Optometry Today - October/November 2021

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Journal of the Association of Optometrists

COVID-Generation Resilience in the face of unprecedented change Page 31

£9.95 REPRO OP

October/November 2021 Volume 61:05

www.optometry.co.uk SUBS

October/November 2021 / Volume 61:05

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OCULUS MYOPIA MASTER® THE CONTINUING PROFESSIONAL DEVELOPMENT EDITION

Giving you the personalised data to provide a clearer future

COME AND SEE US FOR A DEMO AT: AIO Conference 9th & 10th October Optix Conference 15th - 17th November

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/ www.optometry.co.uk

BIRMINGHAM OPTICAL Unit 4 Gravelly Industrial Park, Birmingham B24 8HZ t: 0808 123 2020 e: sales@birminghamoptical.co.uk www.birminghamoptical.co.uk

EXCITING NEWS INSIDE CET Demonstrating cultural competence in practice

Spotlight The launch of the AOP’s new online Locum logbook

In practice CET high-achievers share their passion for learning

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The CooperVision® Binocular Progressive System™ uses different lens designs to optimise vision for all levels of presbyopia.1,2

Easy and successful fitting supported by the fitting guide / OptiExpert™ for 98% successful fit.*1,2

The greatest parameter range of any one-day multifocal contact lens3 from -12.00 to +8.00DS across low, medium and high adds.

CLIENT

Introducing MyDay® daily disposable multifocal.

An evolution in lens design system and fitting approach built into a high-performance one-day lens that makes MyDay® multifocal easy to fit, easy to establish and easy to optimise.1,2

Unsurpassed comfort versus other leading one-day multifocal contact lenses.1,2 Unsurpassed vision at all distances versus other leading one-day multifocal contact lenses.1,2

Do you have a vacancy at your practice?

Are you looking for a new optometrist or dispensing optician to join your team?

Why not advertise on Optometry Today (OT)’s online jobs listing, a service that is now free to use for AOP members for a limited period?*

Scan the QR code to learn more about the lens design, access the fitting guide / OptiExpert,™ register for interactive learning modules and product specifications.

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

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OptiExpert™ is available for mobile and tablet devices or download web app at www.coopervision.co.uk/optiexpert

Excited to hear more? Talk to your CooperVision w Development Manager today.

Find out more: www.optometry.co.uk/jobs *Free to use until the end of January 2022

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Welcome

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here is little I remember of my four months as interim CEO of the General Optical Council (GOC) in 2018. But I still have a strong sense of the confusion I felt when briefed by the team running the Education Strategic Review (ESR). It was clearly something that the organisation regarded as fiendishly important and deserving of the highest priority. Yet try as I might, I could not grasp what it was meant to achieve.

Coming back into the sector and reviewing what all that effort has delivered, I find myself still in that place. For most students, it appears, the shape of their courses is likely to look much as it has in the past. Courses will be the same length, covering much the same ground, with dedicated placements towards the end of their studies, and the College of Optometrists still playing an active role. What, I ask myself, has all this been about?

Look a bit closer, and there have been tweaks here and modernisations there – refreshing things that have been in place for years is never a bad thing. It may be that the implications of the changes are yet to reveal themselves: just because it seems that most universities offering optometry will continue to work with the College of Optometrists for the next few years, it does not mean that they will not decide to use the freedoms they have gained in the future. But was it really necessary to go through such an intensive work programme just to get to that result?

What concerns me most is not what the ESR did do, so much as what it did not. Given the threats to the sector from automation and online sales, and the opportunities presented by the desperate need of hospitals to free up capacity by outsourcing lower risk work like eye care to a highly skilled optometry workforce, the sector could be set for huge changes in the next few years. An ESR that is not grounded in a thorough examination of what future optometrists will do – and even how many optometrists will be needed – risks being a futile exercise. The ESR seems to take it as read that the optometry of the future is much the same as the optometry of the present. For me, the reality is plain: change is coming and we need to be ready to shape the future of the profession.

“The sector could be set for huge changes in the next few years”

Adam Sampson, AOP chief executive

October/November 2021

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Welcome

OCTOBER/NOVEMBER 2021

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Contents

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Me and my glasses on page 25

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07-21 SPOTLIGHT

Spotlight

AOP MEMBERSHIP RENEWALS

The news in digest Picture this British Paralympian cyclists OT reports OT and CooperVision share findings on the impact the pandemic has had on contact lens services The edit Optics in 16 stories 100% Optical What COVID-19 measures are being put in place for the 2022 show Clinical roundup Study audits HES referrals in England and Scotland Supplier insight Options for scleral lenses AOP roundup Membership renewals, an online version of the AOP’s Locum logbook and a High Court judicial review

4 www.optometry.co.uk

“I think sometimes those who have had a membership for a long time possibly don’t realise the extent of support available” Suzanne Page, AOP head of membership, PAGE 20

23-29 HIT LIST

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

Practice management systems Me and my glasses Contemporary artist, Colin Davidson Get the look // Anatomy of a frame With Lizzy Yeowart The shortlist The October/November selection Behind the brand Haag-Streit Simulation

October/November 2021

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31-36 COVID-GENERATION

SPECIAL REPORT

“Don’t underestimate the students of COVID-19” Indy Ghuman, final year optometry student at Aston University

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CET 65-89 Education and training for the eye care practitioner

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65 CET welcome 66 Communication essentials: cultural competence in practice 71 Heterophoria: which cases need treatment?

75 Fluoroquinolones: indications for use and potential adverse effects 80 Cushing’s syndrome 86 Casualty cases 88 Ocular complications of diabetes In this edition of OT, practitioners can test a range of competencies: OPTOMETRISTS // 5 THERAPEUTIC OPTOMETRISTS // 2 DISPENSING OPTICIANS // 1 CONTACT LENS OPTICIANS // 1

ONLINE

39-55 IN PRACTICE

Business insight and career development The discussion Three top CET point scorers reflect on what education means to them Pre-reg focus Peter Grant and Luke McRoy-Jones How I got here Aston University’s Raquel Gil-Cazorla Key milestones Setting up the AOP’s mentoring scheme How do I...

“Reflect on my learnings?”

Hakim Group’s Claire Slade explains What I have learned Becoming a Dementia Friendly practice The workshop The AOP’s Henry Leonard advises on safeguarding children Life as a locum Yee Ting Liu

Cover story

The ABC of CPD As the end of the current education cycle draws closer and the profession prepares to transition to a new offering, OT explores what the change from CET to CPD means for practitioners PAGE 57-63

OT video highlights

A Survival Pack CET Video on ocular trauma Watch the video on

www.optometry.co.uk/cet

90-98 ENDNOTES

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

Jobs Cult Vision’s take on recruitment I could not live without... ”My retinoscope,” says domiciliary optometrist, Kamaljit Kalsi Last word Martin Skehan’s ambition to row across the Atlantic

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

October/November 2021

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Contents

CONTENTS

Picture This VERSION

Spotlight

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08 OT REPORTS

What OT's reader survey discovered about the impact of the pandemic on optometry

17 CLINICAL ROUND-UP

Research on referrals from community optometry to the HES, and UK myopia studies

20 AOP SUPPORT

An online version of the AOP Locum logbook, and membership renewals approach

SUBS

PICTURE THIS ART PRODUCTION CLIENT ParalympicsGB

Pedal to the medal Gold medal winning British cyclists, Lora Fachie and Corrine Hall, compete at the Tokyo 2020 Paralympic Games. Reflecting on the importance of the games, Fachie told OT that it raises awareness about what people with disabilities are capable of: “A disability isn’t something to be sad or embarrassed about. It is something to celebrate. You can still be successful and achieve great things.”

Fachie, who competes in para-cycling tandem road and track events, was born with hereditary sight loss. She spoke about her blog, Blindingly Good Food, in the June/July edition of OT. October/November 2021

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VERSION

COVID-19 AND OPTOMETRIC PRACTICE

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October/November 2021 Volume 61:05 Issn 0268-5485 ABC certificate of circulation 1 January 2020–31 December 2020

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Interim editor: Emily McCormick emilymccormick@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: subscriptions@aop.org.uk

Advertising: Richard Ellacott 020 3771 7242 richard.ellacott@thinkpublishing.co.uk Advertising production: aop@ccmediagroup.co.uk Senior designers: Grant Pearce, Juanita Adu Client Engagement Director: Anna Vassallo Executive director: Jackie Scully Published bimonthly for the Association of Optometrists by Think Media Group 20 Mortimer Street, London, W1T 3JW Printed by Acorn Web, Normanton Ind Estate, Loscoe Close, Normanton, West Yorkshire, WF6 1TW

OT and CooperVision set out to explore some of the ways contact lens services have been affected by the pandemic.

Here, OT outlines some of the key findings Practices have adapted their contact lens journey in a myriad of ways during the pandemic to continue meeting the needs of patients.

OT and CooperVision sought to understand the scale of these changes through a reader survey this summer.

Samantha Armstrong, professional services consultant for CooperVision, commented: “The survey is a temperature check to discover where we are as a profession emerging from the pandemic. We wanted to know what changes were implemented during the more severe stages and whether these had enabled new ways of working going forward.”

ADAPTING TO COVID-19: DIRECT-TO-HOME DELIVERIES

With new protocols introduced during the pandemic, the CooperVision team expressed surprise that more practices had not introduced direct-to-patient delivery or online ordering services during the pandemic.

Direct-to-home delivery of contact lenses was introduced by 32% of respondents during the pandemic and for those who offered the service, 28% felt they would continue beyond the pandemic.

people including 256 employed eye care professionals, 169 practice owners and 143 locums

Discussing the benefits of the service for practices, Armstrong said: “It is better from a time, space and safety perspective. Products do not need to be stored, handled and organised if sent direct.”

Building on these findings, Ann Tenison, customer marketing manager for CooperVision, shared that in a previous survey, the contact lens company found that 83% of patients surveyed wanted their practice to provide a service to deliver contact lenses directly to their house or work, rather than a store pick-up.

63%

40%

46%

32%

increased infection prevention and control introduced a triage service

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CHANGES TO PRACTICE FOLLOWING COVID-19

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

THE SURVEY PARTICIPANTS

offered combined appointments where possible provided direct-tohome delivery of contact lenses

CONTACT LENS FITTING

Average contact lens fittings per month before COVID-19 and following

provide short-term and long-term solutions for practices. Armstrong added: “Contact lenses can help to future proof the practice. If anything happened to close the doors in future or restrict trading, there is still a revenue stream to help support the business.”

250 213

200

188

150 114

100 50

RECOMMENDING CONTACT LENSES

81

The patients’ contact lens journey also saw adjustments during the pandemic, with 40% of respondents introducing combined appointments where possible, and 39% introducing extended aftercare intervals.

The majority of respondents were confident recommending contact lenses to new or lapsed wearers; however, time constraints were identified as a key challenge for 21% of practices, particularly in light of a backlog of patients. Armstrong said: “There is a challenge for practices to find time to fit new contact lens wearers, combined with managing overdue aftercares which have the potential to initiate contact lens drop out.”

“A large concern is that practices are so busy catching up, there may be less opportunity to complete new contact lens fits,” Armstrong suggested. “But, we know as social and leisure facilities re-open, wearers are wanting to embrace contact lenses, either as lapsed or new wearers.”

The experts suggested it is important to continue talking about contact

61

46

33

31

22

18

0 None

1-5

6-10

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Over 20

S Pre-COVID-19 S Now Tenison pointed out that consumers’ habits and behaviours could have changed during the pandemic, emphasising a need for direct deliveries. She said: “The lockdowns have been on and off for around 18 months, so it is quite likely that [direct deliveries] are now the norm from a patient’s point of view. If availability of direct delivery services change, it becomes an inconvenience.”

PRIORITIES IN THE RECOVERY

The survey found an overall reduction in the number of contact lenses being fitted compared to pre-pandemic. Tenison commented: “Throughout the pandemic, reduced clinic capacity, the need to prioritise appointments based on urgency of care required, and a pent-up demand for sight tests, may have affected the number of new contact lens fits.”

As the country moved out of lockdown, spectacle sales were identified as a business priority by half of respondents, followed by sight tests (42%), enhanced services (35%) and contact lenses (27%).

When considering the impact of the pandemic on practices, Tenison shared: “The results of the survey would suggest that the focus has been directed to spectacles for their instant revenue generation, compared to the long-term streams from contact lenses.”

For some, however, contact lens services were crucial, Armstrong

Contact lenses were identified as a business priority as the country moved out of lockdown for 27% of survey respondents shared: “There were many practices that felt that the regular revenue from contact lenses was vital to keeping afloat during the time when the practice doors were closed.”

Recommending spectacles and contact lenses to patients, can not only fulfil patients’ desires to be given informed choice, but it can

CONTACT LENS CONFIDENCE

Most respondents felt confident about fitting new or lapsed wearers, but identified time and proximity challenges as reasons some might feel tentative

10%

3%

Not confident at all

Tentative in the current environment

21%

felt time constraints were a reason ECPs could be tenative about contact lens fittings

31%

Quite confident

53%

20%

felt proximity was a potential concern for fitting contact lenses

Very confident

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Coopervision, 1

SPOTLIGHT

Coopervision, 2

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53%

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of respondents introduced remote consultations through phone calls during the pandemic

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15%

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of respondents introduced remote consultations through teleconferencing systems

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lenses with potential new wearers, sharing: “We know that patients want to be offered the choice and want informed choice – data from surveys suggest that 50% of new wearers will find information online prior to an appointment.”

REMOTE SERVICES

Although recently updated, statements from the General Optical Council and joint regulators during the pandemic allowed practitioners to introduce elements of remote services to manage patients safely during lockdowns.

Opinions around remote services and levels of confidence varied, with 36% of respondents feeling patients appreciated the ease of the service, whilst 31% said it facilitated quicker communication with patients.

However, 20% of respondents felt remote consultations were time consuming, while 20% and 16% felt

patients struggled to use the tech or were not comfortable with it.

The survey found that clear definitions and guidance would be needed if remote tools were to be used in the future.

However, remote tools and services do not need to mean telemedicine, CooperVision highlighted, but could be as simple as a courtesy phone call, or automated text messaging services such as those provided through CooperVision’s My Lens Coach, supporting patients through the contact lens journey and encouraging retention.

FUTURE PRACTICE AND EDUCATION

Many respondents shared that they were looking forward to returning to ‘business as usual,’ though noted that changes might be needed to ensure continued safety and comfort.

Some felt the changes they had introduced over the past two years had created new efficiencies or a more positive patient experience.

The survey illustrated the backlog of appointments as a concern for practices Armstrong suggested, dividing into three categories: “Clinical concerns such as missing patient problems, or retaining contact lens patients, being able to see the patients within an appropriate time window, and the juxtaposition of wishing to increase volume and sales, all while maintaining safety is a real challenge.”

She added: “Considering using digital tools such as texts, emails and post fit phone calls, streamlining customer journeys to enable combined appointments and ensuring patients are put on appropriate aftercare recall

THE TAKEAWAY: BUILDING PRACTICES UP Armstrong advised practices not to solely focus on ‘fixing’ challenges brought about by COVID-19, but to also think about opportunities to build the practice up “and make things even better.”

“Look at what has worked well, and develop further to suit the changing needs of your patients,” she said.

Tenison added that tools and technology are not a

10 www.optometry.co.uk

dates, (following current research regarding 24 months aftercare), can all help to reduce this squeeze in time pressure.”

Overall, however, eye care professionals appear to have remained optimistic and particularly valued continued education.

“It’s almost inspired the desire for more knowledge,” Armstrong observed, explaining: “In response, we have been using innovative and engaging ways of educating, alongside the more traditional methods. Utilising the CooperVision Learning Academy to make learning convenient and current.”

Peer-to-peer education will be a key part of building on the learnings from the pandemic and this is something CooperVision said it will continue to support.

55%

of respondents were interested in seeing more staff training from contact lens manufacturers

54% of

respondents wanted more learning opportunities

51%

of respondents wanted more CET

one-size fits all solution for practices: “Different ways of communicating with and supporting patients will enable the feeling that the patient is receiving a personalised service that best suits their needs.”

For more findings from the COVID-19 and optometric practice survey, keep an eye on the OT website: www.aop.org.uk/ot/industry/contact-lenses

October/November 2021

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INDUSTRY

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Medical Air Sanitisers Clean air has never been so important

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Is your practice a Safe Air Space?

“Optimism Health Group’s investment will allow us to continue expanding our business, recruiting a further 20 optometrists over the next two years” Michelle Le Prevost, managing director of domiciliary provider Visioncall, said an “exciting new chapter” was ahead of the company which was acquired by Optimism Health Group in September. The group has a focus on healthcare services for the 75 to 90-year-old demographic, particularly in eye care, and acquired OutsideClinic in 2020.

ART

The Royal National Institute for Blind People opened a pop-up shop highlighting the difficulty that blind and partially sighted people face accessing packaging information. As part of its Design for Everyone campaign, the shop was filled with products containing vague or no information. Watch OT’s video for more: https://bit.ly/3o04E3G

Stop the spread of viruses PRODUCTION

Reduce allergy symptoms all-year-long Comply with highest hygiene standards Keep staff safe, healthy and at work Reassure your patients

CLIENT

Promote health and raise productivity Reduce sick-leave

6 STAGE FILTRATION TECHNOLOGY AIR8 280 Nano Ideal for the consulting room Effective area up to 24m2

AIR8 720i Edge Ideal for staff area or small front of shop area Effective area up to 64m2

AIR8 1200i Pro Ideal for large front of shop Effective area up to 110m2

4.3 MILLION

fewer eye tests were delivered in 2020, a new report exploring the impact of the pandemic on eye health in the UK has found.

Research by Deloitte Access Economics, commissioned

by Specsavers, also found an estimated 2986 people have lost vision due to delays in identification and treatment as a result of the pandemic.

Essilor has launched a new lens designed for wearers between the ages of six and 12. The Eyezen Kids lens aims to enhance the visual comfort of younger spectacle wearers, taking their parameters of morphology, object distance and gaze direction into account.

The lens features DualOptim technology to align target points for distance and near vision.

£1.8m

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

12 www.optometry.co.uk

“It allows us to support the people who support us” Peter Telfer, managing director of Urquhart Opticians, discussed the launch of a Care and Community Fund to support the practice's community. Through the initiative, launched in response to the pandemic, the independent group will donate £1000 to local charities and groups every month.

has been pledged to medical technology start-up, Occuity, which successfully exceeded its investment target to support the accelerated development of noninvasive optical measurement devices. The company patented a contactless technology to obtain precise measurements from the eye. Occuity’s first device, the PM1 Pachymeter, is designed to measure corneal thickness and is anticipated to be approved for use in the EU by early 2022.

October/November 2021

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Neil Retallic, global professional services manager for Menicon, has become the new president of the British Contact Lens Association. He formally took on the title at the organisation’s September AGM, following past-president Indie Grewal, owner and optometrist at Leightons St Albans. Retallic’s inaugural address explored how optical professionals can support ‘the person behind the contact lens’ following the pandemic.

THE EDIT 60 DAYS IN 16 STORIES

SCIENCE & VISION

46%

Pixabay/Cindy Parks

A study led by an optometrist and doctoral researcher from the Institute of Optometry and London South Bank University will explore whether pregnancy affects vision. It is thought that the research could help optometrists provide guidance and care to pregnant women and potentially provide insight on topics such as whether it is safe to prescribe the first pair of glasses or change a prescription during pregnancy.

greater risk of having a road accident was identified among drivers with central acuity visual impairment compared to drivers without vision problems, in a study published in The Lancet Global Health. The research led by Queen’s University Belfast explored connections between poor vision and vehicle collisions in low and middle-income countries.

“We have developed a novel solution to increase the field of view for people with visual field loss using consumer-available smart glasses” Dr Jordi Asher, a post-doctoral researcher and inventor from the University of Essex, told OT about the AReye platform. Find out more online: https://bit.ly/3AgD8lW

PROFESSIONAL SUPPORT

Pexels/cottonbro

The World Council of Optometry (WCO) and CooperVision have partnered on a new resource providing multilingual information to help eye care professionals apply a standard of care for managing myopia wherever they are based. Organised around the evidence-based standards of care adopted by the WCO, the resource aims to make information more accessible and create a forum to exchange knowledge.

Representative bodies from across NHS primary care set out key ‘asks’ of the Government’s Health and Care Bill as it entered committee stage in September. As part of the Optometric Fees Negotiating Committee (the negotiating body for eye care in England and signatory of the document), the AOP emphasised: “It is essential that optometry has a place at the table to input at a strategic level.”

Adam Sampson, AOP chief executive, has highlighted the role optometry plays in reducing pressure on the NHS as the Government set out its plans to manage COVID-19 through winter in England.

“All the way through the pandemic our members have stepped up to support the NHS in delivering vital eye care to patients – freeing up capacity across NHS departments,” he said.

Pexels/Vitaly Vlasov

IN PRACTICE Moorfields Eye Hospital has launched an online portrait gallery, Faces of Moorfields, featuring the portraits of more than 130 staff and volunteers who worked at the hospital during the pandemic. The gallery formed part of a series of ‘reflect and reconnect’ events organised by Moorfields.

“We have seen a much wider range of clinical and emergency care during the pandemic and my independent prescribing qualification has been very useful”

“I’m so proud that the profession has done so much to adapt to these changing environments” Julie Mosgrove, vice chair of Optometry Scotland, discussed how much has changed for the profession over the past 18-months in a webinar titled, ‘Community optometry: returning to the new normal.’ Panellists covered key questions and guidance for optometrists practising in Scotland.

Dr Martin Smith, practice owner and optometrist at Martin Smith Opticians, described the impact of the pandemic on his practice and how he has adapted as a result. Read more in OT’s 'An optometrist saved my life' feature online: https://bit.ly/3CGsKEJ

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Audit

SPOTLIGHT

100

SPOTLIGHT VERSION

CREATING A COVID-SECURE EVENT

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ExCeL London and Media 10 have introduced measures to keep visitors, exhibitors and staff safe

100% OPTICALI

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A milestone year With 100% Optical a few months away, OT heard how plans are progressing and what COVID-19 measures visitors can expect

ART PRODUCTION

“We are raring to go,” Nathan Garnett, Media 10 event director for 100% Optical, said of the 2022 edition of the show, set to be held from 22–24 January at ExCeL London. With registration now open and the event just a few months away, OT caught up with the team to hear how preparations are developing.

“We are well ahead as we’ve had 18 months to prepare for this show,” Garnett said. Recent developments have included the launch of a new website for 100% Optical, aiming to provide a fresh look and easy-to-use experience ahead of the first optical show in the UK in two years.

“We are delighted with the support we have had from the sector and can now boast our biggest line up of exhibitors.

We were hoping that 2021 would be that milestone year, but 2022 will be extra special after the wait,” Garnett said.

“We are working with exhibitors on their stand activities and I know the education programme is going to be the best yet,” he shared, adding that the programme and event activity will be released through autumn.

Getty/uschools

CLIENT

Comprehensive CPD As the official event partner and education provider to the show, the AOP has been working on a schedule of education for the event.

Discussing what delegates can expect, Dr Ian Beasley, AOP head of education and OT clinical editor, said: “Planning for education at the event is well underway, with a comprehensive programme of high-profile speakers set to deliver content on a broad range of key topics.

“A choice of lectures and discussionbased sessions will be available across

Find out more about the move to CPD from page 57. In the meantime, OT has launched its CET Survival Pack to help practitioners meet outstanding education requirements before the end of the cycle in December. The pack has nine points on offer, covering all competencies for every practitioner type. It can be found at: www.optometry.co.uk/cet all three days, allowing practitioners to meet their professional development requirements under the GOC’s new CPD scheme, which launches in January 2022.”

Brands, awards and debates As restrictions on international travel appear to have eased at the time of writing, Media 10 is positive that international colleagues will be able to join the show.

“This is important as we want to make sure we have some of the independent eyewear brands and new entries to the market, as well as all the major suppliers already there,” Garnett said.

Key features of the show, including the Design Arcade and the Dispensing Workshop, will return, with Garnett also hinting that the Future Practice hub with four suites of education will be “bigger and better” for 2022.

The Love Eyewear Awards is set be held on the Saturday, while event organisers are also working to organise debates with key speakers on the future of the sector, increasing collaboration with the NHS, and “how we can all grow stronger coming out of the pandemic.”

Anna Clover, head of event management at ExCeL London, said the venue has been working closely with the event industry and following the latest government guidance to develop safety measures, adding: “The health and wellbeing of every single person who comes through our doors remains our number one priority.”

Commenting that “we all have a role to play in keeping events safe,” she added: “That’s why everyone who comes into ExCeL London will be asked to provide proof of a double vaccination (NHS COVID Pass), COVID-19 antibodies, or a negative lateral flow test.”

Mask-wearing will be recommended in the venue, and hand sanitiser stations will be available throughout the event.

Within the show, Garnett said: “Every stand will comply with guidelines that are very similar to those in optical practices, with the use of screens, sanitisers, and space for social distancing if required.

“We will also be offering delegates safety packs with partners like William Morris London, so there will be free masks and safety kits available. The event will be a lot safer to attend than a trip to the supermarket.”

The ExCeL cleaning team has been trained to conduct enhanced cleaning regimes using chlorine-based fluids at key touch points. Ventilation has been increased in line with the latest Chartered Institution of Building Services Engineers guidance, and the venue has installed digital signage at bathroom entrances to help with the flow of people.

Clover shared that the measures taken by the venue, 100% Optical and exhibitors will “help ensure the focus of the event is on what matters the most: the optical community reconnecting, networking, and learning about the latest health products and trends.”

Registration for 100% Optical is now open, and Garnett recommended readers and AOP members book in early to be the first to receive notifications on education.

Once registered, he advised: “Please keep an eye on emails from us for more information and access to other benefits, like networking, exhibitor promotions or awards announcements.”

For more information on the event and to register, visit the 100% Optical website: www.100percentoptical.com

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HEALTH

Cooking with coal or wood linked to eye disease

Clinical round-up

REPRO OP

OT’s Selina Powell reviews the latest clinical news and research papers Study examines HES referrals in England and Scotland

SUBS ART PRODUCTION Pixabay/Free-Photos

CLIENT

A new study published in Eye has described the results of an audit of referrals to the hospital eye service (HES) from community optometry in Scotland and England.

A total of 905 referrals, with identifying information removed, from six optometry practices were analysed as part of the research.

Within Scotland, the response rate for referrals where it would be reasonable to expect a reply ranged from 45% to 92%. This was lower within practices in England, with a response rate from 38% to 62%. The researchers found that more than 90% of referrals in both England and Scotland were necessary and sent to the appropriate service.

Despite an an interdisciplinary joint statement on sharing patient information, the authors highlighted deficiencies in the number of replies received by referring optometrists.

“Referral replies help maintain high standards of patient care, avoid unnecessary re-referral and close the feedback loop, thereby raising the standard of referrals,” researchers emphasised. Correspondence from the hospital eye service was infrequently copied to the patient or their primary carer. The study highlighted that this

“Referral replies help maintain high standards of patient care, avoid unnecessary re-referral and close the feedback loop” has important implications during the COVID-19 pandemic when community optometrists are carrying out some functions that were previously carried out in the hospital eye service.

“The next generation of online referral platforms alongside new ophthalmology electronic patient record systems should be designed to ensure that summary information from HES consultations is routinely accessible to both the referring optometrist and GP,” the authors observed in the study.

UK TRIALS TEST EFFECTIVENESS OF ATROPINE, CONTACT LENSES AND SPECTACLE LENSES IN MANAGING MYOPIA

NEWS

Cooking with coal or wood has been linked to an elevated risk of eye disease over time, including glaucoma, conjunctivitis, and keratitis.

The research, which was published in PLOS Medicine, examined the relationship between the type of cooking fuel used by 486,532 people and the development of eye disease over a 10-year follow up period.

People who used solid fuel were 32% more likely to suffer disease of the conjunctiva and had a 17% greater risk of developing cataracts than those who used electricity or gas.

Chan et al.

DOI: 10.1371/journal.pmed.1003716 IMAGING

Scientists develop automated OCT machine

Scientists from Duke University in the US have developed a fully automated optical coherence tomography (OCT) device. The contactless technology, which was described in Nature Biomedical Engineering, uses robotic positioning to align itself with the eye to be imaged as well as active scanning to locate the patient’s pupil.

“Robotic OCT scanners may enable the diagnosis and monitoring of patients with eye conditions in non-specialist clinics,” the authors highlighted.

Patients are able to sit or stand in front of the scanner, without the need for a chin rest as the device automatically corrects for the subtle movement of patients.

Draelos et al.

DOI: 10.1038/s41551-021-00753-6 DIABETES

“Higher levels of myopia are UK studies will investigate the associated with increased risk of effectiveness of low dose atropine eye pathological complications,” she said. drops, contact lenses and spectacle “We are at an exciting time whereby lenses in managing myopia. we now have Aston interventions based University is “We now have on research evidence recruiting children interventions based on that can be used between the ages research evidence” in clinical practice of six and 15 to that will help to take part in the slow down the rate of progression of clinical studies, which will involve a myopia,” Logan observed. range of interventions. Lead researcher Parents or guardians of children with at Aston University, Dr Nicola Logan, myopia who are interested in finding said myopia is often considered benign out more about the trial can contact because blurred vision is frequently the research team by getting in touch easily corrected through glasses, contact through email (myopia@aston.ac.uk). lenses or refractive surgery.

Elevated risk of eye problems in children with diabetic mothers

Researchers from China and Denmark have found that the children of women who have diabetes before or during pregnancy are more likely to develop high refractive error.

The study, which was published in Diabetologia, involved examining data from 2,470,580 babies born between 1977 and 2016 in Denmark.

The proportion of mothers with diabetes before or during pregnancy increased from 0.4% in 1977 to 6.5% in 2016.

Children whose mothers had diabetes had a 39% greater chance of high refractive error compared to children without diabetic mothers.

Du et al.

DOI: 10.1007/s00125-021-05526-z

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SPOTLIGHT

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Changing lives with specialist lenses ART

With scleral lenses seeing an increase in demand over recent years, OT spoke to manufacturers about their importance for patients and the value for practice

PRODUCTION CLIENT

Specialist contact lenses are a key way of meeting the needs of patients with irregular corneas and within this field, some manufacturers have noted an increased level of interest in training for fitting scleral contact lenses.

Ian Sexton, professional services manager for No7 Contact Lenses, shared that between 2017–2018 mini scleral lens sales saw an increase of almost 25% on the previous year. While sales seemed to slow a little in 2019, at the time of writing, the company has seen a 10–15% increase so far this year.

This is reflected in his own experience.

Within the hospital where he runs a specialist contact lens clinic, Sexton said: “I’ve certainly seen a large increase in the number of scleral lenses that are being fitted to patients. That seems to be being mirrored in hospitals across the country.”

“But we’re also seeing a demand for training in these lenses in independent practices,” he continued, adding that “it expands their options as practitioners.”

Scott Brown, clinical director of customfit specialist lens company, Scotlens, suggested that comfort has been a factor in the increase: “The prevalence that these lenses have had almost normalises them as a go-to option for patients that you are struggling with. The fact you can fit them, and patients don’t have to manage comfort, was a big thing.”

As modern scleral lenses have become thinner and more breathable, with a DK/T acceptable for daily wear and costs coming down, Brown suggested there is less inhibition in opting for scleral lenses.

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Josie Barlow, Menicon professional services manager, agreed that there is more interest in fitting scleral lenses. She explained: “From a clinical standpoint, these lenses are really good problem solvers. They are not just for the patients who have irregular corneas; they are great for high astigmats or dry eye patients who have fallen out of contact lens wear because they just can’t cope with standard soft lenses and gas permeable lenses.”

Hansraj Sunassee, hospital business development manager for Menicon’s speciality division, added: “I think sclerals have a stigma of only being for the irregular cornea or for the hospital clinics, but it’s becoming more mainstream.”

Some of this demand is led by patients, he suggested, with a lot of information now available for patients to educate themselves on the options available.

Perception of challenge Suppliers agreed that a key barrier when it comes to fitting specialist lenses, and scleral lenses in particular, has been the perception of challenges involved.

Barlow suggested that, although fitting has simplified over time: “There are still practitioners who are a bit hesitant of fitting scleral lenses because they think it is going to be quite complex and difficult to do, and that’s not the case.”

Manufacturers have evolved too, she added, with more control over the production and as a greater range of equipment has become available to measure more of the eye, making lenses easier to fit as a result.

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Lengthening waiting lists Manufacturers were enthusiastic about the field of specialist lenses, both for the impact it can have for patients, and for the professional development and practice benefits it can bring.

Discussing specialist lenses, Sexton told OT: “It is a really interesting topic and they are fascinating lenses to use.

“We all have patients that come into our consulting room and we’re not sure what to do to help them.

Getty/Zarina Lukash

REPRO OP

SUPPLIER INSIGHT

“It is an exciting time,” Sunassee said.

“I think we’re at a pivotal point because there is so much great technology out there, not just physical technology but lens fitting technology as well that is driving this side of specialist lenses forward.”

Brown, too, suggested that expectations of the lenses can be a barrier to fitting: “I think there’s a perception optometrists have that there is a whole level of knowledge hospital optometrists have that they don’t, and a worry that they are going to do something badly.”

He notes that following the fitting guides is key, adding: “As long as you’ve got the basic skills of putting a lens into the eye, assessing it and refining based on your assessment, you can fit complex contact lenses onto irregular eyes.”

There are downsides to scleral lenses, Brown acknowledges, commenting: “They’re not the ideal first lenses for the patient, because there is no tear exchange and because you’ve got plastic in a large area, they are prone to drying out and getting lipid deposits.”

This is something Lynn White, clinical director of UltraVision, a provider of specialist contact lenses, noted, adding that while scleral lenses can be comfortable and worn all day, others can encounter problems like fogging.

White said that finding a lens that is acceptable and comfortable is the priority for the patient and their quality of life, suggesting that it can be worth trying disposable lenses first, “because the simplest option is the best option for your patient.”

A further concern for practices around fitting specialist contact lenses can be around chair time, White shared, particularly for those practices with shorter appointment times.

"Specialist lenses will be able to solve a lot of patients’ problems and create really great results for everybody,” he said.

The growing waiting list challenges faced within hospital clinics and compounded by the impact of the pandemic also contribute to the reasons for community optometrists and contact lens opticians to fit specialist lenses.

Manufacturers highlighted that, with the waiting lists growing, there would be patients who would prefer to be seen by an optometrist rather than move through the hospital appointment structure.

Sexton noted: “Patients who are struggling and would rather pay privately will be looking to their local optometrist and someone they have been seeing for a long time.”

Reflecting on the challenges faced in hospital clinics, Sunassee suggested this could lead to further collaboration with primary care: “A lot of hospitals, ophthalmologists and corneal consultants are looking for practitioners in the field that they can refer to because they know it’s just a massive waitlist.”

This is something Brown sees continuing: “There’s going to be even more need I think, in five or 10 years time.

If you want your patients to have the optimum solution to their eye problem, you’ve got control to be able to do that.”

Specialisation and differentiation White suggested that now is a particularly good time to get involved in specialist contact lens fitting, noting that many practices have found over the past few years that “having that extra time with the patient has proved to be more profitable.”

The skill is a good practice builder, White shared: “Specialisation is the only way the High Street is going to differentiate itself, I think. Not only with specialist contact lenses – it leads into myopia control and presbyopia, and it’s not difficult to pick up quite a wide range of specialities.”

It can also be beneficial for patient loyalty, with White suggesting “if you take the time to fit a really complicated case, you tend to pull the rest of the family relations and friends in as well.”

Barlow agreed that specialist contact lens wearers can be “very loyal patients,” adding: “You can’t buy scleral lenses from a store online; you are going to buy them

“Patients come to see you, not what is on your shelves” Hansraj Sunassee, hospital business development manager for Menicon’s speciality division from a qualified practitioner. It is great for building your business, your patient base, and for patient loyalty.”

Over the past year, Sunassee shared, Direct Debit schemes have helped practices to see the value of contact lenses within their practices, “showing them that it is something they possibly need to build on.”

“But it also helps them understand they need to differentiate; they need to be standing out because there is so much competition on the High Street,” he added.

Skills and equipment When it comes to the fitting of specialist contact lenses, there are a range of tools that could support practices, from training and resources to devices – with topography top of the list for key equipment that can make it easier to identify the right lens for each patient.

For those thinking of fitting specialist lenses, White recommends getting experience in a range of lenses, noting: “You need to understand the full range of lenses available, and if you don’t want

THE IMPACT OF SPECIALIST LENSES Lynn White: “It is a large area that is very neglected, and it probably has the most profound effect on patients. This is something optometrists can do in the High Street to restore sight, and that is a very powerful and fulfilling experience.”

Scott Brown: “Optometrists should be educated in irregular fitting contact lenses. When it comes to contact lenses, 'the buck' does stop with optometrists and contact lens opticians. We should accept that responsibility.”

to fit a certain type, make contact with a colleague who can so you can always refer people on.”

A range of fitting sets, able to be obtained from suppliers, would also set practices up to fit specialist lenses. Brown shared: “The more sets you’ve got, the more options you’ve got that are going to suit your patients.”

Education would also be beneficial, with training and support available from manufacturers. For example, No7 Contact Lenses recently launched the Irregular Cornea (IC) Specialist website including presentations for optometrists about the lenses, how they work, how they fit, and problem solving.

Menicon’s Sunassee highlighted that practitioners should seek “a reliable lab that can support them – not just with the lens supply – but with hands-on-fitting, the training they need and after-support.”

To make fitting specialist contact lenses a sustainable part of practice, experts emphasised the importance of appropriately pricing their services.

“I think practices are scared to charge more,” Brown noted. “It is a really bespoke service that you are providing for patients, and therefore the service that goes with that is what you need to value charging for.”

Sunassee also identified the importance of incorporating chair time into the equation, adding: “Patients come to see you, not what is on your shelves.”

Ian Sexton: “It doesn’t suit every practitioner, practice or group’s business model, but for those that want to get involved, I would encourage them to take the leap.”

Hansraj Sunassee: “I’ve seen so many patients who come in subdued with their head and shoulders down and once you fit these patients and get them the vision they need, with the relief of a contact lens that is not irritating, they are bouncing around.”

Josie Barlow: “All contact lenses are transformative, but some specialist lenses are truly life changing, because patients can’t function without them in a lot of cases.”

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Suppliers

SPOTLIGHT

VERSION

MEMBER SUPPORT

AOP on your side AOP membership: tailored to life’s changes

SUBS ART PRODUCTION

With the membership renewal process approaching for qualified members from mid-November, Suzanne Page, head of membership for the AOP, has highlighted: “Now is a good time to look at the membership grade you are on and consider what the most suitable option is for you for 2022.”

“The membership has been adapted over time, with the introduction of new grades when we have perceived a need and been able to deliver a suitable package to meet that need,” Page shared. “Everybody experiences changes, whether it is taking a career break, becoming self-employed, purchasing a practice, or starting a

Tips for a smooth renewal CLIENT

Check your address and communication preferences under MyAOP on the website Review whether you are on the right membership grade: www.aop.org.uk/membership Set up a direct debit through your MyAOP account The membership certificates, needed for GOC registration in spring, will be available to download from January 6.

family,” she added. Page recommends reviewing the grades available, as well as the benefits included within membership, which can be found online and in the Member Benefits booklet. Resources available to members range from access to the online forums, to the AOP’s new digital Locum logbook.

“I think sometimes those who have had a membership for a long time possibly don’t realise the extent of support available,” Page noted.

Life’s changes

Addressing life’s changes, the AOP’s parental leave grade offers a payment freeze during the period of leave for a minimum of one month and a maximum of 12 months.

Page shared: “If you are planning a family, whether its maternity, paternity or adoption leave, as soon as you receive a MATB1 certificate, email a scan or clear picture to the membership team and we can organise this for you.”

When planning the return to work, members can contact the AOP to update their membership. The AOP also has a range of return-to-work materials available for parents.

Supporting members “to the highest level” How the AOP supported a member to challenge a GOC decision through a High Court judicial review The AOP has supported a member in a High Court judicial review challenge of a General Optical Council (GOC) decision.

Following government advice in March 2020 to work from home where possible, the GOC moved to send statutory notices by email.

The AOP highlighted concerns, noting the Opticians Act stated this could only be done if the GOC had made specific Rules to allow this and if the registrant had given explicit consent.

In January 2021, the AOP’s legal team was contacted by a member who had received an email regarding an interim order review of which he had no knowledge.

“The member had been served with an interim order notice of a hearing via email, which he had not seen. The GOC had pushed ahead and he had been made the subject of an interim suspension order without his knowledge,” explained Cassandra Dighton, head of professional discipline for the AOP.

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Retirement planning

The newly-retired membership grade is available to AOP members retiring from all work and requires confirmation that they are no longer on the General Optical Council (GOC) register. “Those members planning for retirement might want to think about organising this around their GOC registration,” Page advises, encouraging members to get in touch.

It can also be a good opportunity to get in touch with AOP affinity partner, Lloyd & White, to discuss plans, she added.

A tailored approach

“There is a huge amount of opportunity for members to tailor their membership to the different stages of their lives,” Page concluded.

AOP membership runs from 1 January to 31 December. With the exception of the parental grade, a grade runs through the year, but members can contact the AOP to upgrade as the year progresses.

More details on membership can be found on the AOP website.

The AOP argued that a hearing could not be held because the initial notice had not been served properly and the first hearing had not been convened lawfully.

After the interim order review went ahead, the AOP’s legal team made an application for a judicial review. The GOC conceded that the first interim order and subsequent interim order review should be quashed and provided a draft consent order that would allow this to happen administratively, which the AOP agreed to.

Dighton commented: “This underlines the importance of the service the AOP provides for members. We are robust and if the GOC takes action that is unlawful or inappropriate, we will challenge it to the highest level for our members.”

At the time of going to press, the AOP awaits confirmation that the order has been approved.

Find out more at: www.aop.org.uk/ot/supporting-members-to-the-highest-level Members can contact the legal department on: professionaldiscipline@aop.org.uk.

Pexels/Anete Lusina

REPRO OP

As AOP membership renewals approach, OT hears more about the services available to support members through their career

AOP EXPERT

Communications

John White, AOP interim director of communications

In September the AOP launched its Locum logbook as an online resource for all UK pre-reg and practising locum members. OT found out more: What has led to the decision to take the AOP Locum logbook online?

The AOP Locum logbook is designed for locum members to keep track of items for which they are potentially responsible, and to have documented evidence that they took appropriate actions or have met the requirements of the GOC Standards of Practice.

The logbook was produced in hardcopy format in 2019 and 2020, and sent to members who had locum work marked on their CRM career record as an insert in OT. Feedback at locum events on the hardcopy version was

very positive, but a number of members commented that they would like to be able to access an online version. Johnson & Johnson Vision offered to sponsor the online logbook, which is a financially viable and environmentally friendly way of delivering this product to members in 2021 and future years.

What does the new Locum logbook include?

The first iteration of the online version is very similar to the hardcopy version, but it will evolve as members use it and share their feedback on what additional sections or fields would be useful.

“We already know that members find the hardcopy version useful. Developing an online product makes it that much more secure and accessible”

How do you think this might benefit locum members?

We already know that members find the hardcopy version useful. Developing an online product makes it that much more secure and accessible.

We will store data for 10 years since the last amend to a patient’s record, or if the patient was a child at the time of their sight test, for a year after they turn 25.

If a member leaves, we will store the data for 10 years for all the non-patient data they inputted following their resignation date.

When members input the data into the online logbook, they can be assured that it is available to them for many years to come. You do not get that assurance with a paper version.

Any suggestions or comments about the online tool should be emailed to communications@aop.org.uk

Exam and document at the same time New ZEISS Slit Lamp Imaging Solution The intuitive SL Imaging Solution from ZEISS allows you to take your everyday slit lamp exams to the next level, by integrating high-quality image and video capture into your exam reports. This all-round imaging solution features a modular concept, giving you the option to add slit lamp imaging seamlessly into your workflow. What’s more, it’s the perfect pairing for both of the ZEISS LED slit lamps - SL 220 and SL 800.

01223 679776 www.zeiss.ly/SL- Imaging

customercare.uk@zeiss.com

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AOP Update

SPOTLIGHT

OT FOCUSES ON

VERSION

Enhancements ahead

REPRO OP

Ocuco is launching a new cloud-based booking system to its UK practice management systems (PMS) from December, offering a smoother experience and better responsiveness on mobile phones. Ocuco has also been working on interfaces with the Electronic Eyecare Referral System (EeRS) in conjunction with NHS Digital and the Optical Confederation – supporting the transmission of referral letters using a dedicated platform and template. Additionally, the company is upgrading the software engine behind Acuitas and Focus 2, while recent updates to its solutions included an extension of the integrated lens suppliers available. www.ocuco.com/uk

FOCUSES ON...

PRACTICE MANAGEMENT SYSTEMS

SUBS ART PRODUCTION

Hit list

The trends, launches and looks

CLIENT

A domiciliary system

Opticabase has introduced a new solution for domiciliary optometrists to fill in and submit electronic GOS (eGOS) forms.

Opticabase Home enables optometrists to transfer their patient records, including eGOS forms, to a tablet which they can use on visits to enter the patient’s prescription or examination information, creating the GOS forms to be signed. Once connected to the internet, the information and GOS forms can be transferred back into Opticabase and the GOS forms can then be submitted to PCSE. www.opticabase.co.uk

Flex features

Optinet’s Flex system is set to see its annual feature release from November with new features including card payment and EeRS integration.

Updates will support the submission of eGOS6/PVN claims – enabling previsit notifications to be created and submitted electronically ahead of a visit. Optinet will also introduce Flex web forms, allowing practices to triage patients through an electronic form that can be sent by email or SMS ahead of their appointment. www.optinetuk.com

Integrated solutions

Optisoft shared that its main area of development coming out of the pandemic has been around eGOS, including working on a fully-integrated solution to replace the current eGOS link that will be included in the Optisoft.NET subscription when released. The company has introduced Clinical Records to replace the legacy OptomNotes module, along with a new Community Hub featuring free e-learning videos and a user forum. www.optisoft.co.uk

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GET THE

REPRO OP

LOOK

Q&A ME & MY GLASSES

Optometrist and lifestyle blogger, Lizzy Yeowart, on decorative filigree eyewear

SUBS

Filigree: an Italian phrase made from the Latin words for thread and grain.

It is often decorative fine wire used to decorate different surfaces. Here we look at filigree eyewear from three Italian brands.

ART

Pugnale PRODUCTION CLIENT

Colin Davidson

‘Bizzosa’ by Pugnale is a stunningly decorated double frame model on which the real silver string is sewn by hand.

Ceramic nose pads and the ogive-shaped bridge give optimal comfort. www.pugnaleeyewear.com

Contemporary artist whose portraits have included famous faces from Ed Sheeran to Queen Elizabeth II, tells OT about the important role frames can play

1

3

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New Glasses / Colin Davidson

My spectacles are a mixture between being a means to an end for close work and an addition to enhance my face. Including sunglasses, I probably have 16 pairs of frames. I travelled quite a lot before March last year and I would make a point of buying a pair, so there is a bit of a story behind a lot of my sunglasses.

When you’re wearing glasses, you put a sheet of glass – albeit a lens – in front of your eyes.

In some ways there is a barrier between you and the outside world.

What I was hinting at in the selfportrait was that in some way, the glasses were the subject. It is me, but it’s me wearing the glasses and the eyes behind the glasses are deliberately slightly blurred.

Being a portrait painter, I’m very aware that we communicate through our eyes. I feel that prescription glasses need to enhance that. It’s very important to me that the frames don’t take away from what is one of the most amazing, beautiful things; which is the eye.

The way I make portraits is the opposite of the way a photograph would capture someone’s face. A photograph looks at every pixel and treats it in an equal way, so everything is as focused as everything else. But that’s not why we engage. You don’t recognise someone because of their chin; you recognise them because you recognise their eyes.

Lio-Occhiali The Roe collection by Lio-Occhiali is so named because the Venetian word Roe refers to a wild, thorny bush that typically grows in the wild. The designers have used this as a metaphor for today’s woman and her decisive and strong character. www.lio-occhiali.it

Dolce and Gabbana Dolce and Gabbana is one of the bestknown design houses in Italy, celebrated for its fearless design. ‘Devotion’ is a standout, heavily decorated sun style with smoke gradient lenses. www.dolcegabbana.com/en

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MMG

HIT LIST

VERSION

Frames

Autumn tones

REPRO OP

Dutz Eyewear has introduced its new autumn collection as a “cocktail of colours,” with yellows, reds, pinks and blues all top styles. However, neutrals are also a “must” for the winter, the brand suggests, presenting its ‘DZ2274’ (pictured) in greyed pastel colours such as a soft beige, powder pink, anise yellow and light browns. Designs applied nude shades with a twist, such as powder dust beige and anise yellow with gold accents and acetate for an ostrich feather pattern. www.dutzeyewear.com

SHORTLIST THE LATEST PRODUCT LAUNCHES

SUBS

Frames

Titanium and acetate combinations ART PRODUCTION CLIENT

OWP has launched a range of frames with fine metals and striking acetates, including features from contrasting colours to intertwined metals.

A highlight of the women’s collection, the ‘1457’ frame (pictured), features a fine bezel accent in a bright colour, with sides made of OWP Signature Acetate. In men’s eyewear, the ‘7514’ panto-shaped frame features a high-density acetate front with titanium sides. www.owp.de

Wipes

Eco eye care

The Body Doctor has made its Eye Doctor Lid Wipes and Eye Doctor Tea Tree Lid Wipes biodegradable in what it believes is a first for the optical industry. The wipes are plastic-free and made from viscose fibres which break down in soil, compost, fresh or marine water.

The packaging is also recyclable. The company noted that sustainability is becoming an increasingly important factor for customers. www.the-body-doctor.com

Sunglasses

Bio-beauties

Pala Eyewear has introduced a new collection of sunglasses, made in small batches in a family-run workshop in Italy. The frames are handcrafted from biodegradable acetate featuring natural tones in unisex models. The ‘Malaike Ember’ (pictured) draws inspiration from the 60s, offering a thicker square style in an ember tortoiseshell with green-grey Grilamid lenses. The ‘Karibu Rye’ presents a nature-inspired rye frame with grey-green Grilamid lenses, while ‘Meria Havana,’ returns in a plant-based Havana acetate and matching graduated brown lenses with metal detailing on the sides. www.palaeyewear.com

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

Children

Flexible frames

Continental Eyewear has introduced Lazer Junior’s first range for infants. Designed for children under four years old, the frames feature a plastic flex hinge and safety band for comfort and durability.

The ‘Lazer Junior 2208’ (pictured) offers a rectangular-shaped frame and is available in blue or teal, while the ‘Lazer Junior 2210’ is a rounded style available in blue and purple. The brand suggested the frames are “perfect for little ones with wriggly hands.” www.continental-eyewear.com

Contact lensesi

Daily multifocals

Menicon has launched a new multifocal version of its Miru 1day Flat Pack contact lens. The contact lens is designed to be easy to use for new wearers, as well as patients moving from single vision lenses. It features a Neuro Adaptive design which aims to support adaptation and smooth transitions through near, intermediate and distance viewing. The power range for the new contact lens includes +4.00D to -6.00D (-0.25D steps) and -6.50D to -10.00D (-0.50D steps). www.menicon.co.uk/professional Frames

Full rim styles

Silhouette has added to its portfolio of full-rim frames with its Infinity View collection. The collection features four new shapes; a cat’s-eye and panto for women, and two rectangular styles for men, with a translucent colour palette.

The frames are made from a combination of Silhouette’s titanium and a polyamide which the brand suggest blend “seamlessly.” The materials are robust, while the polyamide shield prevents warping and is antiallergenic and UV-protective.

All of the frames feature a Silhouette hallmark. www.silhouette.com

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Shortlist

HIT LIST

VERSION REPRO OP

Q&A BEHIND THE BRAND HAAG-STREIT SIMULATION

SUBS

CEO, Markus Schill, on the need for simulator training

ART

HAAG-STREIT SIMULATION

//

PRODUCTION CLIENT

1

Founded as a university startup then called VRmagic, the company introduced the Eyesi Surgical Simulator for intraocular surgery training in 2001

2

The Eyesi Slit Lamp Simulator was introduced in 2019, as a result of a cooperation with Haag-Streit Diagnostics. In 2020, VRmagic joined the Swiss Haag-Streit Group and has been rebranded to Haag-Streit Simulation

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Clockwise from left: Left: The Eyesi Slit Lamp Simulator; Right: CEO, Markus Schill

Worldwide, more than 450 schools for ophthalmology, optometry and medical education use Haag-Streit Simulation devices.

ANATOMY OF A FRAME

Can you tell us about your recent acquisition as part of the Haag-Streit Group?

The acquisition followed a four-year-long successful technology collaboration on the development of the Eyesi Slit Lamp Simulator. During this project, it became apparent that people and expertise in the team complemented each other perfectly. Now, HaagStreit Simulation is expanding the Haag-Streit portfolio for ophthalmology in the field of teaching and training. Being part of the group gives us the opportunity for new product developments on a wider scope.

What role do you see simulation technology taking in optometry training going forwards?

Simulation offers the possibility that each optometry student can become familiar with the same wide scope of pathologies. We are convinced that the database of virtual patients contained in Eyesi simulators is an optimal way to acquire routine both in device handling and in pattern recognition and diagnoses. The standardised curriculum and the computerbased performance evaluation provided by the simulator allow for objective assessment.

What effect has COVID-19 had on Haag-Streit Simulation?

Meeting with customers has not been possible for most of the last year. We have therefore started to offer live online demonstrations. After an initial standstill, we have seen a significant increase in business. Since simulators offer contact-free and safe training possibilities, there is an increased interest in both simulator training and online learning.

We expect this trend to continue and will further expand our offering correspondingly.

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Seve m onths o f ro t h l as r epor o t h i mpac o t h p andemi o s tuden a n p re-re o ptometrists OT evisit t h s ituatio t s e w ha h a c hanged and what challenges remain

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CLIENT

n the face of it, aspects of studying and training seem to have settled for students and pre-reg optometrists since OT last explored the impact of the pandemic on this portion of the profession.

University clinics have been able to go ahead over the past year, with strict protocols in place, and the College of Optometrists confirmed in July that 655 new optometrists had qualified since the start of 2021.

But just beneath the surface, pressures that built up during the pandemic continue to simmer and the potential for ongoing disruption continues to loom.

Placement problems Luke McRoy-Jones, pre-reg optometrist and AOP Councillor, told OT that the AOP’s student committee has identified continued concerns around work experience and pre-reg placement availability, and communication from employers.

He highlighted: “Understanding these concerns is a priority of the AOP and I would like to reassure students on this.”

Commenting on the challenges, he said: “The pandemic has undoubtedly had an impact on the economy and business confidence across the country and this may still have a knock-on effect to those coming onto the Scheme for Registration in the coming years.”

However, with the country in a later phase of the pandemic, the hope is that this should be mitigated.

Research from the graduate careers organisation, Prospects, of more than 3000 university and college students, found that a quarter had lost their work experience opportunities as a result of the pandemic and only 17% had undertaken a placement in the past year.

Indy Ghuman, final year optometry student at Aston University and chair of the AOP student committee, shared that pre-reg and work experience placement opportunities have felt limited: “I think COVID-19 has definitely reduced or diminished the opportunities. It has reduced the breadth of clinical experience you might be able to get.”

“This makes it a bit more difficult for a student to find out what they want to do and what kind

of optometrist they want to be,” Ghuman continued. “We might find that this current cohort of student optometrists are a bit more uncertain,” he added.

Nick Hillman, director of think tank the Higher Education Policy Institute (HEPI), told OT: “There seem to be problems across the board, because employers have downsized their staff, or they’ve been rushed off their feet trying to survive. Employers are more focused on short-term challenges than on the next generation.

“It’s very regrettable and not easy to fix, because who can blame employers for focusing on the dayto-day in the middle of a crisis?”

However, experiencing a range of work settings is crucial for students, he shared, “to enable people to make informed decisions about the future of their lives.”

Hospital experience Challenges in placement availability have affected students across the board, with the Association of Graduate Careers Advisory Services (AGCAS) finding that three quarters of graduates surveyed had noticed a fall in the number of available opportunities since March 2020.

Optometry students have shared the particular challenge of securing work experience and pre-reg placements within the hospital eye service (HES). “The pandemic has opened a lot of students’ eyes to the value of the NHS and many

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are considering hospital pre-reg placements, which they might not have considered before,” Ghuman told OT. “That is a positive thing because it has really increased awareness of these roles.”

As awareness has grown, so too has competition in a time when hospitals are under increased pressure and students report finding it difficult to gain experience.

This has also been seen in the pre-reg environment. To meet the need for hospital experience, the College of Optometrists introduced a virtual HES placement.

Commenting on the provision of placements, McRoy-Jones said: “While the College of Optometrists has done an excellent job of ensuring an online alternative in the shortterm, I feel the long-term goal should be to have in-person placements available again for all pre-reg trainees and at this time, the picture is not clear on whether this will be possible or how.”

Another difficulty is the cohort of optometrists working towards independent prescribing (IP) qualifications who also need HES placements, though new policies have been introduced with the aim of maximising clinical experience opportunities for IP trainees.

Hospital insight: Moorfields Eye Hospital Earlier this year, Moorfields shared the difficult decision not to offer pre-reg placements for the 2021–2022 cohort in order to support the trainees in situ.

THE COLLEGE OF OPTOMETRISTS: THE FLEXIBILITY OF THE SCHEME FOR REGISTRATION Alistair Shaw, head of assessment for the College of Optometrists, explained that, at the time of writing, over 94% of the cohort of students graduating in the 2020–21 academic year had been enrolled on the Scheme for Registration, comparing “favourably” with 96% of the 2019–20 graduating cohort.

Commenting on the perceived delays caused by the pandemic, Shaw said: “A key characteristic of the Scheme’s design is its flexibility. There is not one fixed enrolment date or point – trainees can enrol at any point and will have two years and three months from their individual start date in which to complete the Scheme.”

He added that work-based assessments take place all year round, with the Objective Structured Clinical Examination held four times a year, “so that trainees can follow a timescale that suits them, their employer and, in the case of some integrated courses, their university.”

Sarah Canning, head of optometry and consultant optometrist, and Nathanael Anguige, principal optometrist and pre-reg supervisor, confirmed that the capacity for work experience placements at the hospital remains limited due to social distancing requirements.

The department has observed a reduction in the number of people wishing to undertake a placement, the optometrists noted, but added that there is a slow increase in the number of students returning to carry out placements.

The hospital will be opening placements again for a new cohort of pre-regs to start in August 2022.

Interviews took place in June, with the department seeing “an exceptionally high number of applications” for the four positions.

The 2019–20 cohort have now completed their pre-reg year and

Three quarters of graduates surveyed

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“Understanding these concerns is a priority of the AOP” Luke McRoy-Jones, pre-registration optometrist and AOP Councillor

qualified as optometrists and the newest cohort, who faced a delayed start, have “progressed brilliantly,” the optometrists shared.

Discussing how the experience has changed, they explained that more virtual teaching and training had been introduced, which has been well received “and is likely to stay in place for future years.”

Changes also included arranging month-long placements in practice, rather than one day a week as in previous years. Timetables have been made more flexible, with short-notice changes to allow pre-regs to work in the clinics they need experience in, or the patient numbers for, to complete their competencies.

Supervisors have also increased their meetings with pre-regs. “With all of the pre-regs living away from home, it has been important for the whole optometry department to check in and look out for

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them, ensuring that they feel well supported, as there have been times in the year when they haven't been able to travel home,” Canning and Anguige continued.

Exploring new areas The sense of limitation around work experience placements could lead students to consider alternative paths to their career goals.

AGCAS research identified that most graduates (79.4%) have been made to think differently about their future as a result of the pandemic.

“It might breed opportunity for that individual to seek out other ways of widening their experience,” Ghuman suggested of the challenges.

“That might be engaging on extra courses and further learning, or exploring different settings, such as maybe domiciliary where we’ve seen a big demand. A lot of students might be thinking that this is an area they would like to consider, that they might not have before.”

Simon Raw, optometrist at OutsideClinic, told OT the company has seen a significant increase in the number of students interested in learning about domiciliary eye care.

This is fortunate, he suggested, “as the sector is experiencing major

growth, thanks to an ageing population, where people aim to continue to live independently in their own home.”

To meet this increasing need, more optometrists will be needed in domiciliary, Raw said: “It is vitally important therefore, that we give students experience of the sector at an earlier stage, so they know they have more options to consider when they qualify.”

The domiciliary eye care provider works with universities to educate students on the field and has been delivering lectures as well as live appointment observations over Zoom, in addition to Q&A sessions, during the pandemic.

Raw argued that domiciliary placements need to become the norm in the pre-reg year, adding that this is something the provider is hoping to take the lead on over the next 12 months.

Progression in pre-reg “I think the 2019 graduates have faced the biggest delays as a result of the pandemic,” McRoy-Jones shared, as face-to-face visits were paused in early 2020 due to the pandemic, before virtual assessments were introduced. “This group of

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of graduates report thinking differently about the future as a result of the pandemic graduates spent around 18 months to two years on the Scheme, rather than the traditional 12 months.”

Many 2020 graduates also experienced short-term delays of around three to six months in starting their pre-reg placements, McRoy-Jones explained, as a result of “the backlog of trainees from the previous cohort.”

“This meant that instead of enrolling in July, most enrolled between September 2020 and January 2021,” he shared, pointing out that these delays can have both financial and wellbeing effects on those trainees who are earning a pre-reg salary and perhaps staying away from home for longer periods.

Now on the Scheme, however, he suggested that many have been able to progress as normal.

Important to remember, though, is that a number of graduates

CHALLENGES ACROSS HEALTHCARE: DENTAL TRAINING Gaining required patient numbers has been a key challenge for dental graduates during the pandemic, who undertake a foundation training year in practice alongside assessments The British Dental Association (BDA) told OT the 2019–20 cohort of graduates were the first to be affected by the pandemic when dental practices closed between March and June 2020.

In England, Health Education England adjusted some requirements for minimum numbers of treatments and introduced a special Outcome 6C – demonstrating the individual had reached the competency but not been able to fulfil the minimum treatments due to the pandemic, giving them two years to address the missing numbers. New employers received short-term funding for any training support needed.

In Northern Ireland, Wales and Scotland, individuals were signed off but provided with an additional personal development plan to work to in their next role.

For the 2020–21 cohort of graduates in England, Wales and Northern Ireland, enough clinical activities could be provided to enable foundation dentists to meet most of the requirements and where there have been difficulties, a similar approach to last year was taken.

However, practices in Scotland did not return to the full breadth of treatments at the same time as other countries, affecting the number and types of treatment possible during training. As a result, it was decided that Scottish final-year dental students would not be graduating in the summer 2021, instead repeating the year, with the training for Scottish vocational dental practitioners also extended by up to a year.

“At the time of writing, it is too early to say what the situation with Scottish dental school graduations will be in 2022 and how this will affect vocation training. But the BDA will be watching the situation closely and lobby for the necessary support at the appropriate time,” the association said.

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With students and graduates affected by the pandemic, careers experts have highlighted the role that employers could play in providing support Research from AGCAS and the University of Southampton found that graduates would like more support from employers during recruitment. Dr Michael Tomlinson, associate professor at the University of Southampton, commented that employers hold an “important position” in supporting graduates’ transitions, adding: “Employers can build on good practice in helping facilitate significant forms of work experience and work-integrated learning, as well as offering effective initial training, internships, and work opportunities.”

Similarly, in its report on the impact of the pandemic on early careers, Prospects suggested that to support new entrants into the job market who may not have had the same levels of experience as previous cohorts, “what is particularly important is the preparation for induction and onboarding into employment.”

McRoy-Jones highlighted that for those in university and pre-reg, the pandemic has brought some “significant challenges, uncertainty and worry, as we’ve had to adapt quickly to new ways of working in a changeable climate.”

“I think my message for the profession would be that the next generation of optometrists should be supported and given opportunities wherever possible,” he shared, adding: “I would like to praise many across the profession, employers, and those within training and education for their commitment to trainees and their desire for wanting them to progress.”

Indy Ghuman, final year optometry student at Aston University and chair of the AOP student committee

CLIENT

amongst both cohorts lost their pre-reg placement due to the pandemic. “While only a small proportion of trainees were affected by this, the effects were obviously awful for those involved,” McRoyJones stressed.

Having begun her pre-reg placement this summer, Fatema Master, an AOP student representative, felt the process has been smooth.

She has, however, seen some of the ongoing effects of the pandemic on the pre-reg journey. Speaking

to OT, she explained: “Because of the pandemic, everything has been pushed back.”

Though she was able to enrol for the Scheme in August, she suggested that, “it feels like it has delayed when I can start testing and doing my clinics.”

While progression has felt slower in some ways, Master added: “Being in practice, all the staff have been really helpful and my supervisor has kept in touch with me to tell me what is happening and make a plan for when I could start testing.”

The sense of a slowing of progress was observed by Prospects in its graduate market trends report which found, with experiences and opportunities withdrawn or delayed, “graduates and college leavers alike expressed a sense of plans being delayed or ‘on hold,’ leading to feelings of being in limbo.”

Getting experience in the practice ahead of beginning pre-reg has had its value. Reflecting on her experience of joining her practice ahead of enrolling on the Scheme, Master shared: “I have seen how the practice works, I’ve got used to what lenses they use, the spectacles and contact lenses, and what their systems are.”

She continued: “In a way, I think it has worked out for the better, because I have got a lot of that knowledge which I think will help me in my clinics.”

IN PRACTICE WITH: VALLI GROUP Christine Wrenn, head of operations at Valli Group: “Due to the pandemic, the last cohort of students experienced delays and frustrations in finding or securing placements. It was important to us to offer support and as soon as we were able to progress, we held initial Zoom interviews to establish and match the candidates to the practice team. We introduced the applicants to the relevant supervisors and held trial sessions to ensure the relationship and dynamic

worked well. We currently have two pre-reg students who are progressing well with the support and encouragement of their supervisors.

“Instead of starting their pre-reg in August or September 2020, due to the delays, they started in February 2021, which will have a knock-on effect for the next cohort. We are however confident we will be able to continue to offer pre-reg placements in the coming years and that delays will eventually catch up.”

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Simon Raw, OutsideClinic: “There is no doubt that a placement in domiciliary as part of a student pre-reg pathway provides students with a more rounded experience. They get to support different types of patients, use different equipment and gain some insight into the different career options within optometry.

“While domiciliary pre-reg placements are technically available right now they aren't signposted enough and so students have to make a special effort to incorporate this into their placement year.

“We really believe that domiciliary placements need to be an option for all pre-reg students.”

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Master felt the communications from her placement and supervisor had been helpful in keeping her updated and creating a plan.

This is something she recommends employers could do to ease the transition to practice following the pandemic, “It is difficult for supervisors too, but it is good to have guidance and know how we are going to plan for the future.”

While there might be some delays in the process, she said: “It is good to plan when you might be able to start testing, so you know what you should be doing now in order to prepare and progress.”

The long-term goal “The pandemic has further demonstrated the importance of optometry as an accessible primary healthcare profession,” McRoyJones said. “I think that this will create a lot of opportunity for those currently studying, as well as qualified optometrists, to upskill and take on a greater role in the diagnosis and management of eye disease.”

As he enters his final year of university and prepares for the move into pre-reg, Ghuman shared a message for the profession, commenting: “Don’t underestimate the students of COVID-19.

“I think it’s bred a very resilient group of early career optometrists.

They will have a very different set of skills which are unique, and that’s only going to be a good thing despite the surrounding disruption to their education.”

AOP support for students and pre-registration optometrists Students and pre-reg members can use the AOP’s Pre-reg register to list their availability: www.aop.org.uk/advice-and-support/business/ pre-reg-register OT’s education library hosts OT’s skills guides along with archived CET and CPD articles, covering a range of topic areas: www.optometry.co.uk/cet/education-library

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INDY GHUMAN

“This is my experience, and I am owning my experience – the highs and the lows.

I think the most important thing is that you have gone through it together with your peers, your friends, your lecturers.

Despite your experiences, you have worked as a team, you are coming through the other end.”

FATEMA MASTER

“I’m excited, because it is one step closer to being an optometrist. It’s a bit scary putting it into practice, but I suppose it is about getting used to it and having that experience.”

LUKE MCROY-JONES

“Looking back and considering how far I’ve come in terms of learning and experience, I am proud of where I am today. This is what defines my pre-registration journey and I am optimistic for my future career. I think the fact that I’ve ultimately been able to progress through the Scheme, despite the events of the past 18 months, is positive.”

The Peer Support Line offers a free and confidential helpline for members and nonmembers at any stage of their career. The line can be accessed on 0800 870 8401 or: www.aop.org.uk/peersupportline The AOP’s employment team is available to support and advise AOP members on pre-reg contracts and employment law, and can be contacted on employment@aop.org.uk The AOP’s new mentoring programme is available online: www.aop.org.uk/mentoring

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In practice 43 Pre-reg focus

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Peter Grant shares insight into selecting a pre-reg and the support from his supervisors

45 How I got here

Aston University’s Raquel Gil-Cazorla on her beginnings in Madrid and move to the UK

Business insight and career development

50 How do I...

The Hakim Group’s Claire Slade offers advice on how to get the most out of reflective learning

55 Life as a locum

Yee Ting Liu on being your own boss and the patient she will always remember

THE DISCUSSION ART

Keep on learning

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OT speaks to three optometrists who have exceeded the GOC’s CET point requirements about what education means to them

Getty/Natalia Varlamova

CLIENT

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ducation means different things to different practitioners. While for some it may mean the collection of points in order to meet the requirements set out by the General Optical Council (GOC), for many it will be about an appetite for continued learning, self-improvement and a thirst for knowledge.

Optometrists Steve Clark, Helen Tilley and Simon Falk have all collected far more CET points over the last three years than the GOC’s CET cycle requires. In fact, each of them has more than double the number of points stipulated. But why?

“For me, education is about lifelong learning and making sure that I am trying to be the best practitioner that I can be,” domiciliary professional services optometrist at the OutsideClinic, Clark, told OT. During his 32 years since qualification, the profession has developed and new technology arisen, Clark said: “For lots of reasons, the world changes and things develop and move on. Things like optical coherence tomography (OCT) have appeared during my career and if I didn’t

complete CET and educate myself on it, I wouldn’t know what an OCT looked like let alone what it meant.”

For Clark, who has achieved 83 points to date in the current CET cycle, continued education is also about relearning. “There will be lots of things during my career that I have forgotten as I don’t use them frequently, so I also do CET to remember what I knew in the past,” he said.

Having collected 72 CET points to date, optometrist and owner of Monnow Eyecare, Tilley, shares similar views, calling continued education “vital” to her as a practitioner. “Having been qualified 32 years, I started out in the profession expecting to be refracting and prescribing glasses, fitting contact lenses, and identifying eye disease and sending it on.

“If you want to stay up to date and at the forefront, then you have to do education regularly” Simon Falk

“In 32 years, optometry has changed almost beyond recognition, and I probably spend less than half my time refracting,” she shared.

As an independent prescribing optometrist, Tilley is able to treat eye emergencies in practice and hosts a virtual glaucoma clinic. In order to provide these services, Tilley completed additional qualifications.

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develop and evolve to the changing needs placed on us,” she emphasised, having further educated herself to upskill.

With 81 CET points to date, for Falk, optometrist and director of Simon Falk Eyecare, CET is “a continuation of what you should be doing as a practitioner day-to-day.”

Falk sees qualification as a starting point rather than the end goal. “I have always felt that while optometrists will have completed their qualifying exams and drawn a line in the sand, that doesn’t make them a great practitioner.

On qualification, practitioners may have the knowledge, but they don’t have the in-practice life experience, and the only way they can become that rounded practitioner with all of the skills required is to continue learning,” he shared.

Falk uses education to advance himself as a practitioner, he told OT: “Practice would be extremely boring if you just qualified and said one or two for the rest of your life. Education provides me with continual learning and the opportunity to challenge myself. It also enables me to explore new and advancing areas and disciplines that I might not be able to otherwise.”

Falk highlights that education is not just about advancing himself; it is also about advancing the profession.

“It provides the opportunity to further your profession and not stagnate,” he said, adding: “More is going to come into primary care, tightening the link between optometry and ophthalmology, and if we don’t step up as a profession someone else will. We must enhance our skills to meet these needs and there is an opportunity to do that now. That’s a massive driver: to want to enhance the profession rather than be seen as a good glasses seller.”

Tilley reiterates this, emphasising: “We already have more accurate autorefractors and artificial

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intelligence taking over identifying disease. If we stand still, we will not exist.”

The meaning of education

Tilley was not aware of how many CET points she had consumed in the current cycle until she was asked to check.

She does not see education as the consumption of CET, but rather part of her ongoing development, “enhancing my knowledge base to provide the best service I can to patients.”

Working in domiciliary optometry, Clark aims to tailor his education to his patients’ needs. “The average age of the patients we see at the OutsideClinic is 84, so, relative to optometry on the High Street, there is a lot of pathology,” he said, sharing that on the day prior to speaking to OT, of the six patients he saw, he referred two of them for sight threatening conditions.

As a direct result, in recent years Clark has completed professional certificates in glaucoma and medical retina. “I see a lot of patients with glaucoma and a lot of patients with age-related macular degeneration. I felt that as a practitioner, in order to be able to do the best by my patients, I should complete those certificates.”

The OutsideClinic supports Clark in his ongoing education, providing funding and study days in his working week. “They are supportive employers in helping us to be the best that we can be,” he shared, adding: “It’s easy when you work for a company that wants to help drive you in the direction that you want to go.”

Finding the time

The trio admit that whilst they have been avid learners throughout their careers, it is much easier for them to consume education today because there is more choice in both topics and format than ever before.

“I used to have to take a full day out of practice to travel somewhere to consume education,” Falk recalls.

“Now I can complete education at home in the evening online or during a train journey,” he added.

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“My motivation comes from really enjoying my job, doing the best for my patients and providing an exemplary service in the community” Helen Tilley Having joined the Hakim Group in July 2017, Falk emphasised how it has now become even easier to find and consume education that is of interest to himself and his staff. “One advantage of being with the Hakim Group is that it provides us with access to an online platform full of education, including webinars and videos,” he shared.

As a practice owner, Falk feels it is important to support his colleagues in achieving their educational goals too and, as a result, he provides staff with somewhere to go during their working day to consume education. “We have converted a spare room into a training suite and have installed a large screen TV so that people can go and consume online education,” he told OT. Clark agrees that access to education has never been easier: “When I qualified, education was paper-based and I would have to post answer sheets off for marking; it was all very clunky and quite an effort. But today everything is at your fingertips. I can login at home and watch hugely interesting talks with top class speakers from the comfort of my own home and be one of 500 people listening.”

Clark acknowledges that “life is busy, and it can sometimes feel like there are not enough hours in the day” but says “it’s about a balance.”

OutsideClinic

Staying motivated

Clark accepts roughly 50% of the education offers that he receives.

During his career, he has learnt that, for him, committing to education and having it in his diary is important.

“I like the incentive of an invite on a particular time on a particular day. It motivates me to attend as I said ‘I will do that,’ so I will. At times when I have just made a list of things I should log into, time rarely allows me to and life gets in the way,” he told OT. “I decide what invites to accept based on if I am going to learn something that is going to make a difference to my patients,” Clark said.

It is important for the optometrist to make time for education. Clark’s rule is ‘never eat tea when taking CET.’ “It’s very tempting to do in the modern world, but the reality is you never listen and you never learn this way.”

Falk’s motivation comes from a fear of falling behind and therefore little and often is an approach he tries to stick to. “If you want to stay up to date and at the forefront, then you have to do education regularly. Technology moves quickly and it’s easy to fall behind. Due to my age and associated technological skills, I have to ensure that I learn continually around this area.”

As a practice owner it is also important for Falk to be able to offer his patients the best clinical care. “I want to be able to offer my patients the highest level of care and in order to do this I have to make sure I am practising at my highest level and therefore continually educating myself.”

Tilley shared: “I don’t look at it as consuming CET, rather as part of my development, enhancing my knowledge base in order to provide the best service I can to my patients,”

which is also what motivates her. As a result, she has exceeded the CET points requirement not through trying but by “attending lectures and conferences that interest me,” she said, stressing: “I do online CET where I feel I need my knowledge boosting, but certainly wouldn’t attend a lecture or read an article just because it has points associated to it.”

Tilley emphasises that not all education has to be formal, noting that she learns a lot informally through talking to and discussing cases with colleagues, as well as through clinical WhatsApp groups that she is part of.

“I consult with colleagues and get their opinions and learn so much through this,” she shared. “I don’t look at it as how to fit it into my working week – it’s continual learning from others and mentoring others.”

Tilley added: “My motivation comes from really enjoying my job, doing the best for my patients and providing an exemplary service in the community.”

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Encouraging others

Clark feels that with a plethora of continued learning available, consuming education has never been easier. “It’s flexible and there are lots of ways to do it. Therefore, it is an opportunity really missed if you don’t take up those offers,” he said.

Tilley encourages practitioners to embrace continued learning and development because “that is what makes you a professional.”

“Patients and hospital colleagues will have much more respect for you if you take clinical responsibility,” she added.

“If you keep educating yourself, there will be a better and more challenging career available to you,” Falk closed.

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Discussion, 2

IN PRACTICE

VERSION

PRE-REG FOCUS

REPRO OP

“A busy few months lie ahead”

Education Library.

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

Pre-reg optometrist, Peter Grant, shares insight into selecting his pre-reg and how his supervisors have supported him through his journey

SUBS

O ART PRODUCTION CLIENT

n 1 September I marked one whole year since I started working as a pre-reg optometrist at Julian Davies Opticians in South Wales.

It has been a challenging 12 months in many ways, but one that has helped me grow in confidence and develop as a practitioner. It is hard to believe that I may only be a matter of months away from becoming a fully qualified optometrist. Although I am apprehensive at the thought of managing patients on my own with no supervision, I am excited at the prospect of advancing my career.

The right placement

Having previously worked as an optical assistant at a multiple, I have enjoyed experiencing an independent practice and seeing what it has to offer. While I had the opportunity to complete my placement with a multiple, upon meeting the supervisors at Julian Davies Opticians, getting on so well with them, and learning that they had recently been successful in mentoring a trainee through the Scheme for Registration,

Luke says…

I was keen to secure a position and grateful when I did.

To all those who are currently seeking pre-reg positions, I would strongly encourage you to meet with your potential supervisor before deciding whether that is the right practice for you.

They will be the person you spend most of your time with throughout the year and having a supervisor who is familiar with the Scheme is particularly reassuring.

Progressing in the Scheme

I am currently working towards completing Stage 2 of the Scheme. The format of the assessment is different due to COVID-19, with the aim of limiting patient, trainee and assessor contact as much as possible.

One half of the assessment involves direct observation of a sight test and contact lens check in your practice, with the College of Optometrists providing their own patients.

“After enjoying a week of annual leave in August, spending time with family and getting engaged, I am looking forward to getting back into the swing of things” I have really valued the time that I have spent one-on-one with my supervisors, where I have had the opportunity to discuss trickier patient episodes and learn from their wealth of experience and expertise.

I can appreciate that supervising a trainee fresh out of university must be challenging, so I am grateful for their patience.

The one tip I would give my peers preparing for their pre-reg is… Stay organised and try and get into a routine early on that is sustainable.

The Scheme can be tough in terms of the workload, and it can mount up. On top of working in practice all day, you’ll have to make time to

The other half is carried out remotely via Zoom with a College assessor and involves the use of case studies alongside visual field plots, images and questions, with the aim of the trainee demonstrating competence in 13 overarching competencies.

Unfortunately, I have not passed Stage 2 in time to take the September sitting of the Objective Structured Clinical complete your logbook and reflective accounts, as well as paperwork and revision for assessments. If you can get into a good routine and do ‘little and often,’ it means that the build-up to assessments will go a lot more smoothly, and you can fit in some downtime too.

Examinations (OSCEs).

All being well, I will sit the January OSCEs instead.

Over the next few months, I hope to continue working on my ability to manage patients appropriately, and with hard work and determination, my aim is to be fully qualified early next year.

Once qualified, I intend on becoming Welsh Eye Care Service accredited as soon as possible, which will enable me to diagnose and manage patients presenting with acute eye problems in Wales.

In the future, it is my desire to achieve higher qualifications in glaucoma, medical retina and, eventually, independent prescribing, which is becoming more and more crucial in easing pressure on the hospital eye service.

After enjoying a week of annual leave in August, spending time with family and getting engaged, I am looking forward to getting back into the swing of things in the test room. A busy few months lie ahead, but it is a huge relief to have the finishing line in sight.

The next few months will entail… Hopefully qualification. I passed Stage 2 in August and have now sat my OSCEs. I'm excited about what comes next.

Luke McRoy-Jones is a pre-reg at Merthyr Optical Centre in South Wales.

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Pre reg

IN PRACTICE

VERSION

side of contact lenses, so all those cases would be referred to me.

REPRO OP

From this early stage in my career, I started to present our studies at various international conferences.

HOW I GOT HERE SUBS ART

“It’s important that you try to challenge yourself” Aston University’s Raquel Gil-Cazorla on her beginnings in Madrid, being inspired by US and UK optometry, and achieving her childhood ambitions

PRODUCTION

When I was little, my dad and brother both wore glasses. My brother is a

CLIENT

year younger than me, and I was surprised that he needed glasses to see clearly at distance. So, I went with my dad and my brother to see how an eye examination worked and how they could get the prescription for my brother. I also wanted to wear glasses, because I thought it was really cool. I was curious, and thought: ‘Wow, that’s really amazing.

How can you do that?

How can you calculate a prescription? How do you do an eye examination?’ I was really interested from that point onwards.

I always wanted to do something related to healthcare. When I was

at high school and had to decide what I wanted to do in the future I did look at different professions, and thought optometry was really promising. It’s an autonomous, regulated healthcare profession. That’s why I made the decision to start on this path.

“My Plan B?”

My degree was in optics and optometry. I studied at

Complutense University of Madrid for three years and then worked in practice for a year, but I knew I wanted to expand my clinical knowledge. So, afterwards I did a clinical residency programme at the university for almost two years.

“It’s interesting to see the scope of optometric practice worldwide, and how optometry has evolved since I started practising” After that I went to work in a private eye hospital.

I was exposed to all types of ocular disease, which improved my clinical skills.

It was a very busy and research-active hospital. I was in charge of the contact lens department, and the majority of patients needed specialist contact lens fitting.

I have always been more interested in the medical

These included those run by the British Contact Lens Association, the European Society of Cataract and Refractive Surgeons, and the American Academy of Optometry.

I was inspired by the scope of practice in the US, and by diagnostics and independent prescribing. I did an MSc at the European University of Madrid, which included a six-week residency in Chicago, seeing patients with third and fourth-year students. It was interesting to see how everything worked; the way they were doing these comprehensive eye exams. I was teaching in Madrid in third-year clinics, so it was nice to apply that knowledge there.

I then completed a BSc and an MSc with Pennsylvania College of Optometry, which was mainly distance learning. The teachers came

to Madrid to do the lectures and clinical competencies, and we went to Philadelphia to complete the clinical aspects. It’s interesting to see the scope of optometric practice worldwide, and how optometry has evolved since I started practising. I qualified in 1998, and since then things have really evolved a lot.

After I’d finished my MSc I wanted to apply the knowledge and clinical skill that I’d gained on the course, but I couldn’t use it in Spain as you’re not qualified to work at that level.

I knew that I wanted to do something within the health professions. I’ve always been fascinated with scientists: the people in the lab with microscopes. I wanted to do pure science, or biology. So, maybe a microbiologist.

I then did my PhD in Spain, related to refractive surgery, gaining the Extraordinary Prize (for the best academic results at the university), of which I was very proud.

As soon as I finished, I knew that I wanted to do postdoctoral work in the UK, to learn about other ways to research and practise.

In 2013, I got a postdoctoral position at Aston University, which was initially for three years. I also started the

independent prescribing (IP) qualification. During my postdoc, a lectureship in optometry at Aston became available, and I got it. A few months later, I qualified as an IP optometrist.

I take any opportunities that I can. In Spain, I had

my niche, so everything was easier. But I wanted to grow and acquire knowledge from another country. That was a big step, because it meant starting from scratch. It’s important that you challenge yourself and get out of your comfort zone. Try and learn from every experience, and enjoy it.

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

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HIGH

IN PRACTICE

VERSION REPRO OP SUBS

KEY MILESTONES

ART

“It’s been inspiring to see people’s reaction”

PRODUCTION

AOP membership benefits officer, Sarah Melzack, explains the steps behind a mentoring initiative that is bringing support to optometry’s newest recruits

01 A mentoring programme

CLIENT

has always been talked about by our committee members.

There has always been a need. Everybody goes through changes, professional or personal, and mentoring is a great way to have that one-to-one support when you’re trying to make changes in your life or meet developmental goals.

However, previously other priorities for members had always taken precedence.

02

When mentoring was mentioned in the General Optical Council’s (GOC) Education Strategic Review, we started thinking, ‘Why don’t we take this as an incentive to push it forward?’

Mentoring was mentioned in the GOC 2019 consultation papers as being a valuable way to build optometrists’ confidence during their early years in the profession, up the quality of care they can provide for patients, retain them in the profession,

and help them to fast-track their career by having support and making new connections.

Added to this, hearing what a tough time students have had during the pandemic meant we really felt that there was a need to push that support out as soon as possible.

support without mentors.

We did a lot of research with our student members, our student chair and our membership committee.

It was a lot of scoping to identify how to get the programme to work logistically, in terms of attracting and recruiting, making it appeal, and ensuring its effectiveness.

04 We decided to launch the programme for newlyqualified members first, in September this year.

We know the first year is a really tough, vulnerable time, where you are thrust to the fore and maybe feel on the backfoot.

Self-confidence issues do occur a lot, until you find your feet.

Mixing a pandemic with that, with people having studied in ways they never thought they would, and going into practices that were operating in a way they never imagined, we felt that this group of members were probably those most in need at this particular time.

“We’ve had over 200 members come forward to say that they would like to become mentors. That’s incredible”

03

05 Now that the

of Council members really rooting for the programme, but we wanted to make sure that, if we were going out to this niche group of newlyqualified members, we had identified the categories they would be seeking support with, and also that we had worked out what was going to attract members to become mentors. There’s no

a case of waiting to see how people find the experience.

We will be sending out surveys to mentors and mentees whenever they close a relationship: did the mentors find it rewarding?

Was it what they expected?

Did the mentees find that they worked towards the

The first step was a lot of consultation. We had lots

programme has launched, it’s time for us to wait for relationships to develop. It’s

goals that they went in with? Did they benefit from something else entirely?

These are the things that we really want to hear, so that as we go forward we can continue to tweak the programme to ensure we’re listing all support categories, that we’re recruiting the right mentors, and that we’re selling the opportunity correctly and appropriately to mentees. Also, how can we market this opportunity to others who might benefit from it?

06

I thought we’d have a challenge recruiting mentors, but I was wrong, which is really great. I didn’t know

whether people would want to give up their time, especially after a pandemic that has put people through so much. I thought people might be feeling a bit weary.

Actually, we’ve had over 200 members come forward to say that they would like to become mentors. That’s an incredible thing to see.

The responses people have sent to the mentoring inbox have been full of praise, and sometimes a bit of emotion. People are excited for the programme. They think it should have been done a long time ago. They wish that they had it when they were newly-qualified, and they understand how powerful it’s going to be for those who decide to take it up. It’s been inspiring to see people’s reaction. It makes me really proud of what we might achieve.

How to join the AOP mentorship programme To sign up as a mentee visit: www.aop.org.uk/aopmentor To become a mentor visit: www.aop.org.uk/aopmentee

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KEY MILESTONES

IN PRACTICE

HDI VERSION

HOW DO I...

REPRO OP

Reflect on my learnings Optometrist and head of professional advancement and governance at Hakim Group, Claire Slade, advises on how to get the most out of reflective learning

More information To read more on businessrelated news, insight and experiences, visit our website www.aop.org.uk/ot/ in-practice

SUBS

I ART PRODUCTION CLIENT

t is important for practitioners to reflect on their learnings regularly in order to keep developing themselves both professionally and personally.

Setting goals and reflecting on them at intervals during the year enables you to think about your career, where you want to get to and how to get there. However, as professionals we are busy; we have a day job and family commitments to balance, and reflective learning is something that we can put off. It requires us to be creative, which is very different to our clinical skillset, and the thought of it can be daunting. But it doesn’t have to be.

Reflective learning, put simply, is about thinking ‘I would like to do this, and I would like to be that.’ The next step is then talking those thoughts through and giving yourself the time and space to develop them into a goal.

Finally, you have to think about how you are going to make things happen in order to achieve your goal.

I encourage all practitioners to carve out some time to sit down and think about what they want to achieve. Set goals at the beginning of the year, log them, and sit down and reflect on them part way through the year. Choose a process that works for you and stick to it. Goals can be broad and wide ranging – in

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fact, that is what I would encourage. They don’t solely have to be about CET; for me personally, it is much broader than that. While it could be expanding your knowledge in a clinical area such as optical coherence tomography (OCT), it could also be about networking with your peers, finding a mentor or a buddy in practice, or expressing a desire to become a practice owner. It’s an educational journey that allows you to invest in your future and take responsibility. The process

“Goals can be broad and wide ranging – in fact, that is what I would encourage” of writing your thoughts down, setting goals and reflecting on them will allow you to move forward with your ambitions and reach them sooner than you otherwise might.

Constraints

When it comes to finding the time to reflect on your learnings, I would encourage practitioners to be disciplined and be selfish. I set myself reminders and I will ensure that I make the time for myself. I find a quiet space, I make a coffee and a snack, and I sit down and reflect over the last period.

My reflections

I’m a very structured person and I love a process.

I like working through a cycle. Therefore, for me it’s important to log and keep track of my ambitions and goals on a platform.

This won’t work for everybody, but it does hold you accountable and gives you a structure and timescale to work to. It also helps you to be disciplined in setting yourself a day and time to sit down and reflect. Without these processes, I have found that time slips by. I know that around particular months that I set, it’s my reflective time.

Personally, I use the reflective learning system on the General Optical Council’s website to set out my goals and, as new aspirations come up, I log them.

An example of this for me in the past was OCT because, when the technology came to the forefront, I realised that it was something I really wanted to get into and learn more about. On making that decision, I added an objective for myself on the system stating my goal of starting to use OCT. As a result, I went off and proactively created learning experiences for myself over time, which I know would have been harder for me to achieve had I not set myself the goal and recorded it to hold myself accountable.

Three steps to success 1. Carve out time for reflection and stick to it 2. Set goals and plan how to achieve them 3. Use reflective learning to help you meet your career ambitions.

Other objectives that I have set are a lot smaller, such as joining discussion forums in order to have conversations and monitor what others are doing in a clinical area, which can all be part of your reflective learning journey.

Benefits

Reflective learning doesn’t have to take up a lot of time and having a list of my goals and reflecting on them during the year holds me accountable and helps me keep pace in my development as an optometrist.

I try to advocate reflective learning as much as possible as I see the value of it. I’ve long worked in a corporate environment and it’s obvious to me now that you reflect in order to develop. But as a profession, I don’t think it is something we do enough of. The benefits of reflective learning are rarely discussed, but it allows you to take control of your career – it has helped me get from A to B in my career.

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WHAT I HAVE LEARNED

ART

“I am motivated to continue to develop my skills”

PRODUCTION

Clare Pearce, optometrist and practice director of Pearce and Blackmore Opticians, and Ingrid Patterson, Dementia Friendly communities coordinator, on accessible eye care and expanding skills

CLIENT

What has becoming a Dementia Friendly practice involved?

Clare Pearce, optometrist and director of Pearce and Blackmore Opticians (CP): The process began

with a conversation with Ingrid about what we felt was important in a patient journey and what would be difficult for a patient with dementia to experience.

We put together a pledge document which had action points that we agreed to implement to make the practice a more Dementia Friendly place. These action points for our practice included simple things like getting name badges in black writing on a yellow background, to more timeconsuming things like making cue cards to give to patients during their time in the practice to aid their understanding of what is happening. Ingrid then delivered online training so each individual staff member became a Dementia Friend.

How might the skills from this training be applicable within your role?

CP: Communication is such a

key part of any optometrist’s job and it has to be adapted to each different patient that sits in your chair. Having the opportunity to know how to specifically adapt your communication for a patient with dementia and their carer has been great. Having the training has also given me the confidence to be examine patients with dementia.

How important is it to you to develop your practice through further training?

CP: I am motivated to

continue to develop my skills and build my practice because we never finish learning. My job is kept interesting by continuing to build my skills and those skills then directly benefit my patients. As the sole optometrist at my independent practice, the clinical services that we offer comes down to the

skills I have built up.

Balancing work, my family and studying is a challenge but one that brings professional reward.

I am accredited with the Wales Eye Care Service, which offers emergency eye care and examinations for patients who are in a highrisk category of sight loss.

Being qualified to offer this service means that I can work effectively with the adjacent GP and pharmacy practices to largely keep patients within primary care. I have recently become a low vision accredited practitioner and I’m excited to be able to offer this service to my patients.

Becoming a Dementia Friend and pledging to make my practice a Dementia Friendly business came from a similar motive; I want to be able to continue seeing my patients in an environment that is appropriate and comfortable for them.

What does the process for becoming a Dementia Friendly business involve?

Ingrid Patterson, Dementia Friendly communities coordinator for Cardiff and Vale (IP): Being a Dementia

Friendly business is about enabling people living with dementia and the people caring for them to feel that their needs are understood and supported as part of their everyday life. It’s a straightforward process whereby Marie Curie provides support and resources produced by the Alzheimer’s Society to enable businesses to create a plan.

Businesses choose the actions that they will take and then sign a pledge. They are then presented with a certificate and a pledge sticker.

How did you tailor the training to the optometryspecific audience?

IP: People living with

dementia and their carers have told us that optometry is one of the sectors that they rely on for good healthcare and so people want to feel reassured and that their needs can be understood and supported when they go for eye care and tests.

Using the feedback that people with a diagnosis of dementia have given us, we are approaching local businesses, such as optometry practices, with the offer of being supported to become Dementia Friendly.

Why might optical practices want to consider becoming Dementia Friendly?

IP: People living with

dementia have told us they need confidence to continue using their local services, particularly following periods of lockdown. People have told us that they gain reassurance by seeing pledge stickers displayed in local windows. For example, seeing Pearce and Blackmore Opticians display their Dementia Friendly stickers means that people feel they can go somewhere where their needs will be understood and supported.

Opticians have told us that small changes can make a big difference and that their businesses have benefited. The Dementia Friendly process has enabled engagement with new patients, and their staff have gained confidence.

Share your story Get in touch if you would like to share your experience with OT kimberleyyoung@optometry.co.uk

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WIHL

IN PRACTICE

Advertorial brought to you by VERSION REPRO OP

RODENSTOCK LAUNCHES AN INITIATIVE TO CREATE MORE ATTENTION FOR SUSTAINABILITY AND NATURE VIA EARTHTODAY

SUBS ART PRODUCTION

EarthToday is a large-scale initiative to protect the earth. A collective of more than 100 prominent Dutch people call on everyone to protect nature. Rick Hogendoorn, Rodentock’s director of eyewear sales in Benelux and UK, saw this campaign on television and was very enthusiastic.

Rick discusses how the initaitive came about and what EarthToday means

CLIENT

“

Even before I thought about ‘linking’ EarthToday and Rodenstock, I was very excited and enthusiastic about the story that the founders told about this initiative on a latenight talk show.

On the programme, there was a group of more than 100 entrepreneurs from across the creative, media and tech sectors who have together been working on a solution for one of the greatest challenges we face as human beings: protecting the planet in order to safeguard biodiversity and keep our Earth safe for future generations.

At EarthToday, forces from the tech and media worlds are combined with conservationists, consumers and companies who can protect unique areas of nature. By involving companies and consumers in the mission, nature conservation can accelerate worldwide in such a way that the impact is directly measurable.

EarthToday provides concrete evidence on how physical square metres of nature can be protected. Everyone

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PROTECTING NATURE METRE BY METRE HOW IT WORKS Consumers and businesses that have a m2 on EarthToday receive a unique digital ‘proof of protection’ issued by the Union of Nature Foundation (an international partnership of conservation organisation) and is registered by name.

The geolocation is marked by a virtual flag on the m2 concerned and can be visited virtually. The square metre of nature is protected by one of the participating nature conservation organisations.

advertorial

who protects a square metre of nature also receives a shareholder certificate from EarthToday. In this way, ownership and responsibility are shared.

Step by step After being introduced to EarthToday through the programme, my wife and I were keen to engage and educate our boys. So, the very next day we all crawled behind the laptop and protected some square metres ourselves. Our boys were extremely enthusiastic. A few days later I was asked if we were going to move to Brazil because at school the boys had said ‘We have bought some square metres of nature in Brazil.’ This shows how this project inspires and becomes the talk of the town. You know exactly where you are protecting a piece of land and you have proof of it. Nothing is more fun than telling this at school, in the office or in the local pub. The scalability is the success.

When I was in Germany weeks later at the headquarters of Rodenstock discussing how to add more value to our products, I immediately thought of EarthToday. Of course, we could give away a nice gift, but we would be stimulating over-consumption. When buying a pair of glasses, it is primarily about the quality of the eye measurement and the glasses themselves. A gift is more of an extra. That is why I have introduced EarthToday, to provide relevance and added value in the form of sustainability.

Of course, it is not realistic for a company to think that they are immediately sustainable, but we can think about every new step we take to become sustainable.

Contracts that expire, for example, is an opportunity to choose sustainable packaging. At head office, they were immediately enthusiastic.

Because EarthToday is a Dutch initiative and I am responsible for the business unit for eyewear within Benelux and the UK, we are going to roll out the cooperation in these countries first. In time we will investigate whether we can expand the cooperation within Europe.

Protected area Something very beautiful is about to happen for certain!

It is our goal to protect 100,000 m2 together with 250 independent opticians, and to create more awareness for nature and sustainability with the campaign. We see that sustainability outside of optics is getting more attention in many sectors. Fortunately, as consumers we are also becoming more aware. We imagine that this will be the case within optics – so let’s embrace this and get going!

”

Rodenstock is happy to discuss how it is going to be working with EarthToday in more detail with practitioners directly. If you are interested, please contact your Rodenstock account manager for more information.

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Workshop VERSION SUBS ART

Safeguarding children OT poses a monthly scenario from a practitioner.

This month, we look at safeguarding children, with the AOP’s Henry Leonard

PRODUCTION

The scenario

CLIENT

Hema, resident optometrist “I am an optometrist who has been working as a resident in an independent for 15 years. I have recently experienced a parent refusing glasses for their child who I strongly feels requires them. I have tried to explain the benefits of wearing spectacles and the long-term impact that not doing so will have on their child. Can you advise?”

The advice Henry Leonard, head of clinical and regulatory at the AOP

S

afeguarding children, young people and vulnerable adults is a professional duty for registered optical practitioners and practices, in the same way as it is for all other health and social care practitioners and providers. As registered practitioners, we have insight into the possible implications for a child who is denied proper vision correction, especially if this takes place within their visual development period. A parent who is refusing to provide their

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child with spectacles despite there being a clear clinical need could amount to a safeguarding issue in itself, but may also be indicative of wider neglect.

Firstly, it’s important to ensure the parents understand what you found during the examination, what action you have recommended, and why this is important. If the child’s visual acuity is still developing, or they are at risk of becoming strabismic, it’s important to explain the possible long-term implications of delaying treatment. Aside from the everyday risks of a child not being able see clearly, you may need to explain how this could impact on the child’s academic and social development.

Next steps

If the parents still don’t accept the need to correct their child’s vision, it may be helpful to send them some information in writing, so they can make an informed decision in their own time.

If you have concerns about the possible implications for the child should their parents decide not to follow your advice, you should ensure you follow this up within an appropriate timeframe.

In some cases, it may be necessary to write to the parents again, to explain that you have a duty of care

“A parent who is refusing to provide their child with spectacles despite there being a clear clinical need could amount to a safeguarding issue in itself, but may also be indicative of wider neglect” towards their child, and you are concerned that their continued refusal to follow your advice may have serious implications for the child’s welfare.

It’s important to get the tone of the letter right. You don’t want to upset the parents unnecessarily, but you may need to make it clear that your professional role requires you to take action to safeguard the child’s wellbeing if this becomes necessary. This may eventually include referring the matter to your local safeguarding team, in the best interests of the child.

The AOP’s clinical and regulatory team can offer advice on safeguarding issues of this nature on a case-by-case basis, considering factors such as the child’s age, refractive error, visual acuity and binocular status, to help AOP members reach a decision on how best to address these types of issues when they arise.

If you’d like to discuss a case you’ve encountered in practice, please contact regulation@aop.org.uk Member support For more clinical and professional support visit www.aop.org.uk/ advice-and-support/clinical

Getty/ Irina Cheremisinova

REPRO OP

THE WORKSHOP

It may be helpful to ask the parents why they don’t want their child to wear spectacles, to gain a better understanding of their concerns. For example, the parents may be surprised to learn that most children are quite happy to wear glasses and generally adapt quickly to wearing them.

There is now a wider range of attractive frames than ever before, and less stigma about wearing glasses than there may have been when the parents were at school.

If the parents are worried about the cost, you can reassure them that financial assistance is available for all children in the form of optical vouchers towards the cost of optical appliances.

It may also be a good opportunity to discuss the possibility of contact lenses, as many parents may not have considered this as an option for their child. If the child enjoys a particular sport, for example, you can explain the benefits of vision correction, and which type may be most suitable.

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VERSION

have stated. But I shouldn’t complain as it means that there is always work.

REPRO OP

Just before the pandemic, I relocated to London and had to build up my locum network again. I moved

SUBS

LIFE AS A LOCUM

ART

“I wanted a more rounded experience of the industry”

PRODUCTION

Locum optometrist, Yee Ting Liu, talks to OT about the benefits of being her own boss and how a patient who returned to say thank you reminded her why she is an optometrist

CLIENT

I spent the first four to five years of my career as a resident optometrist at Specsavers in Allerton, Liverpool. Although I really

enjoyed my residency role and made a lot of friends who I ‘grew up’ with professionally, it does get repetitive being in the same environment. In 2018 I started locuming as I was after variety. I also wanted to learn about how things worked outside of one High Street practice. I wanted a more rounded experience of the industry.

It is really daunting taking the leap into locuming. I was

probably booking two days a week initially, so it was quite different from being full-time.

Slowly it built up and as it did I was given affirmation

ABOUT YEE TING

Qualified: 2013 Previous roles: Resident optometrist in a multiple Based: London.

about my abilities as a clinician – the feedback from my employers after a locum shift did this. It is a really nice feeling when you are invited back to a practice again.

Having my own schedule and being my own boss is the thing I most like about being a locum. Plus, the

flexibility. If I want to take a break, I can, and if I want to work hard, I also can. Being able to manage my own time is great.

The thing I least like about locuming is last minute cancellations – you can’t

predict these, but they are rare. Sometimes clinics just aren’t busy enough. I think this was felt by many locums as we were coming out of lockdowns, when footfall couldn’t be predicted.

The other thing is getting bombarded by emails about potential work. I often get emails from services that I have signed up to for work in locations that are far outside the catchment area I

because I wanted to explore areas of the UK that I haven’t seen before. From time-totime I go home to Liverpool and can locum when I’m there, which is another part of the flexibility that locuming affords me that I enjoy.

During the pandemic, I have been really fortunate not to have caught COVID-19.

However, over the last 18 months there have been occasions where I have had to cancel work in order to selfisolate. This is inconvenient for everyone and highlights job insecurity, which you have to consider when you become a locum. At times all of my work was cancelled and I felt like I would be the last person that practices would require when things opened up. It was stressful.

I will always remember when a patient came in to say thank you. She was 30

years old, had children and presented to me because her vision had deteriorated quite rapidly. After an initial examination, I took her to a different practice down the road that had an OCT. I made an urgent referral as things just weren’t making sense. It was later confirmed that she had a cranial pharyngioma.

She has since had the tumour removed. She came in with flowers to say thank you.

When you feel that you have really helped someone and have been their first port of call, it reminds me why I became an optometrist.

A DAY IN THE LIFE 7.15am I wake up and will double-check where I’m going and my route in case there is traffic or line closures. Even if it is a practice that I am familiar with, journeys can be unpredictable.

9am When I arrive, I say hello to everyone, especially if I’m working somewhere new. In a place I have visited before, I may have a catch up with someone I know. I then go to the test room to make sure everything is turned on and working ahead of my first patient.

1pm At lunch I will go out for a walk, otherwise it’s a very sedentary job. I will buy lunch and check out the local area and support local businesses if I can. Then I will usually spend some time with the staff as it’s nice to build relationships at work.

5pm I make sure that I have done all my referrals and written up all my notes; I don’t want to end up in a panic and remember something two hours later. In the past I’ve forgotten to pack up my Volk lens, so nowadays I double and triple-check that I have packed up all my own equipment before I leave.

Leaving things and having to go back is frustrating, but easily done.

AOP Locum Logbook Find out more: www.aop.org.uk/locumlogbook

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THE ABC OF CPD

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OT outlines the switch to a new era in lifelong learning ART PRODUCTION Eva Bee

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icture a moment of hesitance in practice.

Perhaps observing something you have never seen before in a scan. Or finding the right words to convey a difficult truth to a patient.

For Dr Teresa Chan, this is where healthcare professionals can find the epicentre of reflective learning.

“For me, it is the moments of discomfort where you feel that something didn’t go very well or you feel that it could have gone better – that is where you need to do some processing,” she told OT. This may be reflection on paper or over a pint with a colleague in the pub. Chan observed that this occasion for contemplation can be thought of as a note to your future self – recounting what happened, why you chose to reflect on this moment and feedback for what to do differently in the future.

Chan is associate dean of continuing professional development at the McMaster University Faculty of Health Sciences in Canada.

In July, she contributed to an article published in Academic Medicine titled What the COVID-19 Pandemic Can Teach Health Professionals About Continuing Professional Development.

Chan shared with OT that the COVID-19 pandemic has given everyone an opportunity to reassess the way that we live our lives.

“I think that in this big upheaval CPD is one of the many things that has to change, specifically within the health professions because we care for other people. If the pandemic has taught us anything, it is that we all 58 www.optometry.co.uk

sometimes have to up our game,” she emphasised.

“It might take a global pandemic for some of us to change, but if all of us were constantly evolving it wouldn’t be such an uphill battle,” Chan added.

Within optometry, as well as widespread changes to the way that care is offered as a result of the pandemic, longer-term trends such as evolving technology, changing demographics and extended roles within primary care mean that the demands on optometrists have changed.

Taken in this context, the shift by the General Optical Council (GOC) to a more flexible approach to learning after qualification can be seen as an acknowledgement that as optometrists change the way they practise, they should also change the way they learn.

What does the shift from Continuing Education and Training (CET) to Continuing Professional Development (CPD) mean on a

THE CHANGES EXPLAINED

This year marks the swan song of CET. From 2022, a revamped scheme will see changes to post-qualification education requirements as well as a new name – CPD. In consultation documents on the changes, the GOC highlighted that CPD reflects the move away from a scheme that focuses on core competencies to one that fosters lifelong learning.

The regulator added that the name CPD is also consistent with the approach taken by other healthcare regulators.

The standards that underpin learning will also change, from standards of competence to standards of practice. The former faced criticism for being overly prescriptive, while the GOC believes the new standards will enable flexibility and cover a wider set of professional skills.

CPD IN A NUTSHELL What to expect in January 2022

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practical level? OT details what is known about the new scheme below.

36 points over a three-year cycle, including 18 interactive points Four domains: professionalism, communication, clinical practice, and leadership and accountability Optometrists and dispensing opticians need to complete at least one piece of CPD in each domain Registrants to complete a mandatory reflective exercise with a peer Non-approved CPD can count towards an individual’s points as long as it meets certain criteria.

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“When you are an elite performer in a certain domain, sometimes going outside of your own field to learn new techniques and skills from another discipline will be the nudge you need to realise what you were missing” DR TERESA CHAN In terms of how the new scheme will work, optometrists and dispensing opticians will still be required to complete 36 points over a three-year cycle, including 18 interactive points.

CPD will be grouped in four different domains: professionalism, communication, clinical practice, and leadership and accountability.

Registrants will need to complete at least one piece of CPD from each of the four domains and can tailor their CPD based on their scope of practice.

Therapeutic optometrists will complete a further 18 points from an additional specialty domain. For contact lens opticians, 18 of their 36 points will need to be in the additional specialty domain.

Optometrists, therapeutic optometrists and contact lens opticians will continue to take at least one peer review per cycle.

There is an additional requirement for registrants to complete a mandatory reflective exercise with a peer, but the details of how this will be implemented are not yet clear. As part of the new scheme, registrants will be able to take up to half of their CPD from sources that have not been approved by the GOC as long as it meets a series of criteria.

The non-approved CPD must have been developed for healthcare

professionals and be at least an hour in length.

Registrants will also need to complete a short, written statement for each piece of non-approved learning to explain why it is relevant to their CPD.

coach, or even as a peer, is useful,” she added.

Within the new CPD scheme, there is flexibility for optometrists to study a wide range of subjects and incorporate non-approved CPD, which may be completed alongside other healthcare disciplines.

Chan emphasised that healthcare WHY CHANGE? professionals should not operate in Asked for her thoughts on what silos. “If you are only focusing on makes high-quality CPD, Chan the expertise of your specialty, observed that it is any learning then you are probably that can help to change a not comprehensively healthcare professional’s In September, thinking about all the practice for the better. the AOP launched skills you need to be “If what we do is a new mentoring a great practitioner,” constantly changing, programme for newly qualified members she said. then we have to to receive additional “There’s a reason evolve with that,” support from more why footballers she shared. experienced members. sometimes learn to “We have to change dance. There’s a reason the way that we interface why ballerinas sometimes with the world. What you take karate. When you are an learned in optometry school is not elite performer in a certain domain, going to see you through your whole sometimes going outside of your career,” Chan said. own field to learn new techniques She advised against embarking and skills from another discipline on a professional development will be the nudge you need to journey alone, noting that realise what you were missing,” reflection is seldom taught within Chan elaborated. undergraduate courses.

Optometrist and Cardiff University “It is an atrophied skill. If flipping academic, Marek Karas, is also an towards a more reflective and advocate of professionals stepping tailored learning experience – outside their comfort zone when it don’t try to do it alone... If you want comes to CPD. Last year, Karas and to change your practice, finding colleagues published Continuing someone who can act as a mentor, October/November 2021

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“My research in this field has woken me up to realise that my behaviour is to do things that I want to do, not what I should be doing” MAREK KARAS

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professional development requirements for UK health professionals: a scoping review in BMJ Open. “My research in this field has woken me up to realise that my behaviour is to do things that I want to do, not what I should be doing. Now I tend to go and do courses that I am less confident in,” he said.

Planned learning is a key aspect of CPD that differentiates it from CET. At the moment, medics are the only healthcare profession within the UK that use objective measures within this process.

“They have to sit down with a mentor and plan their learning using objective sources of information – such as patient feedback and clinical audits. They look at where they could improve in their practice,” Karas explained.

When people can choose what they learn without objective input there can be a tendency to focus on areas that they are already knowledgeable about. “What you should be training in is what you are not good at. What you don’t know is what you should be focusing on, not what you know,” Karas emphasised.

In their overview of CPD requirements for health professionals in the UK, Karas and colleagues note that of the nine statutory regulators for healthcare professions, the GOC is the only regulator to use the term CET rather than CPD. They highlight that while CET instils the core skills needed for continuing practice, CPD has a broader ambition to develop the individual across their whole career.

“It asks the practitioner to reflect on their own practice, identify their own individual learning needs, plan to meet these needs, and then evaluate their learning while documenting this cycle in a personal

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development plan or portfolio,” the authors noted.

Before the introduction of the new CPD scheme, the GOC was the only UK healthcare regulator outside of medicine that accredits CET. From January next year, the GOC will audit a certain percentage of CPD providers each year rather than approving each piece of CET. “The question remains open – is that a good thing or a bad thing?”

Karas said.

Whether the new scheme supports high-quality CPD will be influenced by how the GOC manages different quality assurance processes, he added. Despite some remaining uncertainty on the scheme’s implementation, Karas emphasised his support for the GOC’s expansion into CPD. “Moving to the new framework from standards of competency to standards of practice will mean a move from what we practise to how we practise. The advantage is that you allow the practitioner to evolve – and acknowledge this evolution because optometrists are already doing it,” he noted.

Karas added that enabling people to count learning from a nonapproved provider towards their CPD also has strengths. “If you work in a hospital, you might want to go along to a training day with ophthalmology. At the moment, you can’t use that towards your CET,” he said.

Turning to research examining the effectiveness of CPD, Karas noted that there is limited evidence illustrating the impact of CPD on practice.

“In terms of modalities of CPD, there is not a huge evidence base for what is most effective at influencing practice. What has been shown is that peer-to-peer learning,

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DR TERESA CHAN ON… REFLECTION AS AN ‘ATROPHIED’ SKILL

“Don’t try to do it alone. Chances are you haven’t done it in a while.

It’s like going to the gym and you haven’t lifted a weight. You need someone who is going to be your spotter. They can give you feedback and tell you when you are off balance.”

BASING CPD IN THE WORKPLACE

“Continuing professional development is probably best anchored within the workplace. If you want to change a light bulb, you probably change it in the room where the light bulb is. Instead, what is happening is that we are seeing that the light bulb is burned out and then we are going to a classroom where they talk about light bulbs generally – not even the light bulb that you were interested in changing. You come back into the room, you’re staring at the light bulb and you’re still not sure how to change it.”

THE VALUE OF CONTINUOUS IMPROVEMENT

“Many optometrists are also small business owners. If you have a small business and you are not competing with the rest of the world – whether that is because you don’t have the same technology as the business down the street, or your COVID-19 compliance is not as good – then you are at a disadvantage. Upping your game is a real requirement when there is a marketplace.”

interactive CPD and the use of personal development plans are more effective than traditional lecture or print-based CET,” he said.

Karas noted that the healthcare professions have moved on from early resistance to the idea of mandatory training.

“Earlier on in the process, people did not want to be compelled to do CPD. They said, ‘I am qualified, why should I be made to do it?’

That discussion is now over as it is mandatory for all UK health professionals. The next challenge is to get people to plan their learning,” he said.

THE DATA

In 2018 the GOC conducted a consultation on continuing education and training titled, Fit for the Future: A lifelong Learning Review. The consultation, which sought feedback on how the CET scheme could evolve to meet future challenges, received 994 responses.

Asked for their views on the current scheme, most of those surveyed reported that CET helps to encourage professional development (73%), improve registrants’ practice (76%) and gives registrants the flexibility to undertake CET in relation to their individual scope of practice. However, 58% of those

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surveyed thought that the current scheme risked optometrists and dispensing opticians losing skills and knowledge in some areas of practice, while opinion was split on whether the tools provided by the GOC to help registrants reflect on their practice were helpful (44% agreed and 44% disagreed).

A lack of clarity around the idea of reflection and its benefits was perceived to be the biggest barrier to registrants reflecting on their practice, with 63% highlighting this as a challenge. Around three quarters of those surveyed (74%) agreed with the concept of giving dispensing opticians and optometrists more control over their learning and development.

Organisations that responded to the consultation highlighted weaknesses within the current CET scheme, with nine of 17 organisations disagreeing that the scheme gives registrants the flexibility to undertake CET in relation to their individual scope of practice, and seven of 17 organisations disagreeing that the scheme helps encourage professional development.

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PRACTITIONER VIEWS: THE VALUE OF CPD

“CPD is vital to make sure that you're keeping up with the latest developments, industry standards and trends” REBECCA RUSHTON 62 www.optometry.co.uk

For Inverness-based hospital optometrist, Stanley Keys, a key aspect of effective CPD is that it is clear and clinically relevant. He welcomes the planned changes to CET, noting that a tailored approach recognises the different clinical demands that optometrists have.

“The changing of the name to CPD from CET is useful as it brings our profession into line with other healthcare professions and is therefore more relatable for our colleagues in other roles,” Keys said.

As an optometrist working in the

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Highlands, he delivers eye care to rural and often remote populations.

“Any educational initiative – whether it’s a formal qualification or ongoing continued education – is always beneficial, particularly in a region such as the Highlands and Islands, to help with delivery of essential eye care closer to our patient cohort,” Keys emphasised.

Continuing education is also valuable for Ian Morris – an optometrist who practises in Wick, 100 miles away from the nearest ophthalmology department. “Even if you are covering old ground there is always a snippet of information that you can take from it,” he told OT. Morris noted that while undertaking CPD in a remote area can be more challenging, he has close contact with the clinicians who deliver courses. “You get to speak to the actual person that you may be sending a patient to,” he observed.

Southampton-based optometrist, Rebecca Rushton, noted that working as a locum can be isolating.

“Any sole practitioner can find themselves in an echo chamber if they don't regularly interact with other professionals or the broader optometric community. CPD is vital to make sure that you’re keeping up with the latest developments, industry standards and trends.”

She welcomed the concept of embedding reflective practice into what optometrists learn. “We should all be constantly improving ourselves, whatever our current level and scope of practice,” Rushton highlighted.

She is also looking forward to being able to count non-approved CPD towards her professional development. “I work in refractive surgery, so it’ll be great to be able to count time at refractive surgery conferences towards my CPD.”

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AN EVOLVING RELATIONSHIP OT clinical editor and AOP head of education, Dr Ian Beasley, gives his take on changes to how optometrists learn after qualification

T

o call it a love affair would be a stretch, but I guess after nine years we’ve kind of worked out how to rub along together. The deal? – if I tick an inordinate number of boxes to meet my continuing education and training (CET) requirements, then in return, the General Optical Council (GOC) retains my name on the rollcall so I can earn an honest crust.

Fair exchange, no robbery.

But after almost a decade of marital harmony, the GOC has got itchy feet and the terms of our relationship are set to be redefined come January 2022. “It’s not you, it’s me,” the optical regulator stressed.

It’s clear that the profession has moved on in recent years, driven by technology, higher qualifications and the devolution of healthcare.

The GOC has recognised the need to change the way in which practitioners retain and develop their skillset, and so, the current CET scheme is being revamped and rebranded as continuing professional development (CPD) from next year.

During several candlelit webinars over the past year, the GOC has offered reassurance that much will stay the same. For instance, a quiet night in reading clinical articles in OT

will still allow points to be accrued towards the minimum of 36 required over the three-year cycle. And, in keeping with the current scheme, at least half of the 36-point tally will need to be ‘interactive,’ which can be achieved by attending virtual and in-person events. An expectation that points should be spread across the

an optometrist working exclusively in a glaucoma clinic will no longer be required to consolidate their knowledge in areas such as optical appliances or contact lenses if it’s not relevant to their role.

In addition to the four core domains, there will be a ‘specialty’ domain for contact lens opticians and therapeutic optometrists. For contact lens opticians, 18 of their 36 points need to be within this additional domain. Therapeutic optometrists will need to earn an additional 18 points in the specialty domain on top

“The new domains are far less prescriptive than the previous system and will allow practitioners to tailor their learning relative to their scope of practice” cycle also remains. With peer review set to continue on similar terms, at first glance, it’s hard to see what’s different about the new system.

The biggest overhaul will see a divorce from the competency-based approach. Instead, there will be four core domains and registrants will need to earn at least one CPD point in each of these over the course of the cycle. The new domains are far less prescriptive than the previous system and will allow practitioners to tailor their learning relative to their scope of practice. For example,

of their 36 general points.

Under the new scheme, the more liberal approach applied to registrants also extends to CPD providers, so practitioners may start to see innovative approaches to education filtering through over time. For instance, bite-sized pieces of content offering partial CPD points may well be on offer.

With this renewal of vows, the new scheme has the potential to deliver benefits to practitioners, the wider profession and, most importantly, our patients.

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CET IN THIS ISSUE

Education and training for the eye care practitioner

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Communication essentials: cultural competence in practice

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Fluoroquinolones: indications for use and potential adverse effects

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Casualty cases

LEARNING OBJECTIVES LEARNING OBJECTIVES LEARNING OBJECTIVES

• Recognise the importance of PRODUCTION

practising in a non-discriminatory, culturally sensitive way

LEARNING OBJECTIVES

• Recognise the importance of

practising in a non-discriminatory, culturally sensitive way

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Heterophoria: which cases need treatment?

LEARNING OBJECTIVES

• Be able to assess cases of

heterophoria and manage the patient accordingly

LEARNING OBJECTIVES

• Be able to understand the clinical assessment of heterophoria

• Be able to recognise the adverse reactions that can arise with use of fluoroquinolones

• Be able to interpret retinal OCT scans

• Be able to manage patients presenting with anterior segment pathology

LEARNING OBJECTIVES

• Be aware of the indications, contraindications and side effects than can arise with fluoroquinolones

LEARNING OBJECTIVES

• Be aware of the adverse ocular

reactions that can arise with use of fluoroquinolones

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Cushing’s syndrome

LEARNING OBJECTIVES

• Be able to assess cases of

anterior and posterior segment pathology and manage the patient accordingly

88

Ocular complications of diabetes

LEARNING OBJECTIVES

• Be able to identify the features

LEARNING OBJECTIVES

• Be able to obtain relevant history

of diabetic retinopathy and understand the implications for management

from patients with Cushing’s syndrome • Be able to recognise the ocular manifestations of Cushing’s syndrome

THE CET EXAMS WILL EXPIRE ON:

EXAM QUESTIONS & REFERENCES MCQs for OT’s CET exams appear online at www. optometry.co.uk/cet. Exams expire on 28 December and cannot be submitted after this date. 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

CET SURVIVAL PACK

GOC within 10 working days. AOP members and subscribers will then need to log into the CET 28 portfolio by clicking on ‘MyGOC’ on the GOC website to confirm points. Visit www.optometry. co.uk/cet, and click on ‘Related CET article’ to view the article and accompanying ‘references’ in full.

DECEMBER 2021

The current CET cycle will end on 31 December. Have you collected all of your required points yet?

OT has launched its CET Survival Pack, designed to support you in meeting the requirements of the GOC’s CET cycle. Sponsored by Johnson & Johnson Vision, the Survival Pack contains nine exams which, when combined, cover all of the required competencies for optometrists, therapeutic prescribers, dispensing opticians and contact lens opticians. Take the exams online at: www.optometry.co.uk/cet

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Communication essentials: cultural competence in practice

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Dr Linda Moore PhD, MPhil, BOptom, MCOptom, MA, MSc, BSc (Hons), MBPsS, AssocCIPD

Introduction ART PRODUCTION CLIENT

Advancing globalisation in recent decades has resulted in the increased cultural diversity of many countries.

Until the end of June 2019, UK population figures show that the non-UK born population was 9.4 million (~ 14%), with a non-British population of 6.2 million (~ 9%).1 The 2016 Census figures for the Republic of Ireland show a similar trend, with around 11% of its population classified as non-Irish nationals.2 This demonstrates a need for healthcare practitioners, including optometrists and dispensing opticians, to be able to engage in effective intercultural communication with service users. The aim of this article is to explain the theory and development of cultural competence underpinning intercultural communications in practice, in accordance with professional standards related to cultural awareness for these professions (see Table 1).

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What is culture?

Culture is the holistic inter-relationship of the beliefs, traditions, rules, customs, habits, language, expectations, roles, values and way of life of a particular group of people, society or nation.6-8 Truong and Fuscaldo’s description of culture in their study of cultural diversity experiences of optometrists is adopted here.9 According to their description, culture encompasses the beliefs and behaviours relating to ethnicity, nationality and language. Our culture influences our identity, self-worth, personality, perceptions, behaviours, way of dressing, concept of space and time, boundary-setting, nonverbal and verbal communication styles in interaction with others.7 Culture frames the way in which individuals and communities interpret the world, negotiate health behaviours and engage in decision-making concerning health service utilisation.8

Culture, ethnicity and race Ethnicity describes a grouping of people with shared, common ancestry or collective identity through a cultural heritage; this may include a common geographic region, place of origin, language, family, values, norms, traditions, beliefs and religion.6,10,11 Culture and ethnicity are not homogenous; they are flexible and

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Getty/ franckreporter

SUBS

This article describes the theory of cultural competence and its relevance to eye care practice.

subject to change as they continuously evolve,9 as is demonstrated by acculturation, a process whereby an individual in contact with another culture begins to internalise aspects of the culture new to them.10 Race is conceptually different to ethnicity, although these terms are sometimes used interchangeably when race is considered as a social construction, defined by cultural norms related to behaviour and beliefs.11 Race is usually used to identify groups of people based on physical, phenotypical differences, such as stature, skin colour, hair colour, bone structure, facial shape and genetic markers.10,11 It has been suggested that racial or ethnic variation in health status results primarily

CET

Table 1 GOC Standards of Practice for Optometrists and Dispensing Opticians3 7.1 Conduct an adequate assessment for the purposes of the optical consultation, including where necessary any relevant medical, family and social history of the patient. This may include current symptoms, personal beliefs or cultural factors CORU Standards of Proficiency for Optometrists4 and Dispensing Opticians5 1.8 (Optometrists) 1.10 (Dispensing Opticians) Recognise the importance of practising in a non-discriminatory, culturally sensitive way and acknowledge and respect the differences in beliefs and cultural practices of individuals or groups 2.1 (Optometrists; Dispensing Opticians) Be able to communicate diagnosis/assessment and/or treatment/management options in a way that can be understood by the service user 2.2 (Optometrists; Dispensing Opticians) Be able to modify and adapt communication methods and styles, including verbal and nonverbal methods to suit the individual service users considering issues of language, culture, beliefs and health and/or social care needs 5.15 (Dispensing Opticians) 5.20 (Opticians) Be able to identify and understand the impact of organisational, community and societal structures, systems and culture on health and social care provision Table 1 Professional standards regarding cultural awareness in practice

from inter-group variations in relation to exposure or vulnerability to behavioural, psychosocial, material and environmental risk factors and resources.11

Cultural competence in healthcare Cultural (‘transcultural,’ ‘intercultural,’ ‘cross-cultural’) competence in healthcare is the ongoing attempt at understanding the values, beliefs, traditions and customs of diverse groups of people12 and its impact on patient care.13 The practitioner-patient encounter includes the interaction of the cultural systems of the

patient, practitioner and healthcare organisation.14 Culture potentially influences the multi-faceted nature of this interaction through possible differences in communication and social styles, world view, customs, expectations, rules, roles, and myths, among other culture-specific factors.7,14 This may result in sociocultural mismatches between the healthcare provider and patient,15 possibly leading to miscommunication and misunderstanding.7-9,13 The consequence of this may be incorrect or suboptimal treatment, poor patient compliance, reduced

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access to healthcare services, poor health outcomes and a perpetuation of health inequalities.8,13,15,16 Truong and Fuscaldo’s study into the cultural interactions of Australian optometrists showed that, at times, practitioners found it difficult to negotiate cross-cultural differences.9 Optometrists in this study indicated that culture influences the practitioner-patient relationship, which may have a negative impact on clinical encounters due to difficulty in negotiating culturally-based eye health beliefs. They also suggested that optometrists might benefit from additional training and strategies to deal with cultural differences in health beliefs and practices.

Healthcare decision-making and delivery needs to be undertaken in a way that meets the patient’s social, cultural and linguistic needs.13 Culturally competent patient-centred care aims to reduce health and healthcare disparities, making healthcare more accessible and effective8 while meeting the healthcare needs of diverse populations.16,17 Advantages of a culturally competent approach include the need for fewer diagnostic tests and referrals, reduction in length of hospitalisation, improved efficiency and cost of care. The ever-changing nature of culture9 means that cultural competence is dynamic and should be regarded as a lifelong learning process.15 Models relevant to the evolution and associated processes of cultural competence in healthcare are described here, demonstrating the ongoing process whereby the healthcare practitioner should strive to achieve the ability to work effectively within the patient’s cultural context.18-20

Models of cultural competence

Howell’s theory assumes that individuals move on a continuum through a four-stage cognitive process from being unskilled to becoming highly skilled.10,14 These stages are: unconscious incompetence, conscious incompetence, conscious competence and unconscious competence.10 This forms the foundation of CampinhaBacote’s The Process of Cultural Competence in the Delivery of Healthcare Services, a model which has been used in a diverse range of healthcare settings as the framework for the development and implementation of culturally-responsive healthcare services.12,18-20 It is often favoured over other cultural competence models due to its practicality in diverse and international healthcare settings.12 Campinha-Bacote’s model also assumes that cultural competence is not a single event, but rather, it is a continuous process. It is based on the premise that a direct relationship exists between a healthcare practitioner’s

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level of cultural competence and the ability to provide effective and culturally-responsive healthcare service to users.18-20 According to this model, cultural competence rests on five non-sequential and interdependent constructs which all need to be experienced to achieve cultural competence.11,19 The constructs described next are preceded by Howell’s ‘unconscious incompetence’ stage,10 defined by a lack of awareness by healthcare practitioners that cultural differences may exist between them and their patients.14,21 Cultural awareness The cultural awareness construct relates to the selfexamination and in-depth exploration of one’s own cultural and professional background,19,20 aligning with Howell’s conscious incompetence stage, during which healthcare practitioners become aware of, recognise and acknowledge the existence of a deficit in cultural knowledge, but remain uncertain as to what to do about it.14,21 Critical self-reflection should include consideration of the potential impact of biases, stereotypes and prejudices on patient-provider interactions, clinical decision-making and health service delivery.8,14,19,21 The personal beliefs and biases about a particular group may lead to the healthcare practitioner treating a patient differently, increasing the potential for misdiagnosis and over-medication.20 Campinha-Bacote asserts that the healthcare practitioner does not have to accept a patient’s beliefs, but should respect that the patient’s belief system may be different to their own.20 This reduces the risk of cultural imposition by the healthcare provider, which is the tendency to impose one’s own beliefs, values and patterns of behaviour on another culture.14,19,20 This is closely aligned to ethnocentrism, which is the belief that one’s own culture and lifestyle are superior to that of others.6 Becoming culturally aware should also involve consideration of how differences in social position and power may shape clinical interactions.23 Jones gives the example whereby the optometrist may be considered a figure of authority and, therefore, should not be questioned, even when the patient lacks understanding.7 Furthermore, those in perceived positions of power or authority may regard their own practices as the norm, while labelling the practices of marginalised or minority groups as abnormal.8,22 Healthcare practitioners should be flexible and humble enough to undertake a cultural assessment for each individual patient.15

Cultural knowledge The cultural knowledge construct is the process of intentionally seeking and obtaining evidence-based, non-biased, information about diverse cultural and ethnic groups19,20 in order to learn more about patients’ cultures.14,21 It aligns with Howell’s conscious incompetence stage;10 this may include reading material or attending workshops on cultural competence or having direct cross-cultural experiences with patients from culturally-diverse backgrounds.14 Information is sought and integrated in relation to nonverbal behaviours, health-related beliefs and cultural values, disease incidence and prevalence, and treatment efficacy.19 Nonverbal communications vary from culture to culture and include differences in facial expressions, eye contact, personal space, gestures and body positioning. Cultural interpretation of these nonverbal behavioural cues is significant in practice as they may complement, contradict, repeat or accentuate, regulate or negate the message being verbally communicated.

Unintentional disrespect or unwillingness to acknowledge and appreciate these cultural norms may present a communication barrier.7,11,16 At other times, the intentional reliance on nonverbal gestures may be used as replacements for verbal communications, particularly in the presence of language difficulties.16 Many cultures regard silence and indirectness as a sign of respect, whereas healthcare practitioners may interpret these same silences as meaning that the patient does not understand what was said.11 It is, therefore, important to give patients enough time to respond during eye examinations and lens dispensing.

Cultural issues in relation to touch and physical space are also relevant to eyecare services. Some patients may experience the proximity and contact of the eyecare practitioner during an eye examination as being culturally intrusive.24 These procedures should, therefore, be explained in advance to the patient. The alignment of Western medical health advices with culturally-rooted traditional medical beliefs should also be considered, as these may be important to some patients’ perceptions of their health status and recommended management plans.11 Other aspects of eyecare that may potentially be impacted by cultural beliefs are compliance with the use of prescription eye drops25-27 or wearing of spectacles28 and the perception of vision impairment as a curse or punishment.29 Enhancing cultural knowledge should include information about inter-racial differences in disease incidence and prevalence.19,30 Differences have been

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demonstrated in relation to ocular parameters and diseases. These include differences in macular thickness profiles,31 impact of age-related macular degeneration on vision-specific functioning,32 relative risk of angle closure and increased intraocular pressure,33 visual loss after diabetic retinopathy surgery,34 Graves’ ophthalmopathy, dysthyroid optic neuropathy, myopia, dry eyes35-37 and contact lens intolerance.37 Cultural knowledge about ethnic pharmacology should be considered. This studies the inter-race and inter-ethnic group variations in drug metabolism,29 clinical effectiveness and side effect profiles of therapeutic drugs. Some therapeutic agents will, therefore, be more effective than others in a given racial group, for example, in relation to the use of hypertension medications.30 Cultural skills These are acquired when applying cultural knowledge to clinical settings19,20 as healthcare practitioners perform a culturally-based patient assessment, which involves the exploration of patient understanding and explanation of disease.19 Leininger defined a cultural assessment as a ‘systematic appraisal or examination of individuals, groups, and communities as to their cultural beliefs, values, and practices to determine explicit needs and intervention practices within the context of the people being served.’38 This should also include assessment of patient linguistic needs, as this impacts on the patient’s engagement with examination, instructions14 and recommended management. A culturally competent healthcare provider can help to ameliorate health literacy deficits.12 A translation service should be considered at this point if needed.19 This construct aligns with Howell’s conscious competence and unconscious competence stages.21 Cultural encounters Healthcare providers should seek out opportunities to directly interact with others in cross-cultural interactions; this gives the healthcare practitioner an opportunity to refine or modify existing cultural beliefs, reducing stereotyping, while acquiring experiential knowledge relevant to cultural healthcare management.11 Cultural desire This encompasses the inherent motivation of the healthcare practitioner to want to engage in the development of culturally-relevant knowledge

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Communication

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Table 2

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Resource name

Website

Health Education England e-Learning for Healthcare41

The Cultural Competence e-learning tool

https://www.e-lfh.org.uk/programmes/culturalcompetence/

Health Services Executive (HSE) 43

Health Services Intercultural Guide

https://www.lenus.ie/handle/10147/311962

ART

Organisation

Table 2 Cultural competency resources

PRODUCTION CLIENT

and skills.18 It involves having a genuine passion to being open and flexible with others, while accepting differences and building on similarities.11,19 Such cultural humility incorporates a commitment to selfevaluation and self-reflection, to realise the dignity and worth of others, while also redressing patienthealthcare practitioner power imbalances where they exist,15,19 forming part of a patient-centred approach in healthcare, which involves a less controlling, less authoritative patient interview style.15 The healthcare practitioner uses empathy to focus on and understand the patient’s point of view,7 while valuing the individual patient’s perspective and encouraging communication of healthcare needs;15 this approach also guards against stereotyping in its recognition of each patient as a unique blend of intracultural and intraethnic diversity, accumulation of life experiences and possible acculturation to other cultures.10,19

Cultural competence training

A number of studies have shown that cultural competency training of health professionals has been effective in advancing their cultural knowledge, skills and attitudes and overall cultural competence.8,22,39-41 Few studies have addressed the influence of cultural competence training on patient outcomes, most likely due to the challenge of empirically defining health outcomes within cultural contexts due to the multiplicity of influences on both health and culture. There is no single, uniform model for cultural competency training in healthcare, but it is recommended that training addresses attitudes, behaviours, skills, internal and external outcomes.16 Central to this is the understanding that cultural competence is a developmental process.8,16,22 A one-time training programme is insufficient for intercultural

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competence development.16 Cultural competence is usually achieved through a combination of formal training initiatives and an ongoing self-reflection in relation to the cross-cultural experiences of the healthcare practitioner. Online resources that can be considered in relation to training and gaining of cultural competence in the health services are available (see Table 2).

Conclusion Cultural competence in clinical practice should not be defined by a discrete endpoint, but instead, as a lifelong commitment for healthcare practitioners.15 It is the responsibility of optometrists, dispensing opticians, eyecare service provision organisations and educational institutions to be proactive and culturally sensitive in addressing healthcare for culturally diverse communities; this should include valuing diversity, respect for cultural values and the promotion of quality eye care,14 tailored for the individual patient’s needs.

About the author n Linda Moore is registered as both an optometrist and graduate psychologist in the UK and Republic of Ireland. She has over 20 years of experience as an optometry lecturer, including supervision of postgraduate education research in healthcare domains. She has a special interest in employee wellbeing in healthcare settings, the workplace and educational experiences of the visually impaired and communication in healthcare practice.

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Heterophoria: which cases need treatment?

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1

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

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The article explains the main types of heterophoria and, most importantly, when it needs to be treated.

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Introduction

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Heterophoria is a normal finding and is usually compensated. When considering binocular coordination, decompensation is defined as a failure of the vergence eye movement system to overcome adequately a deviation that has been hitherto compensated. A decompensated heterophoria occurs when a heterophoria that has not previously caused problems becomes problematic.1 Clinically, a decompensated heterophoria is virtually synonymous with a heterophoria that requires treatment.

There are three good reasons for treating or correcting binocular vision anomalies:1 If they are causing symptoms or poor performance If they are likely to deteriorate if left untreated If there is a problem that may need treatment at some time in the future but is more amenable to treatment now.

Typically, decompensated heterophoria attracts attention because it is associated with symptoms. Although there is some evidence that decompensated heterophoria can impact on reading speed,2 it is not likely to cause dyslexia.3 Table 1 Symptom 1 Blurred vision

Symptoms of decompensated heterophoria

The symptoms of decompensated heterophoria are summarised in Table 1. Few patients report difficulty with stereopsis, but an important sign is when a patient closes or covers one eye when reading. With some children, this manifests as the child reading with their head at a strange angle or resting on the page, so that the nose acts as an occluder. The difficulty with many of the symptoms in Table 1 (such as symptoms 1 and 6–10) is that they are non-specific: many other problems can cause the same symptoms. For example, sore and aching eyes can result from dry eye as well as from binocular vision anomalies; this means that clinical testing is required, to detect if there are signs of decompensated heterophoria.

Signs of decompensated heterophoria

As with most healthcare conditions, there is no single diagnostic test that has the perfect ability to discriminate all patients with a decompensated heterophoria (sensitivity) from patients who do not have a decompensated heterophoria.

The key tests will now be Generic description described in turn.

Visual perceptual symptoms

2 Diplopia 3 Distorted vision 4 Difficulty with stereopsis

Binocular symptoms

5 Monocular comfort 6 Difficulty changing focus 7 Headache

Asthenopic symptoms

8 Aching eyes 9 Sore eyes 10 General irritation

Referred symptom

Table 1 Summary of symptoms of decompensated heterophoria1

Cover test The most common variety of the cover test is the cover-uncover test and a full description is provided elsewhere.1 The magnitude of heterophoria is a poor indicator of whether it is compensated, but an estimate of the magnitude should be undertaken and recorded in case it changes in the future.

During the cover test, the recovery eye movement after the cover is removed is a useful indicator of compensation; this is the principal objective method

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Figure 1

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Figure 1 The Mallett fixation disparity test, horizontal sub-test PRODUCTION

of detecting decompensated heterophoria, so practitioners must rely on this in patients who are young or have communication difficulties. Cover test recovery can be quantified using the Institute of Optometry Cover Test Analysis (IOCTA) grading system (see Table 2).

CLIENT

The Mallett fixation disparity test For most older children and adults, a key method of assessing whether a heterophoria is compensated for near vision is the Mallett fixation disparity test.

When using the Mallett unit to establish whether symptoms result from a decompensated heterophoria, the test should be carried out while the patient wears any refractive correction they use in everyday life. In contrast, when the test is used to prescribe prisms, the test should be carried out with the patient wearing the refractive correction the clinician plans to prescribe.

The Mallett test is fundamentally different to dissociation tests: it tests for fixation disparity and therefore the patient remains fully fused throughout.

The patient must be instructed to report any misalignment of the Nonius markers (coloured strips), even if the misalignment is minute and transient (seen as a moving of the lines).4 There are two sub-tests, and the sub-test for assessing horizontal deviation is shown in Figure 1.

Research by Pickwell and colleagues indicates that the Mallett fixation disparity test has a reasonable sensitivity (~75%) and specificity (~78%) for detecting symptomatic heterophoria. Like most clinical tests, the less than 100% sensitivity and specificity means that in some cases, other tests are required, as detailed in the bottom half of Table 3 (page 74).

The Mallett unit detects fixation disparity but measures the aligning prism (associated heterophoria):

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the minimum prismatic correction that brings the strips into alignment. Care should be taken to ensure natural viewing conditions, for example, using full aperture trial prisms and stabilising binocular vision between the introduction of different prisms.1 It is also important to use the instructions validated by Karania and Evans: the patient should be asked to report any movement of one of the Nonius markers, however subtle.4 In pre-presbyopes, an aligning prism of 1Δ or more is often associated with symptoms; with presbyopes the cut-off is 2Δ.5 For many cases, the combination of symptoms, grading of cover test recovery movement, and the Mallett fixation disparity test will provide sufficient information to diagnose decompensated heterophoria.

Sometimes, these indicators provide discordant results and additional tests are required.

Additional tests The additional tests that are most instructive for diagnosing decompensated heterophoria depend on the type of heterophoria. For convergence weakness exophoria (an exophoria that is marked or problematic for near vision), Sheard’s criterion is useful, which states that the fusional reserve used to overcome the exophoria (near convergent fusional reserve; measured with base out prisms) must be at least twice the exophoria. For near esophoria, Percival’s criterion is more useful. In essence, this criterion is that the divergent fusional reserve should be at least half the convergent fusional reserve.

Other tests that can be useful are to assess the sensory status, ideally by using the Mallett unit binocular status test to quantify any foveal suppression.1, 6 Sensory status can also be assessed with stereopsis tests, although the test norms vary from one test to another, and with the TNO test with different editions.7 Combining test results Although a battery of tests is helpful to reach a diagnosis, the more tests that are undertaken the more likely it is that a normal patient will fail a test. To put it another way, a normal patient is one that has not been tested enough! One way round this problem is to combine test results in a more intelligent way, and an algorithm has been developed to assist in the diagnosis of decompensated heterophoria and a related condition, binocular instability (see Table 3, page 74); this is based on the scientific literature and has been used in several research studies.1 For most patients,

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Figure 2 Dissociated deviation

Motor

Sensory

fusion

fusion

is usually suppression so the patient may be unaware of these episodes, which are more apparent to Compensated heterophoria or decompensated heterophoria or strabismus friends or family.

There may be a smaller Figure 2 Simplified schematic model illustrating the factors that can cause a heterophoria exophoria at near which to decompensate. Reproduced with permission from Pickwell’s Binocular Vision Anomalies, is compensated. In basic sixth edition, 2021, Evans BJW1 exophoria, there is an only the first part of the algorithm is necessary because exophoria of similar size at distance and near. a careful cover test and Mallett fixation disparity Differential diagnosis test will tell the practitioner all they need to know. If It is clear from the broad range of symptoms in symptoms are only reported at one distance (see next Table 1 that the differential diagnosis of decompensated section), the algorithm is applied for that distance only. heterophoria requires the optometrist to consider In rare cases, where symptoms are associated with several alternative conditions. These include dry distance and near vision, two versions of the algorithm eye, refractive error, accommodative anomalies and may need to be completed. incomitant deviations.1 The symptom of headaches Common types of heterophoria can be triggered by countless conditions, including A commonplace form of decompensated heterophoria a variety of neurological causes. This is one of the is convergence insufficiency exophoria syndrome reasons why orthoptic testing is best undertaken as (CIES). Typically, there is a near exophoria causing part of a comprehensive eye examination and the symptoms during near vision tasks. CIES is different, clinician should always keep an open mind about but can co-occur with, near point of convergence diagnosis. insufficiency (NPCI). For a further discussion of Computer vision syndrome (CVS) or digital eye the distinction, see Chapter 8 in the 2021 edition of strain is an example of a multifactorial condition that Pickwell’s Binocular Vision Anomalies.1 can cause many of the symptoms listed in Table 1.

In divergence excess exophoria there is a distance In some respects, CVS can be considered as an old exophoria that is usually large and prone to problem, asthenopia, triggered by our present day decompensating to an intermittent exotropia. extended use of digital displays.8 Therefore, CVS can be considered as an umbrella term for the conditions Typically, this happens spontaneously when the that can cause asthenopia. patient daydreams or looks in the far distance. There To give two specific examples, dry eye often Table 2 explains the symptoms of CVS,9 and decompensated Grade Description esophoria has been found in a minority of cases.10 1 Rapid and smooth Symptoms of text appearing to blur, move, or distort have 2 Slightly slow/jerky been linked to a controversial condition, sensory visual 3 Definitely slow/jerky but not breaking down stress (Meares-Irlen 4 Slow/jerky and breaks down with repeat covering, syndrome).11 This condition should only be diagnosed or only recovers after a blink after the practitioner has 5 Breaks down readily after one to three covers excluded conventional causes of symptoms, Table 2 The IOCTA grading system for cover test recovery eye movements including decompensated heterophoria.12 Fusional reserves

Fusion lock

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Table 3

SUBS

Sign or symptom

Score

Score as 1 to 3 based on the number/severity of symptoms of decompensated heterophoria

+3

Cover test: heterophoria detected

+1

Cover test: absence of rapid and smooth recovery (+1 if quality of recovery 'border-line')

+2

Aligning prism (Mallett): ≥1Δ for under 40 years or ≥2Δ for 40 years and over

+2

Aligning prism (Mallett): <1Δ but unstable

+1

Foveal suppression of one line or more on the Mallett foveal suppression test

+2

If score: ≤ 3 probably normal, ≥ 6 treat, 4-5 continue in table adding to score so far ART

Sheard's criterion: failed

+2

Percival's criterion (only use in near vision cases): failed

+1

Dissociated heterophoria unstable so that result is over a range ≥ 4Δ (ie, ≥ phoria ± 2Δ )

+1

Fusional amplitude (divergent break point + convergent break point) < 20Δ

+1

If total score: ≤ 5 unlikely to need treatment, if >5, likely to benefit from treatment PRODUCTION

Table 3 The Evans algorithm for the detection of decompensated heterophoria. A patient accumulates a ‘score’ based on the figures in the right column according to the signs and symptoms listed in the left column. For vertical heterophoria, only the top half of the table is appropriate and dissociation tests may be useful1

CLIENT

Overview of the management of decompensated heterophoria A detailed description of the treatment of decompensated heterophoria is beyond the scope of this article and this is covered in detail in several chapters of a recently published textbook.1 The general approach to treatment is to enquire about any changes in occupational/ leisure factors that might explain the new symptoms.

In the absence of such a simple explanation, Figure 2 highlights the main factors that influence whether a heterophoria is compensated. As Figure 2 shows, one reason why a heterophoria decompensates may be that the heterophoria (dissociated deviation) has increased. If the reason for such an increase is not apparent, the patient should be referred in case the reason is pathological.

Fusional reserves may be adversely affected by a deterioration in general health or by stress/anxiety. An impaired fusional lock can result from problems that are easy to resolve, such as uncorrected anisometropia,13 or from more intractable anomalies such as unilateral retinal traction.

If a change in the working environment accounts for the symptoms, the optometrist may be able to provide advice on improvements to the workstation.8 If this is not possible, any barrier to sensory fusion should be alleviated. For example, if anisometropia is present, contact lenses are the best optical form of correction.13 The other two approaches to treatment are to reduce the heterophoria (with spherical lenses or prisms; base

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in for exophoria) or to increase the fusional reserves with eye exercises.1

Conclusion All eye examinations should include basic orthoptic tests that will detect heterophoria. This is unlikely to require treatment if there are no symptoms. The symptoms of decompensated heterophoria are nonspecific, so clinical tests are necessary to determine whether the symptoms result from heterophoria or from some other cause. The symptoms of decompensated heterophoria can significantly impact a patient’s quality of life,14,15 and therefore the detection and treatment of the condition represents an important role for the eye care practitioner.

About the author n Professor Bruce Evans is director of research at the Institute of Optometry and a visiting professor to City, University of London and to London South Bank University. He is a fellow of the College of Optometrists and holds their higher qualifications of Diploma in Contact Lens Practice and Diploma in Orthoptics. He was awarded fellowship of the BCLA in 2006. He has authored over 250 publications, has given more than 250 invited lectures, and has authored six editions of books on binocular vision and two on dyslexia and vision. He also works as a practising optometrist.

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Fluoroquinolones: indications for use and potential adverse effects

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Dr Katrina Schmid BAppScOptom (Hons), PhD, Grad Cert Higher Ed, Grad Cert Ocular Therapeutics, SFHEAA

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This article outlines the clinical use and potential adverse effects that can arise with the use of fluoroquinolones.

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Introduction

PRODUCTION CLIENT

The fluoroquinolones (modified quinolones) are generally considered the most potent and effective of all the topical ocular antibiotics. With emerging antibiotic resistance becoming an increasing world problem, eye care providers are told to use these agents judiciously and only for the most severe ocular infections.

However, there are additional reasons to limit the use of these agents. There are increasing reports of serious adverse effects of these antibiotics particularly from systemic use. Though it is generally considered that topical fluoroquinolones are safe to use, knowledge of this topic is important for all prescribers. This article is based on a recently published, peer reviewed paper.1

How do fluoroquinolones work and what are they used for?

They are a group of broad spectrum, bactericidal antibiotics with a similar mode of action that includes inhibiting the replication and transcription of bacterial DNA synthesis by blocking DNA gyrase or topoisomerase-IV.2 In 2016, about 30 million fluoroquinolone prescriptions were issued.3 In the UK, ciprofloxacin, ofloxacin, levofloxacin, moxifloxacin and delafloxacin are available for systemic use.4 The use of these agents has been limited to serious life-threatening bacterial infections.5 They are indicated for the treatment of respiratory and urinary tract infections when no other effective alternative is available. They are no longer used routinely because of the risk of serious side-effects.6 The list of contraindications is long and includes allergies to fluoroquinolones, past reaction to antibiotics, personal or family history of aorta problems, heart problems, past tendon problem, seizure risk, kidney problems and diabetes.

Topical ocular fluoroquinolones are primarily used in the treatment of bacterial corneal infections. In the UK, four eye drops are available: ofloxacin (second generation), ciprofloxacin (second generation), levofloxacin (third generation) and moxifloxacin (fourth generation). In the US, the list also includes norfloxacin

and in Australia only ciprofloxacin and ofloxacin are available for ocular use.7

Are systemic fluoroquinolones safe to use?

Systemic fluoroquinolones have many potentially dangerous side-effects including increased risk of heart problems, tendon ruptures, nerve damage, hypoglycaemic coma and disturbances to mental function (see Table 1, page 76).8-17 Golomb et al presented four cases of previously well adults who developed severe, persistent symptoms of tachycardia, tendinopathy, muscle weakness, sleep disturbance, cognitive decline and psychiatric problems.18 The affected individuals were unable to work and had greatly reduced quality of life. Documented potential issues include the following: Heart problems: fluoroquinolones can weaken the aortic wall increasing the risk of its dissection or aneurysm, which are life-threatening events15 Tendon damage and rupture: tendinopathy most often involves weight bearing tendons, with 90% of cases affecting the Achilles tendon.19 Increased risk of rupture is associated with corticosteroid use and rheumatic, vascular or renal disease. The tendon damage is thought to be due to the stimulation of the release of tissue-damaging substances or enzymes that degrade collagen20 and also mitochondrial toxicity or inhibition of integrin receptor signalling21,22 Peripheral neuropathy: side-effects include a serious and potentially permanent peripheral neuropathy.13 The onset of symptoms (tingling, burning, numbness or pain of the feet, legs, hands or arms) may be rapid, that is to say, within a few days of starting treatment.23 Etminan et al established the increased risk was similar for the different types of fluoroquinolones.24 The exact mechanism is unknown but may involve mitochondrial dysfunction25 Hypoglycaemia: a listed potential risk includes hypoglycaemia sometimes resulting in coma.

Although this occurs more frequently in people with diabetes taking an oral hypoglycaemic medicine

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Table 1 Adverse effect

Evidence

Common >1%

Allergy, rash, itch

McGee et al, 20198

Nausea, vomiting, diarrhoea, abdominal pain, indigestion (dyspepsia)

Norrby, 1991; 9 Oliphant and Green, 200210

Headache, dizziness

Norrby, 1991; 9 Oliphant and Green, 200210

Insomnia, depression

Norrby, 1991; 9 Oliphant and Green, 200210

Restlessness, tremors

Oliphant and Green, 200210

Sensory disturbance (hearing, taste, vision)

Oliphant and Green, 200210

Joint pain (arthralgia), muscle pain (myalgia)

Kim 201011

Tendonitis (inflamed tendons), arthritis (inflamed joints)

Norrby, 1991; 9 Kim 201011

Interstitial nephritis (kidney inflammation), high liver enzymes (this may indicate inflammation or damage to cells in the liver)

Norrby, 19919

Anaphylaxis (potentially life threatening, severe allergic reaction), angioedema (swelling of skin, tissue under the skin or mucous membranes), StevensJohnson syndrome (serious disorder of skin and mucous membranes), toxic epidermal necrolysis (extremely severe skin reaction)

McGee et al, 2019; 8 Patel et al, 201312

Peripheral neuropathy (nerve damage may be irreversible),

Morales et al, 201913

Hypo- or hyperglycaemia, hepatitis (inflammation of the liver), blood dyscrasias (blood disorder), Clostridium difficile-associated disease (an infection of the colon caused by the bacteria Clostridium difficile),

Deshpande et al, 200814

Aortic aneurysm or dissection

Pasternak et al, 201815

Tendon rupture, especially of the Achilles tendon (onset may be rapid or take months)

Oliphant and Green, 2002; 10 Wise et al,

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Relative risk

Infrequent (0.1 to 1%) SUBS ART PRODUCTION

Rare (<0.1%)

CLIENT

2012; 16 Stephenson et al, 201317

Table 1 Potential adverse effects from systemic use of fluoroquinolones

or insulin, it can also occur, albeit less frequently, in non-diabetic patients.26 The suggested mechanism based on animal studies is an increase in insulin secretion via blockade of adenosine triphosphate (ATP)–dependent potassium channels27 Mental health: it is suggested that fluoroquinolones can increase the risk of suicidal behaviour.28

What is fluoroquinolone toxicity?

Fluoroquinolone toxicity and the large collection of

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irreversible effects that have been described, has led to the naming of a potentiality permanent syndrome called fluoroquinolone-associated disability (FQAD)29 and the health condition of having been ‘Floxed.’ An Internet search query of ‘What is the most dangerous antibiotic?’ gives the answer ‘The quinolones including ciprofloxacin.’

Many thousands of people are members of support groups for affected individuals (for example, the Fluoroquinolone Toxicity Group, Ciprofloxacin Toxicity

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Figure 1

Cell cycle arrest

Inhibit cell proliferation

Anti-cancer actions of fluoroquinolones

Induces apoptosis Enhances microRNA biogenesis

Inhibit cancer cell epithelial-mesenchymaltransition (EMT) Enhances cancer cell stemness

Enhances known chemotherapies

Figure 1 Suggested anti-cancer activities of the fluoroquinolones. These include inhibition of cell cycle, cell proliferation and inhibition of EMT. Enhancing the stemness (original cell character) of cancer cells, ability to induce cell apoptosis and microRNA biogenesis. They can also enhance the anti-cancer effect of other known chemotherapies. Figure based on that in Yadav and Talwar.45

Group). The posts describe the ongoing problems that past users of these agents still experience and the large impact on their quality of life.

From 2013 to 2017, there was an average per year of 625 enquiries to the American Food and Drug Administration’s (FDA) Division of Drug Information about systemic fluoroquinolones;30 these were primarily from patients describing chronic symptoms including joint and muscle pain, muscle weakness, mood swings, confusion, anxiety, debilitating fatigue and insomnia.18

What are the ocular effects of systemic fluoroquinolones?

Whether or not systemic fluoroquinolones cause ocular issues remains unclear. Collagen serves as a critical component of the vitreous body of the eye and in maintaining retinal attachment, but whether fluoroquinolone use increases the risk of retinal detachment remains controversial.

Daneman et al performed a longitudinal populationbased study in Ontario, Canada.31 They did not find a significant association between fluoroquinolone use and retinal detachment risk and suggest a range of possible reasons, including that the type of collagen in retinal tissue (type II) may be less affected than other forms of collagen, or that as the retina is under less tension than ankle tendons it is less prone to rupture.

Etminan et al had previously reported a link between oral fluoroquinolone treatment and elevated risk of retinal detachment but the increased risk was small at only four per 10,000 person-years.32

Are there any side effects of topical ocular agents?

It is generally considered that topical fluoroquinolones do not pose the same risk as systemic use and are safe to use,33 although there are case reports linking Achilles tendinopathy to moxifloxacin eye34 and ear35 drops. Listed precautions include if patients have a history of tendon damage or hypersensitivity to

previous quinolone use.

Topical agents may be problematic to the eye itself (see Table 2, page 78).33,36,37 Thompson has provided a comprehensive review of the typical ocular sideeffects, which are dose dependent.33 Frequent instillation of ciprofloxacin eye drops is associated with white precipitates on the ocular surface due to crystallisation of the compound, which is a consequence of its pH solubility profile.

Toxic effects on ocular collagen may be the reason for increased risk of corneal perforation. Nevertheless, the systematic review by McDonald et al on the use of topical antibiotics for bacterial keratitis did not find evidence of increased risk of corneal perforation with fluoroquinolones compared with other antibiotic combination therapies (usually aminoglycoside plus cephalosporin).38 Using animal models, it has been shown that topical quinolones increase the expression of inflammatory markers MMP-1, MMP-2, MMP-8 and MMP-9,39 suggesting the potential for corneal cytotoxicity and impaired wound healing. Related to this, these agents are toxic to the corneal keratocytes and endothelial cells40 and this is maximal with ciprofloxacin, followed by ofloxacin, gatifloxacin and moxifloxacin, and least with levofloxacin.

Why are there so many adverse effects?

Based on the adverse effects, this class of antibiotics doesn’t just harm microbes but also severely damages human cells (as can other antibiotics). The key question is why – in other words, how does the

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Drugs, therapeutics

VERSION

Table 2 REPRO OP

Relative risk

Adverse effect

Evidence

Reasonably likely (>10%)

Local irritation, burning, stinging and itching

Thompson 200733 Hyndiuk et al, 199636

SUBS

Common (>1% to 10%)

ART

Infrequent (0.1 to 1%)

Rare (<1%)

Corneal precipitates

Hyndiuk et al, 199636

Corneal perforation

Mallari et al, 200137

Eyelid oedema and lid margin crusting

Hyndiuk et al, 199636

Blurred vision

Thompson 200733

Chemosis

Hyndiuk et al, 199636

Hyperaemia

Thompson 200733

Lacrimation

Hyndiuk et al, 199635

Superficial punctate keratitis

Hyndiuk et al, 199635

PRODUCTION

Table 2 Ocular side effects of topical fluoroquinolones

Table 3 CLIENT

Observation

Model

Evidence (reviewed in Yadav and Talwar, 2019) 45

Inhibit cell growth, apoptosis

Colon cancer cells

Herold et al, 200248

Meta-analysis shows reduced mortality rate in cancer patients

Humans with cancer

Paul et al, 200744

Anti-cancer effects

Human breast cancer cell lines, non-small cell lung cancer cell lines

Al-Trawneh et al, 201049

Anti-cancer action potentiation of other agents

Prostate cancer cells

Pinto et al, 201150

ERK mediated apoptosis

Human colon cancer cells

Jemel-Oualha et al, 201451

S-phase arrest, apoptosis

Human pancreatic cancer cells

Yadav et al, 201552

Table 3 Selected evidence of anti-cancer action

damage occur? The underlying cause appears to be the adverse effects on cell mitochondria which, in humans, are similar to bacteria; the mitochondria of human cells are thought to have evolved billions of years ago from bacteria-like cells.

Kalghatgi et al have reported that antibiotics build up reactive oxygen-containing molecules in mitochondria causing severe oxidative stress and preventing them from functioning normally.41 The

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consequent mitochondrial depletion and mutation can be delayed42 and this could account for the latency of symptoms.

It has also been shown that ciprofloxacin causes DNA breaks in mitochondria in mammalian cell culture models.42 The fluoroquinolones may also bind iron atoms from the active sites of enzymes that modify DNA and this could lead to epigenetic changes that cause adverse effects.43

CET

About the author n Dr Katrina Schmid is associate professor in the School of Optometry and Vision Science, Queensland University of Technology. Her teaching expertise includes ocular pharmacology and in particular the mechanisms, uses and side-effects of ocular therapeutic agents.

Can damage to the mitochondria be prevented or treated?

There are no currently effective treatments to prevent these adverse effects and the damage does not seem repairable. Michalak et al suggest a range of possible treatment avenues to investigate, including: a) reduction of oxidative stress; b) restoring the altered mitochondrion potential; c) stimulating mitochondrial proliferation; and d) regulating the disturbed gene expression and enzyme activity.29 Mitochondria targeted antioxidants protect against mitochondrial damage and may be useful in limiting the adverse effects.22 It is unknown whether taking a simple antioxidant like vitamin C in conjunction with antibiotic treatment is beneficial. Some minerals (for example, calcium, iron, magnesium, zinc) bind to these antibiotics and prevent their absorption, and thus while they may reduce side effects, they also reduce their effectiveness.10

Could fluoroquinolones be used as anti-cancer treatments?

Emerging data shows the potential of the fluoroquinolones to treat cancer. Paul et al conducted a meta-analysis of quinolone trials in cancer patients where the quinolone was administered prophylactically to reduce the risk of infection.44 There was a significant reduction in non-infection related mortality and the suggestion was that this was due to an anti-cancer action. This potential has also been reviewed by Yadav and Talwar,45 an approach termed drug repositioning or drug repurposing. These agents could be used in combination with other known anticancer drugs for an improved therapeutic effect.45 The production of quinolone hybrids may lead to the development of agents with even greater anti-cancer activity.46 What evidence is there that fluoroquinolones stop the growth of cancer cells?

There are numerous examples of fluoroquinolones inhibiting cancer cell proliferation.45,47 Some key points and examples are detailed in Table 344,45,48-52 and includes the finding that moxifloxacin and ciprofloxacin suppress the proliferation of pancreatic cancer cell lines.52 There is evidence that ciprofloxacin inhibits cell growth and intrinsic apoptosis activities of cancer cells.48 Data also shows that several novel fluoroquinolones display

anti-cancer properties against human breast cancer (MCF-7) and non-small cell lung cancer lines (A549).49 It has been proposed that these effects are due to immunomodulatory, pro-apoptotic, anti-proliferative and anti-metastatic actions (see Figure 1).45 Complicated cellular effects are involved, including blocking the S-phase of the cell cycle, decrease in the levels of p27, p21, CDK2, cyclin-A and cyclin-E, triggering of extrinsic and intrinsic mitochondrial apoptotic pathway, downregulation of anti-apoptotic protein Bcl-xL and upregulation of pro-apoptotic Bak proteins.52 Thus, although the effect on mitochondria may account for FQAD, this action is also likely involved in the observed anti-cancer activity.

Conclusion

The fluoroquinolones do have actions against human cells, that is to say, they have more than simple antibacterial activity. The actions account for the adverse effects that can arise but also mean these agents have the potential to be repurposed as anti-cancer therapies.

Patients taking these agents should read the warning on the packaging. They need to be aware of the potential risks and to contact their doctor immediately if they experience symptoms like numbness, weakness, tingling, burning or pain. Patients using ocular forms should be monitored for corneal thinning and risk of corneal perforation.

Main points Fluoroquinolones are powerful antibiotic agents Systemic fluoroquinolone treatment is restricted to respiratory and urinary tract infections when no other effective alternative is available Systemic fluoroquinolones potential side effects include increased risk of heart problems, tendon ruptures, nerve damage, hypoglycaemic coma, and disturbances to mental function Topical fluoroquinolones are generally considered safer but there are reports of adverse events Emerging data shows the potential of the fluoroquinolones to be repurposed to treat cancer.

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VERSION

Cushing’s syndrome REPRO OP

Dipa Michalik BSc (Hons), MCOptom

1

Figure 1

CET

HPA axis

POINT

Hypothalamus

Pituitary gland

PRODUCTION CLIENT

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P

ACTH

Adrenal glands

A

Cortisol

Cortisol and its effects Cortisol is mainly produced via the adrenal glands and has many functions in the human body. It mediates the stress response, regulates metabolism, the inflammatory response and immune function.3,5 Prolonged systemic exposure to elevated cortisol levels can result in significant health risks with increased mortality and impaired health-related quality of life.6 Systemic effects of excess cortisol include:7,8 Obesity 90% (of cases), ‘moon face’ and buffalo hump Hirsutism 75% Hypertension 85% Diabetes 20% Glucose intolerance due to insulin resistance 75% Striae – thinning of skin 70% Easily bruised 35% Purplish stretch marks especially on abdomen Acne 35% Osteopenia 80% Weakness 65% Depression and/or mood disorder

H

CRH

Lo op

ART

Research suggests that Cushing’s syndrome (CS) may be more common than we realise1 and optometrists are well placed in the community to spot various early warning signs. CS is an endocrine disorder caused by having excess of a powerful, naturally occurring hormone called cortisol in the blood, which can lead to serious health problems, including increased risk of mortality, if undetected. CS is classified as either exogenous (external cause) or endogenous (internal cause), when the body itself produces too much cortisol, usually due to tumours of the pituitary or adrenal glands.2 Exogenous CS is more common due to prolonged intake of steroid medication.3 Cushing’s disease (CD) is the term used exclusively when a benign tumour (adenoma) of the pituitary gland causes high cortisol,4 while CS refers to the general condition characterised by the effects of excess cortisol which is common to both. Less common is pseudo-Cushing’s syndrome, which occurs due to chronically elevated levels of cortisol caused by depression, alcohol abuse, anorexia nervosa or high oestrogen levels.5

Feedback

Introduction

Negative

SUBS

This article outlines the characteristics of Cushing’s syndrome and uses a case example to present the clinical features.

Figure 1 Cortisol control – HPA axis. Image courtesy of N Michalik

Menstrual disorder 70% Impotence and decreased libido 85% Cognitive issues.

Cortisol control The whole cycle of cortisol production is controlled by the hypothalamus pituitary adrenal axis known as the HPA axis, where two other hormones play a critical role in its production: corticotrophin-releasing hormone (CRH) and adrenocorticotropic hormone (ACTH) (see Figure 1).

The hypothalamus releases CRH, causing the pituitary gland to secrete ACTH, which stimulates cortisol production from the adrenal glands. The loop works as a negative feedback system so if the

CET

Figure 3

Figure 2

Before

After

Figure 2 Patient JP. Facial changes associated with Cushing’s syndrome. Images courtesy of JP

cortisol level drops too low, more CRH is released by the hypothalamus which in turn causes the anterior pituitary to release ACTH, prompting the adrenal glands to secrete cortisol. Conversely, if cortisol levels are too high, continued CRH and ACTH release is inhibited thus switching off the HPA axis.

Both cortisol and ACTH are synthesised in varying amounts throughout the day and are found in the blood, saliva and urine. This diurnal variation is key in diagnosing CS, as blood and saliva cortisol levels are lowest at midnight and highest in the early morning5 in the normal patient but different in CS. In a symptomatic patient, the use of systemic steroids causing high cortisol must be ruled out. Then, tests are done to find out if the disease is: ACTH dependent – caused by a pituitary gland tumour (CD) or rarely lung/renal tumours ACTH independent – caused by overactive adrenal glands or adrenal tumours (CS).

If tests show high cortisol levels at night which remain high in the morning, CS would be the likely diagnosis.

ACTH must also be tested: low ACTH with high cortisol suggests an adrenal cause while high ACTH with high cortisol suggests the pituitary adenoma hypersecretion of ACTH from a small (microadenoma) or large (macroadenoma) tumour. Rarely, other

Buffalo hump Figure 3 Buffalo hump. Image courtesy of Marvin Bergsneider, UCLA

cancerous tumours that release ACTH, such as small cell lung cancer and renal cell carcinoma, can cause hypercortisolemia.9,10

Case history

A 47-year-old female patient was first seen by the author in August 1996 for difficulties with her near vision caused by increased computer use. She was healthy and had low myopia and early presbyopia.

All results were normal and appropriate spectacles for work were dispensed. Regular routine examinations took place from 1997 to November 2001 which revealed a gradual increase in presbyopia, while other tests were normal. In April 2002, she was seen by the author’s colleague for ‘sore and scratchy’ eyes which were noted as ‘injected.’ The patient was under her general practitioner (GP) and had been undergoing tests for a hormone imbalance. Tear breakup time was low at two seconds with almost no tear prism so Viscotears lubricant was advised. Three months later, she returned to see the author as an emergency as her eyes were slightly red, watery, felt uncomfortable and her vision was ‘filmy.’ She had been undergoing blood tests for some months and was prescribed hormone replacement therapy by her GP for six weeks but was feeling worse. A critical observation

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CET 4, 1

Pathology, systemic disease

VERSION REPRO OP

he suspected CS but as the patient had multiple problems including slightly elevated blood pressure, spells of light headedness a few hours after meals, hirsutism and menorrhagia which had resulted in various investigations at dermatology and gynaecology clinics, he felt hormone imbalance and polycystic ovarian disease were possible causes. However, he needed to exclude the possibility of CS by carrying out cortisol testing and other hormone investigations.

The consultant also noted ‘a suggestion of a buffalo hump’ Before After (see Figure 3).

Following these further tests, the consultant confirmed Figure 4 Facial changes associated with florid Cushing’s syndrome due to steroid medication.

Image courtesy of Ozlem Celik, Mutlu Nivazoglu, Pinar Kadioglu et al the diagnosis of CS as cortisol levels were high and ACTH was that on arrival, her stress was palpable, but levels were low to normal, therefore it was very likely having seen her several times in the past, a red flag in that the cause was adrenal in origin. Effectively, her those first few minutes was her subtly changed facial high cortisol was ACTH-independent, making adrenal appearance which was a cause for more concern than investigations with computerised tomography (CT) or the presenting symptoms. Visual acuities were R6/6 magnetic resonance imaging (MRI) necessary to locate L6/6 and slit lamp examination was unremarkable the exact pathology. A CT scan revealed a large adrenal with an improved TBUT of nine seconds. Her face tumour which was removed in December 2002. It was a looked slightly puffy and she had fine ‘downy’ facial huge relief for the family to be told that there was finally hair (not that unusual in menopausal women in her a medical reason for her symptoms and there was age group). When asked about this slight change in immense gratitude for encouraging her to seek a second her appearance, she agreed that her face was puffier opinion. However, after a few months, metastases were than normal and that she had more fine facial hair. found and very sadly, she died about six months later.

When asked if she was taking, or had been taking any Signs of CS for the optometrist steroids, the answer was a definitive ‘no;’ this was a Early or mild CS is not easily recognisable, especially pertinent question to ask as it is well documented that because the body changes develop slowly. Comparing steroids can cause weight gain and puffiness and old and recent photographs may show definitive can lead to a ‘moon face’ appearance (see Figure 2).7,11 Suspicion of CS was aroused but rather than changes in facial and physical appearance while increasing the patient’s anxiety by discussing the practitioners who have seen the same patient over possibility of such a serious cause, the option of seeking many years, may notice obvious changes in physical a second opinion with a consultant endocrinologist was appearance earlier in the process. However, florid CS is discussed in view of the many tests she had already hard to miss (see Figure 4). had without improvement in her sense of wellbeing.

Physical indicators She and her husband decided to have a private The most obvious sign to look for during the eye consultation with a renowned and respected consultant examination in these cases is the facial appearance. endocrinologist, to whom she was referred via her GP. The consultant’s report in August 2002 showed With high levels of cortisol, the classic ‘moon face’ may Figure 4

SUBS ART PRODUCTION CLIENT

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CET

If CS is suspected, asking about possible development of hypertension, osteoporosis, diabetes, muscle loss and weakness, depression and anxiety is pertinent,3 all of which the patient may not think to mention.

Be aware that CS has a slow progression and may not be diagnosed for some time which can lead to depression in many patients.

Figure 5

Ocular indicators Visual acuity may be reduced if the pituitary adenoma (macroadenoma) grows forward and compresses the optic nerve and if it grows upward into the brain cavity, it may compress the optic chiasm, causing visual field loss (more commonly bitemporal hemianopia although altitudinal and unilateral defects can occur so it is imperative to check visual fields).12 Large tumours may also cause visual disturbances, double vision and headache.3 Colours may also appear faded as with other types of brain tumour. Exophthalmos caused by an increase in orbital fat volume has been reported in the literature,13,14 a feature for the optometrist to be alert to. It has been proposed that this fat deposition can cause an increase in volume of the retroorbital tissues and thus raise intraocular pressure (IOP).15 Furthermore, an increase in IOP caused by steroid use has been well documented over the years,16 so it follows that IOP may be elevated in patients where high endogenous steroid production is suspected.

Easy bruising and poor wound healing

Abdominal striae and obesity Figure 5 Bruising and striae. Images courtesy of Marvin Bergsneider, UCLA

be seen, as in the case here, though it may be subtle.

Another noticeable sign is abnormal fat distribution in upper body, while arms and legs remain the same or become thinner. Fat pads on the back of neck (dorsocervical) and shoulders (supraclavicular) cause a hump-like appearance or buffalo hump.8,11 Bruising may be visible on hands or legs, or the patient may notice bruising more easily and the patient may develop striae, apparent as obvious stretch marks (see Figure 5). An increase in facial hair is easy to observe but is a subject to be approached gently when asking the patient.

Steroid medication and CS

Exogenous CS occurs due to high-dosage, long-term steroid medication, which may be taken as pills, inhalers, skin ointment or rectal suppositories.8 Steroids are commonly prescribed for many conditions seen in practice such as rheumatoid arthritis, asthma, eczema, chronic obstructive pulmonary disease (COPD), Crohn’s disease, ulcerative colitis and lupus, and less commonly for myeloma, post-organ transplant and temporal arteritis.7 Of course, another side effect of systemic corticosteroid use is cataract,11 highlighting the importance of taking a proper history and list of medications during the eye examination.

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CET 4, 2

Pathology, systemic disease

CET 4, 3 VERSION REPRO OP

About the author SUBS

n Dipa Michalik has worked as an optometrist for over 37 years in an independent practice setting (Skye Optometrists) and also alongside ophthalmologists in specialist cataract and refractive clinics. Michalik has presented at numerous major European conferences, contributed to the sixth edition of Kanski’s renowned ophthalmology textbook and was a poster prize winner at the BCLA. She was also company director and committee member of Herts LOC and supervised final year clinics at City, University of London.

ART

Genetics

PRODUCTION CLIENT

Diagnosing CS is complicated by the fact that cortisol levels normally vary throughout the day and can elevate with stress. Variations between different laboratory test methods and their reference ranges can compound the problem. Added to this, the normal rhythm of cortisol production can change in patients doing shift work.4,18 Sometimes, diagnosis is only confirmed by MRI scans but in CD, very small (microadenoma) tumours may not be visible at an early stage, in which case a more invasive test known as venous sampling may be needed.4

when specifically investigated,1 due to significantly improved screening tests increasing detection.19 Due to the multiple symptoms of CS, it may not even be considered during early stages thus causing a delay in diagnosis as borne out by anecdotal accounts on the websites of charity support groups for CS and pituitary problems.20,21 A common theme seems to be frequent delays in diagnosis because excess cortisol can wreak havoc on so many systems in the body which can mislead the clinician. Investigations are often carried out to separately address the individual presenting complaints, for example, metabolic disorder, weight gain, blood pressure, or depression, missing out an overall view.

Although cases of endogenous CS are relatively rare, studies suggest that the incidence and prevalence is higher than previously thought.3,22 Improving recognition should be an important goal of the optometric community.

Treatment

Conclusion

Most cases of CS are not genetically inherited but if multiple members of a family present with rare ACTH-related endocrine tumours as in multiple endocrine neoplasia 1 (MEN1) syndrome cases, genetic testing may be advisable.17

Challenges of diagnosis

If tumours are found, treatments include surgery, radiation or medication.

Surgically removing the pituitary adenoma offers the only long-term cure of CD. Specialist minimally invasive pituitary tumour surgery uses an endoscopic technique entering via the nasal passage to remove the tumour, thereby avoiding a head incision.18 There is no effective drug that lowers ACTH production and shrinks the pituitary tumour so if the lesion cannot be completely removed, medications can be given to inhibit the adrenal gland’s production of cortisol.

Radiation therapy can be effective in controlling further growth if the tumour cannot be removed surgically. If it does not respond to medication or radiation, the adrenal glands may need to be removed but replacement of cortisol with hydrocortisone or prednisolone will be required afterwards.

Incidence rates of CS vary but are estimated to be 10–15 cases per million,3 with higher prevalence in females; however, it is being found more frequently

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This was a particularly compelling case in which simple observations of subtle facial changes prompted referral to an endocrinologist, resulting in the diagnosis of CS. Observation rather than refraction and clinical tests led to the suspicion of an abnormality simply by looking at the patient during a short consultation. This case highlights the advantage of continuity of care, which is not always possible in the current model of optometry. Seeing the same patients over many years gives the optometrist the unique opportunity to observe subtle, unusual features which may not otherwise be noticed.

Having knowledge of endocrine disorders may prove useful to practitioners even though the optometrist may only play a small part in the patient’s journey.

By writing this case in her memory, a promise made to her husband by the author has finally been fulfilled, to remind practitioners of the importance of how seemingly simple observations can detect such a serious underlying health issue and may improve quality of, or even save, a life.6

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91OPTJUL21143.pgs 28.09.2021 12:26

VRICS VERSION

1

Casualty cases

CET

POINT

REPRO OP

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

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

Image A

Image B

ART PRODUCTION CLIENT

01 What is the above finding called? a) Follicles b) Papillae c) Pseudomembrane d) Concretions 02 Which of the following conditions is least likely to be associated with this finding? a) Bacterial conjunctivitis b) Allergic conjunctivitis c) Viral conjunctivitis d) Giant papillary conjunctivitis 03 Which of the following would be a treatment consideration for this condition? a) Topical antihistamine b) Topical steroid c) Topical lubricant d) All of these options

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A 56-year-old patient started taking glaucoma drops once at night in both eyes two weeks ago. She presented due to significant irritation in both eyes since starting the drops.

04 What is the likely diagnosis? a) Corneal abrasion b) Preservative toxicity c) Band keratopathy d) Allergic keratoconjunctivitis 05 What class of glaucoma drop is typically instilled once at night? a) Prostaglandin analogues b) Beta blockers c) Alpha-adrenergic agonists d) Carbonic anhydrase inhibitors 06 The intraocular pressure has responded well to the drops. What would be the next best course of action? a) Microinvasive glaucoma surgery b) Bilateral peripheral iridotomy c) Change to a preservative-free option d) Advise the patient they will have to live with it

Image C

VRICS

Image D

A 72-year-old patient attended with a one-week history of vision loss in the right eye. Her vision is R 6/24 L 6/6.

A patient attends casualty after being caught in the eye by her child’s finger.

07 What would be the least useful test in this situation? a) Amsler chart b) Dilated retinal examination c) Gonioscopy d) Fundus autofluorescence

10 Which of the following symptoms is least likely to be present? a) Epiphora b) Floaters c) Pain d) Photophobia

08 Which of the following would be the most likely first-line treatment consideration for this finding? a) Macular laser b) Intravitreal anti-vascular endothelial growth factor c) Intravitreal dexamethasone d) None of these options

11 Which of the following are potential management considerations? a) Bandage contact lens b) Cyclopentolate 1% c) Oral painkillers d) All of these options

09 What would be the most appropriate advice to give the patient to take care of their left eye? a) Come back again in two years for a routine sight test b) Self-monitor regularly with an Amsler chart c) To take an omega-3 supplement every day d) To get her blood pressure checked regularly with her general practitioner

12 The patient returns a year later reporting that the symptoms have recurred on numerous occasions since. What can be recommended in the first instance? a) Ointment at night with topical lubricants during the day b) Topical steroids c) Topical antihistamine d) Rigid gas permeable contact lens

About the author n Alan Hawrami qualified as an optometrist in 2012 and locum for various community ophthalmology clinics. has extensive experience working within the hospital eye service, mainly in a casualty setting. He currently shares his time between hospital and working as a

Hawrami is also undertaking a master’s degree in advanced clinical optometry and ophthalmology at University College London.

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VRICS 1

Pathology

VRICS VERSION REPRO OP

Ocular complications of diabetes

1

CET

POINT

Prashant Shah MCOptom, PGDipOphth, DipClinOptom and Yashita Shah MCOptom, PGDipOphth

SUBS

This feature presents cases of ocular pathology related to diabetes.

Readers are invited to review the images and access additional resources where necessary to answer the questions.

Image A

Image B

ART PRODUCTION CLIENT

A 40-year-old asymptomatic patient attends for a routine sight test. Left visual acuity is 6/7.5 and current medication includes metformin and ramipril.

01 What type of lesion does the blue arrow indicate? a) Exudates b) Soft drusen c) Geographic atrophy d) Cotton wool spots 02 In which layer of the retina would these lesions be predominantly located? a) Between the retinal pigment epithelium and Bruch’s membrane b) Nerve fibre layer c) Photoreceptor layer d) Outer plexiform layer 03 In which layer of the retina would microaneurysms be predominantly located? a) Nerve fibre layer b) Inner nuclear layer c) Photoreceptor layer d) Bruch’s membrane

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04 What lesion is the blue arrow indicating? a) Branch retinal vein occlusion b) Vitreous haemorrhage c) Pre-retinal haemorrhage d) Choroidal neovascular membrane 05 Based on the diabetic eye screening programme, what would be the most appropriate grade for this retinopathy image? a) R1 b) R2 c) R3 d) M1 06 What other features may be visible on examination for retinopathy at this grade? a) New vessels elsewhere b) New vessels at the disc c) New vessels on the iris d) All of these options

Image C

Image D

A 65-year-old type 2 diabetic patient attends with right visual acuity of 6/12.

A 70-year-old male patient presents with right visual acuity of 6/24 and intraocular pressure of 23mmHg.

07 What is the name of the condition indicated by the OCT scan? a) Central serous retinopathy b) Choroidal neovascular membrane c) Diabetic macular oedema d) Vitreomacular traction

10 What abnormality is shown in the image? a) Iris hyperpigmentation b) Rubeosis iridis c) Hyphema d) Corneal neovascularisation

08 What would be the most appropriate grade for this image, based on the diabetic eye screening programme? a) M0 b) R2 c) R3 d) M1 09 What symptoms might the patient present with? a) Blurred central vision b) Distorted vision c) Colours appearing faded d) All of these options

VRICS

11 Which of the following conditions is least likely to be associated with this finding? a) Diabetes b) Wet age-related macular degeneration c) Ocular ischaemic syndrome d) Retinal vein occlusion 12 Which of the following clinical investigations is least important in these cases? a) Tonometry b) Gonioscopy c) Fluorescein angiography d) Ishihara test

About the authors n Prashant Shah is an experienced optometrist and CET author with postgraduate diplomas in ophthalmology and in clinical optometry.

n Yashita Shah is an experienced optometrist working in independent practice. She holds a postgraduate diploma in ophthalmology.

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91OPTJUL21114.pgs 27.09.2021 12:46

VRICS 2

Pathology, systemic disease, diagnostics

Jobs VERSION REPRO OP

Jobs

www.optometry.co.uk/jobs

SUBS

MY CAREER ADVICE

“APPROACHING US DIRECTLY SHOWS INITIATIVE”

PRODUCTION

What is the one piece of advice that you’d give to someone who wanted to work for Cult Vision?

CLIENT

Research our company and who we are. Have a look at our website and social media. If you can see yourself working for us, get in touch directly and email your CV along with a short personal message. Approaching us directly shows initiative and demonstrates that this person is interested in working for our business rather than just any optical practice.

Even if we are not hiring at that time, we will still keep CVs on file and when there is a vacancy, we will look through the direct applications before even announcing the role.

When you are shortlisting candidates, what is the very first thing that you look for?

When reading through CVs, we first look at the person’s previous work experience to make sure it is relevant for the role. Also, any longer employments will stand out as it shows that the candidate is committed.

Our staff stay with us for a few years, so it is important to us that there is a good ‘match’ from the beginning.

If we get a lot of applications, we start to look for anything that makes a candidate ‘stand out’ and why a candidate may suit the role more than others.

How important is the cover letter in the application?

We generally don’t ask candidates to write a cover letter, we ask them to send in their CV. We then arrange a phone call with the most suitable candidates. Following that we then invite candidates for a face-to-face interview. Anyone can write a good cover letter (or get someone to write it for them), so we much prefer to talk to the candidate and get to know them in person.

If we did receive a cover letter with an application, we would look for a personal approach that is targeted at working for Cult Vision and what the person could bring to the business, rather than just a standard cover letter for any job application.

As an employer, it’s easy to spot who has done their research and who is especially keen to work for your practice.

“We are a friendly, independent opticians and we want customers to feel comfortable when they come in for their eye test. We encourage staff to talk to our customers when they come in so they feel welcome; this also makes the job so much more interesting” 90 www.optometry.co.uk

WHAT STEPS IS THE DOES BIGGEST HAKIM GROUP TAKE TO MISTAKE A CANDIDATE ENSURE THAT THE CAN MAKE IN AN HIRING PROCESS IS FAIR? INTERVIEW? To say what they think we want to hear. The more genuine we all are in the interview, the better.

What is important in an interview is to find out whether the candidate will thrive in the working environment, not just for a few months, but ideally for a few years. As an example, we are more likely to hire a shop assistant who may not have years of experience in the optical industry but who is enthusiastic and keen to learn, rather than someone who has worked in optical practices before but who may not thrive in a smaller practice such as ours.

A new employee is preparing for their first week at Cult Vision.

What tip would you give them?

Do a little research about us, and the area. We are a friendly, independent opticians and we want customers to feel comfortable when they come in for their eye test. We encourage staff to talk to our customers when they come in so they feel welcome; this also makes the job so much more interesting. Apart from that, get plenty of rest as there will be a lot to learn, in the first weeks especially, and as long as you show up with a positive attitude, you will be fine.

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Marianne van Gils Nicolaou, general manager at Cult Vision, discusses the benefit of research and how it is not always about experience

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Marketplace Services and products for the practitioner

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THE RETINOSCOPE

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OutsideClinic’s professional services optometrist, Kamaljit Kalsi, discusses the importance of the retinoscope and the advances of technology in domiciliary care

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the retinoscope provides a rapid ‘insight’ (pardon the I COULD pun) into the patient’s eye NOT LIVE . health and prescription.

WITHOUT.. I believe that it is always a helpful starting point. In many ways, it’s a ‘back to the basics’ approach and reminds me of my university days 25 years ago.

It is excellent for a preliminary review of the ocular media. I also find it very useful in determining how dense cataracts are by just looking at the light bouncing back from the retina at the outset of a consultation. orking in the domiciliary sector, I have always heavily relied upon Technological advances the retinoscope, which I believe is a Since I joined OutsideClinic some 20 crucial piece of equipment. years ago, I have seen how technology Whilst there have been many has improved the service that we can advances in technology, all of which offer patients and how the company has contribute to efficiency and accuracy successfully adapted to embrace these. resulting in better patient care, this relatively ‘old fashioned’ piece of equipment is simple to use, being “This relatively ‘old handheld, and still incredibly relevant fashioned’ piece of to our profession. It is effective in equipment is simple to use, various sectors, not least domiciliary, being handheld, and still but also with children and infants. incredibly relevant to Critically, within my role, it helps with the type of patients I see – some our profession” of whom may have limited ability to I remember the days when we used communicate and may have recently paper records and an A to Z, whereas become housebound due to a variety now we, of course, have a SatNav of conditions, including dementia, and an advanced, bespoke EYEris for example. tablet programme.

Often our patients’ needs are The tablet is another wonderful piece complex, and an appreciation of this is of equipment. It makes testing more vital. Not all patients will be wearing efficient, and referring patients is as their correct glasses, and sometimes simple as a click of a button. Another they may have misplaced their advantage of this programme is that it prescription. Equally, with all patients,

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allows you to add fundus photographs to patients’ data files, so when I need to review the last test records, an image is stored and can be easily referred to if needed. Moreover, the programme allows the submission of eGOS forms, which is more effortless and secure in terms of GDPR.

The wireless age Working in the domiciliary sector does, to some degree, restrict the equipment we can use due to the very nature of the role (hopefully, a portable OCT will be available in the not too distant future).

Yet, I have always found it rewarding, and the choice of equipment available for me to use has hugely improved.

Wireless/battery-powered equipment makes my tests run more efficiently.

Sending ‘real time’ results to our head office whilst not worrying about patients tripping over cables when carrying out an eye examination is a simple example. Moreover, less time is needed to set up and more time can be spent focused on the patient’s needs.

Further to these two great pieces of equipment, every optometrist is also equipped with a portable slit lamp, fundus camera, I-Care tonometer and a Welch Allen PanOptic ophthalmoscope.

The PanOptic ophthalmoscope, with a bespoke face screen designed within OutsideClinic, has been a great saviour during the COVID-19 pandemic, enabling me to carry out a fundus examination with additional screen protection for the patients and me.

Despite all of these advances in mobile testing and even when working in practice, the retinoscope is my essential piece of equipment regardless of the testing environment. I first handled it in university, and it remains one thing I always rely on.

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last word

LAST WORD

My secret life

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Do you have a personal passion to share with readers?

Get in touch with selinapowell@ optometry.co.uk

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Optometrist, Martin Skehan, talks with OT about his aim to row more than 3000 miles across the Atlantic

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“You never really get more than a two-hour break unless it is because of adverse weather conditions” 98 www.optometry.co.uk

y rowing team, the Wrekin Rowers, plan to row across the Atlantic in December as part of the Talisker Whiskey Atlantic Challenge. We anticipate the journey will take between 40 and 50 days. The accepted pattern is two hours rowing, two hours rest, then you’re back rowing. That is around the clock. You never really get more than a two-hour break unless it is because of adverse weather conditions.

In any journey where you are out there for more than five days – that is serious exposure to the elements and to the psychological and physical challenges. My family bought me the St Christopher medal for Christmas. That will be coming with me.

One of the things you have to do at repeated times during the crossing is get out of the boat and clean it. I have a feeling that it will probably be me who is sent out of the boat to clean the barnacles off. If you don’t, it really slows down your progress. While you are out there you have your crew mates on the lookout for sharks. After day three you don’t see any land. But I am looking forward to seeing the ocean wildlife, the night sky and the enormity of it all. You will never see a night sky like that anywhere on land.

There are race regulations that specify you have to carry a certain amount of food per kilogram per person. I will be eating 5000 calories per day.

When you set out, the boat is

really weighed down. As you make your way across the boat gets lighter. All your packaging is retained on board and is accounted for at the end of our crossing.

One of our crew members, Stuart Richards, has Leber's optic neuropathy. He began to notice changes in his sight between the ages of 20 and 24 then he rapidly lost a great deal of his vision. He can see around him, but he has very low visual acuity.

He is highly motivated to bring everything else that he can to the journey. And we know he will make up for any inadequacy in his vision in every other way. He is a fantastic individual.

Another crew member is his brother, Gary Richards.

He is remarkable as well because in every challenge we have done, he has supported Stuart. If he wants to do something, his brother will support him to make it happen. Along with our skipper, Stuart Shepherd, I’m now part of that. I am really bound into this because of the teamwork. It is not just about me getting there, it is about us getting there.

Main: Getty/Piola999, Inset: Martin Skehan second from right

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MY T SECRE ...

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VERSION REPRO OP SUBS ART PRODUCTION

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CLIENT

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

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OptiExpert™ is available for mobile and tablet devices or download web app at www.coopervision.co.uk/optiexpert

Excited to hear more? Talk to your CooperVision w Development Manager today.

Find out more: www.optometry.co.uk/jobs *Free to use until the end of January 2022

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Journal of the Association of Optometrists

COVID-Generation Resilience in the face of unprecedented change Page 31

£9.95 REPRO OP

October/November 2021 Volume 61:05

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October/November 2021 / Volume 61:05

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OCULUS MYOPIA MASTER® THE CONTINUING PROFESSIONAL DEVELOPMENT EDITION

Giving you the personalised data to provide a clearer future

COME AND SEE US FOR A DEMO AT: AIO Conference 9th & 10th October Optix Conference 15th - 17th November

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BIRMINGHAM OPTICAL Unit 4 Gravelly Industrial Park, Birmingham B24 8HZ t: 0808 123 2020 e: sales@birminghamoptical.co.uk www.birminghamoptical.co.uk

EXCITING NEWS INSIDE CET Demonstrating cultural competence in practice

Spotlight The launch of the AOP’s new online Locum logbook

In practice CET high-achievers share their passion for learning

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