being met through periodic, thematic and sample-based reviews. A serious concerns review can be initiated if a provider is failing to ensure the necessary outcomes.
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For more information, please contact us on: 01438 740823 sales@bibonline.co.uk bibonline.co.uk
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Principles of equality and diversity are incorporated into the GOC’s planned education framework. The GOC proposes that those who are responsible for student selection receive equality, diversity and unconscious bias training. The optical regulator would also require education providers to gather and analyse data regarding progression of students by protected characteristic. Equality and diversity data should inform curriculum design, delivery and assessment.
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PRE-REG SUPERVISION GRANT Pharmacist: £18,440 Optometrist: £3,549
A new funding model Designing new courses and integrating clinical experience into academic study will come at a cost to education providers at a time when resources are already strained in the wake of COVID-19. This could also have implications for students if the cost of undertaking an optometry degree changes. The AOP has voiced concerns that the financial impact of changes has not been properly evaluated and the resulting implementation risks will need to be managed as the December 2020 deadline for confirming the new model draws near. Optometry training is funded much
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less generously than some other healthcare disciplines, including pharmacy. For example, pharmacists are eligible for a pre-reg supervision grant of £18,440 a year compared to a grant of £3,549 for the supervision of pre-reg optometrists. A GOC paper prepared in advance of a roundtable in March on funding considerations explored potential ways of securing new funding. Avenues highlighted included calling for an expansion of the number of placement providers who are eligible for a pre-reg supervision grant, so it is
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not restricted to practices funded under the GOS contract. The optical regulator also highlights the potential to call for funding from Health Education England and equivalent institutions in Wales, Scotland and Northern Ireland. Dentistry, pharmacy and medicine already receive support in this manner.
Have your say Share your thoughts on the GOC’s Education Strategic Review. Consultation closes 19 October https://consultation.optical.org
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INDUSTRY SUPPORT
a trusted brand for
Research by Fight for Sight and the London School of Economics indicates that sight loss costs the UK economy £25.2 billion a year. The report highlighted the personal impact of sight loss and its wider costs to society – which have been compounded by COVID-19.
10 + YEARS REPRO OP
Clinitas dry eye soothing solutions ¨
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“The huge changes brought about by COVID-19 need to be used as a way of kickstarting the green recovery” Coral Eyewear founder, George Bailey, spoke to OT about the eyewear brand’s successful Kickstarter campaign to raise awareness of its sustainable frames and support a scaleup of production ahead of the autumn launch.
Clinitas Soothe® & Clinitas Soothe® Multi
CLIENT
The spectacle brand, Cubitts, has opened its first practice outside of London, with a new base in Brighton. Speaking to OT, Cubitt’s marketing and communications manager, Liz Moffatt, explained that the outbreak of COVID-19 had delayed the opening of the new store, “but we feel very lucky to be in this position.”
W
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Clinitas® 0.2% & Clinitas® Multi 0.2% • 0.2% sodium hyaluronate • Extends established range
A survey by Alcon into the impact of COVID-19 on contact lens usage found that 90% of patients expect to return to their normal wearing schedule. Approximately 75% of the 1500 contact lens wearers surveyed said they were open to discussing upgrades.
Add Comfortear® Lacrisolve® 180 plugs to your dry eye toolkit, when patients need more than dry eye drops. Contact Altacor for further information.
www.altacor-pharma.com 0118 902 6766
12 www.optometry.co.uk
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Media 10, organisers behind the industry show 100% Optical, have announced plans to move the 2021 event to a new date. The decision followed an announcement made by the UK Prime Minister to postpone the restart of exhibitions and conferences. The optical event will now take place from 8–10 May at ExCeL London.
Zeiss Vision Care has launched a new website and self-service platform, bringing all of its resources into one place and enabling professionals to manage their accounts online.
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• Choose from resealable individual droppers (with 12 hour use) or a multidose soft tip dropper (3 months use from opening) • 0.4% sodium hyaluronate, the highest strength available on the market • Preservative free and contact lens friendly
Bayfields Opticians and Audiologists completed three new acquisitions in its first deals since lockdown began. The three agreements, which founder and CEO, Royston Bayfield, described as “significant in our overall expansion plans,” added Gohil and Grey in Leamington Spa, Pendleburys in Maidstone, and Cooper & Leatherbarrow in Barnard Castle to the group.
THE AUDIT
SCIENCE AND VISION Research has found that using ‘no water’ labels on contact lens cases could help to reduce the number of patients who expose their contact lenses to water. Researchers from the School of Optometry and Vision Science Sydney at the University of New South Wales found that in a trial of 188 contact lens wearers, the overall water exposure score and endotoxin levels reduced significantly in a group that received cases with stickers, compared to those that received plain cases.
619,000
The number of monthly searches made worldwide for ‘optometrist’ and
‘optometrist job,’ placing the profession at the top of the list of the most-Googled science, technology, engineering and mathematics (STEM) roles worldwide, according to recent research by electronic component company, RS Components.
This year, the ELZA Institute in Switzerland carried out what it called a world-first crosslinking procedure at the slit lamp. Professor Farhad Hafezi, chief medical officer at ELZA Institute, spoke to OT about the future of cross-linking and treating bacterial keratitis at the slit lamp, suggesting this method could “democratise access and increase global coverage.” Watch the video online at: youtu.be/ hBwWT62wnIU
Pixabay/Juraj Varga
GUIDANCE & ADVICE Experts have noted an increase in reports of dry and uncomfortable eyes among regular face mask wearers. Observing this, the Centre for Ocular Research and Education (CORE) created guidance for optometrists to recognise and treat maskassociated dry eye (MADE). Dr Lyndon Jones, director of CORE, commented: “Face masks are crucial in the fight against COVID-19, and ECPs are well-positioned to provide patients with advice on appropriate wear in order to maximise eye comfort.”
The General Optical Council (GOC) approved temporary changes to its Optometry Handbook and supervision policy in light of the continuing impact of COVID-19 on students and training. Changes include a reduction of 10% in the total number of GOC stage 2 patient episodes a student must achieve, and an extension to the stage 1 Certificate of Clinical Competence for summer 2018 graduates.
Hull University Hospital has launched a new fully integrated refractive laser eye surgery suite. The state-of-the-art Bausch + Lomb suite is the first of its kind in the country and will be used to treat NHS patients throughout the North of England undergoing cataract procedures and corneal surgery. The hospital suggested the new suite would improve the accuracy of complex eye surgery, and attract medical talent to the region.
IN PRACTICE
“Pound-for-pound and penny-for-penny, a pre-reg optometrist is arguably one of the best value assets in the practice. Perhaps even more so in the context of the current crisis” OT clinical editor, Dr Ian Beasley, highlighted the benefits a pre-reg optometrist can bring to the practice, particularly as optometrists work through the backlog of patients post-lockdown.
Optometrist Drew Thompson has been recognised as a ‘COVID-19 Hero’ by the Mayor of Fylde for producing face masks during the pandemic. Engaging 3D printers and a team of volunteers, including his family, Mr Thompson produced and donated between 1500 and 1600 face shields for frontline and essential workers across the Fylde.
“The pandemic has emphasised that, while we need to innovate, we shouldn’t underestimate the value of having a personal phone conversation” Optometrist Faye McDearmid shared her experience of balancing communication methods through lockdown, and the tools she plans to continue using in the long-term, with OT.
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Responding to redundancy
Shutterstock/ Anna Murcia
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As COVID-19 support measures come to a close, charities have called for an increased focus on wellbeing As the furlough scheme winds down, organisations have seen a rise in employment concerns. The employment advice service, Acas, saw calls to its redundancy advice line almost triple in June and July, rising nearly 170% compared to the previous year, from around 12,000 to more than 33,000 calls. The AOP’s employment team has also seen an increase in enquiries relating to redundancy, as well as concerns relating to changes or cuts in hours as practices try to handle the new challenges brought about as a result of COVID-19. Liz Stephenson, the AOP’s head of employment, explains: “Practices have struggled with the suspension of routine work and some have had to see fewer patients due to changes in working methods, the need to ensure social distancing within practices and additional hygiene requirements, meaning it takes longer to see one patient.” The AOP legal team has been working to provide guidance and support to members facing these difficulties. For more on redundancy guidance, go to page 49.
“We are now beginning to see the real fallout from an economic and social shut down that has lasted for most of this year” Simon Coombs, founder and director of Working Minds
“We have been advising members as to their rights when being made redundant, assisting them in relation to questions to ask and points to make, and arranging for them to be accompanied by trade union representatives where appropriate,” Ms Stephenson commented, adding that members seeking support should get in touch at the earliest possible stage. The wellbeing impact Mental health charity, Mind, has warned that the impact of unemployment and financial difficulties on mental health could grow as the Government measures come to an end. Working Minds, an organisation providing support in education and the workplace, has seen an increase in enquiries over the past three months, a trend that founder and director, Simon Coombs, expects to continue. He told OT: “We are now beginning to see the real fallout from an economic and social shut down that has lasted for most of this year.” Concerns around redundancy and employment bring a range of emotions, Mr Coombs explained: “Grief, loss, denial, anger, rejection, intense sadness. If not managed progressively, feelings of anxiety, low mood and depression can take hold, which impact on the person’s whole life.” Global consultancy, The Wellbeing Project, which works with businesses to measure and support workplace resilience and its impact on wellbeing, has seen concerns evolve over the pandemic. October/November 2020
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In spring, many people had to adapt quickly to the changes and there was a great deal of fear. Sam Fuller, founder and director of The Wellbeing Project, explains that this was followed by feelings of tiredness and isolation. “Now there is a bit of a reset as people prepare themselves for the long-haul, knowing there could be a second wave, or that it will at least be some time until things return to normal,” Ms Fuller commented. The end of furlough is also bringing shape to the concerns around employment and redundancy, she suggests. Keeping well through redundancy Ms Fuller explains that, for those facing redundancy, it is important to remember: “A lot of people find themselves redundant through no fault of their own. It’s not a performance issue, it’s a worldwide issue and something that we have very little control over.” Mr Coombs also emphasises that it is key to remember that, “Redundancy feels personal, but logically, it is a process. If we can bring our thinking along these lines, we can feel less emotional about it and more logical.” Closure is “massively important” to a person’s wellbeing if being made redundant, Mr Coombs adds, suggesting that it is key to create as good an ‘ending’ as possible. “We can also look upon redundancy as an opportunity to make changes,” Mr Coombs added. “It may not have been our choice in the first place but we can choose what we do next and feel more empowered.” Ms Fuller agrees, commenting: “It can become the beginning of a much better thing.” She recommends: “We need to take ourselves away from a black and white mindset. That means: ‘What jobs can I do, what opportunities are there for me in the meantime?’” When supporting employees or colleagues through the process of 16 www.optometry.co.uk
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Ensure there is closure and try to make it a ‘good ending’ Remember that redundancy isn’t personal, or a performance issue Managing energy is important, such as taking time to exercise and eat well Remind yourself of your achievements and the skills you can bring to a new role The AOP’s legal team is available to members seeking advice – go to page 49 for more on the support the AOP can provide.
“A lot of people find themselves redundant through no fault of their own. It’s not a performance issue, it’s a worldwide issue and something that we have very little control over” Sam Fuller, founder and director of The Wellbeing Project
redundancy, Ms Fuller recommends keeping communication open and checking in to ensure they are okay. Mr Coombs adds: “Ensure there is closure and that the person does not cut contact or become less communicative or make excuses. Support their routines, offer emotional support and try to remind them of their worth.”
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Tackling colour vision deficiency bringing together experts from across Europe, this project offers the prospect of establishing the cellular and molecular basis for why patients with type 2 diabetes have both retinal disease and a parallel risk of cognitive impairment later in life. “Such an understanding of what is happening in both the eyes and the brain will be the foundation for early diagnosis and the development of new treatments that will improve patients’ lives.” The EU Horizon 2020 grant will provide €6 million (£5.4 million) to the project.
Multifocal contact lenses slow myopic progression by 43% displaying the highest increase in A new study published in JAMA myopia, with -1.05 D progression. has investigated the effectiveness of Researchers highlighted that high multifocal contact lenses in slowing the power multifocal contact lenses slowed progression of myopia in children. myopia progression by 0.45 D and eye The research involved 294 myopic growth by 0.23 mm children between the ages of seven and 11 "High power multifocal compared with single-vision contact who were assigned contact lenses slowed lenses. either high power myopia progression by In comparison multifocal contact 0.45 D" to medium power lenses, medium power multifocal contact multifocal contact lenses, high power multifocal contact lenses or single vision contact lenses. lenses slowed myopia progression by After three years, those in the first 0.29 D and eye growth by 0.16 mm. group had myopic progression of -0.6 The scientists highlighted that further D, with those in the second group research is needed to understand the experiencing -0.89 D progression and clinical importance of the findings. those who wore single vision lenses
New research published in Current Biology has explored the effect of wearing spectacles with spectral notch filters for patients with colour vision deficiency. The study found that those with anomalous trichromacy experienced improvements in their colour vision after wearing the specially adapted EnChroma spectacles for two weeks. The researchers observed an increased chromatic contrast response in those with colour vision deficiency but not in volunteers with normal colour vision. The authors noted that it was unclear how long the effect lasted after the participants took off the specially adapted glasses. Werner et al. DOI: 10.1016/j.cub.2020.05.054 DIABETES
Using smartphones to screen for diabetic retinopathy
New research published in Ophthalmology has explored the potential of smartphone technology for diabetic eye disease screening in India. Ophthalmic assistants at Sankara Eye Hospital in Bangalore took retinal images of 381 eyes in 193 patients. The authors concluded that smartphone-based fundus imaging can meet diabetic retinopathy screening requirements in an outreach setting, but not all devices are suitable in terms of image quality and diagnostic accuracy. Wintergerst et al. DOI: 10.1016/j.ophtha.2020.05.025
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NEWS
Researchers from the University of Maryland School of Medicine have located stem cells in the area of the optic nerve that transmits signals from the eye to the brain. The study, which is described in Proceedings of the National Academy of Sciences, provides new insight into how glaucoma may develop. To carry out the research, scientists examined the optic nerve lamina, a 1mm wide band of tissue between the retina and the optic nerve. The presence of neural progenitor cells was identified using antibodies. Bernstein et al. DOI: 10.1073/pnas.2001858117
OT’s Selina Powell reviews the latest clinical news and research papers
A new research project will examine how the retina can reveal signs of cognitive impairment in patients with type 2 diabetes. Scientists from Queen’s University Belfast and from Vall d’Hebron University Hospital in Spain have been awarded funding from the European Union to undertake the research through a Horizon 2020 grant. The four-year Recognised project will investigate whether the biological mechanisms that cause structural and functional alternations in the retina in people with type 2 diabetes could be the same pathways that influence the development of cognitive impairment and dementia. Lead researcher from Queen’s University, Professor Noemi Lois, said the research could help to identify cognitive impairment in diabetes patients earlier, enabling the provision of better support. “Importantly, this study will help us to understand better the mechanisms of cognitive decline in people with type 2 diabetes, which is required for the development of new treatments,” she said. Professor Alan Stitt, The McCauley Chair of Experimental Ophthalmology at Queen’s University, shared: “By
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Main and inset images: Inspecs
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Manufacturers and suppliers for the optical industry have had to switch to supporting practices remotely throughout the pandemic. With analysts suggesting the remote model is here to stay, OT spoke to companies from across the sector to hear their thoughts The lockdown in the UK necessitated a move to virtual communications for many professions, particularly for those in business to business (B2B) sales. This has accelerated digital trends that experts believe were already gathering steam. Surveying seven sectors in 11 countries, the management and consulting firm McKinsey & Company found that, by April, almost 90% of sales had moved to a remote model. Surveys by the firm in August found that digital self-service and remote sales are “likely to be the dominant elements” of interactions going forwards. Over the past few months, B2B interactions within optometry have moved away from the traditional format of face-to-face meetings to remote models, first supporting practices through the lockdown, and continuing as they try to work through the backlog of patients. The right thing Like many, contact lens manufacturer Alcon’s sales team have been delivering 20 www.optometry.co.uk
remote account management, in lieu of in-person visits, since April. “Initially, it was simply ensuring customers knew we were here for them, and that we were listening to what they needed from their partners,” explained Graham Firth, Alcon’s head of sales. Now that practices are finding their feet once more, the team has found that conversations have begun to shift back to more product-focused topics. “We have enabled a more visual feature via iPads, which allows the customer to see exactly what is on the account manager’s screen, as if they were there in person,” Mr Firth explains.
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Operating remotely has had its benefits for the team, being time and costeffective, as well as more environmentally friendly. Customers have also been more proactive in reaching out to the team, realising that operating remotely means the account manager is more accessible. The team has not yet seen a strong demand for in-person sales, Mr Firth said: “There have been a few questions of ‘when are you coming to see me?’ It is nice to know we are welcome. “But for now, the right thing is to continue our ‘safety-first’ approach for our employees, customers, their staff and patients – and I think our customers appreciate this approach,” he added. Enhanced flexibility While some practices are open to reestablishing face-to-face meetings, others have been too busy managing the backlog of appointments – something many of the suppliers noted when speaking to OT – recognising the need to squeeze conversations in before a practice opens, between appointments or at the end of the day. Chief commercial officer for eyewear frames designer and distributor Inspecs, Steve Tulba, explained the sales team has kept “as engaged as possible” whilst being mindful of the varying effects the pandemic and lockdown have had on different businesses. To offer enhanced flexibility in the way their customers can be served
“It's up to us...to utilise the opportunities we have to ensure that the recovery is strong and solid” David Baker, general manager, Rodenstock UK going forwards, Inspecs has worked on developing a B2B e-commerce platform. Designed with independent practices in mind, the platform enables salespeople to engage with customers remotely. “What we have tried to do is give options to people, so that regardless of their time and how they wish to approach the procedures of dealing with COVID-19 at a retail level, we’re there to serve them.” Considering the future for sales interactions, Mr Tulba suggests there will be an "omni-channel" approach. He explained: “Customers may want to view collections and order them entirely online, but with a salesperson talking them through, while others may want to do that entirely independently, and others might want to see a salesperson and look at a product face-to-face.” Getting creative The need to offer flexibility has been a key takeaway for the team at specialist ophthalmic contract sales company, Positive Impact. Speaking to OT in the summer, managing director for Positive Impact, Maxine Green, suggested that face-to-face meetings would be unlikely to happen “in any big way until the end of September, probably into October.” A resource that the company already had in place, webinars were found to be particularly useful for sharing information with customers over the past few months. Noting the potential limitations of the traditional format of inviting practitioners together for a physical demonstration, director of marketing and professional services, Nick Atkins, commented: “We’ve all wondered why we weren’t using these platforms – particularly webinars – a lot more previously.”
Below: Rodenstock created tools for practices to view ranges virtually
With trade shows postponed, the team has also had to take a creative approach to presenting products, filming video versions of the demonstrations they would typically have given at exhibitions. While remote solutions have been beneficial, the company emphasised the benefits that only a face-to-face meeting can bring, suggesting “people prefer meeting people,” and that the longer people are unable to meet, the more there will be a need to do so. Working together at every level Operations at eyewear, lens and equipment manufacturer, Rodenstock, remained open on a revised structure through the pandemic. The company set up emergency packages, which offered a quick turnaround for customers who remained open for essential services. With the business now returned to full operations, David Baker, general manager for Rodenstock UK, explained that the company has worked on creating tools to support remote product engagement. This includes enhancing its platforms for digital discussions and selling, such as with an application that displays the company’s ranges, allowing customers to view them in 360 degrees and explore all the product details. “It’s up to us to give our partners as many options as possible and utilise the opportunities we have to ensure that the recovery is strong and solid,” Mr Baker commented. Looking at the longer-term for B2B interactions, Mr Baker said he believes communication between suppliers and their customers will take more of a ‘multi-level’ approach. “The old buyer-and-seller mentality is old fashioned and outdated. What we have to do, as we do with our partners now, is to set agreed mutual objectives and then we work together to make those happen,” he explained. Suppliers now have to work “at every level” with their customers, or partners, Mr Baker suggested. “We support partners with marketing, systems, patient relationships, shop fitting, communications to patients, even diary management.”
More than just an OCT Observe and measure all the main structures and surfaces of the eye Posterior OCT Anterior OCT OCT-A Angio OCT-B Biometry OCT-T Topographic
(due mid 2020)
True colour fundus imaging
It’s as simple as pressing
the START button
01438 740823 sales@bibonline.co.uk bibonline.co.uk
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AOP on your side Effective communication around flashes and floaters
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compliance, as well as good record keeping. Ms Kanabar said of the podcast: “My work at the AOP involves providing clinical opinions on clinical complaints as well as on GOC and civil cases, a lot of which are on missed retinal detachments. “Usually there is a theme of common mistakes or misunderstandings between the patient and practitioner that has led to the complaint," Ms Kanabar said, adding that managing patients with flashes and floaters "starts with well-trained support staff and practice procedures.” To hear more from Ms Kanabar, find the episode at bit.ly/DOCET_SOE3_audiogram
Supporting members through COVID-19 PRODUCTION
How the AOP has been delivering advice and resources in August and September Advice
Resources
CLIENT
After the Department of Health and Social Care extended access to its personal protective equipment (PPE) portal, the AOP shared steps on how to access the free PPE The AOP employment team shared new guidance for members around rights on redundancy, including redundancy pay, notice and time off to look for work With shielding paused on 1 August, the AOP updated its employment guidance around supporting those employees considered ‘extremely vulnerable’ After the CET claims window opened in England, the AOP shared advice for claiming a CET grant. The 2020 process for CET grants has moved entirely online with new steps required to make a claim. Visit page 50 for more guidance on how to claim. While it is not compulsory for members of the public to wear a face covering in optical practices, the AOP shared information on rights to refuse consultation if a patient refuses to wear a mask The AOP contributed to a consultation on temporary changes to the General Optical Council’s (GOC) Optometry handbook and supervision policy The AOP held a webinar with GOC director, Leonie Milliner, to discuss the regulator's proposed new framework for future optical education and training.
On 4 August the AOP launched new guidance for tackling racism and inequality at work, including resources for employees and employers. The AOP also established an Anti-racism and equality team (ARET) The AOP launched a new AOP locum vacancies list, enabling member practiceowners to upload available positions To support pre-registration optometrists and students, the AOP launched a free Prereg register where members can list their availability for pre-reg placements The AOP hosted a series of locum focus group webinars in partnership with Johnson & Johnson Vision to gain their insight into the issues locum members are facing at a local level. Findings from the groups will help shape support for locum members through the rest of the year On 3 September OT launched a reader survey into contact lens practice during COVID-19, in partnership with Johnson & Johnson Vision In partnership with Johnson & Johnson Vision, the AOP held three virtual peer discussions tailored to independent practitioners The AOP has continued to deliver virtual peer discussions, which were moved online earlier this year due to COVID-19.
Financial and employment
The AOP wrote again to the Treasury, raising concerns for five groups of members who are not eligible for COVID-19 support As discussions with NHS England rolled on, the Optometric Fees Negotiating Committee (OFNC) confirmed that COVID-19 funding would likely be extended to 31 August for fixed practices reaching a minimum level of historic GOS1 activity (predicted to be 40% or more), as well as for domiciliary providers, with no activity threshold
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Shutterstock: Likekightcm
SUBS
Retinal detachments and why these are the leading cause of complaints to the General Optical Council’s Fitness to Practice committee were on the agenda for the September episode of the Directorate of Optometric Continuing Education and Training podcast, Sound Optometry. Tackling “flashes and floaters,” host Michelle Hanratty explained that the episode focused on how to go about addressing the issue with consultant vitreo-retinal surgeon, Stephen Lash, providing clinical pointers on investigating flashes and floaters, while AOP clinical and regulatory adviser, Roshni Kanabar, shared guidance on effective communication to ensure patient understanding and
AOP launches locum vacancies list. Members can advertise locum positions free of charge The AOP has created a new resource to enable practiceowning members to advertise available locum positions free of charge. The new Locum vacancies list is available to all members and was launched to support members with vacancies, or those in search of work. Just days after its launch, the list had already received over 2500 page views. The new resource complements the existing AOP Locum register, where locum members can list their availability. The locum vacancies list can be accessed by visiting: www. aop.org.uk/locum-vacancies
Recognising the challenges optometrists have faced through the COVID-19 crisis, the AOP began offering non or lapsed members 20% off the membership fee in 2020, to ensure more professionals can access AOP support and the benefits of membership Two months after the first phase of COVID-19 support formally ended for optical practices in June, the OFNC raised concerns that NHS England had still not confirmed its position on guidance for future support.
Getty: PrettyVectors
REPRO OP
AOP clinical and regulatory adviser, Roshni Kanabar, appeared in episode three of DOCET’s new optometry education podcast
AOP EXPERTS
Addressing racism and discrimination
Getty: Iiulia Kudrina
The AOP has established a new team to help members respond to experiences of discrimination in practice
The AOP has established the Anti-racism and equality team (ARET) as part of its support for addressing racism and discrimination in practice. The team can personally empathise with members facing racism or discrimination in practice, and offer advice on steps to take. The work was prompted by evidence gathered by optometrist Hamza Mussa and the idea for the ARET team was prompted by AOP member Naveed Butt and his colleagues. Discussing ARET, Kathy Jones, AOP policy adviser, said: “We recognised that not all of our members realised that we could assist on the topic of racism.” “Also, not everybody who faces discrimination is sure that they want to take formal action, but instead might find it useful to talk through their options with someone who can give empathetic and knowledgeable advice,” Ms Jones added.
Farah Topia and Roshni Kanabar, AOP clinical and regulatory advisers, discuss the ARET Why did you want to join ARET and what does this involve? FT: I have lived abroad growing up and have also worked in a number of environments throughout my career. I hope that my varied background and my belief that no one should have to deal with racism whilst simply trying to do their job will enable me to be an effective support mechanism for members dealing with racism and discrimination in the workplace. As well as listening to concerns, we can help members decide if there is any further action they would like to take. This can be supported by the AOP’s legal team.
part of this team, I jumped at the chance for two reasons. Firstly, because I felt that from my days as a locum optometrist working in many different companies and geographies, I had an understanding of how sometimes racism and discrimination can be brushed under the carpet or disguised. Secondly, I am a naturally empathetic person and felt this would allow me to help support our members.
RK: Our role involves speaking to members that have contacted us via telephone or email. When I was first approached to be
What would you say to members who might face discrimination in practice? RK: Please get in touch. Often
people do not speak up for fear of creating a fuss, getting into trouble, or for fear of not having their feelings taken seriously. ARET is here to support optometrists from any background, regardless of age, gender, ethnicity, or background. We are here to provide a listening ear and support. Members who have experienced racism or discrimination in the workplace and would like support or to discuss their options can contact Farah and Roshni by emailing ARET@aop.org.uk
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Patient-facing upgrades
Advanced Ophthalmic Systems (a Sparca company) has launched the latest version of its software, AOS 3.0. While retaining its clinical functions as an objective grading software, the update introduces features such as a new web-based platform which allows the tool to be used on any device, and a patient-facing app to enable athome triage. The tool provides patients with a link, and also allows them to take images to share with the practitioner. www.aos-hub.com
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FOCUSES ON... REMOTE CONSULTATION
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Hit list
The trends, launches and looks
NHS Forth Valley
CLIENT
Expanding Attend Anywhere
Attend Anywhere, delivered through communication platform specialists, Involve, has seen a significant increase in queries. The platform enables practices to embed video consultations to a webpage and see patients in virtual clinics. Patients enter through the practice website and wait in an online waiting area with no dial-in details needed. Mick Roach, director of strategic health alliances at Involve commented: “It seemed that the Attend Anywhere service would be a perfect match for the High Street optometry market.” www.involve.vc/attend-anywhere
Innovation in resources
Simple connections
This summer Ocuco launched its new Virtual Consult platform to facilitate virtual consultations between practices and patients. The tool allows an optometrist to assess a patient’s symptoms and offer actionable advice remotely. While supporting remote triaging, the platform can help to ease the safety concerns of patients travelling to the practice during COVID-19, the company suggests, and can help to keep in-practice footfall within social distancing guidelines. www.ocuco.com/uk
Livi Connect is a new, free platform to enable health professionals to hold video consultations with patients. Livi Connect works with existing systems and enables optometrists to send a one-time SMS link to a patient’s mobile phone, providing them access to a fully-encrypted video consultation. The company told OT that in the months ahead, they are also working on a meeting room with a newly launched booking link for later calls, and a tool to enable screen sharing and for users to send documents securely. www.livi.co.uk/connect
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Q&A ME AND MY GLASSES
LOOK
Optometrist and lifestyle blogger, Lizzy Yeowart, concludes now is the time for something completely different
SUBS
What a year it has been. Cheer yourself and your clients up with bold, brave eyewear – and let’s celebrate the fact that we have got through it all so far.
ART PRODUCTION
Made in the 1970s
CLIENT
Alexander Sims
Pugnale has always prided itself on uniqueness. The rose-shaped Rosaspina has ceramic nosepads and acetate temples for optimal comfort, and is handmade in Italy. Pugnale, ‘Rosaspina’ pugnaleeyewear.com
The British Formula E driver discusses his new partnership with Coral Eyewear and his need for durable frames
1
3
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I have been wearing glasses for four years. I was prompted to go for a sight test as I was experiencing slightly blurred vision, particularly at night. My eyesight had probably been getting worse over time but you don’t notice because it is so gradual. I remember when I first put my glasses on, it was like everything was in high definition. My eyewear is purely function over form. The frame and arms of my glasses can bend almost 180 degrees; they are super flexible. I needed them to firstly be kid-proof. Then, when I’m racing, the arms need to shape slightly around my head when inside my helmet. To not have anything that is solid or rigid felt more comfortable.
Everything Coral Eyewear stands for pairs with my own priorities. For the last 10-12 years I’ve been getting more passionate about sustainability. Wearing glasses is not something I had factored into this before. We heard the story of how Coral Eyewear makes the glasses using recycled plastic and it seemed like a really nice fit. I quite like a simple, fairly understated design of glasses. My eyewear has got to work with my lifestyle. They need to be durable, because inevitably playing with my kids, there is scope for them to get damaged. This is exactly the same for racing. You want something you can put down on the side and it doesn’t matter if they get a bit scratched.
Attention grabbing
For the non-conformist and avantegarde, Genesis eyewear offers designs inspired by Lichtenstein and Mondrian. Be it asymmetric designs or unique colour combinations, every Genesis style demands attention. Genesis, ‘Easy’ area98.it
Finding layers
The layered rim construction of the metal ‘Techno’ geometric frame is a guaranteed head-turner. This design features one rim with a diamond-etched finish, superimposed upon a second coloured rim. X-IDE, ‘Techno’ x-ide.com
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Contact lens
Smart fitting
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Menicon launched a new toric version of its Miru 1day Flat Pack contact lens in September. The lens features Smart Fit technology with a thin bi-aspheric toric design, created to match the natural contours of the eyelid and self-orient. The material also bonds with tears to lock-in moisture and allow for rapid lens rehydration when blinking. The flat pack packaging also uses less raw materials and is recyclable. www.menicon.co.uk
SHORTLIST THE LATEST PRODUCT LAUNCHES
SUBS
Spectacles
Leader of the pack ART PRODUCTION
Wolf Eyewear has released its latest collection of unique, bold frames, inspired by colour: “the more, the better.” The collection, available exclusively to independent practices, introduces a range of materials and styles with colours chosen specifically to work well with a variety of skin tones and hair colours. The acetate used in the collection is made of a high-density laminate, selected to ensure the colour combinations are unique to the brand. www.wolfeyewear.com
CLIENT
Spectacles
Manufactured menswear
Roveri Eyewear has released a new concept frame for 2020, featuring a full carbon fibre structure, in what the company says makes it a first-of-its-kind in eyewear. The ‘CLM-7’ frame features a matte carbon fibre front, with a marble Roveri pattern. The frame is created from a multi-layered block of carbon fibre, and also boasts titanium sides and acetate side tips. The design is available with either polished or satin titanium sides. www.roverieyewear.com
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Drops
Molecular innovation
Scope has announced the launch of its new eye care product, Hycosan Shield. The unique eye drop brings a new molecule to the eye care category, making it the first to market in the UK containing the molecule. The product features a single ingredient, water-free, preservative-free and phosphate-free formulation. Scope also suggests the product has the ability to completely replace the lipid layer. www.scopeeyecare.com
To feature in OT’s Hit list, contact kimberleyyoung@ optometry.co.uk
Sports
Along for the ride
Performance eyewear brand, SunGod, has launched a new cycling-specific Pace Series. Comprised of two models, ‘SunGod Velans’ and ‘SunGod Vulcans,’ the sunglasses are made from high-quality, durable materials and feature the brand’s 8KO lens technology, which it suggests offers clarity, strength and weight savings. The models are available in either a half frame or full frame design. ‘SunGod Vulcans’ features a larger cylindrical lens, offering a 180 degree field of vision, while the ‘SunGod Velans’ uses a refined toric lens. www.sungod.co
Framesi
Planet positive
Coral Eyewear is launching its collection of sustainable, infinitely recyclable, ‘planet positive’ eyewear – with each pair removing plastic and abandoned fishing nets from the ocean. The Endangered Collection features six ophthalmic designs, as well as a range of sunglasses, in four colourways: black, brown, blue and red. Each of the frames had been named to raise awareness of marine animals under threat of extinction. www.coraleyewear.com
Sunglasses
Soft-toned style
OWP has shared new statement sunglasses for Mexx. The new styles include a 70’s-inspired acetate model for women, available in soft tones including lavender, Bordeaux and nude or black. The super-fine super-fine metal sides also feature a small conical metal accent. The ‘2542’ model features a rounded frame in acetate along with simple metal arms and colours ranging from transparent Bordeaux to nude or blue-violet to Havana. www.mexx-eyes.com
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FOCUSES Q&A ON... BEHIND NEW THE BRAND WOMEN’S EYEWEAR
TOPCON SUBS
John Trefethen, VP of global marketing and product design, on reacting to COVID-19
ART
TOPCON
//
Clockwise from top: The Myah device; John Trefethen; Topcon provided breath shields to customers
How has the outbreak of COVID-19 affected Topcon?
PRODUCTION CLIENT
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Topcon’s core competencies are based on three points. The first is simple access. Topcon’s devices are designed to be easy to use, operated with ‘the press of a button’
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Topcon simplifies access to data by pulling it all together under one device-agnostic dashboard and work to give meaningful access to that data
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Topcon connects devices so clinicians can operate them remotely, safely and at convenient times that work for the patient.
Though revenues took a dip because of the pandemic, Topcon rebounded quicky. Topcon’s automated phoropter, CV5000, is a mainstay of the product portfolio. The device was already available for remote control and has been selling in record quantities. When the pandemic first arrived, we started a project called the ‘Safe Distance Campaign,’ providing modifications to our existing technologies to help maintain distance in practice. We also created a webpage called ‘Topcon Cares,’ highlighting support for our customers. Did the outbreak affect any plans or launches? 2020 was our year to launch six products into the world. As an industry that has relied heavily on trade shows, we have had to pivot. This autumn, Topcon Healthcare is launching a new experience for receiving product and announcements virtually. Experts will be presenting on very relevant topics for today, while Topcon will also be launching our new products to the world, including a new companion to the digital phoropter. Could you tell us about the launch of the Myah device? Launched in Europe this summer, Myah continues in the tradition of Topcon’s multimodal device technologies. Myah is a combination instrument that provides the tools to support myopia management. The device also provides progression reports for analysing treatments, as well as a suite of dry eye tools.
STYLE
NOTES This issue, OT columnist, Lizzy Yeowart, considers a dispensing scenario. This month: frames for a 66-year-old female glasses wearer
Elegance epitomised
Hair and skin fades with age. A vibrant pop of colour will stop the wearer from looking washed out. Think of Prue Leith. For elegant, warm neutrals Coco Song is hard to beat. Coco Song, ‘CCS 125’ area98.it
Lizzy says "A 66-year-old woman is likely to have a strong sense of her own individual style. She will know exactly what she wants – and what suits her."
Crystal touch
Glamorous grandmothers won’t be able to resist the Aurora by Pier Martino. In handmade acetate with Swarovski crystal detail, the soft neutral will flatter all skin tones. Pierre Martino, ‘Aurora’ piermartino.it
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Voices from optics and beyond
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A positive new world is in our grasp. Optometry simply needs to break out and find a new vision
ART
Richard Edwards
PRODUCTION
T
Shutterstock
CLIENT
hirty-seven years ago this month I left home to start my optometry degree at Aston University and embark on a career in optics. I was full of hope, optimism and excitement. I’ll admit that it didn’t last long. The following year, the government of the day deregulated the dispensing of spectacles to adults, and a few years later removed universal entitlement to NHS eye examinations and dental checks, introducing charges for eye examinations. These were seismic shifts that changed the sector permanently. On reflection, I am hugely proud of how my profession adapted to its ‘new normal’ and rapidly evolved new business models and ways of working. Yes, there were casualties, including my employer at the time. But, by and large, we all got on with life in a new and increasingly competitive commercial environment. I actually think optics over the subsequent decades was an exemplar of how a profession can adapt to thrive in changing times and balance clinical and commercial dynamics, while delivering great patient care. Since those tumultuous early years, we have seen technological developments and evolving consumer expectations that incrementally ratchet up the demands on our profession and yet, at its heart, our core function has not changed at all. We refract in similar ways and, while we have infinitely better technology to examine the eye, many optometrists spend their time doing what we were doing in the 1980s. Relatively few have broken out to broader clinical roles in the management of eye conditions. Most worryingly, the existence of our practices is still utterly dependent on the cross-subsidy
of product sales to negate underfunded eye What is your view? examinations and cover the ever-increasing costs Email OT with of running a well-equipped practice. your comments And now COVID-19. Suddenly, we find newsdesk@ ourselves once again grappling with an external optometry.co.uk disruption the likes of which we have not encountered for decades and the potential to change everything about our world. What will be the ultimate effect of the pandemic? What is irrefutable is that there has been an acceleration in societal changes that is unlikely ever to be reversed. In August, 39% of non-food retail took place online in the UK, up 10% on last year. Although eyewear has been resistant to this, it will inevitably change. Can anyone really believe that the generations who live their lives online will really do anything else when they hit presbyopia? It would be easy to be despondent. Yet I am more convinced “I see enormous than ever that a positive new world opportunities to awaits the visionaries who can grasp reinvent our role onto new opportunities that this in society” period of rapid disruption will bring. Reasons to be cheerful I see two enormous opportunities through which we can reinvent our role in society and carve out a prosperous future. Management of chronic eye conditions It is calculated that 80% of sight loss occurs in the over-60s demographic. The Office for National Statistics (ONS) data in the Foresight Report 2016 indicates in the UK 14.7 million people are aged 60 and above, and by 2030 this is projected to be 20 million (ONS 2013). Projected growth in the over-65s demographic from 2010 to 2030 is 50%, over-85s it is 100% and as much as a seven-fold increase in centenarians. On top of which, the UK population could also have risen by 10% to 71 million. A ‘multiplier effect’ behind this raw data is the expectation of ‘healthy life expectancy‘ in this rapidly growing demographic.
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Perspectives
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The demand for management of eye conditions will grow significantly. Ophthalmology in the NHS is the largest outpatient department with 7.8 million appointments per annum. The system is at bursting point before we ask the question of whether, post COVID-19, it is really the most appropriate environment for elderly people to attend for routine follow-ups. Even without the pressures of COVID-19, the hospital sector was never going to be able to cope with the demographic time bomb, and optometry has to be the solution for meeting the majority of chronic eye health needs of society in the future.
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Myopia management The prevalence of myopia in many parts of the world has already reached epidemic proportions and the rapid evolution of new products and strategies in our armoury to manage myopia progression should create new opportunities. When policy makers, and, perhaps more importantly, the public understand the eye health risks associated with myopic progression then this could be a catalyst to redefine our role for years to come.
“Even without the pressures of COVID-19, the hospital sector was never going to be able to cope with the demographic time bomb”
CLIENT
My priority OT speaks to the profession about practice during COVID-19 www.optometry. co.uk/coronavirus
And reasons to be fearful? In the last year, I have been disappointed and concerned to see some of the reactionary responses from many of my peers to innovative change. To illustrate this concern, I would share an anecdote from a friend who teaches A level maths. He told me that last year his brightest handful of students went on to study to become chartered accountants. No surprise there, I hear you say – however, none of them went to university. They joined the big four accountancy firms on their degree apprenticeship schemes. The routes by which people enter graduate professions has been evolving for some years, and yet the visceral response in optics to follow where other professions have already gone provoked an online petition of protest. I am not an apologist or advocate for degree apprenticeships – I don’t know enough of the detail. But I was disappointed to see the reaction to this potentially inclusive channel for people to join our profession. Surely, if we do not like the model proposed, we should work on it as a mature profession to see whether or not we can make it work, as other professions have already?
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My plea In order to the seize the emerging opportunities, we will need to create new, flexible career paths and specialisms that we can pursue throughout our careers. We also need to shift our collective mindset. The shift from CET to CPD signposts a potentially more forward-looking and aspirational expectation from our regulator. The reality, though, needs to move beyond CET, and not just the name – or the professions will not advance. What we are trained to do will have to evolve in lockstep with how we are trained to do it. Again, COVID-19 will accelerate innovation and new ways of teaching for all disciplines. Optometry and optics will be no different, but we must embrace innovation and not resist it. I know it is easier to define the problem than the solution, but I do believe we have to think our way into new ways of learning, behaving and practising. It doesn’t happen the other way around. The challenge facing our profession is how do we ‘jump the tracks’ to get off the tramlines of traditional commercial thinking and product sales, and seize the opportunities around properly funded or charged-for eye health condition management, which will redefine and secure our future. Some years ago, when going through some significant changes in my own career, a colleague shared a book with me that they said had helped them to think differently about how we manage our way through change. The book, Who moved my cheese? by Dr Spencer Johnson, is a parable in which we see how two mice each respond to significant change in their world. One thrives and the other…doesn’t. It may not be a bad idea for all of us to take the time to read this short story, reflect on how we need to behave to play our own part in creating an exciting new future, and how we, both as individuals and as a profession, come out on the winning side. That way we can meet the needs of those who depend on us for vision, clinical care and confidence in their own eye health regimes. It is the role of the Optical Confederation Education Forum to help the Optical Confederation member bodies map that way forward. Richard Edwards is an optometrist and director of OPTOMiSE Consulting, and co-chairs the Optical Confederation Education Forum
In a changing sector, the GOC’s consultation on education is an important next step Leonie Milliner
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n July, we launched our Education Strategic Review (ESR) consultation on proposals to update our education and training requirements of the General Optical Council (GOC) approved qualifications leading to registration as an optometrist or dispensing optician. We are now seeking views on three documents that will replace our current quality assurance handbooks for optometry and ophthalmic dispensing: Outcomes for Registration, which describe the expected knowledge, skills and behaviours a dispensing optician or optometrist must have at the point they qualify and enter the register with the GOC; Standards for Approved Qualifications, which describe the expected context for the delivery and assessment of the outcomes leading to an award of an approved qualification; and Quality Assurance and Enhancement Method, which describes how we propose to gather evidence to decide whether a qualification leading to registration as either a dispensing optician or an optometrist meets our outcomes for registration and standards for approved qualifications, in accordance with the Opticians Act. Our proposals have been developed based on feedback from our 2018 ESR consultation on draft education standards and learning outcomes, and in conjunction with our two expert advisory groups for optometrists and for dispensing opticians. We launched the ESR because the sector is changing rapidly due to an ageing population, new technology, increased expectations and service delivery pressures across all four nations. Approved qualifications The Opticians’ Act gives us the power to approve qualifications, which is central to our role in protecting the public. Our proposed standards include the principle that qualifications we approve must be either a qualification regulated by the Office of Qualifications and Examinations Regulation, Scottish Qualification Authority
or Qualifications Wales, or an academic award listed on one of the national frameworks for higher education qualifications for UK degree-awarding bodies. This is a significant improvement upon our current requirements, which do not require qualifications we approve to be an academic award, such as a degree, or a regulated qualification. In addition, we’ve commissioned the Quality Assurance Agency to advise us on the Regulated Qualifications Framework level we should approve qualifications at. Single point of accountability Our proposal is that all providers must be legally incorporated, be able to describe how they are organised, and be responsible for measuring students’ achievement of the outcomes leading to the award of the approved qualification. Our use of the term ‘single point of accountability’ signals this important change, and strengthens our ability to ensure new providers of approved qualifications are appropriately constituted and hold the authority to award either an academic award, such as a degree, or a regulated qualification.
“We are seeking views on documents that will replace our current quality assurance handbooks for optometry and ophthalmic dispensing”
Integrated clinical experience In our call for evidence, we heard that students and their employers want earlier and higher quality clinical experience which is more firmly integrated into their education and training. We are proposing that at least 48 weeks of professional and clinical experience must be integrated within the approved qualification in one or more ‘blocks’ of time. By incorporating more clinical experience into students’ training as part of a quality-assured academic award or regulated qualification, future registrants will be better prepared to meet the needs of patients and service users, in a sector which is constantly changing. Have your say While the pandemic has placed a lot of uncertainty on the sector, it has also made it more apparent that we need to consult now. We value feedback, and hope this will continue to ensure that optical education is fit for the future. Visit consultation.optical.org to have your say. The consultation will close on 19 October. Leonie Milliner is director of education at the General Optical Council
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“I decided that I was going to halve my portions so I could stretch my food out” Elizabeth Manuel
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Two days later, my breathing was worse and I hen I was 46, I had a near-fatal subarachnoid made my first ever 999 call. I couldn’t speak. That brain haemorrhage. My husband was told was the scariest thing – I was trying to ask for an to go home and tell the children, who were ambulance, but nothing was coming out. Eventually 15 and 16, that mummy would probably be dead by the Hampshire Police traced my number and an morning. I was given a 10% survival chance. ambulance turned up 15 minutes later. I was admitted When I woke up from a two-week coma, I knew to hospital and spent a few nights there to stabilise something wasn’t quite right. I looked at the clock at before coming home at the beginning of April. the end of the bed in my hospital room and said, ‘Why The first thing I did, right at the start of lockdown, are there only numbers on the right side?’ I have a was to consider how dense hemianopia with I was going to get no sight in my left field food. I tried to get a in either eye. I have lost supermarket shopping about 15% of my right slot every day for a few field as well. weeks but was unable When I had my to. I was working out stroke, I was working how much food I had full-time as a district left in the freezer. I judge in Portsmouth. decided that I was In a moment, my life going to halve my was almost wiped out. portions so I could I was paralysed, mostly stretch my food out. blind and couldn’t I wrote to all the main work. I could no longer supermarkets saying be the mum who did that I was vulnerable, everything for her kids. alone and could not Everything became get a shopping slot. No harder. Although I did one replied. I wrote to go back to work in 2015, my MP, who told me in the end, with chronic “I think it is really important to recognise to contact the council. fatigue, chronic pain and the Royal National Institute of Blind People I had one neighbour substantial sight loss, I for their hard work to ensure internet who put a note through was medically retired the door early on in 2017. shopping slots for those with sight loss” saying that they were COVID-19 has been a really tricky period. Normally I function well, travelling happy to help. Apart from the fact that I had this one neighbour, I would have run out of food. independently and leading a very full life. I was I think it is really important to recognise the Royal advised to self-isolate from the beginning of March. By National Institute of Blind People (RNIB) for their 29 March, I was showing symptoms of COVID. I woke hard work to ensure internet shopping slots for those up with a sore throat, a headache and a new cough. with sight loss. There was a petition of over 22,000 By the end of the day my breathing was getting pretty names calling for the Government to do something scrappy. Friends told me to ring 111, which I did. I about this. It shows the power of a group of people got diagnosed over the phone by two clinicians with who share experiences making their voice heard. suspected COVID-19.
Patient leaflets The AOP has produced a series of downloadable eye condition leaflets www.aop.org.uk/patients
Retired district judge, Elizabeth Manuel, suffered sight loss following a stroke. She welcomed the decision to implement priority deliveries for visually impaired shoppers during COVID-19 following campaigning by several charities, including the RNIB
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Peter Grant and Luke McRoyJones on preparing for their placements post-lockdown
49 The workshop
AOP head of employment, Liz Stephenson, on guidance for managing redundancy
50 How do I...
The AOP’s Henry Leonard unpicks the new process for making a CET claim in England
51 How I got here
A chance conversation at the age of 15 kicked off a varied career in optometry for OT’s clinical editor
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hile it can be hard to comprehensively define ‘comfort’ and ‘discomfort’ in contact lens wear, addressing any issues a patient may face is crucial for ensuring that they do not discontinue wear – a message that was reiterated during a roundtable of eye care professionals (ECPs) held by OT and contact lens manufacturer, Alcon. In a wide-ranging conversation, the roundtable sought to explore contact lens comfort and consider the business implications that result from patient dropout.
Defining and addressing contact lens comfort
A 2013 report by the Tear Film & Ocular Surface Society (TFOS) indicated that contact lens discomfort is a “regular and ongoing” problem for practices, with estimates suggesting that 31–79% of wearers experience discomfort with their contact lenses. With comfort being a subjective and non-clinical test, ECPs recognised that this can be hard to measure. Kieran Minshull, director and contact lens optician at LK Leon in London, noted that what a patient would recognise to be a reasonable level of comfort may depend on their determination to continue wearing their contact lenses.
THE ROUNDTABLE
Meeting the critical need for contact lens comfort Eye care professionals identified the importance of comfort to patient satisfaction and improving levels of dropout in a roundtable hosted by Alcon and OT
“What might be acceptable for a patient who enjoys wearing their contact lenses, someone else could find that level of comfort unacceptable,” Mr Minshull commented.
To truly gain an understanding of a patient’s level of comfort, the ECPs suggested a deeper level of questioning is needed. “I very rarely talk to a patient about contact lens
“We need to open the conversation more to find out exactly what patients are feeling” Kieran Minshull
comfort because it is quite ambiguous,” explained Michelle Beach, optometrist and founder of Park Vision in Nottingham. She suggested, instead, asking a variety of questions to ascertain comfort, such as: “When are you taking them out and why? Can you feel them? Do they feel gritty? Do you think your vision suffers?”
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Optometrist and director at Scott Waters Opticians in Newbury, Sacchin Sharma, suggested that the weartime a patient can achieve with their contact lenses is also a “tell-tale sign” of how comfortable their lenses feel. When fitting a new contact lens patient, ECPs agreed
that communication, and building a rapport, was key. As clinical questions alone do not always create space for relationship-building, the ECPs noted that it is also important to ask more personal questions to get to know the patient. Mr Sharma commented:
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TOP TIPS: DELIVERING A GOOD CONTACT LENS SERVICE Kieran Minshull
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arise is important so that patients don’t equate their one experience with the whole world of contact lenses.” Michelle Beach, optometrist and practice owner, Park Vision, Nottingham
CLIENT
Kieran Minshull, contact lens optician and director, LK Leon in London “Supply the best possible lens for that patient. Give them the opportunity to experience it and decide whether it is an affordable option for them. You want to simplify the process so you don’t have to take steps to refit later. “It is doesn’t work, such as for finance reasons, then it has to be explained that going down one lens option may reduce the comfort.” Declan Hovenden, optometrist and head of optometry, Technical University, Dublin “If problems with discomfort are not addressed and the patient discontinues, they equate that one experience of lenses with all contact lenses. “Communicating the message that there is always an alternative Declan Hovenden or solution to any problems that may
44 www.optometry.co.uk
“It’s really worth doing the pre-fitting homework. Find out as much as you can about the patient and exactly what they want in terms of contact lens wear. “Have a look at what their eye looks like before you start. Try and pre-empt comfort problems and complications. Then if they start to feel they are getting problems, they might remember that: ‘She mentioned I might have this issue, so I can go and talk to her about it.’” Sacchin Sharma, optometrist and director, Scott Waters Opticians, Newbury “I compare contact lenses to a pair of trainers. The recommended trainer might vary based on the activities you need them for. It doesn’t mean everyone can complete the same tasks with those shoes. Likewise, not everyone will be able to wear the contact lenses all day, for example.”
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“If you get a patient who is happy in their contact lenses they are really, really loyal”
Michelle Beach
Michelle Beach
“Asking about their hobbies and getting to know the patient more is very important for us to break the ice, and understand what they are trying to achieve from their contact lenses.” For those patients who are struggling with discomfort in their contact lens wear, Mr Minshull suggested that patients can find it difficult to communicate exactly how their lenses feel. “I think we need to open the conversation a little more to find out exactly what they are feeling. If they are able to be more specific with the symptoms, that may help us to move forward and find a better solution,” he said. However, all ECPs pointed to time constraints as the biggest limiting factor when exploring comfort with patients, reducing the questions practitioners can ask in a consultation. Declan Hovenden, optometrist Sacchin and head of Sharma optometry, Technical University, Dublin, asserted that more research is needed into the issues that prevent practitioners being as proactive as they could be. He told the group: “If we could understand the barriers better amongst our peers, then we would be in a better position to move forward, advise them on how to
change that, and how we deal with contact lens practice as a profession. That would address the level of contact lens discontinuation.” Responding to patients’ needs in contact lens wear
Research quoted by Professor Philip Morgan, head of optometry and director of Eurolens Research at the University of Manchester, in a recent report noted that 73% of patients who are considering discontinuing lens wear did not intend to discuss it with their practitioner, raising it instead with friends or consulting the internet. Commenting on these findings, Mr Hovenden emphasised that developing rapport is important for building trust and the patient’s sense that they can return to the practice if they have any problems. Ms Beach also said that she found the report “powerful,” particularly noting research cited in the piece, which found that contact lens wearers who discontinue in the first year, tend to do so within the first two months. Having read and reflected on the report, Ms Beach explained that she had since appointed a ‘contact lens buddy’ in the practice to keep in regular contact with new patients after their fittings, establishing open communication.
Being pro-active is key for catching contact lens patients with the potential to drop out, particularly in the initial few months of a contact lens trial, the group agreed. A report by TFOS highlighted the importance of early intervention to prevent and manage contact lens discomfort, “even before the onset of symptoms,” to improve long-term prognosis for successful wear. Commenting on the importance of contacting the patient proactively to ask how they are getting on, Mr Minshull shared: “It’s critical that there is a series of contact points with the patient, certainly in the first few months, to examine exactly what the problem is, and make them feel comfortable to come in if there are any issues.” As well as addressing any issues with new contact
lens wearers, ECPs also recognised the need to offer new and updated material technologies to existing patients. Even where they have not expressed any issues with comfort, new products could offer an enhanced experience, it was agreed by the group. “We have a duty as a practitioner to inform patients that there are better products on the market for them to try,” Mr Minshull said. This could mean updating patients on the new products available to them during their next visit. Using the right language when discussing new contact lens products with patients was also considered to be important for the ECPs. “I find a lot of patients want the ‘latest’,” explained Mr Hovenden. “Most people want to be up-to-date and want to have what they
WHY THE PATIENT-PRACTITIONER RELATIONSHIP IS KEY... Declan Hovenden “The emphasis around communication is very important. We can talk about the clinical things that we can do, or the solutions that we can come up with, but at the core of it all is communication and making sure that the channels of communication are open between the practitioner and patient.”
Kieran Minshull “We need to go through the pre-screening of a patient a little more so we have an indication of where potential complications might arise. We need to have systems in place where we can check with patients on regular occasions to see how they are doing, to guide them through those crucial first weeks.”
Michelle Beach “As an eye care professional, you have to remember that if you get a patient who is happy in their contact lenses, they are really, really loyal. The demographic of our contact lens patients is spread wide.”
Sacchin Sharma “Creating a relationship with a patient where they can talk to you openly is very important. Time can limit how many questions you can ask, so having a checklist in your mind is a good starting point.”
Neil Harvey
perceive as the best. Usually in most people’s minds, the latest equals the best.” Considering the bigger picture of dropout
Research by Professor Morgan noted that contact lens discontinuation also has a global impact on the contact lens sector, particularly the size of the market. Calling this a “huge missed opportunity,” Ms Beach pointed out that many of those patients who dropout would otherwise be visiting the practice regularly, potentially buying new glasses or sunglasses and driving additional revenues. Reflecting on the level of patients potentially discontinuing contact lens wear, Ms Beach continued: “I would consider that a bit of a failure – and we’re not doing enough about that.” Building on this conclusion, Mr Hovenden noted that it is not simply issues of discomfort, such as dryness, that are the cause of dropouts. “It is our failure to manage the dryness that is causing the dropout of lens wear,” he said. As many people now turn to social media to share their experiences or seek out views from others, Mr Minshull observed that if a contact lens does not suit a patient, they could share their negative experience on social media – potentially dissuading new prospective customers. Meanwhile, a positive experience of contact lens wear – whether a first-time wearer, or a patient who receives a product that enhances their comfort – can also be spread through the
COMMUNICATION, TRUST, AND GETTING TO THE ROOT OF DROPOUT Neil Harvey, professional services manager for Alcon, shares three key points from the discussion 1 ) Communication and the relationship between practitioner and patient builds trust, which then allows them to come to the ECP with challenges 2 ) Think beyond the typical clinical questions used in a fitting that tend to give us simply ‘yes’ or ‘no’ answers. When you’re getting into the lifestyle of the patient and finding out more about their needs, it reaches a point where comfort or discomfort of the patient can be uncovered 3 ) Contact lenses are vital to the business. In rejigging some of the things we would normally do in practice, ECPs can identify the potential for dropout and increase comfort for patients.
patient’s social groups, Mr Sharma noted, emphasising the importance of sharing positive testimonials. “This spreads amongst family and friends. If you give someone a good solution, they are going to mention it.” OT Roundtable To watch the roundtable, hosted by OT and Alcon, visit www.youtube.com/c/OptometryToday_AOP/videos
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“I was delighted to get a confirmed start date”
OT skills guidesI OT has developed a range of short video skills guides to aid students in their studies www.aop.org.uk/ otskillsguides
After months of disruption to his studies, newly graduated optometrist, Peter Grant, tells of his excitement to begin his pre-reg placement
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his has been an extraordinary year for us all. On 16 March, I was in the primary care clinic at Cardiff University carrying out a sight test; the next day, university was shut down, lectures and clinics were cancelled, and I was clearing out my locker. Little did I know that would be my final patient episode at university and my last eye examination for six months. In May, I sat my final exams online in my bedroom. The exams were open book and had been altered from previous years in order to assess our understanding and application of knowledge rather than just regurgitating facts that could be easily found in our notes. We had a 24-hour window to upload our completed paper to limit the effects of any technical problems and to take into consideration students in different time zones. Throughout lockdown the university did an excellent
job of keeping us up to date with developments regarding exams, graduation and pre-reg. They also organised revision webinars in the weeks leading up to exams for any lastminute questions and queries concerning the new format of the online assessments. I passed all my exams under the strangest of circumstances and graduated, albeit virtually, with the class of 2020. I look forward to the real graduation in summer 2021, when we can celebrate properly. My pre-reg was due to begin the first week in August. However, COVID-19 led to it being postponed by a month. There had been uncertainty as to whether enrolling on the pre-reg scheme would even be possible this year, so I was delighted to get a confirmed start date. When considering where to do your pre-reg, I think it is important to keep your options open and assess all possibilities, whether that is in a multiple, independent or
of independent optometry practices in the South Wales Valleys.
Luke says... I’m undertaking my pre-reg year at… Merthyr Optical Centre. Located in Merthyr Tydfil, it is part of a small group
The process of finding a placement was… A little bit last minute. The original plan had been to complete my preregistration training with the multiple practice where I had been working in the holidays from university. However, my circumstances with the practice changed and I decided to
hospital. Having previously worked as an optical assistant in a multiple, I was interested in experiencing an alternative working environment and therefore decided to seek a pre-reg position in the independent sector. After a successful interview back in second year, I secured my pre-reg with an independent optician in South Wales.
“I could never have imagined entering the working world in the midst of a global pandemic” Organising my pre-reg before starting final year at university allowed me to concentrate on my studies and not worry about future employment. The practice group I will be working for, Julian Davies Opticians, is well established with several store locations in South Wales, one of which, St Mellons, I
seek an alternative placement. Looking for a position so late in the year and amid a global pandemic was daunting at first, but thankfully a few of my connections were able to help. I chose this location because… The group has an excellent reputation owing its the high level of patient care and its involvement in shared care schemes. It also has a history of supporting
will be based at. I have found the staff very friendly and the practice owner has been particularly helpful during the uncertainty of lockdown. At the time of my interview, the practice had a pre-reg optometrist so I felt reassured that they would be familiar with the current scheme for registration and have the experience and resources to support me through the year. Now that pre-reg is just around the corner, I am excited to get started. It has been nearly six months since I had any patient interaction, so I am looking forward to working with the public again, albeit under much stranger circumstances. I could never have imagined entering the working world in the midst of a global pandemic. However, I am eager to put into practice the clinical skills and knowledge I have learnt from my time at university and improve and adapt these skills for today's climate.
pre-registration optometrists through training and also newly qualified optometrists with further qualifications. The practice itself is well equipped, with a diverse patient base and a supportive and highly experienced team, creating an excellent environment for a pre-registration optometrist.
Luke McRoy-Jones is a prereg optometrist at Merthyr Optical Centre in South Wales
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Managing redundancy
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Every issue, OT poses a scenario from a practitioner. This edition we’re tackling redundancy
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John, optometrist “I work for a small chain of independents, which closed for all but urgent and emergency care during the lockdown, with all staff being furloughed. Since returning to work there have been rumours of stores closing and staff being made redundant. Although there are no redundancies confirmed as yet, I’d like to be fully prepared and know my rights in case this does happen.”
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The advice Liz Stephenson, head of employment at the AOP
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t’s an unfortunate reality that, as the furlough scheme ends, many more people are going to find themselves at risk of redundancy. Whilst the prospect of leaving a job involuntarily can be daunting, the best thing to do in this situation is to prepare accordingly. The AOP can offer members guidance on redundancy rights, including pay and notice periods. Redundancy pay
Check your contract to see whether there are any contractual enhanced
redundancy pay provisions as part of your company’s existing policy. It’s important to note that if there has been a practice of paying more than the statutory minimum in the past you may be able to rely on this precedent. If there are no enhanced redundancy pay provisions, those with more than two years of service will have the right to statutory redundancy pay. This is calculated as follows: Half a week’s gross pay per complete year of service under the age of 22 One week’s gross pay per complete year of service if you are between the ages of 22 and 40
One and a half week’s gross pay for each complete year of service if you are aged 41 or over Caps on redundancy pay include: A cap on a week’s pay of £538 A maximum of 20 years’ service You can calculate the statutory redundancy pay you could be entitled to, to make sure that this is reflected accurately in your redundancy payment. Remember, you may be entitled to more than this under the company policy. Notice and time off to look for work
Check your contract to confirm how much notice you are entitled to. Under statute, you will be entitled to at least one week’s notice per year of complete service, up to a maximum of 12 weeks. This is the minimum entitlement, and you may be entitled to more. Those who are under notice of redundancy and who have more than two years of service also have the right to reasonable time off to look for work. Preparing to leave work
You will have consultation meetings with your employers in which they should consult with you regarding the redundancy. This should be your opportunity to ask any questions about the process, including why this is happening, what process will be followed, how people are being selected, and details of any payments you can
“Calculate the statutory redundancy pay you could be entitled to, to make sure that this is reflected accurately in your redundancy settlement”
expect to receive if you are made redundant. It is also your chance to put forward any alternatives you can think of that would help avoid redundancy, and to put forward any arguments as to why you shouldn’t be made redundant. Have a list of questions you want answers to when you go into these meetings. If your employer has also mentioned supporting you in further training or other provisions, this is also something that could be discussed in these meetings.
AOP support
If you are in need of legal advice, you can contact the AOP employment team. To get in touch email employment@aop. org.uk, letting the team know the date of any meeting in the subject line. This will allow them to prioritise any meetings. You should also send the employment team your contract of employment and any other relevant documents, such as the employee handbook or any other relevant correspondence. Make sure you include a copy of any correspondence relating to the redundancy. If you would like to try to arrange for a trade union representative to attend a meeting with you, make sure you contact the above email address and let the team know as soon as you are invited to the meeting.
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Make a CET claim in England?
AOP advice For more information on claiming CET grants, visit our guidance online bit.ly/3lFgX1S
This year, those making a claim for a CET grant in England need to do so online. Henry Leonard, head of clinical and regulatory at the AOP, breaks it down
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As we know, optometrists have to do a certain amount of Continued Education and Training (CET) over the three-year cycle to meet regulatory requirements. The NHS provides grants to those who provide GOS sight testing in order to help them cover the costs related to this training. Under the current system in England and Wales, every individual optometrist has to claim the payment through an NHS contractor, such as their employer. The system in Scotland and Northern Ireland allows individuals to apply for the grant directly. The grant is claimed in arrears, meaning the application window that is currently open allows you to make a claim for CET completed in 2019. The cap is set at £573. How the process has changed
This year, the CET claims window for England opened on 1 August and will close on 30 November. For the first time, the process to claim CET grants will be entirely online. This means that postal forms will no longer be accepted,
“For the first time, the process to claim CET grants will be entirely online” 50 www.optometry.co.uk
and that you will need to complete your section online first. Who is eligible?
Optometrists and ophthalmic medical practitioners (OMPs) who perform General Ophthalmic Services (GOS) are allowed to claim a grant towards CET they have undertaken. To make a claim within the window, during the relevant claiming period you must have: Been on the relevant ophthalmic list for at least six months Undertaken GOCapproved CET Performed primary ophthalmic services under a GOS contract. Preparing to make a claim
To complete your section online, you’ll need to be registered with the correct roles on Primary Care Support England (PCSE) Online. If you want to make a claim for a grant within this application window, you need to ask your practice’s user administrator to set you up and attach you to the practice you work at. Those wishing to make a claim for a CET grant in England must do so via a contractor. You are expected to claim through your employer if you’re an employee, but you’re
THE CLAIMS PROCESS As a performer, you should:
Log in to PCSE Online as a GOS performer Select ‘Ophthalmic’ and click on ‘make a claim’ Select ‘CET’ On the declaration page, check your details, sign the declaration, and select ‘Save awaiting contractor signatory’ Your claim will then be automatically forwarded to your contractor signatory to sign If you are also contractor signatory, once you have saved your claim you can read and sign the declaration and click ‘submit’ to complete. As a contractor, you should:
Log in to PCSE Online as a contractor signatory Select ‘Ophthalmic’ and click on ‘Search for a claim’ Search for the claim using the drop-down menu Click ‘Open’ to view the claim Read and sign the declaration Click submit Your claim should now be complete.
not obliged to. Locums are advised to apply through a practice that they work for, but again they are not obliged to do this. If you work for more than one contractor and they have both given you paid time for CET, it is up to you whom you nominate, but you should check whether there are any CET clauses in your locum contract/s (if applicable). If you’re approaching a contractor you have not worked for, you can reassure them of your eligibility by providing evidence of your CET activity, plus a written
statement from an employer showing you’ve undertaken GOS sight tests. If you cannot find a contractor to vouch for you, your Local Optical Committee (LOC) or Regional Optical Committee (ROC) may be able to assist. What about in the rest of the UK?
The CET claims window in Northern Ireland will open on 1 January 2021 and will close in March. The window in Wales runs from 30 September to 1 November. In Scotland the window will close on 30 November.
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It seemed almost enshrined in law in my hometown during the 1980s that school leavers were destined to work in the car industry. However,
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just two weeks of work experience on an industrial estate in Coventry was enough to convince me that my delicate hands were destined for lighter work. As a rapidly progressing myope, trips to the local opticians during my childhood were frequent, and a chance conversation with my optometrist at 15 years of age led to the start of a career in optics at his practice a few months later. So, at sweet 16, with some mediocre GCSE results under my belt, I began to learn the ropes. I started out as a fledgling lab technician before spending a year or so as an optical assistant. I commenced my training as a dispensing optician (DO) in 1990 via the ABDO correspondence course with block release at Anglia Polytechnic University, as it was known back then. A month after gaining my Fellow of British Dispensing Opticians (FBDO) qualification, I embarked on the undergraduate optometry programme at Aston University. I
continued to work as a DO at the practice during weekends and holidays,
“I worked out pretty sharpish that I wasn’t really cut out for the world of business” HOW I GOT HERE
“I haven’t made the most of my Netflix subscription recently” OT clinical editor, AOP head of education, teacher at Aston University: Dr Ian Beasley explains how his ‘itchy feet’ have kept his career varied
before undertaking my pre-reg position there in 1996. After qualifying as an optometrist in 1997, I remained at the practice full time, combining the role with sessional hospital work and undergraduate teaching. Towards the end of 2007, I started to get itchy feet and began searching for a new challenge. And
then, in typical style, two opportunities arrived at once. Firstly, I opened a new practice in partnership with my existing employer in early 2008 – while also finding myself enrolled on a professional doctorate at Aston University later in the same year. This was a tough period in my career as getting the
“After completing the professional doctorate, I developed a real appetite for research... This was no doubt helped by a research excellence award from the College of Optometrists”
business off the ground proved difficult, with the double blow of the financial crisis along with two new multiples opening in the town just a few months after we launched our practice. I worked out pretty sharpish that I wasn’t really cut out for the world of business. On the other hand, after completing the professional doctorate in 2013, I developed a real appetite for research. This new-found love was no doubt helped along by the gift of a research excellence award from the College of Optometrists for my published work. Get me! At this point, my career began to diversify a little further with an opportunity to join OT as clinical editor while simultaneously taking on a post-doctoral research post. I also continued
working in practice a couple of days per week, alongside
undergraduate teaching at Aston University. A couple of years later I had my feet firmly under the table at the AOP, expanding my responsibilities by taking on the role of head of education. I also thought that it might be a neat idea to start a PhD, keep a foothold in practice and continue with teaching. Safe to say that I haven’t made the most of my Netflix subscription in recent years. I decided to put my retinoscope on a deep charge in February this year and finally left the practice where it all began over 30 years ago. With
my clinical work on ice and my PhD due to finish next year, it will be nice to kick back a little, although those pesky feet of mine are already beginning to itch. That, in a nutshell, is how I got here.
“My Plan B?” It’s only just hit me now as I write this piece that there was never a Plan B. That serendipitous chat with my optometrist back in 1989 set me on a path, and I never looked back.
Get in touch Share your career journey with OT. Email lucymiller@ optometry.co.uk
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WHAT I HAVE LEARNED
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Katerina Sisperova
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“I wanted to do more to help”
Tejinder Kahlon Optometrist at Moorfields Private Eye Hospital and The Institute of Optometry
As practices find their feet in the ‘new normal’ post-lockdown, three optometrists reflect on what they learned through the peak of the pandemic ART
I have learned... to operate remotely Alistair Duff
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IP optometrist and clinical director at Urquhart Opticians
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We were lucky enough that the Scottish NHS health boards pushed for the use of Attend Anywhere software to allow optometrists to speak to patients virtually. This software had been used in the remote highlands of Scotland before lockdown. The interface is very simple for the patient; they log in via a link sent by email or text and enter a secure
waiting room. I found I conducted the examination as I would in the test room. History and symptoms are more important than ever as you don’t have access to the trusty slit lamp over video, although, cameras on up-to-date devices are very good so small details of the eye can be noticed. Anterior eye issues were the mainstay of what I used Attend Anywhere to deal with – for example sub conjunctival haemorrhages, lid lesions and even to view a folded contact lens. The odd
consultation had to be escalated to the emergency triage centre during lockdown when I was not comfortable with the patient’s symptoms. Pharmacies also played their part as we could email them to get drops from an approved list that patients could pick up. I am grateful that in this interim period where the virus is still out there, we can continue to provide these remote services to reduce footfall in practice and contact points for patients. This also saves time on cleaning a whole exam room just to view a sub conjunctival haemorrhage.
I have learned... to engage patients with social media Nicola Cooper-Heenan Optometrist and owner of Cooper & Barr Opticians, Thirsk
Social media posts before COVID-19 were delegated to the more creative members of staff. I had felt it took up a lot of time for little benefit. During lockdown, with the majority of my staff furloughed, it fell to me to update it. When it came to re-opening, I made some video posts as I had heard that they have better engagement and it seemed an easier way to explain all the changes we were making. Since then, we have made posts
on anti-fog treatments for glasses, and socially-distanced eye tests. There were many more shares and likes than our posts received pre-COVID. There has also been an increase new patients making enquiries through our Facebook and Google pages. Now that my team are back from furlough, I am using them in the videos more than myself. Having had a positive response, we have decided we are going to keep doing them. I think it has helped to give the business some personality, but also allows people get to know us as friendly and approachable.
During lockdown, both practices I work in had to close and I was furloughed. I felt grateful that I was safe at home, especially whilst having to home-school my children, but I wanted to do more to help. When I saw the advert for an NHS Test and Trace clinical contact caseworker (CCW), I applied straightaway. Strong communication and problem solving are key skills for optometrists, so I was already in a good position when starting my new role on the virtual frontline. We also need to make decisions under pressure. As a CCW, I have had to use my clinical knowledge to know when to escalate complex cases. I soon learned that the job was not simply to trace contacts, but to provide emotional support. It requires a great deal of compassion, and my skill set has enabled me to provide this support in anxious cases. In my CCW role I have received extensive training around memory-jogging techniques – a skill which I will carry into my role as an optometrist for more effectively taking history and symptoms. Share your story Get in touch if you would like to share your experience with OT kimberleyyoung@optometry.co.uk
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To all members of the Association of Optometrists. The AGM of the Association of Optometrists will be held virtually, via Zoom, on 4 November 2020. The AGM will commence at 12pm. All members wishing to attend are invited to register their interest with Liz Routh, lizrouth@aop.org.uk by 12pm, 3 November. Agenda for the Association of Optometrists’ Annual General Meeting 2020
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1. Introduction by the chairman 2. To receive and approve the minutes of the last Annual General Meeting, held on 11 June 2019 3. Roll of deceased members 4. To receive the chairman’s report 5. To receive the chairman of Finance Committee’s report 6. To approve the Annual Financial Report and Accounts for the year ended 31 December 2019 7. To consider and, if thought correct, approve the proposal of the Board that BDO LLP be re-appointed as the Association’s auditors. 8. Any other business.
By Order of the Directors. Henrietta Alderman, chief executive, 2 Woodbridge Street, London EC1R ODG 1. Please note that a full set of the 2019 Annual Report and Financial Statements will be available at www.aop.org.uk 2. A member entitled to attend and vote at the meeting convened by the notice set out above is entitled to appoint a proxy to exercise all or any of his or her rights to attend and speak and vote in his or her place. A proxy need not be a member of the Association 3. A form of proxy is available on the AOP website at www.aop.org. uk. To be effective, the instrument for appointing a proxy must be deposited with the Association’s chief executive’s office via email (janicephillips@aop.org.uk) no later than 3.45pm on Friday 30 October 2020. Completion of the proxy does not preclude a member from subsequently attending and voting at the meeting in person if he or she so wishes.
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Benevolent Fund AGM The AGM of the Benevolent Fund of the AOP and the College of Optometrists will be held virtually at 3pm, 4 November 2020. The agenda is available on page 83.
2019 AT THE AOP Highlights from the Annual Report
Writing in the AOP’s Annual Report, chief executive Henrietta Alderman explained that Influence had been the Association’s theme during 2019, shaping its work for members. Members’ views through consultation responses, particularly related to the General Optical Council, ensured that their voices were heard at every stage and mode of practice, Ms Alderman said. She added that the AOP values the councillors representing members in every mode of practice
54 www.optometry.co.uk
who have worked hard to assist in the delivery of excellent service to those members. In 2019, the AOP responded to members’ needs as it expanded its education offering through faceto-face meetings, webinars and the journal, OT. The website continued to be enhanced and updated – new additions for 2019 included the revised locum listing, refreshed job board and the GOS audit tool. The AOP also focused on a holistic provision of services surrounding its exceptional insurance and legal defence package.
Facing the COVID-19 test Reflecting on 2020 so far in his welcome statement, chair of the AOP, optometrist Mike George, wrote: “2020 will be dominated by COVID-19 and the importance of protecting, supporting and representing the membership of AOP has never been more critical.” Setting out the AOP’s theme for 2020, Influence through change, he explained that the long-term plan incorporates the impact of artificial intelligence on optometry, a theme developed with the thinktank Reform. “Since COVID-19 has impacted all our lives, this work and the plan will be adjusted accordingly,” he noted. Mr George said that the AOP had continued to develop strategic links with NHS England during 2019, and the ongoing discussions on commissioning and the future funding of eye health in England
is a key priority in a constantly changing landscape. “We maintain good working relationships with colleagues in Optometry Northern Ireland, Optometry Scotland and Optometry Wales to advise and support our members across the differing devolved NHS systems. UK-wide, there is a recognised overstretch in ophthalmology departments in hospitals, in A&E and in GP practices. Expanding the NHS’ use of optometrists within the primary care setting is critical and the AOP, working with sector colleagues, is determined to influence the change that is needed. COVID-19 has accelerated both the pivotal links and the potential changes within primary care.” The AOP’s Annual Report is available at www.aop.org.uk
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NOTICE OF THE AOP ANNUAL GENERAL MEETING
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THE IMPACT OF COVID-19
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THE PATH AHEAD FOR CONTACT LENS CARE
Times have been tough for practices as COVID-19 altered the way contact lens services could be delivered. OT speaks to Johnson & Johnson Vision experts and optometrists for their reflections on the way forward
Grant Pearce; Shutterstock
OT: What impact has COVID-19 had on the contact lens and patient care sector? Jakob Sveen (JS): COVID-19
has had a significant impact on the eye health industry as a whole. It is only now that we are seeing the early stages of recovery. For contact lenses specifically during COVID-19, with travel restrictions and limited social interaction, the
reduction in typical usage occasions has resulted in a decrease in contact lens wear. A survey we’ve conducted has shown that 47% of patients say they are wearing contact lenses less than before lockdown. The good news is that 79% say they are likely to return to their normal contact lens wear (UK Covid Omnibus wave 4, Bilendi, 24 Aug 2020).
"ENGAGING WITH CONTACT LENS PATIENTS IS A GOOD WAY TO HELP PROTECT BUSINESS FOR THE LONG-TERM" Jakob Sveen, managing director Europe & general manager UK and Ireland October/November 2020
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Marie-Therese Hall, optometrist and professional affairs consultant at vision care, for Johnson & Johnson Vision shares her experiences of lockdown
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The past few months have been a challenge but very rewarding. I have learnt a lot as a practitioner and the experience has reinforced some of my skills. This was mostly through remote care over the phone, triaging and consulting on symptoms, hearing concerns or providing reassurance. We also saw the occasional patient face-to-face for urgent or essential care.
CLIENT
I think patients were initially concerned over whether contact lens wear was safe. Very quickly, guidance and papers were released to say that the risk of transmission through tears is low and it was reassuring to have that scientific evidence as back-up. This also gave us an opportunity to advocate for stringent hygiene and contact lens care procedures, and a chance to remind patients not to wear them if they feel unwell. People’s lifestyles have changed. Most contact lens wearers have continued as normal, but we have noticed that some occasional users are now wearing their contact lenses more often. Where they might have worn them a couple of times a week to exercise, for example, they are now doing so more often. I think we’re seeing a resurgence in interest in contact lenses. With the need to wear masks in public and use of personal protective equipment in the workplace, I think people are seeing contact lenses as having functional benefits, as opposed to just thinking of them as a lifestyle choice. I think people have been taking a step back and considering their health priorities. This has been a period of self-reflection for me as an optometrist. I think it had been very easy to get into a routine. When lockdown first happened, everything was stripped back to what was essential to decide the best course of action for the patient. I think it has given me more clinical autonomy. It has been inspiring to see how the profession has come together; there has been a motivation to look after the eye care needs of everyone. There was a sense of collaborative working between practitioners. It has also given us the opportunity to educate the public, on eye health concerns, but also what optometrists can do. 56 www.optometry.co.uk
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Kamlesh Chauhan: One thing COVID-19 has highlighted for me is the capability and capacity for ECPs working in the community. Seeing what ECPs have been able to do has, in many ways, helped people understand how important they are. With papers now showing there is little difference in how an eye health condition is managed inside the hospital environment compared to High Street practice environments, there is an opportunity for optometry to be put on a pedestal to show what it can do.
Kamlesh Chauhan (KC): One of the things that has stood out to me is seeing examples of how eye care professionals (ECPs) have been supporting patients with essential and emergency care. This applies not just to those dealing with something that might be seen as severe in terms of a case, but also simple things, such as getting spectacles to an elderly person who might have a fall without them. OT: How have you been supporting practitioners over the past few months and how will this evolve? JS: Our first priority when
COVID-19 hit was to reach out to our customers to understand how we could best support them and their practice. As we come out of lockdown, we want to make sure ECPs haven’t lost any confidence and feel as supported as possible. KC: During lockdown we quickly moved to provide resources to ECPs. We trained more than 2500 practitioners in a few weeks, offering webinars and covering everything from reassurance on COVID-19 and contact lenses to topics that aren’t just around the current situation.
The other group is the staff in practices: optical assistants and advisers. They clearly have a great role to play in starting up the businesses again and in the impact they had as well. We've supported over 1200 staff through webinars. Another area we are passionate about is supporting younger optometrists through our Success Through Education Programme (STEP). We connected with over 500 of these students over the past few months. For them this has been a really challenging time and we’re working with the College to find out
"WE HAVE ALL LEARNED NEW WAYS OF WORKING. IT HAS EVEN BEEN SURPRISING HOW EFFECTIVE AND POTENTIALLY ENJOYABLE IT CAN BE" Kamlesh Chauhan, director of professional affairs, UK, Ireland, Nordics and DACH
SHIFTING WEARING BEHAVIOURS
what is happening, as well as with employers to see how they plan to phase their return. We have also given three grants for research through the STEP initiative so students can continue to complete research. OT: How is J&J supporting ECPs in the ‘new normal'? KC: We have all learned
new ways of working. It has even been surprising how effective and potentially enjoyable it can be. The convenience for ECPs of being able to consult from home has been a surprising benefit. We want to
DIRECT DEBIT SCHEMES ARE KEY Jakob Sveen: Direct debit schemes have been part of our industry for some time. What we saw with the lockdown was a need to change how we engaged patients who previously would come in for a personal interaction with their ECP. Practitioners did an impressive job of quickly setting up home delivery options while finding ways to maintain a strong relationship with patients. I think this will be a trend going forward, looking at how we support our customers to continue to deliver convenient support to patients. That said, human interaction is always important. Rekindling that is going to be important, and something our team is supporting ECPs with.
amalgamate the new way of doing things with how we communicate face to face. This is a pattern we can see across healthcare industries. The programmes we are currently running are focused on how to get patients back into the practice safely, protecting staff and patients while generating positive results. From that perspective we are looking at how we can help ECPs innovate in how they set up the infrastructure of their practices. OT: Why should ECPs be proactively engaging contact lens patients post lockdown? JS: Engaging with contact
lens patients is a good way to help protect business for the long-term. We know from surveys that 79% of patients are likely to return to normal wear as they come out of lockdown, so this is an opportunity to encourage contact lens usage and help patients recall the benefits. We know contact lens patients are valuable because they provide sustained business revenue, with a higher spend on vision care as they wear both glasses and contact lenses. KC: The sooner an ECP engages with contact lens wearers who may have stopped contact lens wear through lockdown, there is a higher chance of them returning as a customer. We are working on resources for this, including new options for engagement as we know now that things like remote consultations are effective.
Optometrist and professional affairs consultant for Johnson & Johnson Vision, Simon Donne shares his reflections on contact lens wear during the lockdown The practice was closed for everything except urgent and essential services. In our team, I was working remotely, triaging and providing contact lens consultations over the telephone. If a patient wanted to order a supply of contact lenses and their aftercare was due, I would carry out a full symptoms and history, ensuring they were happy with their vision, comfort and wearing time. Our contact lens direct debit scheme absolutely helped the practice through the lockdown. We have a lot of patients on direct debit and at a time when people weren't coming in and buying glasses, the fact that we had a guaranteed income every month helped us survive. We only had two patients cancel their direct debit during lockdown, and we have hundreds of people on the scheme. A few patients have said they were wearing their contact lenses less as they weren't going out so much. I think in many cases this is because people were working from home and didn’t feel the need to get as dressed up as they might if they were going into the office. On the other hand, some patients have been wearing their lenses more, especially if they had issues with their glasses steaming up whilst wearing face coverings. It is a bit of a balance. There is a lot we have been doing differently that we are going to carry on doing. One of the biggest areas is the telephone consultation. If someone has had an issue with their eyes, for example, we would have normally booked them back in a week later to ensure that everything was fine. Currently you need to find a time when there are fewer people in the practice to maintain social distancing, and clean down afterwards. Why are we not doing that over the telephone or through platforms like Zoom? I think there are a lot of follow-ups you can do remotely. For example, if you fit someone with contact lenses, why not do the six months’ aftercare remotely, only bringing the patient into the practice if necessary. Contact lenses now are the best they’ve ever been and if, at the end of their aftercare, everything is great, it is likely that it still will be in six months’ time. October/November 2020
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LONG VIEW
Michal Bednarski
How should the education and training of optometrists evolve to future-proof the profession? OT asked optometrists from different modes of practice for their conclusions
W
hat will a classroom of optometry students look like in 10 years’ time? Having a well-functioning and agile optometry education system is key to
ensuring that the profession remains resilient through current and future challenges. This is particularly pertinent at a time of global upheaval, when
practice owners face concerns about keeping their businesses afloat, while many pre-registration and newly qualified optometrists have been left in limbo with the pandemic limiting
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opportunities for less experienced optical staff. The General Optical Council’s Education Strategic Review aims to re-design the education of optometrists and dispensing opticians to ensure that the optical education system remains fit for purpose as technology and healthcare systems change. Key planned changes include moving from what, for most students, is a two-stage degree with a pre-registration year to a singlestage approach where one provider is responsible for each student’s education, from the day they start their degree to registration as an optometrist. The optical regulator plans to move away from a granular, prescriptive approach to one that allows flexibility in how set outcomes are met over the course of a student’s education. However, concerns have been expressed about how consistency will be maintained across different education providers. Professional bodies, including the AOP, have also highlighted risks that could result if the new model cannot be adequately funded.
WHY CHANGE? Research undertaken by the optical regulator has investigated perceptions of how optical professions will change moving forward and the implications that this has for education. A 2016 GOC survey of 4139 optometrists, dispensing opticians and optical students found that 87% of respondents thought their role would change significantly within the next five years. Factors that were predicted to influence this shift
60 www.optometry.co.uk
THE HOSPITAL WISHLIST
FOUR KEY EDUCATION PRIORITIES FROM THE HOC
1
Problem-solving. From the start, instead of learning lists of conditions, we should be enabling our students to think through problems, before coming to a diagnosis or decision. Right now, this shift in perspective mainly comes during pre-reg, where a patient will come in with a history, have a clinical examination, and then students learn to piece these bits of information together
2
Smaller groups. This could even involve some one-to-one time with students to make sure they learn the clinical skills correctly, so that they leave university confident with things such as Volk. This would set them up much better for pre-registration and their careers
3 4
Using hospital experience wisely. Hospital placements offer students the chance to observe how hospital optometry could broaden their knowledge and horizons. Revising topics relevant to a specific clinic makes for a more engaging placement.
included technological changes (with 69% of respondents flagging this consideration), an ageing population (55%) and changes in consumer behavior (54%). Of the optometrists surveyed, close to half (47%) were involved in the delivery of extended eye care services. The proportion of practitioners offering advanced clinical care varied depending on which country respondents were based in, with 75% of Welsh practitioners involved in offering extended eye care services. The research also revealed that six in 10 (64%) optometrists had considered gaining additional qualifications to prescribe medicines or assist in the management of
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OCT interpretation. This is a major topic both in hospital and community optometry
patients' eye conditions. In addition to this research, the optical regulator has explored the views of newlyqualified practitioners on the current optical education system. A GOC survey in 2018 of more than 700 optometrists
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BIGGER PICTURE
What training do optometrists in other countries receive?
HOSPITAL Sharing the views of the Hospital Optometrist Committee (HOC), Sheffield Teaching Hospitals optometrist Holly Higgins emphasised that the education of optometrists needs to meet the new demands placed on the profession. This includes being better trained to deal with eye casualties, incorporating independent
HOLLY HIGGINS
YEARS
AUSTRALIA & NEW ZEALAND Optometry is a Master’s qualification in Australia and a Bachelor's qualification in New Zealand. The course length is mainly five years in both countries. There is no pre-registration period.
HOW SHOULD EDUCATION CHANGE? Technological change, an ageing population and a shift to provide more healthcare services in the community are changing the roles that optometrists and dispensing opticians perform. But while the impetus for education to adapt to an evolving world is common to all optical professionals, the skills that practitioners value in future optical graduates may vary depending on their perspective and mode of practice. OT asked optometrists from a range of professional backgrounds for their views on the skills that are necessary to future-proof the profession.
5
US & CANADA Optometry is a four to five-year postgraduate degree following at least three years of undergraduate study. Optometry graduates receive an Optometry Doctorate (OD) degree.
U
SOUTH AFRICA Optometry is a four-year undergraduate degree. Graduates may be required to complete an internship following qualification.
SA
What training do other UK health professionals receive? MEDICINE Five years of undergraduate education followed by a twoyear foundation programme and at least three years of specialty training under supervision. NURSING A three-year undergraduate degree. The Nursing and Midwifery Council specifies that newly qualified nurses should undertake a year of preceptorship (guidance and support) following qualification.
DENTISTRY Dentists complete a five-year Bachelor of Dental Surgery (BDS). For dentists who wish to work within the NHS, this is followed by up to two years of foundation training. PHARMACY Pharmacists undertake a four-year Master of Pharmacy followed by one year of preregistration training.
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Source: Collaborate Research for the General Optical Council, 2017
and dispensing opticians who had qualified in the past five years found that 60% of newly qualified optometrists felt there was not enough clinical experience within their academic study.
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prescribing into the course and a focus on time management, as well as dealing with stress in the clinical environment. The HOC suggests that smaller course sizes may help to ensure that students arrive in the workplace with improved practical skills. “Lastly, communication skills and learning the best and most empathetic way to talk to patients is a key way that training needs to evolve,” Ms Higgins said Turning to the attributes that are particularly useful in a hospital setting, the HOC emphasise the importance of optical coherence tomography interpretation, although this can
be built up over time in-house. In the experience of HOC members, many students enter pre-reg with limited confidence in the “crucial” skill of assessing the retina using a bio-headset and indirect ophthalmoscopy. Experience with refraction and retinoscopy for high prescriptions and understanding how this differs to a normal refraction also needs more attention, Ms Higgins highlighted to OT. A shortage of ophthalmologists has added to the value that hospital optometrists bring to secondary care. Optometrists can become specialised to a very highly skilled
“A few weeks in a hospital as part of the prereg is really not enough” DON WILLIAMS level in clinics such as glaucoma, medical retina and corneal clinics. The HOC notes that some hospital optometrists have branched out
PATH TO REFORM
A timeline of the GOC’s Education Strategic Review to date
DECEMBER 2016 A comprehensive review of education is initiated by the GOC. Optometrists, dispensing opticians, training providers, professional bodies, optical businesses and individuals respond with their views
GOC 62 www.optometry.co.uk
DECEMBER 2017 – MARCH 2018 The GOC begins a consultation on draft concepts and principles that could underpin a re-designed education and training for optometrists and dispensing opticians NOVEMBER 2017 A roundtable event brings together different stakeholders from the optical sector
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SUMMER 2018 Standards for education programmes and learning outcomes for students are developed by the GOC with input from stakeholders
“I think that the lockdown and the pandemic have taught us we can do a great deal more of our educational training online” STEPHEN KIRLEY
into new skillsets, such as carrying out intravitreal injections and performing YAG laser treatment.
INDEPENDENT PRESCRIBING Birmingham optometrist Don Williams qualified with independent prescribing in April 2019. Mr Williams told OT that he believes that students should undertake an additional two years of training to become optometrists – bringing the course closer to the requirements seen in countries such as the US. He added that in his view the current clinical component of optometry education in the UK
NOVEMBER 2018 – FEBRUARY 2019 A consultation on draft Education Standards and Learning Outcomes is conducted
is insufficient. “The programme needs to incorporate more pathology and clinical exposure to these pathologies,” Mr Williams explained to OT. “A few weeks in a hospital as part of the pre-reg is really not enough,” he added. Mr Williams would like to see some elements of the current independent prescribing qualification incorporated into the undergraduate education of optometrists in the UK. To attain the full qualification, optometrists would need to complete a substantial number of clinical hours. Ultimately, Mr Williams would like to see IP-qualified
AUTUMN 2019 – SPRING 2020 The GOC confirms further work is needed following the consultation and an Expert Advisory Group is formed to guide this process
optometrists work towards a title that has a similar level of respect to that carried by the optometry doctorate (OD) programme in the US and Canada. “If you have done six or seven years of studying, then that should be reflected in our degree and title,” he concluded.
DOMICILIARY Glasgow-based domiciliary optometrist, Stephen Kirley, told OT that the COVID-19 pandemic and new ways of working as a result of the outbreak will have a significant impact on changes to optometric education. “I think that the lockdown and pandemic have taught us we
JULY 2020 A three-month consultation on the GOC’s proposed outcomes for registration and education standards begins. The consultation sets out the planned future benchmarks for optometry students and providers that train optometry students. A planned quality assurance framework is also outlined as well as an impact assessment for the proposals
DECEMBER 2020 The GOC aims to approve the outcomes for registration and standards for approved qualifications by the end of the year
2022:
There are plans for the new education framework to be implemented by Autumn. However, there will be a transition period so it could take some time before all students are learning under the new model.
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can do a great deal more of our educational training online,” he said. In terms of topics that could be covered more thoroughly, Mr Kirley highlighted that a greater awareness of dementia and its effects would be advantageous. This could be introduced through a dedicated module during the undergraduate education of optometrists. “We have an ever-advancing life expectancy within our population and dementia is becoming more prevalent as a result,” Mr Kirley told OT. “Providing as much training in this field as possible would greatly aid practitioner understanding and improve patient management,” he added. Domiciliary optometrist for the OutsideClinic, Matthew Burford, told OT that the pandemic has “brought into sharp focus the importance of an agile and multiskilled work force.” He added that domiciliary optometry is vital, but unfortunately it is often overlooked. The OutsideClinic has worked with universities to raise the profile of the skills required in domiciliary optometry. “High levels of ‘soft skills’, such as active listening and emotional intelligence, are required as we
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are often dealing with the most vulnerable members of society,” Mr Burford shared. “Performers also need to be clinically confident and competent to deal with a range of conditions and investigative techniques within a patient’s home.” Mr Burford highlighted the need for education and training to be a “career-long journey.” “Flexibility with ongoing training, such as with a continuing professional development-based system, will allow optometrists and dispensing opticians to focus on their particular areas of skill and interest whilst maintaining core knowledge,” he concluded.
LOCUM
Optometrist Craig McCoy works as a locum within different Scottish independent practices. Mr McCoy, who has an independent prescribing qualification, told OT that education and training needs to evolve so optometrists are eye health professionals “first and foremost.” Practical experience of seeing and treating patients with different eye conditions – including binocular, refractive and pathological conditions – is essential, he emphasised. “I worked as a resident for four years in a busy multiple before changing and becoming a full-time locum in independent practice,” Mr McCoy said. “I’m concerned at the trend for optoms to start locum work straight after qualifying,” he added. Flexibility and a “cool head” are valuable qualities when it
“Unless optometrists are eager to upskill and share some of the burden with secondary care under an appropriate funding model, a lot of people could lose vision” CRAIG McCOY
comes to working as a locum, Mr McCoy said. “They only come from experiencing a wide range of patients,” he observed. Mr McCoy believes that it is important newly qualified optometrists gain experience working in an employed role before exploring working as a locum. He highlighted that the increased prevalence of eye disease linked to the ageing population and reduced capacity within the hospital eye service following the pandemic has created a “huge backlog” of patients awaiting assessment and treatment. “Unless optometrists are eager to upskill and share some of the burden with secondary care under an appropriate funding model, a lot of people could lose vision,” he concluded.
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Education and training for October/ 2020 the eye care practitioner November
PRODUCTION
In this issue
68/ Is binocular vision a critical component of myopia management? Dr Sara J McCullough PhD, MCOptom, Prof Cert Glauc
Course code: C-76085
73/ Advances in the management of central retinal vein occlusion
CLIENT
Dr Sarah Ah-Moye MBBS, BSc, Dr Juan Lyn Ang MD, Mr Hemal Mehta MBBS, MA, FRCOphth
Course code: C-76150
78/ Helping parents understand their child’s myopia – a ‘dual purpose’ approach Sarah L Morgan BSc (Hons), MCOptom, MPhil, FAAO, FBCLA
Course code: C-76228
84/ Gaining insight: patient perspectives of the cataract journey Jo Mackenzie BSc (Hons) MCOptom, PG Cert TLCP, DipTP(AS), DipTP(SP), DipTP(IP), PG Cert HCL
Course code: C-76073
88/ Specialist spectacle dispensing Claire McDonnell FAOI, MSc, Patricia Mordaunt PG Dip, FBDO
Course code: C-75932
90/ External eye pathology
Professor Simon Barnard PhD, FCOptom, FAAO, FEAOO, DipCLP, DipClinOptom, DipTp(IP)
Is binocular vision a critical component of myopia management?, page 68
“Where the child remains amblyopic after treatment, it is important to consider the potential consequences of fitting contact lenses to a child with good vision in only one eye. The risk of contact lens induced keratitis should be discussed with the parents and balanced with the risks and likelihood of myopia progression and future visual difficulties.” Dr Sara J McCullough
Course code: C-75973
Competency tracker
In this edition of OT, practitioners can test a range of competencies:
Optometrists Therapeutic optometrists Dispensing opticians Contact lens opticians CET exams in this edition are available online from 10 October 2020
Helping parents understand their child’s myopia, page 78 “Where parents are themselves emmetropic, the need for vision correction, in whatever form, may be unfamiliar. Parents need to appreciate that there is no cure for myopia. The word ‘correction’ when used with ‘vision correction’ can be misconstrued by the lay person as ‘curing’ vision in some way and should be avoided in dialogue with patients.” Sarah L Morgan
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Is binocular vision a critical component of myopia management?
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Dr Sara J McCullough PhD, MCOptom, Prof Cert Glauc SUBS
This article describes the elements of binocular vision assessment that are important with regard to the risk of myopia development and progression in children and how this might influence myopia control strategies.
ART
Optometrists Dispensing opticians
PRODUCTION
Contact lens opticians
Introduction
CLIENT
A thorough binocular vision assessment is an important feature of any eye examination and particularly for children. With regard to myopia development and control strategies, the pertinent binocular vision assessments are within the scope of practice for a primary care optometrist and should, at a minimum, include an evaluation of accommodative function and an assessment of ocular motor balance. Essentially, it is important to establish whether there is a phoria present at distance and near fixation and how well it is compensated – that is to say, does it recover well and is it likely to be comfortable and asymptomatic, or is there is a tropia present? This can be simply evaluated using a distance and near cover test. The degree of compensation and fixation disparity can be assessed using, for example, the Mallett Unit and a measurement of the patient’s fusional ranges. An evaluation of the interaction between the accommodative and vergence systems can also be achieved by calculating the accommodative convergence to accommodation ratio (AC/A ratio); this describes the patient’s convergence ability per unit of accommodation exerted. A typical response is generally between 2-5:1 depending on the method of measurement.1 An assessment by the heterophoria method using a comparison of the size of phoria between distance and near fixation will result in a higher ratio than when using the gradient method, which compares the size of the phoria when accommodation is stimulated or relaxed by concave or convex lenses. Habitual binocular status is important to consider prior to changing to a different refractive correction as the
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change in correction method can alter the vergence state and the resultant binocular status. It is also important to consider if there is a tropia present, as it is likely that management of the binocular vision problem will be prioritised before commencing myopia management. These aspects will be discussed in detail in this article. While the recent International Myopia Institute guidelines state that currently there is no consensus on the gold standard techniques for assessing binocular vision prior to instigating myopia management, at a minimum they suggest an evaluation of both the accommodative and vergence systems as described above. They would also suggest that the same tests are used at subsequent visits to monitor any change in binocular function with myopia management.2 A summary of the binocular vision tests discussed within this article and their significance can be found in Table 1 (page 70).
Accommodative response It has been reported that myopes tend to have larger accommodative lags than their emmetropic peers3 and that a lag of accommodation, and thus hyperopic defocus on the central retina may be a stimulus to eye elongation and myopia development (see Figure 1). This theory has Figure 1
Accommodative lag
Figure 1 Illustration of accommodative lag
Figure 2
Some base in prism induced at near
Slightly reduced accommodative demand
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the accommodative lag found in myopes is a precursor to myopia development – that is to say, present in children at risk of developing myopia, the pre-myope, or is a consequence of the changes within the eye that are resultant from myopia development.5,6 Similarly, the evidence is equivocal on whether myopic progression is faster among those with lags of accommodation or larger accommodative lags with some supporting the theory5,7,8 while others do not.9–12 Although the evidence is conflicting with regard to accommodative lag and myopia progression, measurement of accommodative response is a quick and easy test to perform and can be helpful to include as a further risk indicator for myopia development.
Ocular motor status
No base in induced. Shift towards exophoria
Increased accommodative demand
Figure 2 Illustration of change in phoria and accommodation in a myope when wearing spectacle lenses and contact lenses when viewing at near
been supported by studies whereby myopia has been promoted in eyes with induced hyperopic defocus.4 An assessment of accommodative response accuracy is, therefore, a useful test to help identify those children who may be at increased risk of developing myopia. An accommodative lag occurs when there is a significant reduction in accommodative response compared to the accommodative demand. For example, if you ask a patient to look at a target at 25cm (a 4D demand), an accommodative response of less than 4D represents an accommodative lag. Larger accommodative lags lead to a greater amount of central hyperopic defocus and thus potentially a greater stimulus to myopia development. However, it is currently unclear whether
It has been suggested that near esophoria is associated with more rapid myopia progression and there is a shift towards esophoria during myopic progression.13–15 Those with near esophoria are thought to relax their accommodation in an attempt to relax their convergence at near to help maintain single vision. The reduced accommodation as a result would in theory promote axial elongation as previously described above. In some studies, children who developed myopia also showed an elevated AC/A ratio in the several years prior to myopia development compared to their age-matched peers who remained emmetropic.5,16,17 However, the evidence surrounding near esophoria and myopia development and progression is conflicting. Those who support the theory have reported that progression was slightly faster in those with near esophoria (approximately 30%) compared to those with orthophoria or exophoria, although this difference was small at only 0.09D greater progression per year.13 Others have reported annual progression to be statistically significantly greater in those with near exophoria compared to near esophoria; however, again, this difference wasn’t clinically relevant.18 Unpublished data from the Northern Ireland Childhood Errors of Refraction (NICER) study, a large,
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Table 1 Summary of the pertinent binocular vision tests and their relevance to myopia control strategies
SUBS
Used for
Normal result
Abnormal result
Significance and management of abnormal result
Distance and near cover/uncover test
Assessment of oculomotor balance at distance and near fixation
No movement of unoccluded eye, small to moderate movement of occluded eye with brisk recovery once cover removed
1. Movement of unoccluded eye suggests the presence of a tropia
Assess compensation of phoria, for example using a Mallett Unit, and fusional range
ART
Test
PRODUCTION
Dynamic retinoscopy
CLIENT
Assessment of AC/A ratio
2. Moderate to large movement of occluded eye with sluggish or no recovery once cover removed suggests poorly compensated or decompensating phoria
Treatment of tropia or decompensating phoria required prior to commencing myopia control strategy Caution required when changing from spectacles to contact lens correction if large, poorly compensated exophoria present Patients with near esophoria may be at greater risk of myopia development
Assessment of accommodative response (determining presence or absence of accommodative lag)
Accurate accommodative response to the accommodative demand, for example, accurately accommodates 4D when asked to view a target at 25cm
A lag of accommodation – that is to say, produces an accommodative response less than the accommodative demand
Patients with an accommodative lag may be at greater risk of myopia development
Assessment of the patient’s convergence ability per dioptre of accommodation
AC/A ratio= 2-5:1
AC/A ratio >5:1
Patients with higher AC/A ratios may be at increased risk of myopia development
nine-year evaluation of longitudinal changes in refractive error among white, UK based children and young adults aged between 6–7- and 15–16-years, and 12–13- and 21–22-years19, found that the majority of those in the study who were myopic or developed myopia during the study period (n=211) were either orthophoric (74%) or exophoric (18%), with the minority being esophoric (6%) on near cover test (with correction). Similarly, the majority of myopic participants from the MiSight 1 day randomised controlled clinical trial20 were orthophoric
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Those with larger accommodative lags may potentially have a greater risk than those with smaller accommodative lags Patient may respond favourably to myopia control with bifocal/ multifocal spectacle lenses where other treatments; for example, contact lenses are potentially contraindicated
Patient may respond favourably to myopia control with bifocal/ multifocal spectacle lenses where other treatments, for example, contact lenses are potentially contraindicated
(67%) or exophoric (23%) at near compared to only a small number presenting with esophoria (8%).
Accommodative lag and near esophoria
As a result of reports that those with near esophoria and accommodative lag were likely to have faster myopic progression, researchers investigated whether these individuals would have less myopic progression when bifocal or progressive addition lenses were prescribed compared to single vision distance spectacles. The
treatment effects in studies that specifically targeted children with these conditions show some, but not obviously different results compared to those where these restrictions were not employed. There is also an indication that executive-type bifocals may provide the best results for the optical treatment of myopic progression over other types of multifocal lenses, particularly when those with near esophoria and accommodative lag are considered.21 However, caution must be taken that this is only in one study population and further replication is required before clear cut advice can be given. For clinicians, we can, therefore, say it is likely that the majority of myopic patients will either be orthophoric or exophoric at near with fewer presenting with esophoria (less than one in 10). Children presenting with near esophoria, an accommodative lag and elevated AC/A ratio may be potentially at greater risk of myopia development or show faster progression of myopia once myopia has developed than their orthophoric or exophoric peers; however, the results are still inconclusive. Other risk factors for myopia development such as family history of myopia, East Asian ethnicity and visual environment (low time outdoors, intense near work)2 should be evaluated and are likely to outweigh the binocular vision risk factors discussed.22 Those rare myopes who exhibit both near esophoria and accommodative lag could be prescribed multifocal lenses such as executive bifocals (where other treatment options such as myopia control contact lenses might be potentially contraindicated) as they may respond favourably to this treatment modality compared to the majority without these binocular vision features.
How might a patient’s binocular vision be affected by myopia control strategies?
It is important to check the ocular motor status of a myopic patient before changing from single vision spectacles to a contact lens correction. When myopes look through a spectacle lens at near, there is some element of base in prism induced, therefore, they need to exert less vergence in spectacles than they do in contact lenses. The off-centre power of the minus lens is also less during near tasks and, as such, accommodative demand is less with spectacles compared to contact lenses (see Figure 2). However, moderate levels of myopia are required for this to be significant. For example, using Prentice’s rule (P=cF) with an inward eye movement of 2mm in each eye for near vision, the patient would need to be a -5D myope to obtain 1Δ base in. So, if a child has a well-compensated exophoria that shows brisk recovery on cover test, no
CET
fixation disparity and normal fusional ranges, there should be no issue changing from spectacles to a contact lens correction, particularly when low levels of myopia are present. However, if a child has a large exophoria, that shows poor, sluggish recovery on cover test, an exo-slip on fixation disparity and/or a reduced positive fusional range, then changing to contact lenses may cause decompensation of the exophoria. In this instance, it would be beneficial to deal with the binocular vision issues first by providing orthoptic exercises to improve convergence and positive fusional reserves, for example, pen to nose exercises, dot cards, positive/near stereograms, before changing the refractive correction modality. An easy way to confirm that you have not disrupted the patient’s binocular status when changing refractive error correction type is to perform a cover test with the new correction to ensure it has not significantly increased the size of the phoria present or caused it to decompensate. Ruiz-Pomeda et al23 recently conducted a randomised control trial comparing binocular vision and accommodative characteristics between those wearing single vision spectacles and MiSight 1 day lenses in children aged eight to 12 years and followed them over a period of two years. Those in the MiSight 1 day group became slightly more exophoric at near over the two-year period; however, the change did not differ significantly on average to the group of children wearing the single vision spectacle lenses. This change in near phoria may be explained by the children using the near addition to relax their accommodation and, therefore, their convergence, or from the effect of changing from spectacle lenses to contact lenses as described above. The near point of convergence, accommodative amplitudes and responses were within normal limits for those wearing the MiSight 1 day contact lenses, did not change over time and did not differ significantly from those wearing the spectacle lenses. When changing children from single vision spectacles to myopia management contact lenses it is unlikely to cause clinically significant changes to binocularity or accommodation. Nonetheless, it is worthwhile reviewing the ocular motor status with the new correction to ensure that the binocularity or accommodative function hasn’t been disrupted.
Contact lenses in those with compromised binocular vision
Cases of children with anisomyopic amblyopia are rare and were reported in less than 1% of myopic European children aged between five to 16 years.24
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A recent report by Bullimore (2017)25 also revealed that there was no increased risk of corneal infiltrative events in children compared to young adults – in fact the risk was markedly lower as parents supervised their younger children with cleaning regimes. However, the final binocular vision consideration that may be important prior to commencing a myopia management strategy is the case of a myopic child with amblyopia as a result of significant anisometropia or a manifest strabismus. If the child is amblyopic or strabismic, treatment should be first initiated to manage the binocular vision issues prior to myopia control. Where the child remains amblyopic after treatment, it is important to consider the potential consequences of fitting contact lenses to a child with good vision in only one eye. The risk of contact lens induced keratitis should be discussed with the parents and balanced with the risks and likelihood of myopia progression and future visual difficulties. Children with significant anisomyopia but good vision in both eyes may benefit from a contact lens myopia management strategy to negate the unwanted effects of aniseikonia. Fast-paced development may see alternative options to contact lenses coming to market in the future such as Defocus Incorporated Multiple Segments (DIMS)26 or low dose atropine therapy.27
Conclusion Binocular vision is important to consider for the young myopic patient, particularly when the clinician is planning on initiating a myopia management strategy. At a minimum, a measure of accommodation and ocular motor status are required prior to commencing myopia management and the same tests should be repeated on subsequent visits. It is also of interest to glean information on signs of accommodative lag, the presence of near esophoria and a high AC/A ratio, as children with these features, although at a low incidence, may be at a higher risk of developing myopia or having faster progression once myopia has developed. Although strategies such as myopia control contact lenses are unlikely to significantly alter the binocular and accommodative status of a child, it is important to check these clinical features before and after fitting these refractive modalities, as with any refractive error correction, to ensure they have not been compromised as a result.
Acknowledgement
This article was supported by CooperVision.
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Exam questions and references
Under the enhanced CET rules of the GOC, MCQs for this exam appear online at www.optometry.co.uk. Please complete online by midnight on 27 December 2020. You will be unable to submit exams after this date. Please note that when taking an exam, the MCQs may require practitioners to apply additional knowledge that has not been covered in the related CET article. CET points will be uploaded to the GOC within 10 working days. You will then need to log into your CET portfolio by clicking on ‘MyGOC’ on the GOC website (www.optical.org) to confirm your points. Visit www.optometry.co.uk, and click on the ‘Related CET article’ title to view the article and accompanying ‘references’ in full.
About the author n Dr Sara McCullough is a lecturer in optometry and vision science at Ulster University. She is a coinvestigator on the Northern Ireland Childhood Errors of Refraction (NICER) study, a large, prospective study investigating the progression of refractive errors in children and young adults in the UK with a particular interest in the risks and progression of myopia development. She has presented her research findings and clinical expertise at numerous national and international conferences and CET events. Dr McCullough also provides undergraduate lectures and clinical tutorials on binocular vision and orthoptics at Ulster University and is a research advisor and examiner for the College of Optometrists.
Course code: C-76085 Deadline: 27 December 2020
Learning objectives n Be able to understand the relevance of binocular vision status with respect to myopia (Group 8.1.6) n To appreciate the impact that changing from spectacle to contact lens correction can have on binocular vision status (Group 5.1.2) n Be able to understand the relevance of binocular vision status with respect to myopia (Group 7.1.7) n To appreciate the impact that changing from spectacle to contact lens correction can have on binocular vision status (Group 5.4.1)
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Advances in the management of central retinal vein occlusion
1
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Dr Sarah Ah-Moye MBBS, BSc, Dr Juan Lyn Ang MD, Mr Hemal Mehta MBBS, MA, FRCOphth
POINT
SUBS
This article provides an overview of the diagnosis and investigation of central retinal vein occlusion and an update on the management of the condition.
ART
Optometrists Dispensing opticians
PRODUCTION
Introduction
CLIENT
Central retinal vein occlusion (CRVO) is a sightthreatening retinal vascular disease.1 The total number of people with retinal vein occlusion (RVO) in the EU is estimated to be 900,000 and is expected to rise to 1.1m by 2050.2 Globally, the estimated prevalence is 0.8%, increasing with age.1,3 Patients with CRVO report significantly worse vision-related quality of life scores compared with controls.4 The natural history of CRVO is that vision usually deteriorates over time, with a small group experiencing some spontaneous visual improvement. However, without treatment most patients do not usually achieve a visual acuity (VA) of greater than 6/12.5 Patients with CRVO are categorised as ischaemic if they have significant retinal non-perfusion.6 If left untreated, more than one in five eyes with ischaemic CRVO experience anterior segment neovascularisation.5 Macular laser was trialled as a therapy for macular oedema secondary to CRVO in 1995 but showed no significant benefit.7 Intravitreal dexamethasone therapy was demonstrated to provide visual benefit in the GENEVA trial and was recommended by the National Institute for Health and Care Excellence (NICE) in 2011 to treat macular oedema secondary to CRVO.8 However cataract progression and raised intraocular pressure (IOP) can be an issue with steroid therapy. In the past few years, treatment with intravitreal anti-vascular endothelial growth factor (anti-VEGF) therapy has emerged as an effective treatment for macular oedema secondary to CRVO with NICE approval.9,10
Pathophysiology CRVO results from blockage of the central retinal vein (CRV) as it leaves the eye through the lamina cribrosa.11
A blockage results in a rise in retinal capillary pressure and subsequent increase in vascular permeability, in turn leading to leakage of fluid into the retina causing macular oedema.1 Disturbance of the blood supply to the retina (retinal ischaemia) can exacerbate this process, as production of VEGF promotes permeability of retinal capillaries and leakage, resulting in further macular oedema.1,12 Intraocular levels of VEGF have been found to be significantly elevated in patients with CRVO-induced macular oedema.13 Macular oedema is the leading cause of visual impairment in CRVO.1 Reduced VA is a consequence of disruption of photoreceptor function by an oedematous and haemorrhagic macula and in some cases retinal ischaemic damage.14
Risk factors
Systemic risk factors Increasing age, hypertension, diabetes mellitus, abnormal lipid profile, smoking and obesity are systemic risk factors for CRVO.1,15–17 Hypercoagulable states, including Factor V Leiden mutation, protein C or S deficiency,18 anticardiolipin antibodies,19 hyperhomocysteinaemia19,20 and dehydration are conditions that have also been reported as risk factors.1 These risk factors are in line with Virchow’s triad, which consists of venous stasis, changes of the blood vessel wall and blood hypercoagulability.21 Ocular risk factors Elevated IOP is a risk factor for CRVO as it may compromise retinal venous outflow.17 Other ocular risk factors include external compression of the CRV, for example, as occurs in thyroid eye disease.22
Diagnosis and clinical manifestations Typically, patients with CRVO report sudden, unilateral, painless loss of vision.14,21 Classic features are (see Figures 1 and 2, pages 74–75):1 Widespread deep and superficial intraretinal haemorrhages in all four quadrants (termed ‘blood and thunder’ appearance)
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Posterior segment, retina & pathology
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Figure 1
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Investigations
SUBS ART
Figure 1 Fundus photography of a right eye CRVO with dilated and tortuous veins and widespread intraretinal haemorrhages
PRODUCTION
Cotton wool spots Retinal oedema Capillary non-perfusion Dilatation and tortuosity of retinal veins Possible optic disc oedema.
Common differential diagnoses CLIENT
Ocular ischaemic syndrome (OIS) OIS is a relatively uncommon condition. Severe narrowing of the carotid arteries leads to chronic retinal hypoperfusion and ischaemia.23 Patients often have a history of other vascular conditions, for example, atherosclerosis, hypertension, diabetes, coronary artery disease and thromboembolic disease. Significant asymmetry in diabetic retinopathy (DR) grading between the eyes should make the clinician consider OIS. The majority of patients present with visual loss occurring over weeks to months. Pain is a less frequent presenting feature, which is often described as a dull, constant ache, worse on sitting upright. Pain can be attributed to ischaemic pain or iris neovascularisation. Table 1 details other features of OIS. Diabetic retinopathy DR, a microvascular complication of diabetes, is the most common cause of visual loss due to retinal vascular disease.1 The introduction of the NHS Diabetic Eye Screening Program (England) and Diabetic Retinopathy Screening Service Wales (DRSSW) is thought to have led to significant decreases in certifiable blindness due to DR and maculopathy.24 Therefore, it is probably less common to see patients presenting with sight-threatening DR that may be mistaken for CRVO. Patients with undiagnosed diabetes, poor adherence to screening programmes or recent arrival in the country may be more likely to present with sight-threatening DR that may be mistaken for CRVO.25 See Table 1 for other features of DR.
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Ophthalmic investigations Best corrected VA – particularly low VA could indicate an ischaemic CRVO Relative afferent pupillary defect (RAPD) – presence of RAPD likely indicates an ischaemic CRVO Slit lamp microscopy to examine for the presence of iris neovascularisation27 IOP measurements are required at every clinic visit, particularly due to the risk of ‘100-day glaucoma’, a term that describes development of neovascular glaucoma typically within three months of onset of the CRVO28 Gonioscopy to examine for the presence of angle neovascularisation29 Dilated fundus examination to examine for the presence of retinal or disc neovascularisation, a rare complication of ischaemic CRVO1 Colour fundus photography to identify and document clinical features such as vein tortuosity, retinal haemorrhages and cotton wool spots Optical coherence tomography (OCT) can establish the presence and degree of macular oedema associated with CRVO Fundus fluorescein angiography (FA) is an invasive test conducted to assess the presence and extent of macular and peripheral ischaemia30 OCT-angiography (OCT-A) – as OCT-A becomes more widely available, it may become a more suitable non-invasive alternative to FA to assess macular nonperfusion.31 Systemic investigations Detailed medical history Blood pressure monitoring: uncontrolled hypertension is linked with developing RVO in the fellow eye or recurrence in the same eye27 Recommended tests in those over 50 years of age:27 o Serum glucose (to check for diabetes) o Full blood count (to check for obvious hypercoagulable state) o Erythrocyte sedimentation rate (to exclude giant cell arteritis) o C-reactive protein (to exclude giant cell arteritis) Younger patients may require more comprehensive tests.27
Ischaemic versus non-ischaemic
CRVO can be classified into ischaemic or non-ischaemic subtypes. The Central Retinal Vein Occlusion Study (CVOS) defined ischaemic CRVO as greater than 10-disc
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Figure 2
Figure 2 Fundus photograph (left) and OCT (right) of an acute CRVO. The fundus photo demonstrates optic disc oedema, and flame haemorrhages in all four quadrants. The macular OCT shows intra- and sub-retinal fluid with disruption of the foveal outer retinal layers
areas of retinal capillary non-perfusion on seven-field FA.5 Other features that could indicate ischaemic CRVO include:1,32 Poor VA (less than 6/60) Presence of RAPD Presence of multiple dark deep intraretinal haemorrhages Presence of multiple cotton wool spots High degree of retinal vein dilatation and tortuosity. Patients with ischaemic CRVO are more likely to develop complications such as anterior neovascularisation.27 Patients who initially present as non-ischaemic, have the potential to transform to an ischaemic CRVO. The CVOS study showed that 15% of patients initially diagnosed as non-ischaemic converted to ischaemic CRVO within four months.5
Optometric management in primary practice The Royal College of Ophthalmologists recommend that treatment should be initiated within one to two weeks of initial assessment, stating that: ‘All patients suspected to have RVO by the optometrist, general practitioner, or other health workers should be referred directly to the nearest eye casualty, or eye clinic. Optometrists may be used for ‘screening’ or first examination of patients suspected of having RVO. Referrals from the optometrist should be sent directly to an ophthalmology department and should not necessarily pass through the general practitioner as such a route introduces unnecessary delays. Self-referral or presentation to the eye casualty/clinic should be encouraged, especially in patients who have second eye involvement.’1
Management of visual loss
Macular oedema There are two treatments that have emerged to manage
macular oedema: intravitreal anti-VEGF and intravitreal corticosteroid therapy. Intravitreal anti-VEGF injection is usually first line therapy. There is an initial loading phase followed by either a pro re nata (PRN) regimen or a treat and extend (TAE) regimen. The minimum treatment interval is four weeks. A PRN regimen delivers treatment based on disease activity. After the loading phase, patients are reviewed on a monthly basis and only treated when they meet pre-defined OCT and visual criteria, for example, worsening macular oedema or worsening VA.33 A TAE regimen aims to inject the drug just before the macular oedema is about to reactivate.33 Anti-VEGF therapy is administered initially at monthly intervals, before the time between treatments is extended as the disease becomes stable. The interval is extended at each appointment for as long as the disease remains stable – when there is reactivation the interval is reduced to restabilise the disease. Intravitreal ranibizumab (0.5mg) and aflibercept (2mg) are both licensed anti-VEGF agents for the treatment of macular oedema secondary to CRVO.34,35 Intravitreal bevacizumab (1.25mg) is an unlicensed anti-VEGF agent which is sometimes used off-label when a licensed drug is not funded.36 These drugs have a theoretical risk of thromboembolic complications such as stroke or myocardial infarction. Therefore, caution is exercised in those with a recent history of a cardiovascular event.27 Intravitreal corticosteroid therapy with dexamethasone implants (0.7mg) are administered as a single loading dose, followed by repeat doses if necessary, at intervals ranging from three to six months. It has been suggested that steroids should be reserved for:27 1. Non-responders to anti-VEGF therapy (after three to six injections)
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CET 2, 2
Posterior segment, retina & pathology
VERSION REPRO OP
Table 1 Differential diagnosis of CRVO, OIS and DR23,26
SUBS
CRVO
OIS
DR
Age
50s–80s
50s–80s
Variable
Pain at presentation
Painless
40% present with pain (dull, ache worse on sitting upright)
Painless
Laterality
Usually unilateral
80% unilateral
Bilateral
Retinal veins
Dilated and tortuous
Dilated but not tortuous
Dilated and beaded
Haemorrhages
Flame-shaped in all quadrants
Dot and blot, midperiphery
Dot and blot, posterior pole and mid-periphery
Microaneurysms
Variable
Mid-periphery
Posterior pole
Hard exudates
Rare
Absent
Common
Optic disc
Often swollen
Normal
Diabetic papillopathy (rarely)
Central retinal artery perfusion pressure
Normal
Decreased (light digital pressure on the lid induces retinal arterial pulsations)
Normal
ART
Features
Future management
PRODUCTION
The LEAVO trial is a recently published randomised controlled trial that compared the clinical effectiveness of ranibizumab, aflibercept and bevacizumab head-tohead for macular oedema due to CRVO over 100 weeks. Aflibercept was no worse than and not superior to ranibizumab in terms of visual outcomes. Bevacizumab may have had inferior visual outcomes over 100 weeks. Fewer mean injections were given in the aflibercept group (10.0) than in the ranibizumab (11.8) or bevacizumab
CLIENT
2. Those who are unlikely to come regularly for the shorter-acting anti-VEGF therapy 3. Those with a recent history of a major cardiovascular event. Triamcinolone acetonide is an intravitreal steroid that is sometimes used off-label. As steroids pose a risk of raised IOP and cataract formation, IOP should be monitored four to six weeks post injection.37
(11.5) group.38 Current research is exploring the safety and efficacy of longer-acting anti-VEGF therapies.39 For example, the RAVEN phase 3 clinical trial is assessing the efficacy and safety of brolucizumab, an anti-VEGF therapy. Longeracting therapies could potentially reduce the number of clinic visits and, therefore, decrease the burden on patients, carers and eye services.
Retinal ischaemia and neovascular complications
Complications
Pan-retinal photocoagulation (PRP) PRP is used to treat neovascular complications of CRVO.27 It is recommended that patients are carefully monitored for signs of neovascularisation of the iris or angles with prompt application of PRP if it becomes evident. PRP is not usually used prophylactically in ischaemic CRVO. However, if close follow up is not possible early PRP may be used as a prophylactic measure against neovascularisation in eyes with significant retinal ischaemia and limited visual potential.27 Management of medical risk factors It is important to control modifiable risk factors in patients with CRVO. Interventions include encouraging patients to stop smoking, undertake regular exercise and giving dietary advice as well as optimising diabetic and hypertensive control. These services are often available via the patient’s general practitioner.
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Severe retinal ischaemia can lead to significant visual loss often resulting in poorer vision at presentation and a more pronounced decrease in VA over time than nonischaemic eyes.40 Retinal ischaemia secondary to CRVO can subsequently stimulate production of new vessels in the anterior segment. Neovascularisation of the iris and drainage angle can in turn cause neovascular glaucoma. The incidence of neovascular glaucoma has been reported to be as high as 16% in cases of CRVO.28 Development of anterior segment neovascularisation is significantly correlated with the degree of retinal ischaemia and also the patient’s baseline VA with, higher incidence in patients with VA worse than 6/60 than in patients with VA better than 6/12.27,28 Less commonly, posterior segment neovascularisation can occur, affecting the optic disc or retina. The SCORE trial has found a 36-month incidence of retinal neovascularisation in 7.6% of eyes with CRVO.27
Outcomes Some studies have found that patients with CRVO have a higher risk of future stroke, cardiovascular disease and higher mortality. However, there is conflicting evidence for this. It may be that RVO and these conditions share underlying risk factors of hypertension and diabetes, and that CRVO is not necessarily a risk factor for cerebrovascular and cardiovascular disease.1 Ischaemia is a prognostic factor for CRVO. Patients with the non-ischaemic subtype generally have better prognoses than patients with the ischaemic subtype, with a low final VA of less than 6/60 in 50% and 93%, respectively.41 VA at baseline was found to be a strong predictor of VA at three years by the CVOS study.42 The patient group with a better baseline VA of better than 6/12 were more likely to maintain this VA. Patients with a VA of worse than 6/60 had an 80% chance of remaining at this VA, irrespective of ischaemic status.42 A study of real-world data from the Royal Free London NHS Foundation Trust identified 32 eyes treated with anti-VEGF monotherapy for macular oedema secondary to CRVO. Patients were treated with either aflibercept or ranibizumab monotherapy over 12 months as per NICE guidance. The mean gain in VA was 13 logMAR letters and 9.7 logMAR letters and the mean decrease in central subfield thickness was 291.5µm and 225µm for aflibercept or ranibizumab, respectively. Patients required a mean 5.8 and 6.1 injections over 12 months for the aflibercept and ranibizumab treatment groups.43
CET
About the authors n Dr Sarah Ah-Moye is an ophthalmology clinical research fellow at the Royal Free London NHS Foundation Trust and has a special interest in real-world data studies for retinal vein occlusions, presenting work at ARVO and EURETINA conferences. She completed her Bachelor of Medicine and Bachelor of Surgery (MBBS) and Bachelor of Science (BSc) at St George's, University of London in 2016. n Dr Juan Lyn Ang is an ophthalmology clinical research fellow at the Royal Free London NHS Foundation Trust. She completed her Bachelor of Medical Studies (BMed) and Doctor of Medicine (MD) degrees at the University of New South Wales, Australia in 2014 and is completing her Masters in Epidemiology at London School of Hygiene and Tropical Medicine. n Mr Hemal Mehta is a consultant ophthalmic surgeon at Royal Free London NHS Foundation Trust. He specialises in medical retina conditions and cataract surgery. He is leading the expansion of the ophthalmology department's clinical trials unit at Barnet Hospital, evaluating emerging therapies, particularly for retinal diseases. The clinical research during his fellowships at Sydney Eye Hospital and Moorfields Eye Hospital is the basis of his MD thesis on ‘Novel endpoints in diabetic retinopathy clinical trials’ registered at Cambridge University.
Conclusion
RVO is a significant event for many patients. Optometrists play a key part in identifying cases and taking timely action to ensure the best outcome.
Exam questions
Under the enhanced CET rules of the GOC, MCQs for this exam appear online at www.optometry.co.uk. Please complete online by midnight on 27 December 2020. You will be unable to submit exams after this date. Please note that when taking an exam, the MCQs may require practitioners to apply additional knowledge that has not been covered in the related CET article. CET points will be uploaded to the GOC within 10 working days. You will then need to log into your CET portfolio by clicking on ‘MyGOC’ on the GOC website (www.optical.org) to confirm your points.
References Visit www.optometry.co.uk, and click on the ‘Related CET article’ title to view the article and accompanying ‘references’ in full.
Course code: C-76150 Deadline: 27 December 2020
Learning objectives n Be able to explain the implications of retinal vein occlusion to patients (Group 1.2.4) n Be able to interpret symptoms of retinal vein occlusion and manage the patient accordingly (Group 6.1.2) n Be able to explain the implications of retinal vein occlusion to patients (Group 1.2.4) n Be aware of the presenting characteristics of retinal vein occlusion (Group 8.1.2)
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CET 2, 3
Posterior segment, retina & pathology
VERSION
Helping parents understand their child’s myopia: a ‘dual purpose’ approach
REPRO OP
Sarah L Morgan BSc (Hons), MCOptom, MPhil, FAAO, FBCLA SUBS
This article outlines the approaches that can be taken to help explain the implications of refractive outcome to parents of children with myopia.
ART
expressed by an observant teacher. These scenarios are examples of the possibilities an ECP might encounter when examining a child for the first time. Specifically, when myopia is the refractive outcome, it is useful to consider the existing knowledge and experience of the parent(s) when delivering the conclusions of the eye examination and discussing next steps.
Optometrists Dispensing opticians
PRODUCTION
Contact lens opticians
Background facts
Introduction
CLIENT
Diagnosing myopia in a child is a normal part of everyday practice. This article discusses key elements of how eye care professionals (ECPs) can optimise their interaction with parents and children. ECPs themselves are extremely familiar with myopia and this is perhaps the greatest distinction between them and the parents of the newly diagnosed myopic child: context. Where one parent may have some sense of refractive error running in families, another may not make the link. A simple understanding of myopia, let alone the relationship between the various optical components of the eye, for example, corneal curvature and axial length, remains largely unknown by parents,1 so the education gap is wide. Parents deserve to be informed about the likelihood of their child requiring vision correction, as well as the key milestones in their growth and development where optometric examination is both diagnostic and prognostic in helping to predict the future refractive status and needs of their child.
Myopia: the first diagnosis A child may be brought for an eye examination for a variety of reasons. When one or both parents require vision correction, eye examinations are part of their regular healthcare checks, which may lead them to consider having their child examined. In contrast, emmetropic parents may not recognise the importance of regular eye examinations for their children. In some instances, a child’s vision problem may be picked up via a school vision screening programme or from concerns
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1
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POINT
Conducting an eye examination of a child is routine for ECPs with the regular history and symptoms forming part of the initial discussions, including the reason for the visit. When myopia is suspected, or the child has been identified as having the potential to become myopic, the usual questions are asked in addition to those which focus on gaining more detail for the myopia risk profile of the child (see Tables 1 and 2). Open questions at the start of the consultation allow the ECP to gain vital insight into the child’s everyday life experience (see Table 3, page 80), and the current level of awareness of myopia (and the long-term visual experience of living with myopia) with one or both parents. This knowledge at the beginning of the eye examination, and well in advance of its conclusion, gives the ECP time to consider how best to communicate their recommendations, in addition to being able to ask further questions to help discuss and educate the parents and the child about the future implications of myopia as the child grows.
Knowledge pathway: discussing next steps When formulating where to start with professional advice on myopia for an individual child, the ECP can consider the knowledge pathway framework (see Figure 1, page 80). This helps to establish where to begin in terms of educating the parent(s) and child, taking into account their current experience. What is myopia? This is the first step on the pathway when the parent(s) are not themselves myopic. They first need to appreciate how their child is currently functioning visually. The Vision Simulator (CooperVision) is a great tool for
CET
Table 1 Key history to establish potential for myopia: child Questions for the child
Rationale
What’s the main reason your mum/dad has brought you in to see me today?
Useful to have the child’s perception about why they are having an eye examination
How do you find your vision when you’re reading close-up – for example, a book/tablet/mobile phone?
This helps to establish how the child feels about their near vision and may help to highlight any accommodative or binocular vision problems at near
At school: How is your vision for the white board in class? Where do you sit in class? How would you manage seeing the board in class if you were sitting at the very back? At home: How do you find reading the writing on the television – for example, when viewing the TV guide page?
These questions help to establish any problems with distance vision The parent is able to listen to the responses and consider whether or not they themselves have noticed any issues with this aspect of their child’s vision It can be helpful to ask the parent directly if they were aware of any difficulties or whether this is news to them. In the latter case, this informs the ECP that the parent did not expect their child to have any visual problem and can be handled accordingly when concluding the examination
Table 2 Key history to establish personal history and/or awareness of myopia: parents Questions for the parent(s)
Rationale
What’s the main reason you’ve brought <insert name of child> in to see us today?
This gives the parent the opportunity to voice any concerns or observations they have made about their child and their vision
What’s your opinion on how their vision is? For example: When reading a book? How well they can see writing on the TV?
These questions give the parent the opportunity to consider whether or not they have noticed any difficulties with their child’s vision – either for near or for distance The responses inform the ECP about the parent’s expected outcome from the examination – whether they thought their child would need vision correction or not
Sometimes, the need to wear spectacles runs in families. Do you (and/or the child’s other parent) need glasses or contact lenses?
This questions both educates about the genetic association of myopia, as well as uncovering whether one, both or neither parent requires vision correction If yes, it is important to get as much information on their prescription as possible – for example, focimeter their spectacles if they are wearing them, or ask them their contact lens powers if known
Has anyone in the family had any eye problems or surgery – even in grandparents – that required hospital treatment?
This question helps to uncover additional information: Amblyopia / squint surgery Refractive surgery Possible myopic pathology (hence the need to include older relatives who may also be myopic) This qualifies whether or not the parent has any context of the impact of myopia-related pathology
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CET 3, 1
Paediatrics, refraction & myopia
VERSION REPRO OP
Table 3 Asking open questions is important to understand the child as an individual
SUBS ART
About the child
Key information
How is school? What’s the favourite thing you do at school? What’s your best subject?
By understanding the child’s school experience, it is easier to appreciate how myopia might impact on their education
What do you do after you finish school? – for example, after school clubs or activities/lessons
Activities help to reveal additional needs as well as specific scenarios where spectacles can be inconvenient
What do you like to do when you’re not at school?
Insight into how the child might spend their leisure time also informs whether they tend to remain indoors or enjoy being outside
How do you spend the weekends?
Some activities may be a key feature of the weekend and this too plays a role in how the child’s myopia can be managed and prescribed for
PRODUCTION
showing the parent(s) the visual impact of uncorrected myopia across a wide range of prescriptions in a variety of school environments (see Figure 2).2 Using plus trial lenses, or ready readers, can also help to show an emmetropic parent how their child currently sees without spectacles or contact lenses.
CLIENT
Myopia forecast Parents with myopia may also have personally experienced how their refractive error advanced over time. For other parents, they may not be aware of the way myopia can increase as their child grows. Vision simulation offers the potential to demonstrate not only how the child may see on first presentation, but also how this might change with progressing myopia. This gives parents some Figure 1 context for the immediate needs as well as their child’s future requirements and demonstrates the importance of regular eye examinations. For ECPs, the reference is dioptric change; this in itself is a meaningless number to a layperson. Showing them the visual impact of uncorrected myopia facilitates their understanding and appreciation. Vision correction options Where parents are themselves emmetropic, the need for vision
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correction, in whatever form, may be unfamiliar. Parents need to appreciate that there is no cure for myopia. The word ‘correction’ when used with ‘vision correction’ can be misconstrued by the lay person as ‘curing’ vision in some way and should be avoided in dialogue with patients. Parents will be well aware that some children need to wear spectacles, but they may not know that contact lenses, in addition to spectacles, can be successfully fitted and worn by children.3,4 Sharing the impact contact lens wear can have on a child based on the results from the ACHIEVE study in particular provides good evidence of this, with children who participated in the study described feeling more competent when taking part in sports or activities, feeling better about their appearance,
Figure 1 The knowledge pathway. Image courtesy of CooperVision
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BLACK YELLOW MAGENTA CYAN
CET
Figure 2
Figure 2 Use of a vision simulator to demonstrate the visual impact of uncorrected myopia to parents.2 Image courtesy of CooperVision
and feeling better about fitting in with friends – all positive outcomes that parents would find desirable for their child.3 Contact lenses for myopia If either parent is myopic with experience of wearing contact lenses, they will be familiar with the clear benefits of spectacle-free vision. It is possible that even with this knowledge, they may not be aware that children can successfully wear contact lenses. When there is no contact lens wear experience in either parent, it is important for the ECP to discuss the everyday benefits of contact lens wear which applies in equal measure to children. Myopia matters An additional area that has the potential to be discussed is the longer-term risk of myopic pathology. In order to appreciate the ocular changes that might ensue due to myopia, the parents must have a basic understanding that myopia usually comes from the eye overshooting its optimal size. Contact lenses for myopia management Once the parent(s) is familiar with the overall concept and benefits of contact lens wear, and that children can successfully wear contact lenses, it is then a small step in knowledge to discuss myopia management options using lenses, such as daily disposable lenses or orthokeratology, which have been approved and specifically designed for myopic children that may help reduce the longer term risk of myopic pathology. Professional advice and expertise It is useful to share case histories with both the parent(s) and the child, so they have some insight into how myopia management can also benefit them. Support staff can
also give information about the expertise of the ECP in advance of appointments, which helps to instil confidence ahead of the consultation. Clearly there are many elements to consider when discussing childhood myopia with a parent, which makes it so important to take essential background history from the parents to inform and help steer conversations appropriately and in the context that they will personally understand. Discussing our professional motivation to reduce the risk of myopia pathology without the context of what comes before is likely to be too much of a leap for most parents to take on board.
Communication: key words and phrases
Explaining the difference between a single vision daily disposable contact lens and the more complex optics of a myopia management contact lens to parents has the potential to lead to much bewilderment. A simpler approach can be to describe a myopia management contact lens as being ‘dual purpose.’ The primary function of the lens is to give the child clear spectaclefree vision – that is to say, the spectacle prescription is incorporated into the lens. The secondary function is to help manage the myopia with specially designed optics, which research has shown may slow down the progression of the myopia leading to a lower overall final prescription – a lower prescription is always better result for everyone (better cosmetically, better practically, and better for the long term health of the eye). In a child where there is no known family history of myopia, it may be better to curtail this relatively complex discussion by saying ‘myopia can have longterm eye health implications (for example, an increased risk of retinal detachment), which is why we are so keen to limit the rapid growth of the eye.’
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CET 3, 2
Paediatrics, refraction & myopia
CET 3, 3 VERSION
About the author
REPRO OP
Case scenarios: experience and success
SUBS
Consider the presentation of the following two cases. Review the history and think about the additional information required to begin discussing the child’s myopia with the parents. It is useful to reflect on where these two cases would sit on the knowledge pathway and how this might inform the first steps in the communication strategy in each scenario.
ART
Case 1: Lukas Patient Age Prescription Correction Boy 11 -3.50DS Spectacles only Interests: School: orchestra (violin) Home: basketball, table tennis
PRODUCTION
Parents Mother
Prescription -8.00DS
Father
-3.00DS
Correction Contact lens wearer History of retinal detachment LASER eye surgery (refractive)
CLIENT
Age 8
Parents
The role of the ECP requires the assimilation of the examination evidence to date coupled with a comprehensive understanding of the family unit in relation to both myopia and experience of vision correction to considerately guide recommendations following the consultation. No parent wants their child to miss out on anything that may benefit them, but without proactive advice and direction, they may remain ignorant. Children deserve the opportunity to ‘see the best they can see’ so that they can ‘be the best they can be’ during their early years’ education right through to high school and beyond.
Acknowledgement This article was supported by a grant from CooperVision.
Exam questions
Case 2: Sofia Patient Girl
n Sarah Morgan is an optometrist and has worked in clinical research at The University of Manchester where she gained her MPhil. She continues to lecture and lead clinical sessions and holds the post of Vision Sciences Fellow. Her business consultancy includes a wide portfolio of projects including staff development and training, advising professional organisations, and healthcare communication initiatives for manufacturers in the UK, Europe and globally. Ms Morgan has lectured extensively across Europe, North America, South Africa, Hong Kong, Australia and New Zealand. Ms Morgan is a Fellow of the American Academy of Optometry and the British Contact Lens Association.
Prescription Correction R -0.75DS First examination L -1.00DS No family history of myopia
Conclusion
A child identified as being at risk of developing myopia attends for their first examination accompanied by one or both parents with a wide range of possible background family history in relation to the diagnosis of and prescribing for myopia. An earlier article by the same author discussed the benefits of pre-handling what the future holds by discussing ‘pre-myopia’ with both the parents and child.5 To facilitate this, the child should be seen on or around their sixth birthday to best align with this key milestone in ocular growth and development according to extensive research data on children who develop myopia.6 Of course, there is some joy when prescribing for a myopic child in saving them from their currently blurry world. There is also the opportunity to discuss their options beyond spectacles including contact lenses for myopia management. When contact lenses are positively considered by the parents and the child, there is a great opportunity to prescribe a dual-purpose contact lens that not only corrects the myopia, but also to offer the additional possibility to slow down the progression of their myopia.
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Under the enhanced CET rules of the GOC, MCQs for this exam appear online at www.optometry.co.uk. Please complete online by midnight on 27 December 2020. You will be unable to submit exams after this date. Please note that when taking an exam, the MCQs may require practitioners to apply additional knowledge that has not been covered in the related CET article. CET points will be uploaded to the GOC within 10 working days. You will then need to log into your CET portfolio by clicking on ‘MyGOC’ on the GOC website (www.optical.org) to confirm your points.
References Visit www.optometry.co.uk, and click on the ‘Related CET article’ title to view the article and accompanying ‘references’ in full.
Course code: C-76228 Deadline: 27 December 2020
Learning objectives n Be able to explain the implications of refractive outcome to parents of children with myopia (Group 1.2.5) n Be able to explain the implications of refractive outcome to parents of children with myopia (Group 1.2.4) n Be able to outline contact lens correction options to parents of children with myopia (Group 1.2.4)
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BLACK YELLOW MAGENTA CYAN
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AGM VERSION REPRO OP SUBS ART
The AOP’s safe practice guidance is an invaluable resource for the team Ravi Sohal
PRODUCTION
ContaCt Lens PraCtitioner, PraCtiCe owner, oPtometrist and aoP member
www.aop.org.uk CLIENT
NOTICE OF THE BENEVOLENT FUND ANNUAL GENERAL MEETING The AGM to be held virtually in November 2020 The 21st AGM of the Benevolent Fund of the Association of Optometrists and the College of Optometrists will be held at 3pm, 4 November 2020, for the purposes of transacting the ordinary business of the Fund.
The AGM will be held virtually. Those wishing to attend are invited to register their interest via email to admin@ opticalbenfund.com with their first name and surname. They will then be sent a link so they can register.
Agenda for the Benevolent Fund AGM 2020 1. Apologies for absence 2. Address by Susan Wilford, chair of the Trustees 3. To receive the Minutes of the 20th Annual General Meeting of the Benevolent Fund of the Association of Optometrists and the College of Optometrists, held on 25 February 2019 4. To receive the Report and Financial Statements for the year ended 30 September, 2019 5. To note that Vivian Bush, Lisa Gerson and Henry Leonard retire by rotation as Trustees. Mr Leonard and Ms Gerson will retire
but Mr Bush has been re-appointed for a further three-year term. The AOP has nominated Aishah Fazlanie to join the Board 6. To confirm the appointment of an Independent Examiner to the Fund for the year 2019/2020 7. Any other business. By Order of the Trustees. Lynne Brown, administrative secretary Registered Charity Number: 1003699
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VERSION
Gaining insight: patient perspectives of the cataract journey
REPRO OP
Jo Mackenzie BSc (Hons), MCOptom, PG Cert TLCP, DipTP(AS), DipTP(SP), DipTP(IP), PG Cert HCL
SUBS
This article considers the practical implications of cataract development, and advice to help prepare patients for surgery, and outlines the improvements that surgery can make to lifestyle.
ART
Optometrists Dispensing opticians
PRODUCTION
Introduction
CLIENT
The prevalence of cataract varies with ethnicity, comorbidity and lifestyle, and the position and nature of that cataract dictates the individual’s symptoms, both in type and severity.1,2 But do we understand the practical difficulties that our patients with developing cataract experience? In 2010, the number of patients globally with cataract and presenting with a visual acuity 6/18 to 3/60 was estimated to be in the order of 35.1 million, while the number of those with a presenting visual acuity of <3/60, which would categorise them as blind, was estimated at 10.8 million.3 In the UK, a study of 14,600 patients aged 75 years and over found that 12.5% of the participants were visually impaired and, of those, the second highest cause for visual impairment was cataract, accounting for 35.9% of cases.4 The median age for cataract surgery in the UK has been shown by the National Ophthalmology Database (NOD) to be 76 and 77 years of age for first and second eye surgery, respectively,5 but there appears to be a lack of published data for average age of onset of the symptoms of cataract, or for the number of symptomatic years patients experience prior to having surgery.
Weighing up the pros and cons
For any surgery, the benefits should outweigh the risks, so it is important for the practitioner to not only understand the possible complications, with particular respect to their patient, but also to understand fully the nature and extent of the difficulties which the patient experiences because of their cataract, so that they may ascertain what the benefit of surgery might be. An attempt was made to prioritise surgery for those having visual impairment caused by cataract alone
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1
CET
POINT
by bringing in a visual acuity threshold of 6/12 as an eligibility criterion, but this was met with some opposition. There are many other factors which should be considered and in October 2017 the Royal College of Ophthalmologists withdrew its own ‘Cataract Surgery Guidelines 2010’ and adopted the NICE Guideline, NG77, Cataracts in Adults.6 Crucially, section 1.2.2 states: ‘Do not restrict access to cataract surgery on the basis of visual acuity.’ The VF-14 quality of life questionnaire is now widely used to assess the impact of cataract on a patient’s life and has been shown to be a reliable and valid measure of functional impairment caused by cataract, providing information not conveyed by visual acuity or general health status.7
Contrast sensitivity
Luminance is defined as the intensity of light emitted from a surface, per unit area, in a given direction, being measured in candela per square metre (cd/m2). For an object to be seen, a noticeable difference must exist between the luminance of that object and its surrounding background. In other words, it is the relative luminance and not the absolute value of luminance of that object, which determines whether or not it will be detected. This relative luminance is known as the luminous contrast and the object’s visibility and apparent brightness is, therefore, dependent upon the luminous contrast. Each eye has a luminous contrast sensitivity threshold – that is to say, a minimum level of contrast that can be detected, which is dependent upon the adaptive state of retina, the field size and the pupil size. Loss of transparency of the crystalline lens occurs naturally with ageing and gives the lens a yellowishbrown hue, so that the level of retinal illumination reduces with time and has been shown in the elderly to be as little as one-tenth that of a young person.8 This alters the patient’s contrast sensitivity threshold, such that a greater luminous contrast must exist for it to be noticeable and there is also a reduction in transmission of the blue end of the visible electromagnetic spectrum, resulting in altered colour perception. Patients with lowered contrast sensitivity generally function less
CET
Figure 1
Studies have further shown an increased melatonin production, improved cognitive performance and better sleep patterns following Figure 1 A cyclist in the shadows (left) is much harder to discern with reduced cataract surgery. For intraocular CSF (right). Image courtesy of Emily Mackenzie implants (IOL) that allow the well in dull or dark conditions – for example it is more transmission of the full electromagnetic spectrum, difficult to distinguish a dark car at night from its melatonin sensitivity to light increased by 45%, background and the contour between cars in a line is cognitive function improved by approximately lost. The turning off of stretches of streetlamps 70% and sleep function by approximately 50% in nowadays certainly does not help the patient with comparison to the group that received a blue-blocking cataract and, even during the day, reduced light IOL,11 with blue-enriched light also improving subjective well-being,12 alertness and cognition.13 transmission makes it harder to see a cyclist in shadows, as shown in Figure 1. Dimly lit passageways or staircases Modern sources of glare become harder to navigate, increasing the probability of Glare is a commonly experienced symptom among falls and objects become harder to find. patients with cataract as light is scattered internally Contrast sensitivity is easy to measure in practice and and the patient becomes sensitive to and is often is such a useful tool for understanding the difficulties a dazzled by the brightness. Haloes form around lights, patient is experiencing. It is also a very good measure the image is degraded, and ghosting or multiple of improvement in functional vision postoperatively images are commonplace. The Rayleigh scattering and may show a marked difference even when the equation tells us that the amount of scatter for any preoperative visual acuity appeared to be good and has given light is inversely proportional to the fourth not significantly improved. power of the wavelength of that light, therefore, it is Not only does reduced retinal illumination impair blue end of the visible spectrum which scatters the the patient’s visual function, but it also disrupts the most. circadian rhythm as the retinal ganglion cells are directly Glare can be very debilitating and can have a connected to the suprachiasmatic nucleus, or ‘master marked restriction on lifestyle, such as preventing clock’ for the body.9 Exposure to bright light during the day allows us to fall asleep at night, as the contrasting patients from driving at night. Most people will levels at twilight then trigger the production of the sleep- think of glare from oncoming headlights and also inducing hormone melatonin from the pineal gland. from taillights, especially in wet or foggy conditions, With retinal illumination reduced during the day due which is greater with cataract, but there are other to cataract, there is not such a significant contrast at glare sources too. The increased use of electronic twilight, so this cascade is inhibited. light-emitting roadside variable message signs (VMS) In the last decade, there have been a number of (see Figure 2, page 86) and LED traffic lights can contribute towards the difficulties faced by drivers, not studies looking at the effect of cataract on circadian only in poor weather conditions, but also in clear, dry rhythms, cognitive function and sleep. These studies conditions. Each LED becomes a separate glare source have shown that the reduction in light levels and altered and the resulting streaks and starbursts from them visible spectrum does impair sleep, such that those with merge to fill in the gaps and hide the letters they are bilateral cataract had poorer sleep quality with lower trying to convey, rendering them indiscernible, even sleep efficiency than an age-matched control group though the patient’s acuity might allow them to read without cataract.10
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CET 4, 1
Cataract, pathology & communication
VERSION
Figure 2
REPRO OP SUBS
Figure 2 Light-emitting roadside variable message sign
ART PRODUCTION CLIENT
the same size of lettering, viewed at that same distance, in a non-illuminated format. The more dilated the pupil is, or the darker the ambient light level or background is, the more apparent this becomes. Similarly, reflectivity from the central band on modern traffic cones can present an unintended hazard for the cataract sufferer. As the individual prismatic components in the band are hit by headlights, the patient is dazzled by the brightness of the starburst from each one. These starbursts merge to cause an apparent elongation of that reflective section in a Maddox-rod-like fashion, making it difficult to assess where the edge of the line of cones actually is. Glare is also experienced in both bright sunlight and in cloudy conditions, which can be very debilitating and may cause epiphora. With an already reduced contrast sensitivity from the cataract, use of dark sunglasses diminishes this further, placing patients at risk of, for example, missing curbs or steps and increasing the risk of falls. Educating the patient at the point where you notice they have cataract is helpful in enabling them to choose the correct colour of lens and to consider frame styles with tinted side shields or to wear broad-brimmed hats to reduce glare rather than contrast and not to instinctively choose the darkest tint possible.
Managing expectations
Because the presence of cataract is so common among the patients in our care and such a high volume of cataract extraction is performed, we should be careful not to underestimate the seriousness of undergoing this operation. Even when carried out under local anaesthesia, it is an invasive procedure with risk, albeit small, of serious complications. The patient must be encouraged to follow advice after surgery and take it easy for at least a few days, avoiding heavy lifting, bending, gardening and all but the lightest housework duties for a couple of weeks. It is standard practice for a person of working age to be signed off work for two weeks. This is necessary, even in the most sedentary of jobs and we should take care to portray this to our retired patients, who are likely to still be very active, but would not be offered a ‘not fit to work’ note.
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Most cataract surgeries are carried out as a day case and with the patient wearing their own clothes. Operating theatres are not generally warm and the patient should dress appropriately to allow them to lie down comfortably without any temptation to fidget from clothes that dig in. In choosing what to wear, thought should be given as to how to remove the clothing when getting ready for bed later, with the operated eye having an eye shield in place and requiring not to be bumped or rubbed. Round-necked or polo-necked tops and other close-fitting garments should be avoided, with button through clothes being the easiest ones to remove without affecting the operated eye. Leaflets and spoken information from the hospital eye departments do not appear to contain such practical advice for the patients. The experiences during the surgery may not be the same for the first and second eyes. Several studies have been conducted to report on visual sensations during cataract surgery and some variation has been found with the type of local anaesthesia.14–18 Many patients report seeing brightly coloured lights during the operation with one-third reporting a changing colour,14 two-thirds reported the clarity and brightness of the lights changing, shadows of the surgeon’s fingers or instruments were seen by 16%, flashes were seen by 36% of participants,17 and some described that it is as if looking through water, a sensation which can also occur a day or two post-operatively. Up to 20% of patients do not experience any light perception at all during the operation. All of these experiences are significant because many of the patients in the studies have reported being frightened by these sensations. Patients receiving only topical anaesthesia (TA) experienced brighter light intensity than those receiving sub-Tenon’s anaesthesia (SA) and patients under TA were more aware of surgical instruments (26.1%) than those under SA and peribulbar anaesthesia (PA).18 To know beforehand that any of these outcomes are possible will be reassuring to the patient. Postoperatively, variable vision is the norm and the patient should not be unduly concerned that the long-term result will not be good just because these fluctuations take place in the early days. Shimmering of vision may be noted postoperatively as the IOL settles into position and may last, intermittently, for some weeks. Some people may not feel anything during the operation and others may think they have felt everything; the two experiences can also happen to the same person, one for each eye. Postoperative pain may be absent, mild or difficult to tolerate for some and may take a couple of months to settle fully. Several studies
CET
About the author n Jo Mackenzie graduated from UWIST in 1986 and has been a hospital optometrist for the majority of her 30-year career, taking an extended role in glaucoma clinics before becoming senior lecturer at Portsmouth University in January 2016 and returning to the NHS in 2019. She took the independent prescribing qualification in 2009 and regularly facilitates peer discussion sessions for the College of Optometrists. During the pandemic, Mrs Mackenzie has been redeployed to the ACCORD Platform, a nationally prioritised rapid drugs testing programme for potential COVID-19 treatments.
have shown that the perceived pain during the second eye’s surgery is greater than for the first.19,20 A well-documented relationship exists between anxiety and perceived pain, with greater anxiety causing greater perceived pain.21,22 Anything that can help the patient’s anxiety will help reduce their pain, improve their experience and aid recovery. Visual analogue scales for anxiety are used widely in research for all different types of surgery showing that the fear of having surgery is greater than the fear of having anaesthesia. The top four causes of anxiety in a study of 734 patients were: 1. Waiting for the operation 2. Being at the mercy of medical staff 3. The result of the surgery 4. Perioperative pain.23 In a study to evaluate the effects of hand massage on patient anxiety during cataract surgery, one group of anxious patients were given a hand massage five minutes before their surgery with results showing that psychological anxiety levels, systolic and diastolic blood pressures, and pulse rate were all significantly lower than before the hand massage. This group also showed significantly decreased epinephrine and norepinephrine levels postoperatively, whereas the control group, which did not receive a hand massage, showed increased levels of epinephrine, norepinephrine, and cortisol levels.24 Handholding seems to have become an integral part of the cataract procedure now, enabling the patient to communicate with the operating team by squeezing the hand they are holding, but this has also shown to have a calming effect. Another study used these same biochemistry tests and visual analogue scales using just handholding rather than hand massage. Reduced epinephrine and reportedly reduced anxiety levels were found in the intervention group compared to the group which did not receive handholding during the procedure.25
Conclusion
There are many other factors to consider besides visual acuity when deciding whether someone will benefit from cataract surgery. Cataracts are very impactful on the quality of life. It is important to ask the appropriate questions to elicit what changes have occurred in their lives, as patients may not necessarily relate these to their ocular health – for example, a lack of confidence may be due to an inability to see clearly. Similarly, patients may assume that vision deteriorates with
age and accept that they must live with how it has become. After an uncomplicated cataract surgery, difficulties such as glare and dazzling, unreadable VMS when driving, will likely cease. Patients are likely to be amazed at how murky their vision had actually become and will find the contrast, sharpness of their vision and vividness of the world again quite astonishing. Very often the worst eye is done first, and at this point it becomes apparent how bad the second eye had become and how much of the world the patient was missing.
Exam questions
Under the enhanced CET rules of the GOC, MCQs for this exam appear online at www.optometry.co.uk. Please complete online by midnight on 27 December 2020. You will be unable to submit exams after this date. Please note that when taking an exam, the MCQs may require practitioners to apply additional knowledge that has not been covered in the related CET article. CET points will be uploaded to the GOC within 10 working days. You will then need to log into your CET portfolio by clicking on ‘MyGOC’ on the GOC website (www.optical.org) to confirm your points.
References
Visit www.optometry.co.uk, and click on the ‘Related
CET article’ title to view the article and accompanying ‘references’ in full.
Course code: C-76073 Deadline: 27 December 2020
Learning objectives n Be able to manage patient expectations ahead of cataract surgery (Group 1.2.4) n Be aware of the impact of cataracts from the perspective of the patient to help guide management decisions (Group 6.1.6) n Be able to advise patients about cataract surgery (Group 1.2.4) n Be aware of the symptoms associated with cataract (Group 8.1.2)
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CET 4, 2
Cataract, pathology & communication
VRICS VERSION
Specialist spectacle dispensing 1
CET
POINT
REPRO OP
Claire McDonnell FAOI, MSc and Patricia Mordaunt PG Dip, FBDO SUBS
This visual recognition feature tests the ability to recognise specialised appliances that can make a real difference to patients but are only relatively rarely seen in practice.
ART
Optometrists
Dispensing opticians Image B
Image A
PRODUCTION CLIENT
01 What type of bifocal is shown in the image? a) Solid b) Fused c) Bicentric d) Cemented
04 Pictured is a pair of: a) Moisture chamber goggles b) Recumbent spectacles c) Field expanders d) Orthoscopic spectacles
02 What prismatic effect do the bifocals pictured have in the near segment? a) Base in b) Base out c) Base up d) Base down
05 These spectacles would normally be used by: a) Patients with field loss b) Low vision patients c) Bed-ridden patients d) Dry eye patients
03 When is this type of bifocal typically prescribed? a) When the patient has amblyopia b) When the patient has aniseikonia c) When the patient has a different prismatic requirement for distance and near d) When the bifocal jump needs to be controlled by prism
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06 These spectacles are: a) Available with refractive power b) Made of two yoked prisms c) Shaded to minimise disability glare d) Available with internal illumination
Image C
VRICS
Image D
07 The Fresnel prism on the left lens is: a) Base up b) Base down c) Base in d) Base out
10 What type of lenticular is shown in the image? a) Blended negative b) Solid negative c) Fused positive d) Profile positive
08 Which of the following is true about Fresnel prisms? a) They are replaced monthly b) They are difficult to remove or replace c) They cause a reduction in visual acuity d) They are only available up to 10Δ
11 The main advantage of using lenticular lenses for high prescriptions is: a) They are unaffected by changes in pantoscopic tilt b) Have no ring scotoma c) Have less chromatic aberration d) Reduced weight
09 Fresnel prisms are usually attached to spectacle lenses by: a) Wetting on one side and attaching to the back of the lens b) Wetting on one side and attaching to the front of the lens c) Submerging into water and attaching to the back of the lens d) Submerging into water and attaching to the front of the lens
12 Lenticulars are now available: a) In 1.76 index material b) In swimming goggles c) In progressive lens designs d) As a polarised lens
Exam questions Under the enhanced CET rules of the GOC, MCQs for this exam appear online at www.optometry.co.uk. Please complete online by midnight on 27 December 2020. You will be unable to submit exams after this date.
About the authors n Claire McDonnell is a qualified optometrist and an optometry lecturer at the Technological University Dublin. Her specialist areas are contact lenses and paediatric optometry. n Patricia Mordaunt is a dispensing optician who has
previously worked in practice and in industry. She is currently a lecturer at the Technological University Dublin and is co-programme chair for the ophthalmic dispensing BSc. She has written articles and made CET presentations and workshops on dispensing. She has a postgraduate diploma in learning and teaching and her specialist areas are dispensing and low vision.
Course code: C-75932 Deadline: 27 December 2020
Learning objectives n Be able to identify and understand the application of specialist optical appliances (Group 4.1.5) n Be able to identify and understand the application of specialist optical appliances (Group 4.2.2)
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VRICS 1, 1
Dispensing
VRICS VERSION
External eye pathology
1
CET
POINT
REPRO OP
Professor Simon Barnard PhD, FCOptom, FAAO, FEAOO, DipCLP, DipClinOptom, DipTp(IP) SUBS
This feature requires the practitioner to consider the signs, symptoms and management options for a range of anterior segment conditions, accessing additional resources where necessary to answer the questions.
ART
Optometrists
Therapeutic optometrists Image B
Image A
PRODUCTION CLIENT
A 57-year-old female patient presents with the signs shown in the image 01 Which of the following best describes the findings? a) Loa loa blepharitis b) Inspissated meibum c) Taenia solium (cysticercus) blepharitis d) Acute bacterial infection of gland of Moll 02 The patient’s primary symptom is most likely to be: a) Itching b) Dry eye sensation c) Formication d) Blurred vision 03 A treatment plan includes: a) Heating the eyelids to 40°C for five to 10 minutes and an eight-week course of oral doxycycline 100mg b) Heating the eyelids to 40°C for five to 10 minutes and a single dose of oral azithromycin 500mg c) Heating the eyelids to 40°C for five to 10 minutes and a course of oral diethylcarbamazine at 8mg/kg/day in three divided doses daily for three weeks d) Removing the parasite with forceps and heating the eyelids to 40°C for five to 10 minutes
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A 35-year-old female patient presents with a one-week history of bilateral conjunctivitis and a three-day history of the lesion shown in the image 04 What is the diagnosis? a) Kaposi sarcoma b) Capillary haematoma c) Pyogenic granuloma d) Lymphatic inclusion cyst 05 Which statement is correct? This condition is: a) Typically found at a traumatic wound site or near a suture line after chalazion surgery b) Neither purulent nor granulomatous c) Also called lobular capillary haemangioma d) All of these options 06 Which statement is correct? a) The lesion rarely bleeds b) Treatment may include a steroid injection into the lesion c) The lesion will always resolve once the primary infection has been treated d) A biopsy is required
VRICS
Image D
Image C
07 The image shows: a) Ciliary madarosis b) Superciliary madarosis c) Alopecia areata d) Anterior blepharitis 08 Which statement is correct? a) This condition may lead to trichotillomania b) This sign may be a presenting feature of a number of vision and life-threatening conditions c) Acute staphylococcal infection is a likely cause d) The mascara used by this patient contains a heavy metal 09 This condition can be caused by: a) Anti-cancer treatment b) Ethambutol c) Rifampicin d) All of these options
About the author n Professor Simon Barnard works in primary care optometry practice in London and is visiting professor of clinical optometry at the department of Optometry and Visual Sciences, Hadassah Academic College, Jerusalem, Israel. He taught at City University, London for 25 years and served as director of ocular medicine at the Institute of Optometry, London.
Course code: C-75973 Deadline: 27 December 2020
Learning objectives n Be able to manage patients presenting with anterior segment pathology (Group 6.1.5) n Be able to undertake differential diagnosis of anterior segment pathology and decide on the appropriate management (Group 1.1.2)
A soft, reusable contact lens (CL) wearer presents with discomfort in her right eye for five months, which has been unresponsive to chloramphenicol and carmellose given by her GP. Despite ceasing CL wear, she reports ongoing discomfort and lacrimation. Examination shows white eyes with no folliculosis. LogMAR visual acuities: R 0.40 L 0.00 10 Given the history and the image, which of the following is the least likely diagnosis? a) Thygeson keratitis b) Epidemic keratoconjunctivitis c) Staphylococcal keratitis d) Vernal keratoconjunctivitis 11 Which of the following treatments is most appropriate in this case? a) Fluorometholone (FML) ophthalmic suspension 0.1% four times a day for one week then twice a day for one week b) Chloramphenicol 1% eye ointment four times a day for five days c) Oral azithromycin 250mg for five days d) Aciclovir eye ointment 3% five times a day for at least five days 12 Following resolution, which of these would form part of the long-term plan in this case? a) Recommend that the patient may recommence CL wear but to be refitted with daily disposable lenses b) Remind patient and record in the notes that she must avoid tap water when handling lenses c) Instruct the patient to return immediately if there is a reoccurrence of symptoms d) All of these options
Exam questions Under the enhanced CET rules of the GOC, MCQs for this exam appear online at www.optometry.co.uk. Please complete online by midnight on 27 December 2020. You will be unable to submit exams after this date.
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Anterior eye & diagnostics
Rec 1 VERSION REPRO OP SUBS ART PRODUCTION CLIENT
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VERSION
MY T SECRE ... S LI F E A
My secret life
REPRO OP
Do you have a hobby to share with readers? Get in touch with selinapowell@ optometry.co.uk
SUBS ART PRODUCTION
Optometrist and AOP interim clinical adviser, Roshni Kanabar, on helping people to preserve special memories through bespoke scrapbooks
CLIENT
“It's really important that each scrapbook is perfect. This is a sentimental gift for someone” 98 www.optometry.co.uk
W
hen my sister was 21, I made her a scrapbook for her birthday. I thought it was so nice to put your memories all into one book and show someone how much you appreciate and care for them. That was the first scrapbook I ever made. My mum, who is a dispensing optician, has a cooking blog. She often gets press tickets to events and I ended up going to a craft show with her in London. I was absolutely fascinated. I bought all my supplies and since then I have been making things. When I was a locum, I made a travel scrapbook for one of the ladies I was working with. My other colleagues started saying they wanted one too, so I started making more scrapbooks and it just grew. A lot of the orders are through Etsy. There are also orders through family and friends as well as word of mouth. I would say in total,
I have made around 50 scrapbooks. I have had quite a few orders from the US and an order from Germany. It doesn’t feel like work. I find it really relaxing – it is like mindfulness. Over the years, I have learned what techniques to use and what materials work well. My craft desk is my happy place. It’s really important that each scrapbook is perfect. This is a sentimental gift for someone. They are supporting my small business and when I do a good job they recommend it to someone else. I am always thinking of new designs. Let’s say I am in the supermarket and I see a nice pattern – I will think, ‘Oh maybe I could create a scrapbook with a similar design.’ I have a list on my phone of around 20 different scrapbooks that I want to make. I had an idea in the middle of the night recently and I thought I had better write it down or else I would forget it. During lockdown, I filmed myself crafting and put the videos on YouTube. My YouTube channel has travel videos but there are also craft and cooking videos. People ask me how I have the time for it all. I am a very active person. I don’t really sit watching TV for a long period of time – I would prefer to be crafting.
October/November 2020
BLACK YELLOW MAGENTA CYAN
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LAST WORD SECRET LIFE, 1
LAST WORD
Feeling
pressured, anxious, or worried? Talking things through can bring clarity, relief and a sense of control over the issues affecting you. The AOP Peer Support Line is a confidential, free-phone helpline for individuals at any stage of their optical career. Calls will be answered 24 hours a day, by an external answering service, with trained volunteers on duty to return calls between 8am and 8pm.
Call our Peer Support Line on
0800 870 8401
www.aop.org.uk/peersupport
Outer covers spread
VERSION
Journal of the Association of Optometrists years
£9.95 REPRO OP
October/November 2020 Volume 60:08
www.optometry.co.uk
Shortlist Creative combos Page 30
SUBS
October/November 2020 / Volume 60:08
ART PRODUCTION CLIENT
Changing the future of childhood myopia
LEARNING & DEVELOPMENT
New OptiExpert™ v2.0 app.
The Myopia Management Programme to help treat young myopic patients
Not actual interface.
Smarter than ever, so you can do more.
Your future in focus Standfirst here please here please standifirst here please hereherhehehre
Instantly converts (virtually) any spectacle prescription into a contact lens prescription.
For iPhone, iPad and Android mobile and tablet devices.
Find out more or download web app www.coopervision.co.uk/optiexpert
*OptiExpert™ is an educational, reference and information tool for eye care professionals. Eye care professionals may choose to use the app in connection with their own patient evaluation but it is not intended to be relied upon for clinical decision-making. OptiExpert™ is not intended as and does not constitute medical or optometric advice nor is it intended to replace the patient evaluation performed by an eye care professional.
BLACK YELLOW MAGENTA CYAN
MiSight® 1 day contact lenses are effective for myopia management2
Get started with myopia management in practice today
Adapting education to build a resilient profession
/ www.optometry.co.uk
NEW OptiExpert™ v2.0 helps make contact lens selection even easier.* Featuring a new smart prescription calculator which converts virtually any sphere, toric or multifocal spectacle prescription into a contact lens prescription. Now that’s smart.
Everyone with myopia has potential for significant ocular health risks1
CET Binocular vision and myopia management
Perspectives Reinventing the role of optometry in society
In practice Meeting the need for contact lens comfort
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