Optometry Today June/July 2020

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Journal of the Association of Optometrists

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CET Fixation disparity and associated phoria

Perspectives Protecting the next generation of optometrists

In practice Locum optometrists respond to COVID-19

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Welcome

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hat comes next? That is the question being asked by every optometrist. As this edition of OT goes to print, complex, high-wire conversations continue about the speed at which primary care can return to routine practice – NHHSLQJ WKH VDIHW\ RI VWD DQG SDWLHQWV DW WKH forefront. And when we talk about ‘routine,’ any return will be in a format far from anything the profession and patients have experienced before.

In a survey conducted by the AOP to listen to members during the crisis, it was clear that no one is untouched by the crisis, be it the third-year student about to start their pre-reg, the locum whose work has disappeared, or the business owner with bills to pay. Over 85% of you told us you were “well supported� by the AOP team during the pandemic. Thank you. We know there is so much more to do.

Along with our detailed online guidance supporting members on the return to work, this month we produced the AOP Infection control DQG SUHYHQWLRQ FHUWLĂ€FDWH. It is a tool designed by our clinical team to give members and patients FRQĂ€GHQFH DQG UHDVVXUDQFH DV SUDFWLFHV RSHQ As we at the AOP have pivoted to virtual technology to maintain contact with colleagues, so too has the profession. New verbs have entered our vocabulary: we Zoom and Houseparty.

Webinars in particular have become an essential part of optometry’s diet – indeed, it is Jill Heath’s I can’t live without pick in this edition (page 89).

In response, the AOP events team has launched a programmes of webinars for the summer – simply register online today.

This edition of OT LV D ÀUVW WR UHVSRQG WR WKH ÀQDQFLDO FKDOOHQJHV WKDW &29,' FUHDWHV ZH took the decision to produce bi-monthly editions for the rest of 2020. In this edition, expect more of the in-depth insight into the stories that matter, DORQJ ZLWK DQ H[WHQGHG &(7 VHFWLRQ IHDWXULQJ VL[ &(7 DFFUHGLWHG DUWLFOHV What emerges strongly from the pages of OT is the spirit of co-operation and resilience that makes eye care practitioners so important. It is a spirit the AOP will defend long after the pandemic is over.

“As we at the AOP have pivoted to maintain contact with colleagues, so too has the profession. New verbs have entered our vocabulary: we Zoom and Houseparty�

Henrietta Alderman, AOP chief executive

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OT investigates

On the ground in Toulouse

The news in digest Picture this Rupinder Nanda’s bespoke eyewear solution for a surgeon OT reports Five opportunities for optics in the wake of COVID-19 The audit The month in 16 stories Health and wellbeing Tools to support the optical workforce On the ground A global view from optical practitioners and businesses AOP round-up The guidance from the clinical and communications experts Supplier insight Preparing to open the practice doors again

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“The lockdown restrictions in France were much stricter than they were in England. Every time you left the house, you had to fill out paperwork�

Mehran Waheed PAGE 18

27-33 HIT LIST The trends, launches and looks OT focuses on...

Online learning platforms Me and my glasses Robert Sands Get the look 1HRQ R HULQJV The shortlist The latest launches Behind the brand CooperVision’s Learning Academy

35-39 PERSPECTIVES Voices from optics and beyond Perspectives /XNH 0F5R\ -RQHV 6RĂ€D )D]HO Dr Waheeda Illahi, Lesley Longstone My vision Souleyman Bah, para-athlete

“Pre-regs have a very different need for patient interaction to experienced optometrists�

Luke McRoy-Jones PAGE 35

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Education and training for the eye care practitioner

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59 CET welcome 60 Fixation disparity and associated phoria – uses in clinical practice 64 Returning to work: a guide for practitioners and employers 69 Meibomian gland dysfunction: the importance of early detection 74 Sight support in schools 80 Anterior eye 82 Macular marvels In this edition of OT, practitioners can test a range of competencies: OPTOMETRISTS // 6 THERAPEUTIC OPTOMETRISTS // 3 DISPENSING OPTICIANS // 5 CONTACT LENS OPTICIANS // 2

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41-51 IN PRACTICE Business insight and career development The discussion Independents on business survival tactics The workshop Remote consultation advice from the AOP’s Roshni Kanabar How I got here With hospital optometrist, Jeremy Parkes Key milestones The story behind LOCSU’s COVID-19 Urgent Eyecare Service Pre-reg focus Tamara Hasan and Daniel Chung Life as a locum OT’s columnists share their month What I have learned Designing a Google Map resource for the pandemic

ONLINE

Cover story

Bridging borders Understanding the common threads influencing the response to the COVID-19 pandemic in Scotland, Wales and Northern Ireland – and the differences

OT video highlight

PLUS: The realities and concerns for optometry’s locum workforce

A guide to infection control and prevention

PAGE 53–58

Watch the CET video on

www.optometry.co.uk

84-90 JOBS, MARKETPLACE & SECRET LIFE Jobs How to respond to competency-based questions I could not live without…

‘Webinars and WhatsApp,’ explains Jill Heath Secret life Andy Poplar on his love of trial lenses

Contact the OT team with your experiences, observations and lessons from practice today: newsdesk@optometry.co.uk Follow us on Twitter @OptometryToday Like us on Facebook OptometryTodayJournal Follow us on Instagram @optometry_today

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10 OT REPORTS

Five opportunities for the optical sector to explore in the wake of COVID-19

18 ON THE GROUND

Optometrists around the world share their experiences of the pandemic

22 AOP SUPPORT

A public eye health campaign in lockdown and the work underway to help members

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Fitting the frame PRODUCTION Nanda Rupinder

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Using personal protective equipment (PPE) has posed unexpected challenges for some spectacle wearers.

Locum optometrist, Rupinder Nanda, told OT how she and a colleague fit a pair of spectacles for her surgeon husband to wear with his PPE, as the tight fit of his mask meant his usual frames could not fit on the bridge of his nose. On fitting the new frames, she commented: “It has given us great satisfaction to be able to help a keyworker during this pandemic to continue to work.”

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This month picture this, 1

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June/July 2020/Volume 60:06 Issn 0268-5485 ABC certificate of circulation January 1 2019 – December 31 2019

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Editor: John White johnwhite@optometry.co.uk Interim deputy editor: Lucy Miller lucymiller@optometry.co.uk Assistant editor: Selina Powell selinapowell@optometry.co.uk

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Senior reporter: Kimberley Young kimberleyyoung@optometry.co.uk Web content and social media executive: Leah Boyle leahboyle@optometry.co.uk Clinical editor: Dr Ian Beasley ianbeasley@optometry.co.uk Clinical editor for multimedia: Ceri Smith-Jaynes cerismithjaynes@optometry.co.uk Video production editor: Laurence Derbyshire laurencederbyshire@optometry.co.uk CET enquiries: 020 7549 2076 CEThelp@optometry.co.uk AOP membership and OT subscription team: AOP, 2 Woodbridge Street, London, EC1R 0DG subscriptions@aop.org.uk

Advertising: Richard Ellacott 020 3771 7242 richard.ellacott@thinkpublishing.co.uk Advertising production: Simon Gould aop@ccmediagroup.co.uk Senior designer: Grant Pearce Account director: Anna Vassallo Executive director: Jackie Scully Published monthly for the Association of Optometrists by Think Capital House, 25 Chapel Street, London NW1 5DH Printed by Acorn Web, Normanton Ind Estate, Loscoe Close, Normanton, West Yorkshire, WF6 1TW All rights in and relating to this publication are expressly reserved.

No part of this publication may be reproduced in any form or by any process without written permission from the AOP or the publisher.

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FIVE OPPORTUNITIES IN THE WAKE OF COVID-19 How can the profession regenerate after a period of massive societal change? While the pandemic has created unprecedented challenges, it may also be a catalyst for new beginnings It is hard to imagine how to move on from an illness that has claimed tens of thousands of lives within the UK. Across the country, there are so many living rooms with empty chairs that were, until recently, a loved-one’s favourite.

Inevitably, individuals and sectors will pick themselves up and take their bearings in this new landscape.

During lockdown, there has been D FKDQFH IRU RSWRPHWULVWV WR UHĂ HFW RQ ZKDW WKH SURIHVVLRQ R HUV DW its essence. What remains when traditional equipment is either discarded or adapted?

Stalwarts of the testing room, IURP DLU SX WRQRPHWHUV WR WULDO frames and even the humble tie, are now viewed with a degree of suspicion because of an enhanced focus on infection control. Although protocols and equipment may

"It's useful to remember that after the Spanish flu, the next decade was the roaring twenties" Dr Euan McGinty, optometrist

change, optometrists will continue to care for their patients; that remains constant.

These extraordinary times have opened up opportunities within optometry.

OT has heard from readers about initiatives being enacted in weeks, that previously would have taken years to implement.

Perhaps the path ahead is not all doom and gloom. As optometrist, Dr Euan McGinty, told OT: “It’s useful to remember that after the 6SDQLVK Ă X WKH QH[W GHFDGH ZDV WKH roaring twenties.â€?

OT SUHVHQWV ÀYH RSSRUWXQLWLHV for optometry following the COVID-19 pandemic.

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A STANDARDISED APPROACH TO URGENT EYE CARE

The pandemic has fasttracked a consistent model for the provision of urgent eye care within England.

Before the pandemic, funding for providing urgent care was dependent on whether a Minor Eye Condition Service (MECS) existed within an area – and what was provided within this service also varied locally.

The new COVID-19 Urgent Eye Care Service (CUES) addresses the patchy provision of urgent and emergency eye care within

the community and also provides a means for funding remote consultations – a key feature of the ‘new normal’ within optometry.

The framework was developed by NHS England, the Local Optical Committee Support Unit (LOCSU) and the Clinical Council for Eye Health Commissioning and is expected to be implemented locally by Clinical Commissioning Groups.

Talking with OT, LOCSU interim clinical director Zoe Richmond said she expected that CUES will

be around for at least two years. “I don’t think we’ll be looking backwards following the implementation of CUES. What it delivers to the system is huge. It goes far beyond just delivering for the immediate crisis in urgent eye care.”

Read more about the planning for CUES on page 48.

"I don't think we'll be looking backwards following the implementation of CUES. What it delivers to the system is huge" Zoe Richmond, Local Optical Committee Support Unit interim clinical director

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Closer relationships between optometry and ophthalmology As the pandemic has unfolded, healthcare professions have been working together in new ways.

Many examples have come across the OT newsdesk of optometrists working with colleagues in secondary care to ensure that patients can continue to receive the eye care they need.

Belfast Health and Social Care Trust ophthalmologist, Tunde Peto, explained that after routine diabetic eye screening was suspended in Northern Ireland, optometrist colleagues looked through fundus images and grading outcomes to ensure that the most at-risk patients were still seen.

“However difficult this situation has been, we have all worked together. We discussed what our strengths are and how we might be able to fit in,” she shared.

Following the outbreak, a new resource was created to help patients and optometrists access the most up-to-date information on the opening times and contact details for ophthalmology

services and eye accident and emergency clinics in London.

An ophthalmology registrar at Moorfields Eye Hospital, Jonathan Than, plotted data contained in the Directory of London Ophthalmology Service Provision into a Google Map (shorturl.at/VXYZ4).

Mr Than shared with OT: “I appreciate that optometrists often face significant barriers when seeking advice from, or referring a patient to, an eye casualty unit. Such barriers include lack of clear referral pathways, inability to contact on-call ophthalmologists, and confusion as to where and when a patient should be referred.

I hope that this map can address some of these issues to break down these barriers and encourage harmonious collaboration between optometrists and eye casualties.”

Read more about the initiative on page 51.

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"However difficult this situation has been, we have all worked together" Tunde Peto, ophthalmologist

Social distancing has meant that optometrists are changing the way they work to limit the amount of patient contact time.

There is a broad spectrum of adaptations that practitioners are making, from taking patient history over the phone to conducting entire patient consultations using video call technology.

Interim guidance from the Royal College of Ophthalmologists on reopening ophthalmology services highlighted that some trusts are considering using virtual and video clinics as a default for most patients in highvolume sub-specialties. Belfast ophthalmologist, Tunde Peto,

told OT that while some elderly patients were apprehensive about online communication before COVID-19, this was the only method that many of them had to talk with their families during lockdown.

“I think we will see the emergence of innovative pathways. :H DUH ÀQGLQJ WKDW SDWLHQWV DUH happy to talk with us on the phone and those who are internet savvy are happy to use video technology.

This is a major shift in everyone’s thinking,” she said.

“I suspect that when the lockdown eases we will be using some of the online options better and we will not have such a pushback from regulators, the

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MORE OPTOMETRISTS MANAGING EYE CONDITIONS WITHIN THE COMMUNITY Many eye care services offered within hospitals were suspended during the UK-wide lockdown, including cataract surgery and screening for diabetic eye disease.

As secondary care faces increased pressure, optometrists working in the community may have the opportunity to ease this burden by managing more

eye conditions within the community.

Before the COVID-19 pandemic, ophthalmology had the highest level of outpatient appointments of any specialty within the NHS. The Royal College of Ophthalmologists has encouraged collaboration with optometrists to help manage workloads

"I think many people will be taking a good hard look at how they they practised before COVID-19" Colin Pettinger, optometrist

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as lockdown eases. In its interim guidance on reopening ophthalmology services, the College encourages the use of referral refinement, virtual screening and clinics, as well as providing “as much care as possible” through optometrist shared care pathways.

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patients and families,� Ms Peto shared with OT. 0RRUÀHOGV (\H +RVSLWDO FOLQLFLDQV SXEOLVKHG D SDSHU LQ (\H outlining how COVID-19 would transform the future of glaucoma care delivery.

'U +DUL -D\DUDP GHSXW\ GLUHFWRU of glaucoma service and consultant RSKWKDOPLF VXUJHRQ DW 0RRUÀHOGV (\H +RVSLWDO H[SODLQHG ´:LWK social distancing becoming a necessary norm for the foreseeable future, we have been given a once in a generation opportunity to discover new ways to deliver glaucoma care. These times have shown us the possibilities that telephone clinics can bring to a glaucoma service and we can see

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them having a place in optometry beyond the pandemic, alongside H FLHQW SULRULWLVDWLRQ RI WKH PRVW at-risk patients, virtual review of remotely collected data and, less often than before, traditional inperson clinics.�

Colin Pettinger, who co-owns three independent practices in the 1RUWKHUQ +LJKODQGV RI 6FRWODQG told OT that he is considering using remote consultations for some follow-up appointments after the lockdown eases. “For me, it has been an epiphany,� he said. “I think many people will be taking a good hard look at how they practised before COVID-19,�

Mr Pettinger added.

Rethinking the time allocated for each appointment Infection control and social distancing measures will increase the length of time that needs to be allocated to safely see each patient in practice.

This creates challenges for the traditional funding model that underpins many practices, but there is also an impetus to reassess whether previous ways of working

were fit for purpose. Practices that already offer longer appointment times and derive a higher proportion of income from clinical care may be better placed to adapt to the challenges posed by social distancing.

Other practices may explore whether this is a model that would be viable within their patient base. Time pressures

are commonly cited as a source of stress within the profession.

A survey of more than 1700 AOP members in 2017 found that more than half of the optometrists surveyed work to ‘tight’ deadlines, with higher daily appointment numbers linked to increased stress levels among survey respondents.

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Alcon donated over 35,000 units of Systane Eye Drops to UK workers on the frontlines of the COVID-19 crisis, aiming to help provide relief from dry eye symptoms, including sore and tired eyes for NHS, care home and hospice workers.

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Gloucester-based supplier, Norville, took part in a cross-country dash to deliver replacement spectacles 45 miles to an intensive care unit nurse in Abergavenny, in South Wales. Dispensing optician Francesca Fulgoni, of Fulgoni Opticians, called the lab at 4:45pm and the glasses were handed to the patient by 8pm.

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INDUSTRY SUPPORT

200,000

individual pieces of PPE were ordered within the first 24-hours of a new online store going live.

Primary Eyecare Services and the Local Optical Committee Support Unit (LOCSU) launched the shop for optometrists to source PPE.

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“We need to be emphasising the fact that domiciliary eyecare is important, and even more important in the new world with the population of people who are shielding”

Imran Hakim, CEO of the Hakim Group, has responded to the challenges ahead for practices, following a survey by the group on future changes for optometry. “We now need to brace ourselves for the next phase as we look to exit lockdown and make critical decisions around practice staff, reforming the customer journey and remote methods of healthcare.”

Inspecs has been ramping up supply of its safety eyewear due to the outbreak. By the end of April Inspecs told OT it had produced around 60,000 units.

By the end of June this will be closer to 300,000. The company plans to produce approximately 200,000 pieces per month from July onwards depending on the ongoing demand.

The Thomas Pocklington Trust has awarded £500,000 of funding to 55 sight loss organisations through its COVID-19 Emergency Fund. British Blind Sport was among the recipients, receiving VXSSRUW IRU D SURMHFW WR R HU live and pre-recorded workouts and activities for its members to participate in at home.

GET YOUR NEWS AROUND THE CLOCK Catch the news from OT online – your daily digest of the latest stories in optics www.optometry.co.uk

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Pixabay/ijmaki

Gordon Ilett, optometrist, AOP Board Member and co-chair of the Optical Confederation’s Domiciliary Eyecare Committee on the role domiciliary care could play post-lockdown.

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CLINICAL PROVISION & EYE CARE

The AOP warned the public to protect their eyes when doing DIY during the lockdown as practitioners noted a rise in eye injuries.

Oxford Eye Hospital reported six eye injuries caused by DIY accidents in one week in April, where one in every two to three weeks would be typical.

THE AUDIT

49 % Hospitals across the country have reported a drop in the number of patients presenting at A&E during the lockdown.

Manchester Royal Eye Hospital told OT it had seen a 49% decrease in the number of patients presenting at the emergency department with retinal detachment in April.

“It has been the perfect storm of circumstances that means teleophthalmology has spread so quickly” Dr Iain Livingstone, project lead and NHS Forth Valley consultant ophthalmologist, discusses the uptake of a new teleophthalmology system, originally trialled in hospital A&E departments, that was extended to optometrists in Scotland during lockdown.

GUIDANCE & ADVICE The AOP released new guidance in May to help members plan for a future return to routine practice.

The resources cover key clinical and employment issues members have highlighted, with planning FRQVLGHUDWLRQV UDQJLQJ IURP VWD and employment duties, working with patients and guidance for practice areas, to hygiene and ensuring business sustainability.

The Coronavirus Job Retention Scheme has been extended up to October. Furloughed workers will continue to receive 80% of their salary, though new flexibility will be introduced in July to bring employees back part-time. From August, employers will be required to contribute a percentage towards salaries that will gradually increase each month.

Pixabay/janjf93

The Strategic Programme of Primary Care in Wales launched a toolkit to help Welsh optometrists work through the challenges posed by the pandemic. The Optometry Practices Services COVID-19 Toolkit covered topics from financial support to remote consultations, aiming to “enable the continuity of services by community optometry practice services at this unprecedented time of pressure.”

IN PRACTICE AOP SURVEY Optometrists in Ireland re-opened on 18 May for both urgent and routine eye exams, though social distancing measures remained in place. Safety requirements included reducing contact time in eye examinations, managing the numbers of people in a premises at one time and maintaining the two-metre principle.

“As we return to some form of normality, what will this mean for pre-registration optometrists who face unique challenges?”

Third-year optometry student and AOP councillor, Luke McRoy-Jones, has highlighted the implications the pandemic could have for pre-registration optometrists and students.

Read more on page 35.

88.7%

An AOP survey of 2256 members found 88.7% of respondents said their roles had changed as a result of the coronavirus pandemic.

Of those whose work had changed, 47% said they were furloughed and 38% shared that they had no work but were not furloughed. Read more on page 22.

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As levels of loneliness and anxiety have risen during the lockdown, OT looks at support for optometrists

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“Some staff and students have lost Throughout the lockdown, mental health relatives at this time, and it was especially charities have reported heightened WHERE TO GO FOR SUPPORT important to reach out to them to offer levels of anxiety and loneliness amongst Financial aid –The Optical support,” Dr Naroo added. “On top of that, members of the public.

Benevolent Fund offers help staff and students are away from family AOP members have seen similar issues through an immediate crisis or members whom they haven’t seen since relating to wellbeing, with an AOP survey financial difficulty the beginning of lockdown, that they would finding a drop in reported health and Post COVID-19 guidance – The AOP normally communicate and socialise with.” wellbeing from an average of nine out of has created a range of resources For those with young family or higher10 pre-lockdown, to an average of eight. covering key issues of safely risk relatives, this adds another level of The biggest factor affecting members' returning to work when lockdown restrictions ease, with advice for concern, Dr Naroo said. health and wellbeing was found to practice owners and employers, be concerns around themselves or employed optometrists and locums Financial worries their family contracting coronavirus The AOP’s survey in April 2020 found (COVID-19), with 42.87% of responses Space to talk – The Peer Support Line can be called on 0800 870 8401. 'money worries' was the second highest citing this as a concern.

Calls are answered 24-hours a day factor affecting members' wellbeing with The AOP Peer Support Line (PSL), by an external answering service, 41.28% of respondents selecting this as a a confidential phone support service with trained volunteers on duty to concern. for both members and non-member return calls between 8am and 8pm.

The Benevolent Fund of the AOP and optometrists, has seen a rise in the the College of Optometrists aims to help number of calls, with a volunteer telling practitioners through difficult situations and immediate crisis.

OT: “This certainly reflects the uncertainty that many of us are “We have had 56 enquiries since March, which represents feeling at present.” three or four years’ worth of approaches in just two months,” “As we approach a new phase of the pandemic, and as the explained Lynne Brown, administrative secretary for The Government considers easing the lockdown, it is important to Benevolent Fund, adding that approximately 15 have gone on to realise that we are all feeling anxious and concerned about what make full applications. the future holds for us,” the PSL volunteer explained.

Many of the enquiries have been from self-employed locums, “It is important to remember that the Peer Support Line is Ms Brown highlighted, particularly younger optometrists who available for you and will listen to you and provide support had only recently become locums. through these uncertain times and beyond,” they added.

Responding to the COVID-19 situation, The Benevolent Fund Callers to the support line are connected with trained peers in has “overhauled” its protocol, swapping visits to applicants for optometry who do not give advice but offer a non-judgemental virtual meetings, and aiming to reach a decision within 48-hours. space to talk.

“We emphasise that we are here to get people through a crisis,” Ms Brown said, urging optometrists to “get in contact.”

Supporting staff and students “If we can help pay some expenses and ease financial According to the Mental Health Foundation, feelings of concerns, then we hope that will loneliness have more than doubled over the lockdown period. contribute to general wellbeing Young people aged 18–24 were found to be the most affected and reduce the worry to an group, with more than four in 10 (44%) reporting feeling lonely. extent,” she added.

For students who have faced changes to their courses this has added pressure onto the usual exam season.

Aston University academic, Dr Shehzad Naroo, COVID-19: told OT that face-to-face teaching at the university THE WELLBEING was suspended on 17 March: “We had three weeks IMPACT IN NUMBERS of teaching remaining for this academic year. The immediate challenge was to ensure that content was In an AOP survey, 42.87% of participants said concern about getting the virus was a delivered to the students.” key factor affecting their wellbeing Further challenges included supporting students Feelings of loneliness have more than who had not yet completed their required GOC core doubled over the lockdown period competencies at the time of lockdown, as well as according to the Mental Health Foundation adapting examinations to be carried out online.

Anxiety UK found the prospect of lifting Video calling systems have been well-used during this COVID-19 restrictions led to an increase in time, with the department supporting staff and students anxiety for almost 67% of its members. with regular communications, Dr Naroo explained.

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In May, OT chronicled the experiences of optometrists across the country as they adapted to the challenges posed by COVID-19. For this edition, we venture further afield to share the stories of optometrists living in France, Canada, Spain and Ireland

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“My six-year-old daughter started colouring in people with face masks”

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Mehran Waheed, Toulouse, France

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Following the outbreak of COVID-19, everyone was pretty blasé – until Silmo was cancelled. People then began to take it more seriously. In France, normally when you start work you have to do la bise, ‘the kiss,’ or handshakes every morning. Some people stopped doing that and the shop became quieter.

The week before the lockdown, schools were going to close.

Because I am classed as a primary caregiver, I am responsible for home schooling my daughter so I signed off work. The French president Emmanuel Macron gave a speech saying that all shops and restaurants were closing. It was very sudden. The full lockdown was a real surprise. Opticians aren’t classed as an essential service like they would be in England so there was no skeleton service. There was no testing.

The lockdown restrictions in France were much stricter than they were in England. Every time you left the house, you had to fill out paperwork. There was always a patrol car going around the

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village where I live.

Once a week there would be a police helicopter. Because I was looking after my child, I was getting almost 100% of my salary.

My colleagues who do not have children were 80% of their salary.

I’m looking forward to going back to practice. My wife is asthmatic. Her doctor has recommended that I try working for a couple of days to see what it is like. I am not concerned about any risk at work, because that will be well-controlled, but I take the metro to get to work. The commute is going to be tricky. I might have to stop work if it is too difficult.

During lockdown, my six-yearold daughter started colouring in people with face masks. We were lucky that we had garden, a pool and it was the south of France. It was not too bad.

“My main concern now is having the funds to see us through the pandemic.

Sleeping is quite difficult” Dr John Wilson, Nova Scotia, Canada During the early stages of the outbreak, I thought ‘What is the panic? This is going to be another seasonal flu virus that we have to deal with.’ But it became apparent talking to family in Italy that this was having a massive impact, and quickly. At the beginning of March, I noticed many more patients were cancelling their appointments or just not showing up.

Initially, my stress levels increased dramatically until we made the decision to close the office. That seemed to make things easier.

My main concern now is having the funds to see us through the

pandemic. Sleeping is quite difficult.

I think I've gained half a stone.

When we return to more routine practice, initially patient load will need to be tailored to maintain personal distancing rules. Patients will be required to attend their appointment with their own masks and staff will wear scrubs and personal protective equipment.

At the moment, non-contact tonometry isn't advised so we will need to look at acquiring alternatives for IOP screening. There may even be a shift in initial teleoptometry screening to reduce patient time within the practice.

“A new scenario has appeared in our lives, and if we want to give our best professionally, we have to adapt” Elena Garcia Rubio, Madrid, Spain I am the director of the National Institute of Optometry, a private practice in Madrid specialising in paediatric optometry, visual therapy and contact lenses. We are a team of five optometrists and two assistants.

For me a turning point was the cancellation of the World Mobile Congress that was to be held in

Barcelona on 12 February. From that moment on, we started to see the danger of this virus. We carried on with normal life until 15 March, when the Spanish Government ordered confinement.

The Government determined that optical stores were one of those essential establishments and therefore they were allowed to open but only for emergency services. This means we cannot do contact lens fitting or new refractions.

My practice is closed, but we are triaging emergency cases on the phone. For those who need to be seen in person, we make an appointment and open the office for them. Using the

patient database, I have called those who may need contact lenses and offered to send the lenses to their houses. The return to ‘normal life’ started gradually from 2 May. From 2 May we were allowed to exercise, but only individually. There is constant improvisation and that creates a feeling of insecurity.

I am very lucky because all my family and friends are healthy and I live in the countryside. Being confined in a house with a garden makes a huge difference. As you can imagine, I am very concerned about the economic situation and how deeply this crisis will affect our sector. A new scenario has appeared in our lives, and if we want to give our best professionally, we have to adapt our business and the way we offer our services to this new situation.

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Optometrists closer to home on how they have been affected by COVID-19

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“Every day that I went to work, I would get stopped at least once by the police, if not twice, on a journey of 45 kilometres”

Dr Valarie Jerome, Newbury

I never realised how much of my identity is wrapped up in helping people, in doing eye exams and helping solve eye problems, until I was forced to stop doing that. I miss it. I have realised that there is more to life than just my work. I have jumped on a trampoline now more than I have in my whole life, I have played with Barbies and I have made slime at 1.30pm in the afternoon on a Thursday. [Lockdown] is teaching me to stop and smell the roses.

Sue Doherty, County Cork, Ireland PRODUCTION CLIENT

I practise on the south coast of Ireland in County Cork, in a seaside town called Youghal. It has a population of around 6000 people.

We have a small independent optometry practice which I opened in 2007.

We closed our doors on 28 March when Ireland imposed restrictions and have triaged queries over the phone since then, providing emergency care where required.

Before restrictions eased on 18 May, I would see around five patients face-to-face each week.

Unlike the UK, optometry practices with Health Service Executive (HSE) contracts in Ireland have not received any average monthly payment or subsidy. HSE payments would be the equivalent of General Ophthalmic Services payments. We are very much out on our own. We had no allocation of PPE from the HSE. We had our first wave of easing restrictions from 18 May. Opticians were designated as one of the first businesses that could reopen, which was a welcome development. The main

thing is that we continue to provide the level of service that we have become known for.

In Ireland, we were stopped by the police service during the lockdown. They were very active in ensuring that people weren’t going beyond the permitted zone or making unnecessary journeys.

Every day that I went to work, I would get stopped at least once by the police, if not twice, on a journey of 45 kilometres. I was asked if my journey was essential and I had to show a letter that I wrote saying that I was travelling to work.

Being able to offer emergency care during lockdown was rewarding and worthwhile.

Within my practice, I have a large paediatric patient base. There were lots of phone calls where a parent would say, ‘The dog ate the glasses,’ ‘My child was jumping on the trampoline and they broke their glasses’ or ‘His brother pulled the glasses off and smashed them.’ We have managed to sort them all and the customers have all been very grateful.

Get in touch Share your 'on the ground' COVID-19 experiences with the OT team selinapowell@optometry.co.uk

20 www.optometry.co.uk

Colin Pettinger, Scottish Highlands

I am using home visual acuity charts that I email to patients, Amsler grids, smartphone photographs and video. On one occasion I used a super telephoto camera to take a photograph of a patient’s eye from 10 feet away. She was an elderly lady with marginal keratitis who didn’t have a smart phone to take a photo with. She lived three doors down from the practice, so we got her to walk down the road and I took the photo from the other side of the glass.

Simon Rose, Hackney

I think the biggest hurdle was dealing with the amount of information coming in – that was really hard as there was a staggering amount of data. You’re trying to run a business, keep everyone safe and pay the rent and you’re assaulted from all angles. Most of it is information overload; dealing with that in itself was really challenging.

John Wallace, Oban

When lockdown eases, I don’t know how it will work for people like me who are meant to be isolating for 12 weeks. I am a sole practitioner and you can’t get locums in this part of the world. That is a big difficulty.

There are locums in Glasgow and Edinburgh but they don’t want to travel two hours out of the city.

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MEMBER SUPPORT

AOP on your side Optometrists outline the impact of the COVID-19 outbreak

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A survey of AOP members has highlighted how many optometrists feel towards the future of the profession in the wake of the coronavirus (COVID-19) outbreak.

The survey, completed by over 2250 AOP members, found 79.8% of practice owner, partner or JVP respondents said their practice has been open for essential eye care since the crisis, while 59.6% said their practice was open for urgent care, and 10.22% said their practice was closed.

Considering the future of their career or the optical profession in the next six months, 56% of those surveyed reported feeling either somewhat or very pessimistic.

Some 22% felt neither optimistic nor pessimistic, and 20% reported feeling somewhat or very optimistic.

The outlook is brighter for the next 12 months, as the number of people feeling very pessimistic dropped from 16% in the short-term to 6.5% in the long-term.

Optimism also grows, with 41% of respondents reporting feeling very or somewhat optimistic, 25% of respondents reported feeling neither optimistic nor pessimistic, while another 25% reported feeling somewhat pessimistic.

Commenting on the survey results, AOP communications director, Vicky Vine, said: “The results provide valuable insight into our members’ experiences and enable us to be better informed to support them through our policy and lobbying activities, our guidance, services and our communications.”

PRODUCTION

Supporting members through COVID-19

Eye care essentials

How the AOP has been delivering advice and resources over the past month

An AOP campaign offered eye care advice in lockdown

Advice

CLIENT

The AOP launched a COVID-19 member survey to gain insight into member experiences and needs As the Government set out plans to ease restrictions, AOP chairman, Mike George, gave a statement on future guidance post-lockdown, outlining the key topics the AOP is working to address The AOP raised concerns over a Vision Direct promotion giving away contact lenses to NHS and keyworkers On 13 May, the Optometric Fees Negotiating Committee (OFNC), Optometry Northern Ireland, Optometry Scotland and Optometry Wales issued a statement on the position of routine sight testing in the UK In response to Dominic Cummings’ statement on taking a drive to test his eyesight, the AOP issued a press release reminding motorists to contact their optometrists if they have concerns about their vision On 27 May, the OFNC shared guidance

with practitioners in England on a range of situations where patient care may now be considered ‘essential’ during the COVID-19 pandemic Following the news that dental practices could reopen from 8 June, the OFNC issued a statement on the implications for optometry

Financial and employment Following a previous letter sent to the Chancellor of the Exchequer raising key issues for self-employed optometrists, the AOP sent a follow-up letter, written jointly with the British Dental Association The OFNC published a statement on 24 April on GOS support payments for contractors in England, confirming the first payments were being paid in line with normal payment schedules Reflecting the extension to the Government’s furlough scheme, the AOP updated its furloughing guidance and employment questions for employers and employees

Resources The AOP created new online and video guidance on disinfecting equipment and premises during the COVID-19 pandemic To help optometrists providing urgent eye care, the AOP produced a new COVID-19 Urgent Eye care (CUES) referral form for use when making a referral to an IP optometrist With greater use of phone or video consultations, the AOP shared new guidance on remote consultations, including guidance on when and how to provide advice remotely The AOP has produced a range of posters on good patient hygiene for members to display in the workplace or practice as they prepare for a future return to routine work On 13 May, the AOP launched its Eye care essentials campaign To help members plan for returning to routine practice, the AOP produced a series of back to work guidance, returning to practice considerations and employment guidance The AOP launched an Infection control and prevention certificate, with a non-interactive CET point for completion and a paper certificate that can be displayed in practice on completion of the training.

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In May, the AOP launched a campaign reminding the public to make time for eye care in lockdown.

Highlighting an increase in eye injuries from DIY activities, greater time spent using screens, and the danger of buying sub-standard contact lenses online, optometrist and AOP spokesperson Henry Leonard said: “Unfortunately, the shift in lifestyle is taking a toll on many people’s eye health.”

One key concern has been a rise in DIY-related eye injuries, Mr Leonard said: “Patients are needing to have foreign objects removed or chemical burns treated because they are not wearing safety goggles.”

Further concerns include purchasing contact lenses from unregulated online suppliers, and a “surge” in headaches and eye strain from an increase in screen time.

The AOP launched a series of social media graphics to help raise awareness and share advice with the public which can be found at: www.aop.org.uk/eyecareessentials

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An AOP member survey highlighted how optometrists feel about the future

Round up, 1

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AOP EXPERT

AOP EXPERT

Clinical

Communications

Dr Peter Hampson, AOP clinical director

Vicky Vine, AOP communications director

Could you tell us about the AOP’s Infection prevention and control certificate?

The certificate aims to address the issues around how the disease spreads and how to prevent that; from disinfection to personal protective equipment, and what you need to do to make the practice a safer environment.

Members are generally aware of the risks around infection, but everyone can benefit from a reminder now and again. I hope it will increase member

and patient confidence and also provide reassurance to others that members take these obligations seriously.

How do you hope the Infection control and prevention certificate can help practices prepare for reopening?

This really fits into the category of providing reassurance.

Patients will understandably be nervous about a number of things that will be different, and want to feel safe. Hopefully being able to display a certificate showing that our members have refreshed their knowledge in this will go some way to providing that reassurance.

Launched on 3 June, the AOP’s new Infection control and prevention certificate is available to take on the CET section of the OT website.

One CET point is available with successful completion.

“Patients will understandably be nervous about a number of things that will be different, and want to feel safe” Dr Peter Hampson, AOP clinical director

Shutterstock/DeawSS

How have you been working to support members in returning to practice in the future?

We have tried to identify areas of practice where we have seen the most queries and then address those areas. That has been through publishing lots of advice on returning to practice, webinars on staying safe and lots of research into the virus and its impact on day-to-day practice.

Could you tell us about the AOP’s latest PR campaign?

We launched our social media campaign, #EyeCareEssentials, in response to some of the eye care concerns that have arisen as a result of COVID-19 and member feedback. For example, Oxford Eye Hospital saw a spike in serious eye injuries as people took up DIY projects during lockdown. This campaign is about reminding the public that despite unprecedented changes to routine sight care, taking care of our eye health is essential.

What challenges did launching a campaign during lockdown present?

Delivering a campaign in such a unique and surreal set of circumstances presented some challenges – not least needing a complete rethink on the campaign on illegal

June/July 2020

practice we had planned.

With Government guidance changing by the hour and new issues coming to light throughout, it was difficult to know the best angle and messages to focus on for members. We hope this campaign achieves the right balance, remaining pertinent in the coming weeks.

What key issues will the AOP communications team be working on in the weeks ahead?

Our key focus will be working with teams to develop the guidance, training and resources that prepare members for the new normal. Fair access to Government support schemes for locums and small business continues to be an area we’re acting on for members.

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Suppliers have responded to the evolving needs of practitionersthrough the COVID-19 crisis and for the return to routine practice

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During the coronavirus (COVID-19) pandemic, optometrists have faced the struggle to obtain supplies of personal protective equipment (PPE) as well as considering what a return to routine practice may look like as lockdown restrictions are eased.

A survey by the Hakim Group that explored the changes to practice that owners are considering post-lockdown found over 87.8% of respondents were considering introducing PPE for staff.

Some 62.9% were considering a one-inone-out policy and 56.5% had considered installing a plastic screen in reception.

BiB Ophthalmic Instruments has seen a rise in demand for a number of its products during the lockdown. CEO, Tim Baker, told OT: “We have seen a 10-fold increase in autophoropters given the distancing requirements. As our range of REVO OCTs can be operated from a remote location, this has also resulted in a massive uptake of sales.”

In the spring, the company launched a new slit lamp breath guard, to help minimise the risk of infection and protect staff and patients. Now, as practices consider a future return to routine testing, Mr Baker suggested: “Aside from the addition of protective screens

“As an industry, we are in this together and if suppliers can support their customers with new and innovative products or develop modifications to existing products, then this will be a great outcome” David Thickens, CEO, Grafton Optical

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Equipping the profession

for instrumentation, which we currently provide, the requirement for PPE is of paramount importance.”

Sourcing PPE While recognising that frontline workers have been prioritised for PPE, many optometrists have shared their struggles in sourcing PPE to be able to deliver urgent and essential care. Aiming to help meet these needs, BiB Ophthalmic Instruments is launching a ‘one-stop’ online PPE shop in line with published AOP guidelines on PPE. “We have a very robust supply chain in place and

we are confident we will meet the high demand,” Mr Baker said.

The Local Optical Committee Support Unit (LOCSU) and Primary Eyecare Services also collaborated to launch an online PPE shop for optometrists.

The online shop saw an “unprecedented” demand, with supplies selling out in 24 hours of going live.

Reflecting on the level or orders, Primary Eyecare Services’ CEO, Dharmesh Patel, told OT: “It is clear there is a PPE challenge for the whole sector.”

Mr Patel added that in the first 24-hours of being live, the online store had received orders totalling 1000 boxes of masks, 1000 boxes of gloves, 500 rolls of aprons and 750 face shields.

Practice tools post-lockdown Grafton Optical reported a high level of popularity for products including its slit lamp breaths shields, explained CEO David Thickens: “To date, over 1500 slit lamp shields have been supplied and are in use in opticians and hospitals across the UK and Ireland.”

As practices plan out new customer journeys and adjustments for the sight test, Grafton Optical is looking at ways to help customers adhere to regulations “while allowing them to deliver the same level of service and care as they have always done.”

Demand has been high and “growing” for its counter top hygiene screens, and

Opposite below Essilor Vision-R800 Right Grafton Optical's newly launched Mask-it eye patch

View from the practice Sarah Lowry, Bramhall

its newly-launched Mask-it Disposable Eye Patches described as “perfect for visual fields examinations.”

“We have a portable vision screener which is proving a popular alternative for auto refraction, allowing a one-metre testing distance. We have seen devices such as autophoropters become more popular as practitioners start thinking about the testing process and the need for cleanliness and appropriate distance,” Mr Thickens commented.

Concerning supply chain challenges, Mr Thickens explained: “We anticipated the demand for slit lamp shields quite early on and are working with a local supplier to hold stock of these items to keep up with the demand we are seeing.”

“Demand for Perspex products is obviously exceptionally high across the board at present and many manufacturers are experiencing delays to their normal material supply channels,” Mr Thickens added. As the company’s hygiene screens are produced to order these are subject to longer lead times.

Going forwards, Grafton Optical said it would be taking its lead from guidance and customer feedback. Mr Thickens said: “As an industry, we are in this together and if suppliers can support their customers with new and innovative products or develop modifications to existing products, then this will be a great outcome from this situation.”

Shifting demand as practices adapt Essilor has noted a shifting demand for its services during the lockdown, with a rise in interest for equipment that can support social distance measures.

“We have seen an increased demand for equipment, such as phoropters and other measuring equipment that respect social distancing requirements,” commented Tim Precious, managing director at Essilor. He suggested using

“The visors have definitely helped me feel more comfortable… This helps me focus more on the job I’m supposed to be doing” Twinkle Patel, practice owner

equipment that can be operated at distance will help to limit contact and “put everyone’s minds at rest.”

“The pandemic will likely change the way we conduct eye examinations forever and while many practices have been putting measures in place to minimise social contact between patients and staff, another way to achieve this is to consider adopting new advances in technology,” Mr Precious suggested.

The company has made several pieces of optical equipment available on deferred payment terms to help support practitioners to conduct eye examinations, take lens measurements and perform eye health screenings while meeting social distancing requirements.

Mr Precious said of the scheme: “We appreciate that cash flow could be an issue in the future and we want to do everything we possibly can to make it easier when business starts returning.”

As countries begin to ease lockdown restrictions, Mr Precious reflected on the changing levels of demand, commenting: “Where easing measures have been implemented in Europe, Essilor has been seeing increased order volume and we believe this provides some hope for UK eye care professionals that business will resume when restrictions are lifted.”

“I managed to order some FFP2 masks and a patient who is a supplier gave me four respirators I can rotate. It took some time, but our LOC managed to provide those of us open with some PPE. On top of this, a friend is kindly making me scrubs, I’ve had a donation of gloves from another patient and my face shield came from donors. Although I’m relieved to have some PPE, when this runs out I don’t know where this next batch is coming from, and I don’t wish to stockpile and make the situation worse.”

Twinkle Patel, Holbury “Sourcing PPE was really difficult, especially at the beginning.

Through social media I came across one of my patients who was making reusable visors. I asked if he could drop one by and I have been using it since.

“I sent out an email to ask if other optometrists wanted a visor. I had over 40 requests.

“The visors have definitely helped me feel more comfortable. I do have the slit lamp shields, but even when doing a refraction, the visor creates a barrier that makes me and the patient feel more comfortable. This helps me focus more on the job I’m supposed to be doing.

“If you can, find somebody in your community that you can team up with to get your PPE. The donations I’ve received for the visors are going back to the gentleman who made them to buy more materials.”

Stewart Mitchell, Bradford “There is the consideration of how we will bear the cost of these measures.

It creates an added layer of expense which could affect the viability of some practices. I think with the cost burden, plus the drop in patients, certainly in the short-term I can’t see us getting back to normal for quite a while.”

June/July 2020

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Staying connected

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Johnson & Johnson Vision has created a series of interactive webinars to help practitioners develop skills while gaining CET points, with live sessions offering insight into key topic areas such as physical and visual comfort. J&J Vision are also launching an eight-part live web series to explore the progress of efforts to create a potential vaccine and treatments for COVID-19 that it hopes will be of interest to all health care professionals. jnjvisioncare.co.uk/alleducational-opportunities

FOCUSES ON...

ONLINE LEARNING

SUBS ART PRODUCTION

Hit list list

The trends, launches and looks

CLIENT

Slit lamp training

Haag-Streit UK has launched a series of virtual training courses on the Haag-Streit Academy E-learning Portal. The series kicked off with a slit lamp course split into four topics consisting of interactive modules, user guides and training videos. The course covers ‘Slit Lamp Basic Skills,’ ‘Slit Lamp Imaging,’ a ‘Haag-Streit Diagnostics Video Series’ and ‘EyeSuite User Guides.’ haagstreitacademy.talentlms.com

Preparing for tomorrow

Zeiss has produced online training programmes to bring its CET resources to customers. The webinars cover topics including UV protection, driving and vision, dispensing, and optical theory and visual conditions. Due to levels of interest in the training, Zeiss are planning on releasing more sessions and additional content. zeissportal.co.uk

Marketing skills

Essilor has launched a webinar programme to provide product and digital marketing training.

Skills covered include how to use pay per click, social advertising and search engine optimisation when communicating with patients. The webinars are running as part of a wider support programme featuring CET training and resources, website analysis and group discussions. Practices can gain monetary credits for completing each webinar. essilor.com/en

AOP webinars and recordings

The AOP is running regular webinars to keep members updated on topics relating to COVID-19 and has compiled recordings and slides from these webinars on a dedicated area of the website. Webinar recordings include clinical and professional guidance, locum advice and information on managing mental health, as well as a discussion on delivering urgent and emergency care during the outbreak. aop.org.uk/coronavirus-updates/aop-covid19-webinars

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LOOK

Q&A ME AND MY GLASSES

Optometrist and lifestyle blogger, Lizzy Yeowart, takes a look at QHRQ R HULQJV

SUBS ART PRODUCTION

Zing away

CLIENT

Robert Sands

The ‘Speed Up’ by Woow looks spectacular as both an optical and as a sun. Own the spotlight because this zingy yellow can turn heads from beach to back garden.

Woow, ‘Speed Up’ www.designeyeweargroup.com/en

The frame stylist and manager at The Spectacle Factory considers how the perception of glasses is changing

1Â

3Â

2Â

4Â

I own six pairs of spectacles and 10 sunglasses. I choose mainly round shapes for general wear or aviators for a more dressed-up look. Within my glasses collection I have shades of tortoiseshell, a green leather pair, and a pair which are mainly red.

A lot of people don’t put enough thought into their eyewear.

I feel it’s our role to make people rethink the impact their glasses can have on their overall DSSHDUDQFH DQG RXWÀWV 7KH majority of patients I see now are open to having multiple pairs for GL HUHQW W\SHV RI ZHDU RXWÀWV RU uses. Glasses are now something people want to have.

My favourite glasses are a pair of JF Rey’s ‘Double Jeu’ frames.

7KH\ KDYH WZR ÀQH PHWDO frames, one square and one round, in contrasting colours and fused together for a really cool and unique, DOPRVW ' H HFW Like many, we’ve been pretty severely affected by the COVID-19 outbreak. We are fortunate that we moved into a new store in January. It’s ultramodern, easy to sterilise and is also very spacious, allowing us to maintain social distance. We have on-site manufacturing so we’re able to help patients in need of emergency glasses.

Hola Mexicana

This openwork design in bright blue was inspired by Mexican culture. The removable pendant on the rim is a sacred heart or an inverted spike, depending on the wearer’s interpretation.

Jean-François Rey, Boz, ‘Jana’ in blue www.jfrey.fr/en

Outrageous and edgy

Theo Eyewear is a Belgian eyewear brand known internationally for its distinctive and trendsetting designs. The resulting frames are outrageous and edgy with bright colours that are playful, happy and quirky.

Theo Eyewear, ‘James’ in neon pink www.theo.be

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Frames

A vintage affair

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Salvatore Ferragamo has introduced its new Spring/ Summer 2020 eyewear collection for men, combining vintage styles with bright materials and embellishments.

The collection includes five sunglasses and two optical frames. The SF224S round sunglasses feature a double bridge detail and textured effect on the lower side. The sides are customisable with an enamel or Havana foil to match the colour of the frame-front rims. www.ferragamo.com

SHORTLIST THE LATEST PRODUCT LAUNCHES

SUBS

Sunglasses

Eco-friendly sunglasses ART PRODUCTION

Austrian eyewear brand, neubau, has unveiled its first 100% biobased line of eyewear. The sunglasses collection is made from natural3D, a plant-based material made in a 3D printer. The Côte du Soleil special edition line draws inspiration from the 1960s and features three models; ‘Romy,’ ‘Alain’ and ‘Maurice,’ named after characters in the 1969 film ‘Las Piscine.’ www.neubau-eyewear.com

CLIENT

Drops

Allergy relief Scope Eye Care has launched Optase Allergy. The new product is designed to prevent and treat the symptoms of allergic conjunctivitis: itching, redness and excessive watering. Created with the naturally-occurring molecule, Ectoin, the formulation strengthens the lipid layer to prevent cracks and dryness on the surface of the eye. The solution also helps to create a protective shield over the bottom layer of the eye, closest to the cornea. www.scopeeyecare.com

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Sunglasses

Diamonds are forever Independent designer, LARA D’, has introduced four new sunglass models for women featuring a natural 24k diamond powder decoration on dark UV protective lenses. Inspired by the cuts of a gem stone, the sunglasses use a 4mm thick lens with facets cut on the surface. With names drawn from Egyptian history, the four models come in gold with brown, black or mirrored gold lenses. www.laradeyewear.com

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

Material

Super light Okia has presented a new ultra-light eyewear collection made from a material called Suflexium, a magnesium aluminium alloy. Designed to be “weightless,” the metal offers high strength and lightness and is one-third of the weight of steel. The material also includes a hypoallergenic feature as well as being resistant to corrosion from facial acids. www.suflexium.com

Lensi

Astigmatism lens Bausch and Lomb has extended the parameters of its Biotrue Oneday for Astigmatism lens, with the new cyl, -2.25, now available to practitioners. The lens utilises Surface Active Technology which uses hydrophilic polyvinylpyrrilidone and Poloxamer 407, a surface active macromer, to form a dehydration barrier that helps the lens maintain 98% of its moisture for up to 16 hours. www.bausch.co.uk

Framesi

Titanium design Blackfin One has revealed three new optical frames; ‘Homewood,’ ‘Vicksburg,’ and ‘Anfield,’ featuring titanium designs in rich colour combinations. The classic men’s style ‘Homewood’ has been reinterpreted with two-tone colour combinations including green/grey, blue/grey, blue/red, blue/dove grey and black/green.

The rounded rims of the unisex ‘Vicksburg’ reclaims the original Blackfin colour pairings and the feminine frame, ‘Anfield,’ features oval rims in a range of hues. www.blackfin.eu

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FOCUSES Q&A ON...

BEHIND NEW THE BRAND WOMEN’S EYEWEAR

COOPERVISION SUBS ART

Country manager of UK and Ireland, Doug Bairner, shares how the company has been operating during the COVID-19 outbreak

COOPERVISION

PRODUCTION

// 1

CLIENT

2 3

How has COVID-19 affected CooperVision?

CooperVision is focusing on supporting employees and customers. We implemented continuity plans by positioning supply to mitigate any potential disruption in production. With in-store pick up of contact lenses being difficult, direct-to-patient home deliveries are more practical. The established VisionXtra scheme continues to support home deliveries for patients.

What do you hope to provide with the launch of CooperVision’s e-learning platform?

The contact lens company has over 12,000 employees supporting distribution in over 100 countries CooperVision has partnered with Optometry Giving Sight and has donated $2.6 million (almost.£2.1 million) Each of the company’s watermark logos are slightly different to reflect the unique needs of the customers and wearers.

The launch of CooperVision Learning Academy was brought forward to support training through the outbreak. This is an unnerving period of change for everyone at the moment, but time away from the daily routine is also an opportunity for self-development, to improve our knowledge and to focus on the future.

What are the company’s main considerations for the next 12 months?

The short-term focus is on helping our customers retain their contact lens patients. As stores reopen, returning to a level of contact lens fitting and aftercare normality will be key to practices and the health of patients.

Clockwise from top: CooperVision Learning Academy platform; country manager, UK & Ireland, Doug Bairner; CooperVision is continuing myopia management education through virtual sessions

STYLE

NOTES Each month, OT columnist, Lizzy Yeowart, considers a dispensing scenario.

This month: eyewear for a 35-year-old mum

Sixties chic

The ‘Riviera’ by Aspinal of London embodies the essence of 1960s glamour.

Handcrafted from highly polished Italian acetate, this confident style features Aspinal’s iconic gold shield at the temple.

Aspinal, ‘Riviera’ www.eyespace-eyewear.co.uk

Lizzy says "Summer is the time for every mum to shine. Whether she is planning a workout in the garden or to join friends for a Friday night virtual dinner party, your eyewear deserves to be on-point."

Taking off

For all-action mums, Red Bull SPECT eyewear has a strong focus on technical innovation and usage in high performance sports. With sophisticated functional elements designed to fit the needs of top athletes, let’s hope they give her wings.

Red Bull Spect, ‘Sonic’ us.redbullspecteyewear.com

June/July 2020

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What is your view?

Email OT with your comments newsdesk@ optometry.co.uk Journal of the Association of Optometrists

In practice Contactless consultations Page 46

years

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CET Fixation disparity and associated phoria

Perspectives Protecting the next generation of optometrists

In practice Locum optometrists respond to COVID-19

Page 60

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Coronavirus support

Visit the AOP’s dedicated section for members available online www.aop.org.uk/ coronavirus

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Now is the time for optical professionals to re-engage with patients and evolve to meet their eye care needs Sofia Fazal

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here have been many moments in history that have shaped the world we know today.

We are all united in disbelief at the impact the coronavirus (COVID-19) pandemic is having globally, taking thousands of lives and changing the world forever. The long-term impact of this virus is GL FXOW WR FRPSUHKHQG :H KDYH DOO EHHQ D HFWHG emotionally, mentally and economically. Many are feeling fearful and uncertain as each day unfolds.

Re-opening our practices and re-commencing our duties as eye care practitioners is something we look forward to, but there is a sense of nervousness and concern as we plan for practising in the world post lockdown. What will this new era of optics bring for us and our patients? “We must strive to Now is the time for optical optimise and improve professionals to evolve and take our procedures WKH RSSRUWXQLW\ WR UHGHĂ€QH RXU and processes, to ZD\ RI ZRUNLQJ ² WR GHĂ€QH D ‘new normal.’ When refocusing reassure our patients on delivering best practice, we and strengthen our shouldn’t look to completely practicesâ€? change what we do, but instead to UH GHĂ€QH LW $V DOZD\V ZH PXVW strive to improve our procedures and processes, to reassure our patients and strengthen our practices.

Now, more than ever, we must build our patients’ trust and belief in our safe provision of eye care, and optical products and services. We will succeed LQ WKH QHZ QRUPDO LI ZH EXLOG WKH FRQÀGHQFH RI our patients by clearly showcasing the hygiene and social distancing processes, protocols and guidelines established within our practices at every stage of the patient journey. Clear communication about the safety measures we are taking is vital for ensuring both employees and patients feel safe and comfortable to return to practice.

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CLIENT

Get involved Read more about the AOP’s Eye care essentials campaign www.aop.org. uk/our-voice/ campaigns

Time to adapt $V ZH UH HQJDJH ZLWK RXU FXVWRPHUV DQG VWDUW WR recover, gradually shaping our new normal, we need to embrace what the future holds. During this time, it has become evident that staying connected with our patients is an absolute necessity. Where we may previously have overlooked making our

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businesses visible on an online platform, we should now invest in online services and embrace digital marketing. It is clear that the use of online services has and continues to be invaluable during this time, and something the public have wholeheartedly accepted.

The need to adapt and become more digital is an essential part of everyday life. Being able to connect online with your patients and suppliers will be key for developing sustainable businesses for the long-term.

Selling of spectacles online has been something many of us have been opposed to, but we should now look at how we can adapt our own businesses to be more online – whether this is through conducting social media advertising, customers choosing frames virtually, provision of contactless dispensing in practice, remote consultations, or the ability to order virtually. $V PRUH SHRSOH ZLOO EH ZRUNLQJ UHPRWHO\ DQG with many opting to conduct business virtually, we may see an increase in patients presenting with symptoms of digital eye strain. Being able to guide these patients and suggest suitable

solutions to support them will provide us with more dispensing opportunities. We must build on the forward-thinking digital and technological progress that has been made during this time and take this opportunity to transform our businesses.

This is not a time to stand still and wait to return to our previous normal. It is a time to challenge ourselves, to strengthen our service delivery and strive for excellence and growth.

Sofia Fazal is an optometrist and professional services manager at Zeiss Vision Care UK/Ireland

As the situation escalated, old professional boundaries in our hospital became an irrelevance Dr Waheeda Illahi

H

ere in the Midlands, we have seen one of the highest number of deaths associated with the coronavirus (COVID-19) pandemic. The Birmingham & Midland Eye Centre (BMEC) is a supra-regional tertiary referral centre accepting ophthalmology referrals from a large geographical area. It is also part of the Sandwell & West Birmingham NHS Trust (SWBH), located in a region that has become one of England’s COVID-19 hot spots. $V WKH QXPEHU RI GHDWKV VWDUWHG WR LQFUHDVH and the country went into lockdown, SWBH immediately started to expand its intensive care unit capacity. Within days, trauma, cancer, maternity and paediatric services were relocated to provide capacity for increasing demand of LQWHQVLYH FDUH EHGV 0DQ\ WKHDWUH VWD IURP BMEC were re-deployed to support the frontline. $OO HOHFWLYH VXUJHU\ ZDV SODFHG RQ KROG DQG DV WKH VLWXDWLRQ LQWHQVLÀHG WKH RQO\ H\H ZDUG supporting all of the ophthalmology departments in the region was closed and emergency ophthalmic in-patients were moved to general wards and sub-divided into COVID and nonCOVID. Uncertainty and the rapidly changing situation fuelled the anguish of the early days as heads of services became aware of the reality of re-deployment of their teams to support an anticipated surge in COVID-19 patients.

With schools and community optometric practices closing, patients stopped attending their hospital outpatient appointments and parents chose not to bring their children for fear of catching the virus. The number of patients DWWHQGLQJ H\H FDVXDOW\ DOVR UHGXFHG VLJQLÀFDQWO\ Being part of a large acute trust with rapidly developing COVID plans meant that, as the situation escalated, professional boundaries became irrelevant and ophthalmology services could no longer remain in isolation from the trust’s contingency response. There was a real fear of the unknown, in particular a fear of what risks VWD PD\EH H[SRVHG WR 3URSRVDOV ZHUH PDGH IRU optometrists, orthoptists, clinical scientists and

RWKHU $+3V WR EH UH GHSOR\HG WR UHSODFH QXUVLQJ VWD VR WKDW WKH\ FRXOG PRYH WR WKH IURQW OLQH Heads of service were given the task of XQGHUWDNLQJ RQH WR RQH PHHWLQJV ZLWK VWD WR inform them that they were likely to be re-deployed DQG LQ VRPH FDVHV KDG WR GLVFXVV KLJKO\ FRQĂ€GHQWLDO KHDOWK LQIRUPDWLRQ ZLWK VWD ZKR SRWHQWLDOO\ UHTXLUHG VKLHOGLQJ 6WD ZHUH WKHQ H[SHFWHG WR inform their families that they may be redeployed into high risk COVID zones. It was not known where they would go or when.

Everything stopped except urgent patients as emergency standard operating procedures were adopted. The optometry department continued to see bandage and extended contact lens wearers, the orthoptic department continued to support stroke and urgent paediatric and neuro-ophthalmology patients, and the vision science team continued to perform urgent ultrasound scans.

Where we are now?

In our hospital, two full time optometrists continue to support hospital wards containing COVID SDWLHQWV $FWLQJ LQ DQ DGPLQLVWUDWLYH UROH WKH optometrists provide vital links to relatives and other health professionals where there is restricted access to the ward. For patients who are unwell, the optometrists help with “The pandemic dialling telephones and facilitating will permanently video conferences with family members. affect the 6WD KDYH GHPRQVWUDWHG D Ă H[LEOH provision of and adaptable approach, providing a ophthalmology surprisingly stoic and philosophical services in the response. They have adapted to working LQ D GL HUHQW PXOWL GLVFLSOLQDU\ WHDP future. There adjusting to the dynamics of a hospital will be increased ZDUG DQG KDYH JDLQHG D GL HUHQW VNLOO VHW use of artificial $V FRPPXQLW\ SUDFWLFHV FRQWLQXH WR intelligence, remain closed for routine sight tests, the virtual telephone hospital optometry department is starting to resume paediatric refractions in addition and video to urgent contact lens assessments. Urgent reviewsâ€?

SDWLHQWV ZKR KDG EHHQ ÀWWHG ZLWK FRPSOH[ contact lenses but needed to be seen for their teaching session prior to lenses being issued will be given priority and reviewed in the coming days. $OPRVW HYHU\ SDWLHQW RQ WKH RSWRPHWU\ ZDLWLQJ OLVW has received a telephone consultation.

7KH &29,' FULVLV KDV D HFWHG PDQ\ VHUYLFHV LQ RSKWKDOPRORJ\ $V WKH UHJLRQ¡V RQO\ SDHGLDWULF OT on the ground Professionals in ocular electrophysiology service, where children optics share their of all ages are referred from as far away as the experiences of Welsh Coast and Derbyshire, we have had to put COVID-19 this unique service on hold. This has been a very www.optometry. stressful time for the parents of these children. co.uk/coronavirus

December 2017 June/July 2020

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7KH SDQGHPLF ZLOO SHUPDQHQWO\ D HFW WKH provision of ophthalmology services in the future.

7KHUH ZLOO EH LQFUHDVHG XVH RI DUWLÀFLDO LQWHOOLJHQFH virtual telephone and video reviews – already useful for children post refraction to check on compliance with glasses wear and in services such as low vision in order to reduce patient visits to hospitals.

In the immediate future, ensuring social distancing in waiting areas, appropriate and DGHTXDWH 33( DQG UHJDLQLQJ SDWLHQW FRQĂ€GHQFH remain the challenges for heads of service. The increased pressure on individuals has highlighted the value of sharing problems, discussing solutions, and the ongoing need for a team approach.

SUBS ART

Dr Waheeda Illahi is head of optometry services at Birmingham and Midland Eye Centre. The article is co-authored by Rosie Auld CBE, head of orthoptic services, and Dr Peter Good, consultant neurophysiologist PRODUCTION CLIENT

The future we had envisaged as a long-term shift is accelerating toward us at a rate of knots Lesley Longstone

T

AOP webinars Go online to view and book onto AOP online events www.aop.org. uk/events

he coronavirus (COVID-19) pandemic has had a massive impact on the optical sector – and on the General Optical Council (GOC).

Following Government guidance, we closed RXU SK\VLFDO R­FH RQ 0DUFK DQG VKLIWHG LQWR remote delivery of our core regulatory functions.

In May, we successfully closed the annual renewal process, dealing with more than 3000 calls from registrants wanting to understand their options. The result was registration levels on a par with what we would expect in any other year.

Remote meetings are the norm now, with weekly NHS and sector body meetings focused RQ &29,' WKURXJK WR RXU DOO VWD DQG &RXQFLO PHHWLQJV EHLQJ KHOG UHPRWHO\ IRU WKH ÀUVW time ever in May. ,¡P SURXG RI WKH ZD\ VWD DW WKH *2& KDYH responded to the triple challenge of continuing to exercise our regulatory responsibilities, the overnight shift in ways of working, and most importantly the need to support the sector in responding to the additional challenges that COVID-19 has brought. We agreed early on that we needed to prioritise work that would enable the sector to respond to the challenge of

38 www.optometry.co.uk

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COVID-19, removing any regulatory barriers that might prevent our registrants from doing the right thing to protect the public in line with Government advice. While our standards of practice remain the same, we recognised in these extraordinary circumstances that our normal expectations about how they are delivered might not be sensible or even possible.

To address this, we issued a joint regulatory statement outlining how we will regulate during this time, and consulting with professional bodies, released further statements on areas such as the supply of spectacles and contact OHQVHV DQG ZRUNLQJ LQ GL HUHQW VHWWLQJV 5HDGHUV FDQ ÀQG RXU VWDWHPHQWV DQG WKH ODWHVW information on our dedicated COVID-19 page on www.optical.org.

The future in fast-forward Many of our statements leave room for professional judgement, as no two situations ZLOO HYHU EH WKH VDPH :H GRQ¡W ZDQW WR restrict our registrants from doing the right thing by being too prescriptive and have made the commitment that when they act LQ JRRG FRQVFLHQFH IRU WKH SXEOLF EHQHĂ€W exercising professional judgement in all of the circumstances that apply, we “We agreed early will support on that we needed them. to prioritise work The that would enable implications of the sector to respond COVID-19 for to the challenge of our Education Strategic COVID-19, removing Review are any regulatory profound. The barriers that future that we might prevent our envisaged as registrants from a medium to doing the right thingâ€? long-term shift is accelerating toward us at a rate of knots, attaching greater urgency to the work. At the same time, we recognise that there are so many other pressures on our education providers and the sector at large that we need to work at a pace that will enable them to engage and importantly, enable us to learn from the COVID-19 experience and what is happening right now in practices, urgent care centres and hubs across the nations.

Lesley Longstone is chief executive and registrar at the General Optical Council

MY VISION

“My teachers were hesitant about me participating in running�

Souleyman Bah

W

hen I moved to the UK from Guinea, I had to learn English. One of the best ways for me to communicate with the other children was through sport. I would play football and basketball, learning words here and there.

Sports day in secondary school was when I really discovered that I had a talent for sprinting. My teachers were hesitant about me participating in running because of my visual impairment living with the rare genetic eye condition, retinitis pigmentosa (RP).

I persisted and not only did I win the race, I broke the school record.

Some of the highlights in my sport include winning a gold medal at the junior Paralympics in Brazil in 2015.

It was an incredible moment For athletes, we stay in the gym, we are always training and no one hears from us. To have that recognition DQG WR KDYH WKDW FRQĂ€GHQFH that someone believes in you and wants you to represent your country was an overwhelming feeling.

Over the years we have had to make a lot of adjustments to help me train successfully without being injured. The biggest risk at the start was running into other people who were training on the athletics track.

7KHUH ZHUH D ORW RI FROOLVLRQV ZKLFK KDG DQ H HFW RQ P\ FRQÀGHQFH , GLGQ¡W ZDQW WR UXQ DV IDVW DV , FRXOG I currently run the 100 metres in 11 and a half seconds DQG , ZRXOG OLNH WR VKDYH WKDW GRZQ WR VHFRQGV à DW 7KDW ZRXOG SXW PH DURXQG ÀIWK LQ WKH ZRUOG I think my biggest challenge with RP, especially because it is degenerative, is that when I feel comfortable with the sight as it is, I will wake up in a ZHHN RU D PRQWKV¡ WLPH DQG WKDW VLJKW KDV UHGXFHG ,W LV constantly readjusting and that can have a bit of impact

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

on motivation and mental health. You feel like you are having to chase constantly and continually adapt as a person. At the same time, it can build strength EHFDXVH \RX DUH DOZD\V DEOH WR DGDSW LQ GL HUHQW VLWXDWLRQV DQG ÀQG ZD\V DURXQG WKLQJV 0\ DWWLWXGH WR OLYLQJ ZLWK 53 KDV GHÀQLWHO\ FKDQJHG over the years.

Before I found sport and athletics, I really found it to be something negative that stopped me from doing things. I was told that I ZDVQ¡W JRLQJ WR EH DEOH WR drive and do so many things in society like everyone else.

It seemed like a barrier and a block.

Finding the Paralympics – being able to train and win – changed my attitude to believing that RP is something positive that I can utilise to inspire other people.

9LVLRQ ORVV LV YHU\ GLÂ?FXOW to live with but it is also something to embrace and realise that it is what makes you unique and special.

“To have that confidence that someone believes in you and wants you to represent your country was an overwhelming feeling�

There is so much out there now that can support you to do whatever you want to do in life, whether that is having a full and complete education, thriving LQ D MRE DQG FDUHHU RU UHDGLQJ D ERRN ,W¡V LPSRUWDQW WR embrace those tools and the individuals out there who have made it their mission to help and assist you to OLYH D IXOÀOOHG OLIH

Souleyman Bah, 21, is a para-athlete and entrepreneur. He appeared in the 2019 season of The Apprentice and won gold in the 100m at the Paralympic School Games in Brazil in 2015.

June/July 2020

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45 The workshop SUBS

The AOP’s Roshni Kanabar explains how practitioners should handle remote consultations

48 Key milestones

How the COVID-19 Urgent Eyecare Service (CUES) can equip practices for the future

The Discussion, 1

VERSION

In practice

Business insight and career development

49 Pre-reg focus

Making the most of education, revision and downtime after being furloughed during pre-reg

ART PRODUCTION CLIENT

Back to work priorities Optometrist and OT clinical editor for multimedia, Ceri Smith-Jaynes, and East London practice owner, Simon Rose, discuss what independent practices need to do to protect their businesses in the next few months

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s lockdown restrictions in the UK ease, thousands of optometrists will be wondering how best to navigate the weeks and months ahead.

For independent practice owners, the near-future might appear especially daunting. Practices will now

Four locum optometrists tell OT how their days have changed and what they’re doing to cope

Returning staff

“We are going to have to change the way we work completely�

Simon Rose, who has practices in Essex and in Hackney, believes that adjusting to new ways of ZRUNLQJ ZLOO EH KLV Ă€UVW challenge. After furloughing VWD DGMXVWPHQWV PDGH WR his own working patterns have made him reassess how he was running his practices previously. He found that he can take on more work himself than he had realised, and now believes that his practices can never go back to their old way of operating. “We’re going to have to change the way we work completely,â€? he said. “I don’t think we’ll ever answer the phones in the practice again – VRPHRQH FRXOG GR WKDW R VLWH I think that’s really important, because then we can focus on the patients in the practice.â€?

From an optometrist perspective, Ceri Smith-

Jaynes believes that the near future will feel austere, partly due to unpredictable patient numbers and insecure Ă€QDQFHV She explained: “The practice may not have HQRXJK ZRUN IRU DOO WKH VWD to return to their usual hours DW Ă€UVW ,¡P QRW VXUH LI ZH¡OO have a tidal wave of patients with pathology to deal with, RU LI ZH¡OO Ă€QG WKDW SHRSOH don’t present to the practice for fear of proximity and we end up very quiet. “I expect the purse strings will be pulled tight; we can’t expect new equipment, ERQXVHV SD\ ULVHV DQG VWD parties. We may have to be Ă H[LEOH ZLWK ZRUNLQJ KRXUV HVSHFLDOO\ DV VWD MXJJOH ZRUN and childcare arrangements,â€? said Ms Smith-Jaynes,

case of an increased demand for remote consultations in the future.

THE DISCUSSION

50 Life as a locum

Simon Rose

need to set their priorities, both in the short and longer term. That might include DGMXVWLQJ WR VWD UHWXUQLQJ to work, adapting to new behaviours and expectations from customers and patients, and ensuring their technology is up to scratch both for marketing and in

June/July 2020

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The Discussion, 2

IN PRACTICE VERSION

The discussion Simon Rose with the Optopol Revo FC, which he has found helpful during the lockdown

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42 www.optometry.co.uk

DQG H[SODLQ WKDW ZH KDYH FOHDQHG WKH FKDLU OHQVHV DQG HTXLSPHQW µ

“Multi-channel communication with patients will be crucial, reminding them of the relationships we have built over the years and the service we offer” Ceri Smith-Jaynes

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June/July 2020

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AOPHouseRavi

VERSION REPRO OP SUBS ART PRODUCTION CLIENT

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91OPTJUN20155.pgs 02.06.2020 18:05

High, 1 VERSION REPRO OP SUBS

My career had been varied, but the one thing that I hadn’t done since I was a pre-reg was work in the hospital setting. When HOW I GOT HERE

ART

“My career in optometry happened by accident�

PRODUCTION

Hospital optometrist at the Manchester Royal Eye Hospital, Jeremy Parkes, discusses a varied career and finding fulfilment in a macular clinic My career in optometry happened by accident.

CLIENT

, KDG FRPSOHWHG D ELRORJ\ GHJUHH DQG ZDV PHDQW WR JR RQ WR GR D 3K' EXW WKH IXQGLQJ ZDV FXW 2QH of my friends was an RSWLFLDQ ZRUNLQJ IRU D VPDOO LQGHSHQGHQW JURXS ZKRVH GLVSHQVLQJ RSWLFLDQ FRPH UHFHSWLRQLVW KDG JRQH R sick. I went into the practice to help out for a month or VR 2QH WKLQJ SURJUHVVHG WR another and I went to the businesses’ Christmas party, GXULQJ ZKLFK WKH GLUHFWRUV R HUHG WR VSRQVRU PH WR JR back to university to complete DQ RSWRPHWU\ GHJUHH ,W ZDV a pure accident; I had never considered optometry before, EXW P\ H[SHULHQFH ZLWK WKH practice meant that I knew H[DFWO\ ZKDW , ZDV OHWWLQJ myself in for.

I completed my prereg placement with an independent practice and

did one day a week at an eye hospital. 2Q TXDOLĂ€FDWLRQ ,

44 www.optometry.co.uk

became a locum because it allowed me to travel. I did that for around four years.

One of my friends was keen on going down the Specsavers partnership route and talked me into joining him. I was a practice

GLUHFWRU IRU DURXQG ÀYH \HDUV :KLOH LW PDGH PH ÀQDQFLDOO\ secure, life in practice wasn’t DV IXOÀOOLQJ DV , ZDQWHG LW WR EH ² , ZDV ZRUNLQJ VL[ DQG D half days a week.

On selling up I went to New Zealand and taught optometry at Auckland University for a year. It was great; I loved the lifestyle. While I had the

RSSRUWXQLW\ WR H[WHQG P\ contract, I had family reasons to return to the 8. , VSHQW WKH QH[W \HDU DV D PDQDJHU DW WKH YLVLRQ centre at UMIST (now the University of Manchester). +RZHYHU , ZDV VWLOO VHHNLQJ D IXOÀOPHQW WKDW , ZDVQ¡W JHWWLQJ

an opportunity came up, I applied and secured a job at Manchester Royal Eye Hospital, where I have been for the last 15 or so years.

What I like about hospital optometry is the colleagues I work with and being at the cutting edge of what I do.

,Q P\ ÀHOG ZKLFK LV PDFXODU treatment, when I started, we ZHUH SURYLGLQJ ODVHU WR WU\ and save patients’ peripheral vision. Today we are able to maintain people’s vision at WKH OHYHO WKH\ DUH GLDJQRVHG ZLWK VRPHWLPHV HYHQ PDNLQJ LW EHWWHU ,W¡V JUHDW WR ZRUN in that environment and IHHO WKDW \RX DUH PDNLQJ D GL HUHQFH A career highlight was definitely five years ago when the Macular Society named me Optometrist of the Year. 0\ FROOHDJXHV KDG

nominated me without me NQRZLQJ ,W ZDV UHDOO\ QLFH WR EH UHFRJQLVHG LQ WKLV ZD\ ,W FDPH DV DQ DPD]LQJ VXUSULVH If there was one thing I would change about optometry it would be the funding. This public

XQGHUIXQGLQJ GRHVQ¡W ZRUN We need a means by which we can tap into a health VHUYLFH EXGJHW DQG EH WUXH primary care providers.

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

CORONAVIRUS: THE IMPACT Working in a hospital setting during the COVID-19 outbreak, it is incredibly quiet – we have cut all nonessential treatments.

While my particular area, the macular clinic, is still functioning as we must continue to deliver anti-VEGF injections to patients, appointments have been streamlined so that patients spend minimum time in the hospital.

It’s a very bizarre and unusual environment to be in. I am used to working in clinics where you have waiting rooms full of people; you are constantly seeing patients and constantly talking to patients.

Right now, we are in a position where we must try to minimise the time we spend with the patient as much as possible to prevent potential contamination.

In terms of uncertainties, nobody knows what is going to happen. Could we [hospital optometrists] be redeployed?

Will they ask us to perform nurse-type roles? As professionals we are trained and know about healthcare procedures, after all.

June/July 2020

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THE WORKSHOP

ART

Using remote consultations Each issue, OT poses a scenario from a practitioner.

Here, we look at how to manage remote consultations

PRODUCTION

The scenario

CLIENT

Paul, AOP member “I’m a pracice owner with a number of patients who are likely to be shielding for the foreseeable future. I’d like to get a strong system for remote consultations in place, for when these patients can’t visit the practice in person.

I’d like more information on how I can ensure my recordkeeping is effective during remote consultations, as well as how to communicate with patients in this way.�

The advice Roshni Kanabar, clinical and regulatory adviser at the AOP and optometrist Setting up the call

GOC standards require registrants to communicate H HFWLYHO\ ZLWK WKHLU SDWLHQWV DQG WKLV LV HVSHFLDOO\ LPSRUWDQW ZKHQ JLYLQJ DGYLFH UHPRWHO\ <RX VKRXOG VHW XS \RXU ZRUNVWDWLRQ LQ D SULYDWH URRP ZKHWKHU DW KRPH RU DW ZRUN DQG PDNH VXUH EDFNJURXQG QRLVH LV PLQLPDO (QVXUH \RX DUH IDPLOLDU ZLWK DQ\ VRIWZDUH \RX DUH XVLQJ EHIRUH WKH FDOO DQG LI SRVVLEOH WU\ WR HQVXUH \RX KDYH DFFHVV WR

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LQIRUPDWLRQ VXFK DV OHDà HWV on managing conditions RU LQIRUPDWLRQ DERXW WKHLU UHIHUUDO LI DSSOLFDEOH 7KH $23 KDV GRZQORDGDEOH OHDà HWV RQ WKLV ² DYDLODEOH DW ZZZ DRS RUJ XN SDWLHQWV ² WKDW FRXOG EH VHQW WR SDWLHQWV :KHQ VHQGLQJ information, use a secure HPDLO ZKHUHYHU SRVVLEOH .HHS D UHFRUG RI DQ\ SDWLHQWV ZKR QHHG IROORZLQJ XS ,I \RX KDYH UHIHUUHG D SDWLHQW IRU XUJHQW LQYHVWLJDWLRQV FRQWDFW WKH SDWLHQW DQG RU VHUYLFH SURYLGHU WR HQVXUH appropriate arrangements KDYH EHHQ PDGH ZLWKLQ DQ DSSURSULDWH WLPHIUDPH Record keeping

(QVXUH \RX PDNH D FOHDU UHFRUG RI WKH SDWLHQW¡V V\PSWRPV \RXU GLVFXVVLRQV DQG DQ\ DGYLFH JLYHQ LQFOXGLQJ SDWLHQW OHDĂ HWV RU UHIHUUDO OHWWHUV WKDW \RX DUH VHQGLQJ 0DNH LW FOHDU WKDW WKLV LV D UHPRWH FRQVXOWDWLRQ DQG LI WKHUH DUH DQ\ VSHFLDO FLUFXPVWDQFHV $Q\ HPDLO FRUUHVSRQGHQFH ZLWK WKH SDWLHQW VKRXOG EH LQFOXGHG DQG VWRUHG ZLWK WKH FOLQLFDO UHFRUGV :H GR not recommend recording WKH FRQVXOWDWLRQ XQOHVV \RX KDYH IXOO\ FRQVLGHUHG DOO WKH FRPSOH[LWLHV DURXQG WKLV DQG WKH SDWLHQW KDV FRQVHQWHG ,I \RX QHHG WR PDNH ZULWWHQ QRWHV ZKLOH ZRUNLQJ IURP KRPH Ă&#x20AC;OH WKHVH DZD\ LQ D ORFNHG FDELQHW VR WKDW WKH\ UHPDLQ FRQĂ&#x20AC;GHQWLDO XQWLO \RX FDQ WDNH WKHP WR WKH SUDFWLFH ,I \RX DUH PDNLQJ HOHFWURQLF QRWHV VDYH WKHP VHFXUHO\ 0DNH VXUH WKHUH LV D FOHDU WLPHOLQH RI HYHQWV IRU RWKHU SUDFWLWLRQHUV WR IROORZ

â&#x20AC;&#x153;Send written information to patients to reinforce any verbal advice given during the consultationâ&#x20AC;?

June/July 2020

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www.optometry.co.uk 45

91OPTJUN20125.pgs 03.06.2020 11:47

The Workshop, 1

IN PRACTICE

Zeiss 1 VERSION REPRO OP SUBS ART PRODUCTION CLIENT

BLACK YELLOW MAGENTA CYAN

91OPTJUN20163.pgs 03.06.2020 12:33

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91OPTJUN20164.pgs 03.06.2020 12:33

Key milestones, 1

VERSION

KEY MILESTONES

REPRO OP

â&#x20AC;&#x153;It is about delivering care in the safest way we canâ&#x20AC;?

SUBS ART

Zoe Richmond, interim clinical director of the Local Optical Committee Support Unit (LOCSU), tells OT about setting up the COVID-19 Urgent Eyecare Service

01 When routine sight PRODUCTION

testing stopped there was a need to understand the impact on the public, and on our patients. We worked very

CLIENT

closely with sector bodies and LGHQWLĂ&#x20AC;HG D QHHG IRU VRPH essential services that would now not be possible in optical practices. That included the essential sight testing, SDUWLFXODUO\ LPSRUWDQW IRU key workers, but also urgent DQG HPHUJHQF\ H\H FDUH WKDW would typically be presenting to optical practices â&#x20AC;&#x201C; but with our closed-door policy would no longer be able to be PDQDJHG LQ SULPDU\ FDUH 7KH COVID-19 Urgent Eyecare Service (CUES) was the solution to that.

02

While we were designing CUES we found that video calls to patients were already happening in optical practices.

So there was a natural WUDQVLWLRQ WKHUH ZDVQ W PXFK ZRUN IRU XV WR GR DURXQG LW LOCSU and NHS England are supporting optical practices WR JHW 1+6PDLO WR HYHU\

practice that gets involved with CUES. With that you JHW D YLGHR FDOO IXQFWLRQ VR that will be available to every optical practice that delivers this service.

The other technology is WKH UHPRWH FRQVXOWDWLRQ DQG WKH YLUWXDO UHYLHZ RI GDWD LW PLJKW FDSWXUH &8(6 LQYLWHV other clinicians into that FRQVXOWDWLRQ VR \RX PLJKW JHW DQ RSKWKDOPRORJLVW LQ WR R HU advice and guidance. That PLJKW EH LQ WKH FRQVXOWDWLRQ RU LW PLJKW EH WKDW \RX SURYLGH WKHP ZLWK GDWD WR SHUIRUP D YLUWXDO UHYLHZ CUES builds on the technology available to us â&#x20AC;&#x201C; VWX WKDW MXVW D IHZ PRQWKV DJR ZH ZHUH GUHDPLQJ DERXW 1RZ ZLWKLQ D PDWWHU RI weeks, we are delivering it in optical practices, and it is available across England. I don't think we'll be looking EDFNZDUGV IROORZLQJ WKH LPSOHPHQWDWLRQ RI &8(6 :KDW LW GHOLYHUV WR WKH V\VWHP LV KXJH ,W JRHV IDU EH\RQG MXVW GHOLYHULQJ IRU WKH LPPHGLDWH crisis in urgent eyecare.

â&#x20AC;&#x153;The functionality, and the close working relationshipsacross primary and secondary care, are developments fit for the futureâ&#x20AC;?

48 www.optometry.co.uk

03 CUES breaks down

barriers between primary and secondary care. When we are

looking at the consultation with the patient there is an opportunity to invite in RSKWKDOPRORJ\ DGYLFH VR WHDPV DQG LQGLYLGXDOV IURP the hospital can support your GHFLVLRQ PDNLQJ When CUES is LPSOHPHQWHG DW LWV EHVW LW goes beyond that. It is DURXQG GHFLVLRQ PDNLQJ LQ SULPDU\ FDUH VR \RX FDQ IXOO\ PDQDJH D JUHDWHU QXPEHU RI patients. <RX FDQ LPDJLQH WKH LGHDO SDWLHQW MRXUQH\ WKH SDWLHQW LV VDW DW KRPH WKH\ have a video consultation ZLWK WKHLU SULPDU\ FDUH clinician, who invites secondary care into that consultation, and issues a UHPRWH SUHVFULSWLRQ WKDW¡V GHOLYHUHG E\ D SKDUPDF\ WR WKH SDWLHQW V KRPH We are tailoring care around that individual.

That is going to be essential, QRW MXVW IRU WKH LPPHGLDWH EXW IRU WKH ORQJHU WHUP :H DUH JRLQJ WR KDYH D FRKRUW RI people that are going to be VKLHOGLQJ IRU D ORQJ WLPH ,W LV about delivering care in the VDIHVW ZD\ WKDW ZH FDQ

04 The idea of extended

primary care services isn't new.

:H YH JRW ORWV RI SUDFWLWLRQHUV in practice delivering this already. CUES introduces LW LQ D PRUH VWDQGDUGLVHG way, at pace and scale across WKH ZKROH RI (QJODQG DQG with a standardised service VSHFLĂ&#x20AC;FDWLRQ CUES also introduces the FRQFHSW RI UHIHUUDO EHWZHHQ RSWLFDO SUDFWLFHV ,I \RX DUH SURYLGLQJ UHPRWH FRQVXOWDWLRQ to your own patient and \RX IHHO WKDW \RX DUHQ¡W EHVW SODFHG WR GHOLYHU WKH IDFH WR IDFH DSSRLQWPHQW VKRXOG LW be necessary, you have the opportunity to book that patient in with a neighbouring practice that perhaps has a practitioner with a higher VNLOO VHW RU D GL HUHQW SLHFH RI HTXLSPHQW ,W DOORZV \RX WR ZRUN LQ D PRUH QHWZRUNHG ZD\ ZLWK ZLWKLQ SULPDU\ care, but also a partnership approach alongside the hospital service.

05

Recovery means two years as a minimum. We are

JRLQJ WR EH LQ WKLV IRU D ORQJ WLPH , WKLQN &8(6 LV KHUH IRU DW OHDVW WKH QH[W FRXSOH RI years. We are inviting local V\VWHPV WR HYROYH &8(6 WR broaden it and do everything WKH\ FDQ WR LPSURYH LW WR GHYHORS PRUH LQWHJUDWHG FDUH The CCGs that are LPSOHPHQWLQJ LW QRZ DUH WDONLQJ LQ WHUPV RI WKHLU UHVHW and how they are going to have to deliver routine care in D YHU\ GL HUHQW ZD\ , WKLQN they see CUES as an enabler WR DOORZ WKHP WR GR WKDW because it pulls the entire web WRJHWKHU ,W¡V D ZKROH V\VWHP approach, and there is going to be value in that.

June/July 2020

BLACK YELLOW MAGENTA CYAN

91OPTJUN20126.pgs 03.06.2020 10:57

VERSION

PRE-REG FOCUS

REPRO OP

â&#x20AC;&#x153;There are many positive aspects to working from homeâ&#x20AC;?

OT skills guidesI OT has developed a range of short video skills guides to aid students in their studies www.aop.org.uk/ otskillsguides

Pre-reg optometrist, Tamara Hasan, on how sheâ&#x20AC;&#x2122;s adapted to a new way of working during the COVID-19 crisis

SUBS

M ART PRODUCTION CLIENT

y last article took readers through a typical week at the Manchester Royal Eye Hospital (MREH) as a trainee. Due to the current situation we are all IDFLQJ P\ ZRUNLQJ ZHHN no longer follows the same pattern. As all pre-registration WUDLQHHV ZLOO EH H[SHULHQFLQJ all Scheme for Registration assessments have been suspended. As only the very urgent cases are being seen at 05(+ , KDYH EHHQ ZRUNLQJ from home.

Though there are XQFHUWDLQWLHV ZKLFK LV ZRUU\LQJ WKHUH DUH PDQ\ positive aspects about working from home.

I am in a lucky position as I have passed my Stage 1 and can now focus all my attention on preparing for Stage 2 and OSCEs. I can dedicate time to having my patient records organised and revising. What is also lucky is that I wrote œUHà HFWLRQV¡ RQ HYHU\WKLQJ that was discussed after each

of my four visits. I have been re-reading these to best prepare for the â&#x20AC;&#x153;Overarching Competenciesâ&#x20AC;? sections of my Stage 2 exam. I make sure that I spend at least two hours each day working towards Stage 2. It has been a nice change in that I can choose when and how to spend my time to optimise my learning.

I have been given tasks that ZLOO EHQHĂ&#x20AC;W WKH GHSDUWPHQW for example collating a guide for future trainees working at MREH. I have enjoyed the process of putting together this guide along with a fellow pre-reg. It is a reminder to myself of the ins and outs RI ZRUNLQJ DW WKH KRVSLWDO but it is also rewarding to NQRZ WKDW P\ H RUWV ZLOO help future pre-regs on their journey. I also like the fact I have been given freedom over the content and layout as writing has always been a passion of mine. Since I cannot learn from seeing

Youâ&#x20AC;&#x2122;ll acquire and refine new skills, and start making a difference to peopleâ&#x20AC;&#x2122;s lives.

Daniel says...

I would tell my early pre-reg self to breathe. While prereg seems daunting at first, if you stay prepared it is very manageable and enjoyable.

My fondest memory of the period so far is testing a three-year-oldâ&#x20AC;&#x2122;s sight and building a lovely rapport while singing Frozen to keep her engaged. At first, she was incredibly reluctant to have her eyes tested. She required a double appointment as sheâ&#x20AC;&#x2122;d tried other opticians and had no luck. Once I discovered

SDWLHQWV P\ VXSHUYLVRUV KDYH been making use of Zoom to host tutorials on a variety of topics. I have enjoyed seeing SHRSOH¡V IDFHV DQG KHDULQJ WKHP JLYH WKHLU WDONV HYHQ LI LW LVQ¡W IDFH WR IDFH LQWHUDFWLRQ Engaging in these online tutorials has stimulated my learning and helps me to LPPHUVH P\VHOI LQ RSWRPHWU\ despite not being at the hospital seeing patients. ,Q WKH WLPH ZKHQ ,¡P QRW

â&#x20AC;&#x153;It is rewarding to know that my efforts will hopefully help future pre-regs on their journeyâ&#x20AC;?

LQ D =RRP VHVVLRQ , PLJKW decide to read an article or two from an optometry journal or research website. I would also recommend preregs check out the webinars

her love of Disney, she found the test much more enjoyable and never wanted to leave. Itâ&#x20AC;&#x2122;s times like these that reaffirms my love of health care.

During my furlough I have been trying to keep on top of revision. Optotutor is giving away free webinars on preparing for Stage 2. Students who are most involved during the sessions are awarded free analysis of records presented at Stage 2. This has been great

and podcasts found on the College and the Directorate of Optometric Continuing Education and Training websites. I recently listened WR D SRGFDVW RQ PLJUDLQHV ZKLFK , KDGQ¡W KHDUG VSRNHQ about in much detail at university. There are many resources out there for us; it just takes going online.

1RZ WKDW , DP DW KRPH it can be tempting to treat it like a holiday. Doing the above work or studyUHODWHG WDVNV KDYH GHĂ&#x20AC;QLWHO\ helped me formulate a work environment and get into a new work routine. +DYLQJ VDLG WKDW LW LV DOZD\V important to have a work-life EDODQFH DQG VR , WU\ DQG Ă&#x20AC;W LQ UHDGLQJ IRU OHLVXUH ZRUNLQJ RXW RU HYHQ FRRNLQJ drawing or learning a song on the keyboard. I urge any SUH UHJV ZKDWHYHU VWDJH \RX PLJKW EH DW WR PDNH WKH YHU\ most of your time while you can â&#x20AC;&#x201C; even if you are still seeing patients.

motivation for revising and preparing for the next part of pre-reg.

Being a pre-reg during the COVID-19 outbreak has been challenging. Working up to Stage 2 and seeing the final goal of qualifying so close, only to be postponed, is devastating â&#x20AC;&#x201C; but itâ&#x20AC;&#x2122;s for the best.

Daniel Chung is a pre-reg optometrist at Specsavers in Cribbs Causeway, Bristol.

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be considerably less for at least the rest of the year. â&#x20AC;&#x153;Businesses will be developing a staggered approach with the reintroduction of their SHUPDQHQW VWD DQG LW¡V RQO\ when practices become busy will locums be used. At this moment in time I will just be watching this space carefully, and making decisions about the future depending on how WKH VLWXDWLRQ XQIROGV Âľ

ART

LIFE AS A LOCUM

PRODUCTION

â&#x20AC;&#x153;I have been trying to take my mind off the uncertaintyâ&#x20AC;?

CLIENT

Life is tough for many locum optometrists at the moment. OT caught up with previous Life as a Locum contributors to see how they are coping Mohammad Chaudhry

Shutterstock/aumvector

STAINES

â&#x20AC;&#x153;I have been out of work since March 23, when the lockdown was announced.

March in general was very quiet, and I had been receiving fewer locum requests than usual. I am one of those unfortunate locums who are not entitled to any government support. I have had to dip into my savings to pay the bills. â&#x20AC;&#x153;I like to keep busy so the current situation is entirely alien to me. Iâ&#x20AC;&#x2122;ve found myself completing almost my entire to-do list. DIY odd jobs, clearing the attic, binge watching new TV series. Iâ&#x20AC;&#x2122;ve even managed to catch up on my CET quota for the year.

50 www.optometry.co.uk

â&#x20AC;&#x153;Itâ&#x20AC;&#x2122;s important to keep the mind active at times like this, so I have been trying WR WDNH P\ PLQG R WKH uncertainty. However, being a locum optometrist and not a furloughed employee with a job to go back to, itâ&#x20AC;&#x2122;s been a YHU\ GL FXOW WKLQJ WR GR Âľ

Shamina Asif

WEST MIDLANDS

â&#x20AC;&#x153;I think the stark reality of what locums will be facing has hit me. Within one week of lockdown, work that I had booked for the next four months was cancelled. â&#x20AC;&#x153;Analysing how devastating COVID-19 has been, I think I have come to terms with the fact that the amount of locum work will

Andrea Mentlikowski

LONDON

â&#x20AC;&#x153;The week before lockdown I was diagnosed with anxiety, something that had not D HFWHG PH IRU \HDUV , GLGQ¡W consciously feel worried, but my body must have sensed an ominous feeling. â&#x20AC;&#x153;When lockdown commenced, all my work instantly dried up. I was initially concerned about how ZH¡G PDQDJH Ă&#x20AC;QDQFLDOO\ so hearing about the governmentâ&#x20AC;&#x2122;s grants for self-employed workers was a huge relief. â&#x20AC;&#x153;The upside of not working is I can concentrate on my daughterâ&#x20AC;&#x2122;s home-learning.

Sheâ&#x20AC;&#x2122;s nearly eight years old and dyslexic, so I take this as an opportunity to give her the one-on-one attention she canâ&#x20AC;&#x2122;t receive easily at school. â&#x20AC;&#x153;It seems that life has been boiled down to the bare essentials; food, shelter and health. Listening to what other people have experienced, I feel incredibly fortunate my family has these LQ DEXQGDQFH Âľ

Alan Henderson

NORTH YORKSHIRE

â&#x20AC;&#x153;Following lockdown, P\ Ă&#x20AC;UVW reaction was to sort out my business Ă&#x20AC;QDQFHV 8QVXUH KRZ ORQJ I was going to be unable to work, I made sure these were in a good way. Fortunately, P\ Ă&#x20AC;QDQFLDO SLFWXUH ZDV healthy. It is one less thing to worry about. â&#x20AC;&#x153;I do feel frustration about not being able to do anything.

The optical industry has a skill set that, following a brief period of re-training, could have contributed to the NHS through its most GL FXOW SHULRG , GLG R HU to volunteer early on via the Gov.uk website, but I did not receive a reply. â&#x20AC;&#x153;I was able to arrange, and deliver, some spectacles to a friend who works as a nurse at Scarborough Hospital.

His original spectacles broke GXH WR SRRUO\ Ă&#x20AC;WWLQJ 33( equipment), and this made me feel like I was at least doing something. â&#x20AC;&#x153;I had hoped to travel to Cambodia with ActionAid in November. As it stands now that looks increasingly doubtful, which is a shame.

3K\VLFDOO\ DQG PHQWDOO\ I keep busy with CET, woodworking, and cleaning. â&#x20AC;&#x153;There are so many people who have lost loved ones during this time, including people close to me. I hope that when life returns to normal, we can all be a kinder society, appreciate the NHS all the time, and understand that we work EHWWHU WRJHWKHU WKDQ DSDUW Âľ

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WHAT I HAVE LEARNED

ART

“This level of collaboration… is one positive to have come from the pandemic”

PRODUCTION CLIENT

Evelyn Mensah, consultant eye surgeon and clinical lead for Ophthalmology Outpatient Transformation in London, and Jonathan Than, an ophthalmic registrar at Moorfields Eye Hospital, discuss the development of a new resource for optometrists

Shutterstock/Aleksandr_a

Can you tell us about the Google Map resource?

Evelyn Mensah (EM):

The arrival of the pandemic has seen eye services change rapidly. Clinics were adapted and reshaped to make sure that people receive the right care, as safely and as close to home as possible.

We wanted to make it easy for optometrists and ophthalmologists to access the information they need to refer appropriately. The new Google Map is the result of collaborative working across /RQGRQ ,W R HUV DFFHVV WR contact details and guidance for eye casualty services and will help to reduce travel times by referring people closer to home.

Will the resource be updated beyond the crisis?

EM: The need for better

information became clear

to us during the pandemic but the new guides and map will have ongoing use for community practitioners.

By making it easy to reach out to other colleagues we can increase the quantity of conversations between practitioners and also improve the quality of referrals as a result.

How can digital tools support collaboration between practitioners?

EM: One of the most

powerful aspects of digital tools is the potential to improve collaboration between clinicians. Within recent weeks we have deployed remote working with video consultations and a range of other new approaches to support eye health services. I’ve no doubt that the technology we are using now is here to stay.

The exact use will continue to evolve and improve, but WKH EHQHÀWV ZLOO VXSSRUW XV during the recovery phase and beyond.

How did you become involved in the project?

Jonathan Than (JT): The

COVID-19 pandemic has been a catalyst for greater ease of access to eye casualty units, in order to reduce patient travel and help to spread the ophthalmic emergency workload to ensure reduced waiting times and less crowded waiting rooms.

The Directory of London Ophthalmology Service Provision, brought together information regarding ophthalmology services during the pandemic with the aim of aiding optometrists and NHS 111 to direct patients appropriately.

I wanted to translate the contents of the directory into an interactive visual representation that would allow me to input the patient’s postcode to immediately identify the closest open unit and its referral details.

How did you refine the data to create the map?

JT: The credit for the

gathering of the majority of the data found within the map lies with the team who

created the directory. Evelyn Mensah, together with the London ophthalmic unit leads, should be commended for creating a resource facilitating ease of referral to local units for ophthalmic emergencies. Daily updates from colleagues across London regarding their changing opening hours and referral pathways as the state of the pandemic changes have allowed me to update the information within the map, and this level of collaboration amongst clinicians and units is wonderful to see and is one positive to come from this pandemic.

How has it felt to work on this collaborative project?

JT: The spirit of co-operation

and collaboration shown amongst all groups of people, from strangers, communities, healthcare professionals or other keyworkers, is one VLJQLÀFDQW JRRG WR HPHUJH from a pandemic that has otherwise caused such VX HULQJ DQG GLVWUHVV Seeing optometrists and ophthalmologists collaborate across London and the UK WR GHOLYHU VDIH DQG H HFWLYH emergency eye care in such testing circumstances has been inspirational and reassuring. To have played a very small part in this delivery of care through the creation of this map is a privilege. I hope this spirit continues long after the pandemic is over.

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

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OT investigates the impact of the pandemic on optometrists in Northern Ireland, Scotland and Wales – and asks how each nation is charting a path forward

ART

A

PRODUCTION

s daily life changed in the UK in the face of an unprecedented challenge, governments and industry bodies PDGH GL FXOW GHFLVLRQV DERXW KRZ to stem the spread of COVID-19.

7UDGLWLRQDO GLYLVLRQV ZLWKLQ DQG EHWZHHQ SURIHVVLRQV ZHUH EULGJHG DV HDFK FRXQWU\ JUDSSOHG ZLWK D much larger threat.

Although there have been common themes in the impact and SDQGHPLF UHVSRQVH ZLWKLQ WKH IRXU nations of the UK, there are also GL HUHQFHV OT VSRNH ZLWK RSWLFDO OHDGHUV WR XQGHUVWDQG KRZ WKH SDQGHPLF unfolded in Northern Ireland, Wales and Scotland – and to consider the path ahead.

Shutterstock

CLIENT

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NORTHERN IRELAND ART PRODUCTION CLIENT

After routine General Ophthalmic Services (GOS) were suspended in Northern Ireland on 24 March, optometrists continued to provide urgent and essential eye care.

Health and Social Care Board Head of Ophthalmic Services, Raymond Curran, told OT non sight-threatening acute eye care is provided across the country through Primary Eyecare Assessment Referral Services (PEARS).

Mr Curran added that these services have continued operating in the wake of the pandemic, although they have been delivered in line with Government guidance to reduce footfall and travel as well as maintaining social distancing.

Essential and urgent care has been delivered virtually where possible during lockdown.

Mr Curran added that it is only R HUHG IDFH WR IDFH DIWHU UREXVW screening and using the appropriate personal protective equipment (PPE).

“About 70% of the urgent eye care has been virtual and primary care optometrists have really embraced that. That has been a really positive element to come out of this adversity,” he explained.

He highlighted that Northern ,UHODQG KDV D EURDG GHÀQLWLRQ RI essential care.

“We appreciate that what is essential to one patient might be GL HUHQW WR DQRWKHU 7KHUH LV D

54 www.optometry.co.uk

June/July 2020

BLACK YELLOW MAGENTA CYAN

degree of clinical decision making around that and professional judgement.”

Of the 271 GOS contractors within Northern Ireland, 270 practices opted to remain open during lockdown.

Mr Curran shared that practices were encouraged to form clusters ZLWKLQ GL HUHQW DUHDV ´7KDW LV both to help their resilience and to SURWHFW WKHLU VWD DQG ZHOOEHLQJ They might cluster for a rota – RQH SUDFWLFH ZRXOG R HU FDUH on Monday, another practice on Tuesday,for example. You can’t mandate that by contract so I haven’t directed it but that has been happening at a locality level,” he highlighted.

This way of working has strengthened working relationships between practices, which were present before COVID-19 in Northern Ireland through practices sharing clinical resources in schemes such as the glaucoma care pathway.

“We have seen practices working together. Practice A might say ‘I’m not sure about that. My colleague down the road has an independent prescriber available today’,” Mr Curran said.

“Notwithstanding the commercial sensitivities around patients moving from one practice to the other, I think that can become fairly well embedded. I think COVID-19 will push us in that

“I don’t want to rush into a primary care optometry scenario where increased footfall and easing of service provision could contribute to a spike in cases” Raymond Curran direction of more intraprofessional sharing of resource,” he highlighted. $ WHPSRUDU\ ÀQDQFLDO VXSSRUW scheme has been available to all contractors within Northern ,UHODQG ZKR HLWKHU FRQWLQXH WR R HU urgent and essential eye care or are redeployed within the wider HSC. Mr Curran highlighted that the support secures the income of contractors, proportionate to their income from previous years.

“As lockdown eases and as service provision returns to some level of normal through a

WALES phased approach, this will need WR EH UHĂ HFWHG LQ WKH Ă&#x20AC;QDQFLDO arrangements,â&#x20AC;? he said.

In Northern Ireland, PPE has been distributed to all practices at no cost to the practice, as a temporary measure.

Mr Curran explained that PPE is available appropriate to the level of risk and clinical task. â&#x20AC;&#x153;That has been widely applauded by primary eye care providers.,â&#x20AC;? he added.

HSC is in the process of developing draft operational guidance for GOS contractors. Mr &XUUDQ VKDUHG WKDW D ULVN VWUDWLĂ&#x20AC;HG approach will be taken to easing lockdown restrictions within optometry in Northern Ireland, with GL HUHQW PHDVXUHV DSSOLHG LQ UHG amber and green stages. â&#x20AC;&#x153;That phasing will mean that we may take a risk assessment for the various procedures that take place in High Street optometry. For instance, aerosol generating procedures might be the last things to be allowed. My view is that domiciliary eye care will probably be one of the last things that will be permitted,â&#x20AC;? he said.

Mr Curran emphasised that any easing of restrictions within optometry is linked to wider societal trends, such as the reproductive value, numbers of cases and deaths as well as the availability of PPE. â&#x20AC;&#x153;All of those elements will inform where we are in the various stages of lockdown. I donâ&#x20AC;&#x2122;t want to rush into a primary care optometry scenario where increased footfall and easing of service provision could contribute to a spike in cases,â&#x20AC;? Mr Curran observed. â&#x20AC;&#x153;We do need to be measured while still being mindful of the sensitivities around commercial pressures that practices face.â&#x20AC;?

Optometry Wales chief executive, Sali Davis, shared with OT that during lockdown the number of open practices in Wales dropped from 352 to 89.

Each primary care cluster within Wales has at least one open optometric practice, with closed practices signposting patients to these hubs.

Practices that are closed receive an average monthly payment based on three years of GOS work, while practices that are open are paid an additional 125%.

PPE has also been provided to all practices that are open at no cost to the practice.

Ms Davis shared that the pandemic has prompted unusual ways of working within Wales, including an owner of a closed independent practice who is assisting an open Specsavers practice down the road. â&#x20AC;&#x153;There are the commercial sensitivities that would have existed a couple of months ago and now you have this lovely working relationship,â&#x20AC;? she said.

Ms Davis estimated that around RQH LQ Ă&#x20AC;YH RSWRPHWULVWV ZKR KDYH lost work following the pandemic are volunteering through a partnership with Community Pharmacy Wales to deliver prescriptions to patients in the community.

A Welsh optometrist has also

signed up to provide eye care alongside her GP husband to patients at a red site; where patients with COVID-19 symptoms can receive a variety of primary care services. â&#x20AC;&#x153;Their logic was that they might as well work alongside each other because the husband is exposed on a daily basis anyway,â&#x20AC;?

Ms Davis said. Altered ways of working during lockdown have provided opportunities for optometrists to take on broader clinical roles.

For example, optometrists KDYH EHHQ R HULQJ GLDEHWLF H\H screening to pregnant women during lockdown following suspension of the national screening service.

Drawn out attempts to establish a community eye casualty pathway in Wales were also fasttracked following COVID-19. ´:LWKLQ WKH Ă&#x20AC;UVW WZR ZHHNV of COVID-19, a practice with independent prescribers in &DUGL DQG 9DOH ZDV VHW XS DV D community eye casualty negating the need for patients to go into hospital, Ms Davis shared. â&#x20AC;&#x153;Because Government have seen the statistics there and seen that we have been able to diagnose and manage patients in the community, they are now thinking that we can do this more widely,â&#x20AC;? she highlighted to OT.

â&#x20AC;&#x153;Within two weeks of COVID-19, a practice with IPs in Cardiff and Vale was set up as a community eye casualtyâ&#x20AC;?

Sali Davis

91OPTJUN20131.pgs 03.06.2020 14:02

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SCOTLAND

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People have had to adapt really quickly, he said.

During lockdown, Mr Quigley Following the outbreak of estimated that only around 5% COVID-19, Emergency Eyecare of calls to optometrists were Treatment Centres (EETCs) were emergencies that required referral established in Scotland for the to an EETC. provision of face-to-face care.

He highlighted that Scottish Optometry Scotland chair, optometrists and dispensing David Quigley, shared with OT opticians have gone to great that optometrists in Scotland lengths to look after their patients, personally delivering spectacles to homes where they could not be posted. In one case, a baby had a foreign body removed on the doorstep of their home while another optometrist covered the cost of a taxi to hospital after overhearing that a patient with iritis did not have money for the fare.

Optometrists have used video calling technology to assess motility and estimate facial measurements. â&#x20AC;&#x153;Against such a horrendous economic backdrop there have been a lot of huge positives to come out of this with people using their ingenuity. I think new ways RI ZRUNLQJ DUH KHUH WR VWD\ Âľ 0U Quigley said.

He added that the COVID-19 pandemic has also provided an opportunity for â&#x20AC;&#x153;Against such a horrendous governments to reconsider how economic backdrop, there optometrists have been a lot of huge are used within the positives to come out of healthcare this with people using their workforce. ingenuityâ&#x20AC;? â&#x20AC;&#x153;When you see David Quigley community eye care stepping in to have made the best of a provide better control of GLÂ?FXOW VLWXDWLRQ ´$V ZLWK DQ\ people who are being referred professional who has a routine, into secondary care, that is a the fact that routine has been tremendous example that we unceremoniously broken without QHHG WR FRQWLQXH Âľ notice has been a huge challenge.

56 www.optometry.co.uk

June/July 2020

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Looking ahead to the easing of lockdown restrictions, Mr Quigley shared his view that opening hours are likely to be extended within optometry practices to allow for stringent social distancing measures. â&#x20AC;&#x153;Community eye care needs to become an exemplar in infection control and social distancing. In order to do that, you will have to adapt your business model DFFRUGLQJO\ Âľ 0U 4XLJOH\ DGGHG He said that everyone has a part to play as the profession moves forward from the pandemic. â&#x20AC;&#x153;Within the optometry community, everyone has knuckled down and got stuck in. Optometry Scotland has representation from every part of the sector â&#x20AC;&#x201C; independents, multiples, larger groups and GLVSHQVLQJ RSWLFLDQV Âľ He added: â&#x20AC;&#x153;Weâ&#x20AC;&#x2122;ve also established great ways of working with our colleagues in ophthalmology, and a fantastic working relationship with the Scottish Government health department whose foresight and ongoing support of community eyecare has protected the visual health of the nation throughout the SDQGHPLF Âľ

My biggest worryâ&#x20AC;Ś

â&#x20AC;&#x153;The most important thing for me is to provide for my familyâ&#x20AC;?

OT explores how the pandemic has affected the locum workforce

W

hen Abid Noorâ&#x20AC;&#x2122;s Sunday shift was cancelled amid escalating anxiety about the spread of COVID-19, he did not think much of it.

The Scottish locum optometrist had no premonition of the profound and lasting impact the virus would have on optometry.

But the announcement days later that all optical practices must close heralded a new chapter of sleepless nights for the sole earner and fatherof-four. â&#x20AC;&#x153;I thought, â&#x20AC;&#x2DC;How am I going to survive Ă&#x20AC;QDQFLDOO\"¡ , KDYH D PRUWJDJH , KDYH NLGV Âľ Mr Noor said. ´, ZHQW IURP D QRUPDO Ă&#x20AC;YH GD\ ZRUNLQJ ZHHN to sitting at home and worrying about where the IXQGV ZHUH JRLQJ WR FRPH IURP Âľ KH VKDUHG Thanks to his independent prescribing TXDOLĂ&#x20AC;FDWLRQ DQG ´D YHU\ XQGHUVWDQGLQJ GLUHFWRU Âľ Mr Noor was able to secure work triaging and treating emergency eye care cases across a group RI Ă&#x20AC;YH LQGHSHQGHQW SUDFWLFHV DQG HVWLPDWHV KH is earning around two thirds of what he took sickness and days at short notice. â&#x20AC;&#x153;It is a shame that we home before lockdown. â&#x20AC;&#x153;It is a shame that we are always are always the first to go. WKH Ă&#x20AC;UVW WR JR ,W FDQ EH D UHDOO\ FROG Other locum It can be a really cold, optometrists across EUXWDO UHDOLW\ FKHFN Âľ KH VDLG brutal reality checkâ&#x20AC;? the UK have not been â&#x20AC;&#x153;I know that is the nature this lucky, with many of locum work, but this is a Abid Noor out of work and some completely unprecedented ineligible for the Self-Employment situation. There wasnâ&#x20AC;&#x2122;t a choice Income Support Scheme. whether to work or not to work. Everyone was In contrast to employees, support for locum IRUFHG WR FORVH Âľ 0U 1RRU KLJKOLJKWHG ZRUNHUV LV UHVWULFWHG LI WKHLU DQQXDO SURĂ&#x20AC;WV DUH Looking ahead, Mr Noor believes that social above ÂŁ50,000, if they became self-employed distancing will result in lower testing capacity within the past year and if their self-employed when routine sight testing commences and work does not represent half of their income. travelling greater distances to secure locum work.

An OT poll of 500 locum optometrists found â&#x20AC;&#x153;The most important thing for me is to provide that 61% were not eligible for the Government IRU P\ IDPLO\ , ZLOO GR ZKDWHYHU LW WDNHV Âľ KH support package. emphasised.

Mr Noor highlighted that locum optometrists A survey of more than 2250 AOP members at provide an invaluable service by covering the beginning of May found that only around June/July 2020

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Feature, 4 VERSION REPRO OP

My biggest worryâ&#x20AC;Ś

SUBS

Locum optometrists share their concerns following the COVID-19 pandemic

ART

â&#x20AC;&#x153;At the end of the day, we are healthcare professionals.

When this virus does pass, we will be employableâ&#x20AC;?

Gautam Passi

PRODUCTION CLIENT

one in 10 optometrists was continuing to work in a paid role. Close to half of respondents were furloughed while around four in ten respondents were not furloughed but also not working.

7KHVH GL FXOW FLUFXPVWDQFHV KDYH IRUFHG VRPH optometrists to look beyond the profession for work, with one respondent taking on four jobs LQ RWKHU Ă&#x20AC;HOGV LQFOXGLQJ DV D GHOLYHU\ GULYHU DQG shelf stacker at a supermarket.

Asked whether he would consider work outside optometry, Mr Noor said his primary concern is FRYHULQJ KLV ELOOV DQG VXSSRUWLQJ KLV IDPLO\ â&#x20AC;&#x153;If there was literally no work, I would do DQ\WKLQJ ,¡P D JRRG GULYHU VR , ZRXOG FRQVLGHU GULYLQJ RU VLWWLQJ WKH +*9 WHVW Âľ KH VDLG /RFXP RSWRPHWULVW *DXWDP 3DVVL SUDFWLVHG six days a week in West London and Surrey EHIRUH ORFNGRZQ +H QRZ ZRUNV RQH GD\ D ZHHN SURYLGLQJ HVVHQWLDO H\H FDUH VHUYLFHV DW an independent practice in Fulham. â&#x20AC;&#x153;It was incredibly sudden. As soon as lockdown was DQQRXQFHG HYHU\WKLQJ FORVHG 7KH GHPDQG IRU ORFXPV ZDV QRQ H[LVWHQW UHDOO\ Âľ 0U 3DVVL VDLG 0U 3DVVL LV QRW HOLJLEOH IRU WKH 6HOI (PSOR\PHQW Income Support Scheme because he has been ZRUNLQJ DV D ORFXP IRU OHVV WKDQ D \HDU +H KDV EHHQ DEOH WR FRYHU KLV PRUWJDJH WKURXJK VDYLQJV DQG 8QLYHUVDO &UHGLW SD\PHQWV Despite the challenges that he is currently IDFLQJ 0U 3DVVL LV RSWLPLVWLF DERXW WKH IXWXUH â&#x20AC;&#x153;At the end of the day, we are healthcare SURIHVVLRQDOV :KHQ WKLV YLUXV GRHV SDVV ZH ZLOO EH HPSOR\DEOH /RFXPV KDYH DOZD\V EHHQ DQ essential part of the optical workforce and will FRQWLQXH WR EH HYHQ DIWHU WKH YLUXV Âľ KH VKDUHG ´, KDYHQ¡W VSRNHQ WR D VLQJOH ORFXP ZKR IHHOV OLNH WKH\ DUH RXW RI D FDUHHU Âľ 0U 3DVVL DGGHG

58 www.optometry.co.uk

Rebecca Rushton My greatest concerns are financial ones. I'm the only earner in my household so my work is very important.

Locums are at the bottom of the pile and I foresee it being a while before we get back to work, and when we do, I suspect our wages will be much lower than previously.

We need to know that employers will take our health and safety seriously, and that sensible PPE and social distancing measures will be observed. I'd also like to remind employers that we're still here. We're here to cover maternity leave, to cover sickness, and to provide extra days in the future should we find ourselves in the position of having a backlog of work to get through; these are exactly the reasons that locums exist in the first place.

Siddika Asaria Safety is my biggest concern; for myself, my patients and those whom I live with. I am also concerned about the availability of personal protective equipment, and whether we will have enough time for adequate cleaning, as well as donning and disposing of PPE. There are also issues with lowered rates and professionals not being paid adequately.

Abid Noor My biggest concern is the unknown. We have no clue as to when we might be able to go out and start practising and earning money. At the moment, there is just a big question mark.

Jaime Patel My main concern is keeping my patients safe. I havenâ&#x20AC;&#x2122;t worked since the COVID-19 lockdown. Many practices are shut, and those that are open only treat emergencies so demand for locums is low. I hope to return to work in June but this all depends on advice from the Prime Minister and governing bodies. We are in unprecedented times and will have to see how things go.

Philip Leeb-duToit Many locums earn well in excess of the ÂŁ50k watershed for self-employed assistance, or are limited companies so fall outside government support. Some are recently selfemployed so miss out on assistance. We are all funding this time on our savings; the longer that this virus is with us, the closer some of us are getting to breaking point.

Gautam Passi My biggest worry will be finding work after we leave lockdown. It will be difficult to find the work that I want, because it will be scattered everywhere. Recruitment platforms, like Locumotive, will help with that.

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91OPTJUN20133.pgs 03.06.2020 13:08

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Education and training for the eye care practitioner June/July 2020

PRODUCTION

In this issue 60/ Fixation disparity and associated phoria – uses in clinical practice Dr Liat Gantz PhD

CLIENT

64/ Returning to work: a guide for practitioners and employers Lizzy Yeowart BSc (Hons), MCOptom

69/ Meibomian gland dysfunction: the importance of early detection

Dr Katrina Schmid BAppScOptom (Hons), PhD

Meibomian gland dysfunction, page 69

Course code: C-75133 Course code: C-75069 Course code: C-75145

74/ Sight support in schools

Cirta Tooth BSc, Prof Cert LV, Higher Cert LV, Prof Cert Paed Eye Care

80/ Anterior eye

Drew Thompson BSc (Hons), MCOptom

Course code: C-75238 Course code: C-74886

82/ Macular marvels

Jaspreet Sajjan B(Optom)Hons, MCOptom, ProfCert MedRet

Course code: C-75202

Competency tracker In this edition of OT, practitioners can test a range of competencies:

Optometrists Therapeutic optometrists Dispensing opticians Contact lens opticians CET exams in this edition are available online from 13 June 2020

“An eye care provider’s initial suspicion that MGD is present is typically based on patients’ symptoms.

However, the severity of the symptoms reported, and the observed clinical signs are often poorly correlated. In fact, asymptomatic MGD is more common than symptomatic MGD; three times as many people with MGD are stated to report no symptoms than those that report having ocular symptoms” Dr Katrina Schmid

Sight support in schools, page 74 “The low vision practitioner plays a role in ensuring that the patient is looked after in terms of social and emotional impact of sight loss, nystagmus, and other aspects of albinism. It is helpful for practitioners to familiarise themselves with local afterschool clubs and sports clubs for visually impaired children, along with forums such as Haggeye, and the Albinism Fellowship” Cirta Tooth

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Fixation disparity and associated phoria â&#x20AC;&#x201C; uses in clinical practice

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Dr Liat Gantz PhD SUBS

In this article, the author outlines the assessment of fixation disparity and its relevance to clinical practice.

ART

dissociated phoria measurements are usually in the same GLUHFWLRQ EXW GL HU LQ WKHLU PDJQLWXGH 19

Optometrists Dispensing opticians

PRODUCTION

Introduction

CLIENT

Fixation disparity describes a small, 10â&#x20AC;&#x2122; or less,1â&#x20AC;&#x201C;3 ELQRFXODU PLVDOLJQPHQW RI WKH YLVXDO D[HV GXULQJ Ã&#x20AC;[DWLRQ of a visual target,2 which is within Panumâ&#x20AC;&#x2122;s fusional area, and is seen as a single object.4 Fixation disparity is also GHVFULEHG DV WKH GL HUHQFH EHWZHHQ WKH FRQYHUJHQFH angle under binocular viewing and the angle subtended by the target at the centres of rotation.5 Figure 1 shows D VFKHPDWLF RI DQ HVR Ã&#x20AC;[DWLRQ GLVSDULW\ LQ ZKLFK WKH visual axes meet in front of the target of regard under ELQRFXODU YLHZLQJ 7KH Ã&#x20AC;[DWLRQ GLVSDULW\ LV VR VPDOO WKDW it is still within Panumâ&#x20AC;&#x2122;s fusional area and, therefore, GRHV QRW UHVXOW LQ GLSORSLD $ ODUJH Ã&#x20AC;[DWLRQ GLVSDULW\ KDV clinical implications related to asthenopia and binocular IXQFWLRQ ,QGXFHG Ã&#x20AC;[DWLRQ GLVSDULW\ UHGXFHV ELQRFXODU visual evoked potential,6 binocular visual acuity,7 and stereoacuity.8 $GGLWLRQDOO\ Ã&#x20AC;[DWLRQ GLVSDULW\ LV ODUJHU when working at a close working distance,9 or under reduced lighting.10,11 This article will consider the options IRU FOLQLFDO DVVHVVPHQW RI Ã&#x20AC;[DWLRQ GLVSDULW\ LQ SUDFWLFH

1 CET POINT

Clinical tests The associated phoria can be measured by several clinical tests; these include but are not limited to, the distance or near Mallett unit, Bernell box, American Optical vectographic slide, the Borish vectograph nearpoint card,19 the POLA VistaVision test, the Light Box (see Figure 2 D VSHFLÃ&#x20AC;F SRODULVHG WDUJHW VKRZQ LQ WKH SURMHFWRU RU D VSHFLÃ&#x20AC;F DQDJO\SKLF JUHHQ DQG UHG

target shown in the projector. The principle in associated phoria measurement is that the clinical test contains both dissociated and associated targets. Dissociated targets have components that are seen separately by the right and left eyes. Associated or mutual targets are viewed by the two eyes together. Hence, the term associated phoria.

Figure 1

Associated phoria The associated phoria is a measure of the prisms required WR QHXWUDOLVH WKH Ã&#x20AC;[DWLRQ GLVSDULW\ ² WKDW LV WR VD\ LQ ZKLFK WKH UHVXOWLQJ Ã&#x20AC;[DWLRQ GLVSDULW\ EHFRPHV ]HUR 13 Associated phoria testing is performed with both eyes open, resembling real world conditions. Conversely, dissociated phoria testing (as measured using the Maddox rod, Maddox rod with Thorington card, or the von Graefe method) is performed with each eye viewing D GL HUHQW QRQ IXVLEOH WDUJHW 14 Therefore, the associated phoria measurement is of interest to clinicians, as this value represents the recommended amount of prism to prescribe to patients,12,15 which is not provided by measuring the dissociated phoria.16â&#x20AC;&#x201C;18 The associated and

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f

f

Figure 1 The visual axes extending from the foveas of the two eyes meet in front of the object of regard (star). The visual axes meet at the horopter, represented by the dotted curve. Panumâ&#x20AC;&#x2122;s fusional area is the grey zone in-front and behind the horopter. In a fixation disparity, the deviation between the object of regard (star) and the visual axes is within Panumâ&#x20AC;&#x2122;s fusional area

CET

Figure 2

from the centre. Results are reported in prism dioptres giving the direction of the prism and represents the amount of prism required to correct the associated phoria. The Mallet unit test contains two circular targets WR DOORZ PHDVXUHPHQW RI ERWK KRUL]RQWDO DQG YHUWLFDO associated phoria.

POLA VistaVision test

Figure 2 The distance Light Box. Placed at a distance of 6m (or 3m with a mirror), polarised spectacles are worn to separate the views of the right (upper and right lines) and left (lower and left lines). The surrounding box, square, peripheral squares, central circle and diamond are associated binocular targets

Mallet unit

The EVANS copy of the Mallet unit is held in a reading position at a distance of 40cm (see Figure 3).20,21 The circular 55’ radius target in the centre of the reading passage contains an upper 33.6’ by 12.6’ green line seen by the left eye and a lower 33.6’ by 12.6’ green line seen by the right eye. The views of the two eyes are separated using polarised spectacles. The dark circle and the centre white rectangle containing three 16.8’ black letters ‘O X O’ with a limb thickness of 4.2’ and equally spaced by 4.2’ are seen binocularly as associated targets. The green vertical lines seen separately by the two eyes are presented directly above and below the central letter ‘O.’ The patient is asked if the upper and lower lines are aligned. If the lines are not aligned, the clinician introduces prism until the two lines are perceived as aligned. If the upper line is seen to the right of the lower line, this represents crossed disparity, or an exo-deviation, which is corrected with a base-in prism. If the upper line is seen to the left of the lower line, this represents uncrossed disparity, or an eso-deviation, which is corrected with a base-out prism. If only one of the green lines appears to be displaced, this is an indication of ocular dominance of the eye whose line has not moved

The POLA VistaVision test includes two targets for the measurement of associated phoria: the Coincidence MKH test; and the ‘OXO’ test. The Coincidence MKH test consists of a binocular associated central circle.

The linear right-hand target and left-hand targets are seen by each eye separately, achieved by using polarising spectacles. This type of target often appears in projection charts. The ‘OXO’ test is comprised of a central binocular associated block of three letters ‘OXO’ with dissociated polarised upper and lower lines that are printed above and below the central ‘X.’ The patient is asked whether or not the targets are aligned. If they Figure 3

Figure 3 The EVANS copy of the Mallet unit.

Image courtesy of Professor Simon Barnard

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Figure 4

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5), Sheedy disparometer (see Figure 6) and the revised %RULVK YHFWRJUDSK QHDUSRLQW FDUG ,,

SUBS

Wesson card

ART

The most popular of these tests is the Wesson card,22,23 which includes holes in its upper section to allow DWWDFKPHQW WR D SKRURSWHU 7KH FDUG FDQ EH SODFHG DW D GLVWDQFH RI RU FP IURP WKH REVHUYHU 7KH DVVRFLDWHG ELQRFXODU WDUJHWV LQ WKH FDUG LQFOXGH D FHQWUDO KRUL]RQWDO OLQH VXUURXQGLQJ OHWWHUV DQG V\PEROV DQG D FHQWUDO square. The test is viewed using polarising spectacles. $ ORZHU YHUWLFDO DUURZ LV YLHZHG E\ WKH OHIW H\H DQG D VFDOH RI FRORXUIXO YHUWLFDO OLQHV LV YLHZHG E\ WKH ULJKW H\H 7KH SDWLHQW LV DVNHG WR VWDWH ZKLFK VLGH WKH DUURZ LV pointing to, and which colour line. The examiner reads WKH FRUUHVSRQGLQJ DPRXQW RI Ă&#x20AC;[DWLRQ GLVSDULW\ IURP WKH WDEOH SULQWHG RQ WKH XSSHU SDUW RI WKH FDUG 7KH DVVRFLDWHG SKRULD PD\ EH PHDVXUHG E\ DGGLQJ SULVPV XQWLO WKH patient reports that the lower arrow is pointing to the FHQWUDO UHG OLQH ZKLFK LV SULQWHG GLUHFWO\ DERYH WKH DUURZ

Figure 4 The Wesson card

are not, prisms are added until the patient views the targets as aligned.

American Optical vectographic slide test PRODUCTION CLIENT

The American Optical vectographic slide test contains a FHQWUDO DVVRFLDWHG ELQRFXODU FLUFOH 7KH FLUFOH LV Ă DQNHG E\ IRXU OLQHV 7KH XSSHU OLQH DQG WKH OLQH RQ WKH ULJKW DUH VHHQ E\ WKH ULJKW H\H ZKLOH WKH ORZHU OLQH DQG OLQH RQ WKH OHIW DUH VHHQ E\ WKH OHIW H\H ZKLFK LV DFKLHYHG XVLQJ SRODULVLQJ VSHFWDFOHV 7KH SDWLHQW LV DVNHG LI WKH OLQHV DUH DOLJQHG ,I WKH\ DUH QRW SULVPV DUH DGGHG XQWLO WKH SDWLHQW views the targets as aligned. The test uses a projection system that is not in common use.

Saladin near point balance card

7KH 6DODGLQ QHDU SRLQW EDODQFH FDUG FRQWDLQV D PXOWLWXGH RI WHVWV LQFOXGLQJ WKH :RUWK GRW QHDU /RJ0$5 YLVXDO acuity, and a Thorington scale for dissociated phoria measurements. The left column contains circular targets for the measurement of vertical associated phoria and Ă&#x20AC;[DWLRQ GLVSDULW\ ZKHUHDV WKH XSSHU URZ FRQWDLQV circular targets for the measurement of horizontal DVVRFLDWHG SKRULD DQG Ă&#x20AC;[DWLRQ GLVSDULW\ 'LVVRFLDWLRQ is achieved using polarising spectacles. The associated ELQRFXODU VHFWLRQV RI WKH YHUWLFDO DQG KRUL]RQWDO

Borish vectograph nearpoint card

The Borish vectograph nearpoint card is secured to the SKRURSWHU DQG SODFHG SDUDOOHO WR WKH REVHUYHU DW D GLVWDQFH RI FP 9HUVLRQ , RQO\ FRQWDLQV DQ DVVRFLDWHG SKRULD WDUJHW 7KH UHYLVHG YHUVLRQ ,, DOVR FRQWDLQV D Ă&#x20AC;[DWLRQ GLVSDULW\ WDUJHW DV GHVFULEHG ODWHU 7KH DVVRFLDWHG phoria target comprises two horizontal lines and two vertical lines. The vertical lines are printed one on top of WKH RWKHU DQG WKH KRUL]RQWDO OLQHV DUH SULQWHG RQH EHVLGH the other. The upper and right horizontal lines are seen E\ WKH ULJKW H\H DQG WKH ORZHU DQG OHIW KRUL]RQWDO OLQHV DUH VHHQ E\ WKH OHIW H\H DFKLHYHG XVLQJ SRODULVLQJ Ă&#x20AC;OWHUV $VVRFLDWHG WDUJHWV LQFOXGH IRXU SHULSKHUDO EODFN FLUFOHV DQG D FHQWUDO EODFN Âś; ¡ 3DWLHQWV DUH DVNHG LI WKH OLQHV DUH DOLJQHG ZLWK SULVPV DGGHG XQWLO WKH OLQHV DSSHDU WR EH aligned if necessary.

Figure 5

Fixation disparity :KLOH WKH DVVRFLDWHG SKRULD GHVFULEHV WKH SULVPV UHTXLUHG WR FRUUHFW WKH Ă&#x20AC;[DWLRQ GLVSDULW\ WKH Ă&#x20AC;[DWLRQ GLVSDULW\ LWVHOI FDQ DOVR EH PHDVXUHG Clinical tests &RPPRQ Ă&#x20AC;[DWLRQ GLVSDULW\ WHVWV LQFOXGH WKH :HVVRQ FDUG (see Figure 4 6DODGLQ QHDU SRLQW EDODQFH FDUG see Figure

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Figure 5 Saladin near point balance card

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Figure 6

Borish vectographic nearpoint card II

Figure 6 Sheedy disparometer

measurements include the circle and central vertical line and the circle and central horizontal line, respectively. The dissociated targets are a pair of horizontal and vertical lines, respectively. The horizontal lines in the top target of the vertical row (for vertical measurements) and the vertical lines in the left target of the horizontal row (for horizontal measurements) are printed in alignment. The examiner places prisms until the patient perceives the alignment which is the associated phoria. The remaining WDUJHWV FRQWDLQ YDU\LQJ R VHWV EHWZHHQ WKH OLQHV 7KH patient points to the target in which the lines appear to EH DOLJQHG DQG WKH H[DPLQHU UHDGV WKH FRUUHVSRQGLQJ DPRXQW RI Ă&#x20AC;[DWLRQ GLVSDULW\ IURP WKH EDFN RI WKH FDUG 9HUWLFDO Ă&#x20AC;[DWLRQ GLVSDULW\ UDQJHV IURP ¡ ULJKW K\SHU Ă&#x20AC;[DWLRQ GLVSDULW\ WR ¡ ULJKW K\SR Ă&#x20AC;[DWLRQ GLVSDULW\ +RUL]RQWDO Ă&#x20AC;[DWLRQ GLVSDULW\ UDQJHV IURP ¡ HVR Ă&#x20AC;[DWLRQ GLVSDULW\ WR ¡ H[R Ă&#x20AC;[DWLRQ GLVSDULW\ ,I WKH SDWLHQW KDV D KLJKHU HVR Ă&#x20AC;[DWLRQ GLVSDULW\ WKH FDUG FDQ EH Ă LSSHG RYHU

7KH %RULVK YHFWRJUDSKLF QHDUSRLQW FDUG ,, Ă&#x20AC;[DWLRQ GLVSDULW\ WDUJHW LV ORFDWHG EHORZ UDQGRP GRW Ă&#x20AC;JXUHV ,W FRQVLVWV RI DQ DVVRFLDWHG ELQRFXODU KRUL]RQWDO VFDOH RI XSSHU DQG ORZHU YHUWLFDO OLQHV VHSDUDWHG E\ ¡ Ă DQNLQJ D FHQWUDO DVVRFLDWHG ELQRFXODU URZ RI QXPEHUV DQG OHWWHUV 7ULDQJOHV DERYH DQG EHORZ WKH VFDOH DUH VHHQ RQO\ E\ WKH ULJKW DQG OHIW H\HV UHVSHFWLYHO\ 7KH perceived position of the triangles relative to the ELQRFXODUO\ YLVLEOH VFDOH VSHFLĂ&#x20AC;HV WKH PDJQLWXGH RI WKH KRUL]RQWDO Ă&#x20AC;[DWLRQ GLVSDULW\

Conclusion &OLQLFDOO\ Ă&#x20AC;[DWLRQ GLVSDULW\ LV XVHG WR GHWHUPLQH LI WKH SDWLHQW UHTXLUHV RSWRPHWULF LQWHUYHQWLRQ /DUJH Ă&#x20AC;[DWLRQ GLVSDULWLHV D HFW WKH SDWLHQW¡V ELQRFXODULW\ DQG typically require either prismatic correction, refractive intervention or vision therapy. The associated phoria PHDVXUHPHQW LQ WXUQ LV XVHIXO IRU SUHVFULELQJ SULVPV LQ the optometric clinic.

Exam questions and references Under the enhanced CET rules of the GOC, MCQs for this exam appear online at www.optometry.co.uk. Please complete online by midnight on 4 September 2020. You will be unable to submit exams after this date. Please note that when taking an exam, the MCQs may require practitioners to apply additional knowledge that has not been covered in the related CET article. CET points will be uploaded to the GOC within 10 working days.

Visit www.optometry.co.uk, and click on the â&#x20AC;&#x2DC;Related CET articleâ&#x20AC;&#x2122; title to view the article and accompanying â&#x20AC;&#x2DC;referencesâ&#x20AC;&#x2122; in full.

Sheedy disparometer

7KH 6KHHG\ GLVSDURPHWHU FDQ EH DWWDFKHG WR WKH SKRURSWHU DW D WHVWLQJ GLVWDQFH RI FP see Figure 6) and is viewed using polarising spectacles. The instrument includes two windows: the upper is used to measure KRUL]RQWDO Ă&#x20AC;[DWLRQ GLVSDULW\ DQG WKH ORZHU LV XVHG WR PHDVXUH YHUWLFDO Ă&#x20AC;[DWLRQ GLVSDULW\ 7KH FLUFXODU WDUJHW VXUURXQGLQJ WH[W DQG FHQWUDO OLQH DUH YLHZHG ELQRFXODUO\ as associated targets. The upper and lower lines in the upper circle and right and left lines in the lower circle are YLHZHG ZLWK GLVVRFLDWLRQ $ ZKHHO LQ WKH EDFN SDUW RI WKH instrument changes the display. Each image contains a YDU\LQJ R VHW EHWZHHQ WKH GLVVRFLDWHG OLQHV 7KH SDWLHQW selects the picture in which the lines are perceived as DOLJQHG 7KH Ă&#x20AC;[DWLRQ GLVSDULW\ DSSHDUV E\ WKH ZKHHO LQ WKH EDFN RI WKH LQVWUXPHQW 7KH DVVRFLDWHG SKRULD PD\ EH PHDVXUHG E\ SODFLQJ WKH LPDJH FRUUHVSRQGLQJ WR Ă&#x20AC;[DWLRQ GLVSDULW\ LQ IURQW RI WKH SDWLHQW DQG DGGLQJ prisms until the patient perceives the lines in the target in alignment.

About the author Q Dr Liat Gantz is a senior lecturer and director of the MOptom programme at the Department of Optometry and Vision Science, Hadassah Academic College, Jerusalem, Israel.

Course code: C-75133 Deadline: 4 September 2020

Learning objectives Q Understand the clinical application and assessment of fixation disparity (Group 8.1.3) Q Understand the clinical application and assessment of fixation disparity (Group 7.1.5)

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Returning to work: a guide for practitioners and employers

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Lizzy Yeowart BSc (Hons), MCOptom SUBS

This article outlines the steps and procedures needed to return to optometry after a career break from the perspective of the practitioner and the employer.

ART

Optometrists Dispensing opticians

PRODUCTION

Introduction

CLIENT

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WRZDUGV WKH RYHUDOO &(7 UHTXLUHPHQW 2QFH WKH &(7 UHTXLUHPHQWV DUH FRPSOHWH DSSOLFDQWV PXVW Ã&#x20AC;OO LQ DQG VXEPLW WKH HOHFWURQLF UHVWRUDWLRQ DSSOLFDWLRQ IRUP RQ WKH *2& ZHEVLWH 2 7KH Ã&#x20AC;QDO VWDJH RI WKH UHVWRUDWLRQ SURFHVV LV WR LGHQWLI\ DQ DSSURSULDWH SHUVRQ WR YHULI\ WKH DSSOLFDQW·V LGHQWLW\ 7KDW SHUVRQ PXVW FRPSOHWH WKH *2& UHVWRUDWLRQ LGHQWLÃ&#x20AC;FDWLRQ IRUP DOVR IRXQG LQ WKH ¶UHVWRULQJ WR WKH UHJLVWHUV· VHFWLRQ RI WKH *2& ZHEVLWH WKLV SURFHVV LV PXFK OLNH YHULI\LQJ D SDVVSRUW DSSOLFDWLRQ 2QFH WKH *2& KDV UHFHLYHG WKHVH IRUPV WKH\ ZLOO HPDLO DQ LQYRLFH IRU WKH UHVWRUDWLRQ IHH ZKLFK LV FXUUHQWO\ Â&#x2019; 7KH DSSOLFDWLRQ LV SURFHVVHG ZLWKLQ ZRUNLQJ GD\V RI UHFHLSW 6XFFHVVIXO DSSOLFDQWV UHFHLYH DQ HPDLO FRQÃ&#x20AC;UPLQJ WKHLU UHVWRUDWLRQ ZLWK WKH *2& DORQJ ZLWK D QHZ *2& QXPEHU EHJLQQLQJ ZLWK 7KH SUHYLRXV *2& QXPEHU FDQQRW EH NHSW QRU XVHG ,W LV D UHTXLUHPHQW RI UHJLVWUDWLRQ WR REWDLQ SURIHVVLRQDO LQGHPQLW\ FRYHU IURP DQ DSSURSULDWH SURYLGHU

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CET

Shutterstock

Professional support

VERSION REPRO OP SUBS ART PRODUCTION Getty

CLIENT

Decision

Checks and references

The decision to admit or decline an applicant to the OPL is the responsibility of NHS England. Applicants are QRWLĂ&#x20AC;HG E\ HPDLO DQG LI WKH DSSOLFDWLRQ LV VXFFHVVIXO DQ inclusion letter can be downloaded from PCSE online.

Scotland Practitioners can only provide, or assist in the provision of, eye examinations under GOS in Scotland if they are on the ophthalmic list of the NHS Board for that area.

Applicants need to supply an original enhanced FULPLQDO UHFRUG FHUWLĂ&#x20AC;FDWH IURP 'LVFORVXUH 6FRWODQG dated no earlier than 28 days before the application.

Practitioners also need to provide two references on their application. In addition, those that havenâ&#x20AC;&#x2122;t worked in Scotland for the last two years, are required to provide D WUDLQLQJ FHUWLĂ&#x20AC;FDWH LVVXHG E\ WKH 6FRWWLVK &RPPLWWHH of Optometrists (SCO) relating to the use of various ophthalmic instruments.

Joining the list

Joining as an assistant

The ophthalmic list maintained by each NHS Board consists of two parts: 7KH Ă&#x20AC;UVW SDUW OLVWV RSWRPHWULVWV RSKWKDOPLF ERGLHV corporate and ophthalmic medical practitioners who provide GOS from their own practice or via domiciliary visits The second part lists anyone who assists in the provision of GOS, such as locums or employees who work in a variety of locations.

Applicants, therefore, need to complete either part one or part two of GOS(S)6 depending on the part of the list they want to join. Contact details for the relevant boards can be found on the practitioner services division (PSD) website.5

Practitioners are able to join the ophthalmic list of more than one board and this can be indicated on the application form through the NHS board for the area where most of the individualâ&#x20AC;&#x2122;s GOS work will be done.

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Wales To provide GOS in Wales, practitioners need to be on the ophthalmic or supplementary list of the local health board (LHB). There are seven health boards, responsible for planning, funding and delivering hospital, community, and primary care services.

Joining the list

In order to join the ophthalmic or supplementary list in

Wales, practitioners need to complete an OPL1 form, which also requires having a DBS check as part of the process. The application can be completed online using the guidance notes on the NHS Wales website.6 If a practitioner wants to provide GOS in another LHB area, then an application must be made to each board to do so.

Joining the supplementary list

Those who undertake sight tests in practices owned by contractors are regarded as â&#x20AC;&#x2DC;assistingâ&#x20AC;&#x2122; in the provision of GOS and must be included in a supplementary list or be a contractor elsewhere.

Any optometrist who is on an ophthalmic or supplementary list anywhere in Wales, can also practise as an assistant in any other LHB area without seeking that LHBâ&#x20AC;&#x2122;s permission.

Northern Ireland Practitioners who want to provide GOS in Northern Ireland need to be on the Northern Ireland ophthalmic list.

Joining the list

Practitioners need to apply to the health board in the area where they are planning to deliver GOS. An application form to join the ophthalmic list in Northern Ireland can be downloaded from the HSC business services organisation website.7

For the employer It is quite likely that an optometrist will return to work after a career break at the practice in which they worked at previously. Maternity leave, adoption leave, sabbaticals and extended paternity leave are the most common reasons for a relatively short (up to one year) break from practice. In these instances, the return to work is usually straightforward for all involved, with the practitioner reporting that it is like they have never been away, once they have carried out two or three eye examinations. Breastfeeding mothers and those returning to work after a leave of absence due to sickness might have additional requirements. Useful advice for both employer and employee with regard to these situations can be found on the National Childbirth Trust (NCT) website8 on the Health and Safety Executive, (HSE), website.9 It is advisable for the employer to conduct a â&#x20AC;&#x2DC;backto-workâ&#x20AC;&#x2122; interview on the day of return, or shortly afterwards, but this is not a legal requirement. The employer should introduce the returnee to any new

CET

PHPEHUV RI VWD DQG DGYLVH WKHP RI DQ\ FKDQJHV in protocol both internal, (within the practice) and external, for example, referral pathways. New equipment and product ranges should also be explained.

An optometrist returning to work in a new practice after a career break will welcome support from their new employer, especially after a lengthy absence from the consulting room. This support can be divided into those relating to clinical matters and others relating to pastoral and personal matters.

Employer support: clinical matters Record keeping Optometrists should familiarise themselves with the UHFRUG NHHSLQJ V\VWHP EHIRUH WKH\ VHH WKHLU Ă&#x20AC;UVW patient. If the practice uses paper records, the optometrist can take a blank one to look over in their own time. If the practice uses a computerised system, employers should agree a time for the optometrist WR OHDUQ KRZ WR XVH WKH V\VWHP DQG DUUDQJH VSHFLĂ&#x20AC;F training if necessary.

Training Employers should arrange for internal or external WUDLQLQJ RQ VSHFLĂ&#x20AC;F SLHFHV RI RSWRPHWULF HTXLSPHQW especially if the practitioner hasnâ&#x20AC;&#x2122;t used it before. For instance, optical coherence tomography (OCT) can be GDXQWLQJ WR XVH DW Ă&#x20AC;UVW DQG WKH SUDFWLWLRQHU ZLOO UHTXLUH appropriate support. If the practice has a dispensing optician, then it is useful if they can give the optometrist an overview of the practiceâ&#x20AC;&#x2122;s most commonly dispensed lenses or arrange for a representative of the spectacle lens company to spend a few hours with the practitioner; a similar approach can be taken with contact lens related products. The optometrist should be made aware of what ancillary products, such as eyedrops are for sale at the practice. The optometrist can then read up about them, so they can recommend the SURGXFWV ZLWK FRQĂ&#x20AC;GHQFH Referral protocols and professional relationships Optometrists need to know what the local area referral protocols are, what professional relationships exist between general practitioners (GPs) and ophthalmologists in the area and what relationships exist between other optometry practices in the area. If the practice employs several optometrists, it is useful to set up a WhatsApp group or similar, to discuss professional and clinical matters, especially if the optometrists donâ&#x20AC;&#x2122;t work on the same days.

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Professional support

CET2, 3 VERSION REPRO OP SUBS

Internal protocols Employers should ensure that the optometrist knows the protocols relating to patient management and know the roles and capabilities of the team members.

ART PRODUCTION

When the optometrist is back in practice 7KH UHWXUQLQJ RSWRPHWULVW PLJKW IHHO ÂśUXVW\¡ ZKHQ Ă&#x20AC;UVW returning so will be grateful for the opportunity to carry out some eye examinations on friends, family or PHPEHUV RI VWD EHIRUH WKH\ VHH D SDWLHQW ,Q WKH DEVHQFH RI D VSDUH FRQVXOWLQJ URRP WKH HPSOR\HU FRXOG R HU the opportunity to use the space over a lunch hour.

Once back in practice, it is sensible for the employer to allow the optometrist some catch-up time in the diary or DOORFDWH ORQJHU DSSRLQWPHQW VORWV IRU WKH Ă&#x20AC;UVW IHZ ZHHNV This might not seem like the best use of clinic time, but it will make for a smoother transition for all involved. The RSWRPHWULVW ZLOO VRRQ EXLOG ERWK VSHHG DQG FRQĂ&#x20AC;GHQFH

Employer support: pastoral and personal matters

CLIENT

Like most people returning to work after a career break or starting at a new place of employment, even the most FRQĂ&#x20AC;GHQW RSWRPHWULVW PLJKW IHHO D OLWWOH DSSUHKHQVLYH 7KH personal and social aspects of a workplace are incredibly important. There are a lot of things that employers can do to alleviate the anxieties that the optometrist might feel. ,QWURGXFH WKHP WR DOO PHPEHUV RI VWD E\ QDPH DQG PDNH sure their roles are clear. Discuss the uniform policy, if any, with the optometrist. Get them a nameplate for their GRRU RU D QDPH EDGJH LI WKH UHVW RI WKH VWD ZHDU RQH ,QFOXGH WKHP RQ VWD QLJKWV RXW DQG ELUWKGD\ FROOHFWLRQV ,I WKH RSWRPHWULVW LV QHZ WR WKH DUHD WHOO WKHP ZKHUH WR go for lunch or where to park. Tell them the history of the practice and if there are any â&#x20AC;&#x2DC;charactersâ&#x20AC;&#x2122; they need to be introduced to or mindful of. Each of these steps will pay dividends because the optometrist will settle back into practice quickly and will be grateful for making the transition to work as smooth as possible which in turn boosts loyalty and job satisfaction.

Exam questions

Under the enhanced CET rules of the GOC, MCQs for this exam appear online at www.optometry.co.uk. Please complete online by midnight on 4 September 2020. You will be unable to submit exams after this date. Please note that when taking an exam, the MCQs may require practitioners to apply additional knowledge that has not been covered in the related CET article.

CET points will be uploaded to the GOC within 10 working days. You will then need to log into your CET portfolio by clicking on â&#x20AC;&#x2DC;MyGOCâ&#x20AC;&#x2122; on the GOC website (www.optical.org) to confirm your points.

68 www.optometry.co.uk

References

Visit www.optometry.co.uk, and click on the â&#x20AC;&#x2DC;Related CET articleâ&#x20AC;&#x2122; title to view the article and accompanying â&#x20AC;&#x2DC;referencesâ&#x20AC;&#x2122; in full.

About the author Q Lizzy Yeowart is an optometrist, Optometry Today columnist, AOP Awards judge and style blogger. She graduated with a first-class degree in optometry from Aston University in 1996 and worked in practice for 15 years. She took a career break to raise her children, during which she began writing her blog What Lizzy Loves. This has led to global collaborations within the world of fashion and optics and features categories including style, food, life, and optometry.

Course code: C-75069 Deadline: 4 September 2020

Learning objectives Q Recognise the importance of working within areas of competence when returning to work after a career break (Group 2.6.1) Q Be aware of the need to have adequate professional indemnity insurance when returning to work after a career break (Group 2.12.2) Q Be able to understand and comply with the GOCâ&#x20AC;&#x2122;s CET requirements when returning to work after a career break (Group 2.17.3) Q Recognise the importance of working within areas of competence when returning to work after a career break (Group 2.6.1) Q Be aware of the need to have adequate professional indemnity insurance when returning to work after a career break (Group 2.12.2) Q Be able to understand and comply with the GOCâ&#x20AC;&#x2122;s CET requirements when returning to work after a career break (Group 2.17.3)

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Meibomian gland dysfunction: the importance of early detection

CET

1

CET

Dr Katrina Schmid BAppScOptom (Hons), PhD

POINT

SUBS

This article discusses the importance of detection and treatment of meibomian gland dysfunction at the earliest possible stage to prevent or delay the onset of dry eye.

ART

Optometrists Therapeutic optometrists

PRODUCTION

Dispensing opticians Contact lens opticians

CLIENT

Introduction Meibomian gland dysfunction (MGD) is the most FRPPRQ FDXVH RI GU\ H\H D HFWLQJ XS WR RI &DXFDVLDQV DQG RI $VLDQV DJHG WR \HDUV 1 It LV JHQHUDOO\ FRQVLGHUHG WR EH D FRQGLWLRQ WKDW SULPDULO\ D HFWV ROGHU SHRSOH DQG LV UHSRUWHG WR EH OLQNHG WR WKH RQVHW RI PHQRSDXVH LQ ZRPHQ But is this really the FDVH" ,V WKLV ZKHQ 0*' VWDUWV" 2U FDQ LW EH D SURJUHVVLYH FRQGLWLRQ ZLWK PXFK HDUOLHU RQVHW WKDQ WKLV" 6RPH W\SHV RI 0*' VKRXOG EH FRQVLGHUHG LQ WKH VDPH ZD\ WKDW SUHVE\RSLD DQG FDWDUDFW GHYHORSPHQW DUH ² WKDW LV WR VD\ D FKURQLF SURJUHVVLYH FRQGLWLRQ )RU H[DPSOH LQ SUHVE\RSLD WKH ORVV RI DFFRPPRGDWLRQ actually commences in childhood,3 and during cataract GHYHORSPHQW WKH FODULW\ RI WKH FU\VWDOOLQH OHQV JUDGXDOO\ UHGXFHV ZLWK DJH ,W LV RQO\ ZKHQ WKH FKDQJHV DUH JUHDW HQRXJK WR D HFW IXQFWLRQ WKDW SHRSOH UHSRUW GL FXOWLHV $OWKRXJK DFFRPPRGDWLYH DPSOLWXGH JUDGXDOO\ UHGXFHV only once it is less than that required for comfortable QHDU YLVLRQ GR SHRSOH VHHN DVVLVWDQFH DQG WUHDWPHQW 5 6LPLODUO\ DJH UHODWHG FDWDUDFW GHYHORSPHQW GXH WR FKURQLF 89 H[SRVXUH OHDGV WR OHQV EUXQHVFHQFH ORVV RI lens clarity and light scatter,6 EXW RQO\ ZKHQ YLVXDO DFXLW\ DQG FRQWUDVW VHQVLWLYLW\ DUH UHGXFHG DQG JODUH VHQVLWLYLW\ LQFUHDVHG WR WKH SRLQW ZKHUH WKHVH QRWLFHDEO\ D HFW YLVXDO IXQFWLRQ GR SHRSOH VHHN RXW FDUH 7 $V LQ WKHVH FRQGLWLRQV ZKHUH ELQRFXODU YLVLRQ WHVWV RI DFFRPPRGDWLRQ DQG YHUJHQFH DQG RU ELRPLFURVFRS\ HYDOXDWLRQ RI WKH OHQV DUH DVVHVVHG DW PRVW YLVLWV D UREXVW VFUHHQLQJ SDUDGLJP IRU

GHWHFWLQJ HDUO\ 0*' LV LPSRUWDQW %ODFNLH et al LQ WKHLU UHYLHZ KLJKOLJKW WKDW 0*' LQFOXGHV D QRQREYLRXV K\SRVHFUHWRU\ REVWUXFWLYH W\SH ZKHUH LQĂ DPPDWLRQ DQG RWKHU VLJQV RI SDWKRORJ\ PD\ DSSHDU DEVHQW XQOHVV VSHFLDO H[DPLQDWLRQ WHFKQLTXHV DUH XQGHUWDNHQ 8 7KLV LV IXUWKHU VXSSRUW IRU WKH idea that MGD is a condition that must be screened IRU XVLQJ WKH DSSURSULDWH FOLQLFDO WHVWV 5HWKLQNLQJ 0*' LQ WKLV ZD\ FRXOG DOVR SURYLGH WKH SRWHQWLDO WR XQGHUVWDQG WKH KLJK QXPEHUV RI SHRSOH H[SHULHQFLQJ FRQWDFW OHQV GLVFRPIRUW DW UHODWLYHO\ \RXQJ DJHV 9

What is MGD? 0*' LV GHĂ&#x20AC;QHG DV D FKURQLF GL XVH DEQRUPDOLW\ RI the meibomian glands (MGs), commonly characterised E\ GXFW REVWUXFWLRQ DQG RU FKDQJHV LQ WKH PHLEXP JODQG VHFUHWLRQ ZKLFK PD\ UHVXOW LQ DOWHUDWLRQ RI WKH WHDU Ă&#x20AC;OP FOLQLFDOO\ DSSDUHQW LQĂ DPPDWLRQ RFXODU VXUIDFH GLVHDVH 26' DQG V\PSWRPV RI H\H LUULWDWLRQ $Q H\H FDUH SURYLGHU¡V LQLWLDO VXVSLFLRQ WKDW 0*' LV SUHVHQW LV W\SLFDOO\ EDVHG RQ SDWLHQWV¡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Ă DPPDWRU\ VLJQV DQG LV ODUJHO\ DV\PSWRPDWLF XQWLO YHU\ DGYDQFHG )RU H[DPSOH WKH RFXODU VXUIDFH GLVHDVH LQGH[ 26', VFRUH DVVHVVHV ERWK WKH IUHTXHQF\ DQG VHYHULW\ RI GU\ H\H V\PSWRPV DQG WKHLU LPSDFW RQ YLVLRQ EXW GRHV QRW VSHFLĂ&#x20AC;FDOO\ DVN DERXW WHDULQJ DQG IRUHLJQ ERG\ VHQVDWLRQ WKDW DUH FRPPRQ LQ 0*'

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91OPTJUN20140.pgs 02.06.2020 23:57

CET3, 1

Ocular surface disease

VERSION REPRO OP

Figure 1

SUBS ART PRODUCTION

Figure 1 Determination of the meiboscore. During meibography the glands are visible as white squiggly lines within the lid tissue. The meiboscore = 1, the area of loss is < 1/3rd of the lid area

CLIENT

Figure 2

monitor changes in symptoms over time.

This means that the clinical picture, based on test outcomes gathered perhaps as part of an ocular surface health screening, becomes fundamentally important.

6RPH RI WKH FOLQLFDO PHDVXUHV XVHG LQFOXGH D WHDU RVPRODULW\ JUHDWHU WKDQ P2VP O phenol red WKUHDG WHVW RI OHVV WKDQ WKH QRUPDO YDOXH RI PP 18 QRQ LQYDVLYH WHDU EUHDN XS WLPH 7%87 RI OHVV WKDQ VHF 19 ocular surface redness, VWDLQLQJ RI WKH FRUQHD DQG RU conjunctiva,21 DQG DVVHVVPHQW RI PHLEXP TXDOLW\ DQG expressibility.19 However, only via direct imaging of the meibomian glands, for example, using meibography,22 can the current KHDOWK RI WKH JODQGV EH GHĂ&#x20AC;QLWLYHO\ GHWHUPLQHG $OWKRXJK early versions of this method involved contacting the eyelid with a transilluminating infrared light probe, QRQ FRQWDFW IRUPV DUH QRZ ZLGHO\ DYDLODEOH 23 Clinically, meibography is used to provide the meiboscore (from ² ZKHUH JUDGH QR ORVV JUDGH DUHD RI ORVV RQH WKLUG RI WKH WRWDO JODQG DUHD JUDGH ORVV EHWZHHQ RQH WKLUG DQG WZR WKLUGV JUDGH ORVV RI PRUH WKDQ two thirds) (see Figure 1).23 The meiboscore and other lid grading scales have been further developed and validated.24 Although gland imaging is best performed using infrared light, when this is not available then red Ă&#x20AC;OWHUV DQG LPDJH SURFHVVLQJ WR HQKDQFH WKH LPDJH DQG YLVLELOLW\ RI WKH JODQGV PD\ EH XVHG DWKRXJK LPDJH TXDOLW\ LV QRW DV JRRG WKH 0*V FDQ VWLOO EH YLVXDOLVHG WR provide an estimate of the degree of gland dropout.25

When does MGD start and why is it often unnoticed?

Figure 2 Meibography image of right eye of 50-year-old female patient who never had symptoms of dry eye previously and has never been diagnosed with MGD. She reports intermittent conjunctival redness inferiorly from a young age but only seeking treatment now as lids stick together when sleeping. Gland drop out is obvious, meiboscore = 3

The ocular comfort index (OCI) was designed to have a linear progression in discomfort scores based on Rasch DQDO\VLV EXW LWV VFRUHV DUH GL FXOW WR HTXDWH WR WKH FOLQLFDO presentation.15 The standard patient evaluation of eye GU\QHVV TXHVWLRQQDLUH 63((' ZDV GHVLJQHG WR TXLFNO\

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7KH 0*V SOD\ D FUXFLDO UROH LQ HQKDQFLQJ WKH WHDU Ă&#x20AC;OP TXDOLW\ E\ FRQWULEXWLQJ WKH OLSLG FRPSRQHQW RI WKH tears to slow tear evaporation. +RZHYHU 0*' LV often a slow and chronic condition in that gland drop out is progressive and often unnoticed. As long as a PLQLPXP DPRXQW RI PHLEXP LV SURGXFHG WHDU TXDOLW\ is maintained, and symptoms are few. However, once a critical number of glands are lost, lipid production may VXGGHQO\ EHFRPH LQVX FLHQW DQG WKH WHDUV HYDSRUDWH PRUH TXLFNO\ FDXVLQJ UHĂ H[ ODFULPDO JODQG WHDULQJ $TXHRXV WHDU VHFUHWLRQ LQ SDWLHQWV ZLWK 0*' LQFUHDVHV DV D FRPSHQVDWRU\ PHFKDQLVP WR VWDELOLVH WKH WHDU Ă&#x20AC;OP 28 (YHQWXDOO\ V\PSWRPV PD\ EH UHSRUWHG XQIRUWXQDWHO\ though at this stage very few glands might remain (see Figure 2).

7KH ODFN RI OLSLGV LQ WKH WHDU Ă&#x20AC;OP DQG DORQJ WKH OLG PDUJLQ FDQ DOVR OHDG WR WKH H\HOLGV VWLFNLQJ WRJHWKHU DW night,1 DV WKH GULHG PXFXV LQ WKH WHDUV DFWV OLNH JOXH 7KH PXFXV FDQ DOVR VWLFN WKH OLG PDUJLQV WR WKH FRUQHD DQG LI

Figure 3

CET

from the MG openings (see Figure 4). Most commonly, symptoms but not signs are reported to improve with 0*' WUHDWPHQWV DQG WLPH FRQVXPLQJ LQWHUYHQWLRQV that provide some relief often have to be continued IRU OLIH $ PHWD DQDO\VLV RI UDQGRPLVHG FRQWUROOHG WULDOV UHSRUWV WKDW RQO\ V\VWHPLF DQWL PLFURELDOV (minocycline, azithromycin, doxycycline) show a UREXVW LPSURYHPHQW LQ 0*' VLJQV 38 although many treatment studies were excluded from the analysis due WR WKHLU GHVLJQ IRU H[DPSOH ODFN RI UDQGRPLVDWLRQ retrospective record analysis).

How prevalent is gland atrophy in children?

Figure 3 The lid margin sticking to the cornea intermittently may materialise as a horizontal line of epithelial cell loss across the surface of cornea that stains with fluorescein. Even if the appearance is initially minor, this should prompt the eye care provider to investigate further the lid margins and health of the MGs

FDUH LV QRW WDNHQ ZKHQ WKH H\HV DUH RSHQHG WKH VXUIDFH HSLWKHOLXP FDQ EH ULSSHG R FDXVLQJ LPPHQVH SDLQ ,Q WKH HDUO\ VWDJHV RI 0*' WKLV FDQ EH D UHODWLYHO\ PLQRU HYHQW DQG WKH SDWLHQW PLJKW QRW UHDOLVH LWV VLJQLĂ&#x20AC;FDQFH WKH appearance of a horizontal line in the corneal epithelium at the level of the lid margin is a suggestive clinical sign (see Figure 3). In this way, recurrent epithelial erosions FDQ RFFXU RI SDWLHQWV ZLWK UHFXUUHQW FRUQHDO HURVLRQ V\QGURPH KDYH 0*' 29 7KH LQĂ DPPDWRU\ FDVFDGH is eventually triggered, and the eyes appear red and irritated. $W WKLV SRLQW WKH 0*' VX HUHU LV OLNHO\ WR VHHN FDUH and tear supplements, including eye drops, gels and ointments, used to control symptoms.31 Heat, lid massage and lid expression,31 steam devices,32 honey eye drops,33 LQWHQVH SXOVHG OLJKW ,3/ 34 lid margin debridement35 and other treatments to improve MG function may also be SUHVFULEHG IRU H[DPSOH RPHJD DQG YLWDPLQ ' %XW LV WUHDWPHQW DW WKLV VWDJH WRR ODWH WR EH H HFWLYH DQG LV D SHUPDQHQW VROXWLRQ DW DOO OLNHO\" (YHQ ZLWK KHDW and lid expression meibum may not be easily expressed

The prospect that meibomian gland atrophy might occur in asymptomatic children, resulting in early 0*' EHLQJ OHIW XQGHWHFWHG LV YHU\ FRQFHUQLQJ 7KHUH DUH YHU\ IHZ LQYHVWLJDWLRQV RI WKH SUHYDOHQFH RI 0*' LQ FKLOGUHQ $ VWXG\ RI FKLOGUHQ DJHG IRXU WR \HDUV ZLWK QR KLVWRU\ RI GU\ H\H ZDV XQGHUWDNHQ WR VSHFLĂ&#x20AC;FDOO\ ORRN DW WKLV LVVXH 39 This study found that RI WKH FKLOGUHQ KDG VRPH JODQG GURSRXW DOUHDG\ HYHQ WKRXJK ZHUH DV\PSWRPDWLF EDVHG RQ WKH 63((' VXUYH\ WKLV LV QRW D RQFH R XQXVXDO Ă&#x20AC;QGLQJ In a group aged 15 years, morphological changes in the meibomian glands have also been reported. The authors state that the meiboscore (2.8Âą1.2) and grading RI PHLEXP TXDOLW\ Â&#x201D; ZHUH PXFK ZRUVH LQ WKLV group of Japanese children than expected (normal PHLERVFRUH WR

2I FRXUVH FKLOGUHQ FDQ VX HU IURP GU\ H\H GXH WR many causes.41 Children can present with early signs of RFXODU VXUIDFH LQĂ DPPDWLRQ SDUWLFXODUO\ RQ WKH QDVDO FRQMXQFWLYD DQG LQIHULRUO\ QHDU WKH OLG PDUJLQ WKLV could be due to atmospheric pollutions, visual habits OLNH LQFUHDVHG XVH RI GLJLWDO GHYLFHV OHDGLQJ WR UHGXFHG EOLQN WLPHV RU ORZ JUDGH FKURQLF LQĂ DPPDWRU\ FRQGLWLRQV 7KHUH LV D GRFXPHQWHG OLQN EHWZHHQ WKH duration of smartphone use and dry eye. Moon et al SHUIRUPHG D FURVV VHFWLRQDO VWXG\ RI FKLOGUHQ WKDW included a dry eye assessment and survey of their use of electronic devices.42 They found that the daily duration of smartphone use was longer in the group diagnosed with dry eye, and that a reduction in use improved both signs and symptoms.

One hour of smartphone use has been reported to LQFUHDVH WKH UDWH RI LQFRPSOHWH EOLQNLQJ IURP VL[ SHU min to 15 per min.43 ,W LV SDUWLFXODUO\ UHOHYDQW WR 0*' WKDW LQFUHDVHG LQFRPSOHWH EOLQNLQJ RFFXUV ZKHQ VWDULQJ at smartphones. In a group of patients with unilateral facial nerve palsy, Wan et al reported that those with

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Figure 4

SUBS ART PRODUCTION CLIENT

Figure 4 MG expression being performed after heat has been applied to the lid margin. In the case where glands are obstructed, or glands atrophied, no meibum will be expressed and no oil will appear at the opening of the glands

incomplete blinking had poor meibum quality and poor gland expressibility.44 Incomplete blinking may lead to MG atrophy and dropout by causing lipid stasis and MG REVWUXFWLRQ ,I EORFNDJH RI WKH RULĂ&#x20AC;FH RFFXUV PHLEXP builds up and the gland eventually atrophies.45 Including MG imaging as a screening test from a young DJH WR LPDJH WKH JODQGV DQG ORRN IRU HDUO\ FKDQJHV IRU H[DPSOH WKH SUHVHQFH RI VKRUWHQHG JODQGV DQG UHGXFHG JODQG DUHD FRXOG EH XVHG GLDJQRVWLFDOO\ WR LQGLFDWH WKH need to commence a preventative treatment. Reduced VFUHHQ WLPH DQG EOLQN WUDLQLQJ PLJKW EH EHQHĂ&#x20AC;FLDO DV D public health message for all children.

Do MGs regenerate?

It was traditionally thought that when MGs were dysfunctional and shortened in length (truncated) that

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they could not regenerate. Is there any evidence to the contrary? If gland dropout can be prevented or reversed is this only for cases of mild MGD (stage 1 to 2) or might improvements also be seen in more severe cases (stage 3 or worse)? Knop et al UHYLHZHG WKH DQDWRP\ SK\VLRORJ\ and pathophysiology of the MGs and described how VXVFHSWLEOH WKH\ DUH WR REVWUXFWLRQ SUHVVXUH DQG DWURSK\ DQG WKH YLFLRXV F\FOH RI VXEFOLQLFDO LQĂ DPPDWLRQ WKDW LV not addressed;45 whether there is the possibility of their regeneration is not described.

Yin and Gong suggest that a one-month period of lid hygiene (eyelid warming followed by moderate to Ă&#x20AC;UP PDVVDJH DQG OLG PDUJLQ FOHDQVLQJ FDQ LPSURYH gland expressibility and results in about a 5% reduction in MG dropout based on meibography in patients with MGD (stage 2 to 3).46 The authors also suggest a morphological improvement in the glands was visible based on the appearance of glands in the meibography LPDJHV +RZHYHU RQH WKLUG RI SDWLHQWV GLG QRW FRPSO\ with treatment and thus as expected showed no improvement. The authors also stated that whether MG atrophy is reversible in patients with severe MG dropout is unknown. Guillon et al also report that a lid hygiene treatment using eye pads (containing capryloyl glycine and ,ULV Ă RUHQWLQD) can improve MG function and reduce JODQG GURSRXW DOWKRXJK QRW LQ DOO SDWLHQWV 47 IPL may also lead to some improvement in MG expressibility and reduce dropout in MGD patients (average MGD stage 2.3).48 LipiFlow treatment is stated to liquefy and remove PHLERPLDQ JODQG REVWUXFWLRQ DQG WKH OLQNHG /LSL6FDQ device can be used to image the meibomian glands.49 Better results in terms of improvements to MG health DUH VWDWHG WR RFFXU ZKHQ 0*' LV OHVV VHYHUH $JDLQ QRW all patients may be expected to show improvement with these techniques.

Other more invasive techniques have also been assessed. There is the potential that debridement of the lid margins might assist if the MG obstructions occur at the gland openings. Korb and Blackie report that debridement of the keratinised lid margin to reveal the gland openings resulted in improved MG function one month later.35 +RZHYHU WKH JODQGV ZHUH QRW LPDJHG so whether any gland regeneration occurred was not VSHFLĂ&#x20AC;FDOO\ DVVHVVHG $ PRUH LQYDVLYH WHFKQLTXH XVLQJ D sterile steel wire to probe the MGs suggests that this does lead to growth and regeneration of gland tissue.50 The aim of the probing was to release scar tissue obstruction along the gland and thus allow for normal meibum Ă RZ ,Q OLGV ZLWK LQGLYLGXDO JODQGV LGHQWLĂ&#x20AC;HG D VLJQLĂ&#x20AC;FDQW LQFUHDVH RI LQ WRWDO JODQGXODU DUHD DQG a 6.2% increase in mean individual glandular area was

REVHUYHG WR PRQWKV IROORZLQJ 0* SURELQJ 7KXV there is some evidence that MG regeneration is possible. +RZHYHU REWDLQLQJ WUDLQLQJ RQ KRZ WR SHUIRUP WKLV technique and convincing patients to have it done may SURYH GLÂ&#x2C6;FXOW 6WHP FHOO WKHUDSLHV FRXOG EH KHOSIXO IRU UHJHQHUDWLQJ WKH PHLERPLDQ RU ODFULPDO JODQGV 51 but none of these are likely to be available soon.

Collectively this means that instigating treatments to preserve the MGs from a young age remains the better RSWLRQ WKDW LV WR VD\ SUHYHQWDWLYH WKHUDSLHV $ WUHDWPHQW WKDW LV HDV\ WR FRPSO\ ZLWK WKDW LV QRW WRR FRVWO\ WKDW targets the cause of the MG atrophy â&#x20AC;&#x201C; the reason for the MG dropout â&#x20AC;&#x201C; and prevents its further progression would prove very popular.

Conclusion Imaging of the MGs using meibography has the potential to improve the care provided to patients with MGD by allowing its earlier diagnosis. Asymptomatic SDWLHQWV HYHQ FKLOGUHQ QHHG WR EH VFUHHQHG IRU 0*' using meibography or lid gland expressibility to achieve this aim. The image of the glands can be used in discussions with the patient about their condition that is present even though they may be asymptomatic. As meibography is a non-contact technique it lends itself to inclusion in the standard battery of eye health tests that FRXOG EH SHUIRUPHG DW HDFK YLVLW &KHDSHU VPDOOHU DQG even portable devices would make its adoption more widespread.

Early diagnosis is of course only part of the required strategy to prevent dry eye caused by MGD. A treatment WKDW LV HDV\ WR FRPSO\ ZLWK WKDW WDUJHWV WKH FDXVH RI WKH MG atrophy and thus dropout and prevents its further progression is required. No current treatment has been proven to meet all of these criteria. At least a few simple DFWLRQV OLNH UHGXFHG VFUHHQ WLPH EOLQN WUDLQLQJ DQG KHDW with lid massage could be suggested.

Exam questions Under the enhanced CET rules of the GOC, MCQs for this exam appear online at www.optometry.co.uk. Please complete online by midnight on 4 September 2020. You will be unable to submit exams after this date. Please note that when taking an exam, the MCQs may require practitioners to apply additional knowledge that has not been covered in the related CET article.

CET points will be uploaded to the GOC within 10 working days. You will then need to log into your CET portfolio by clicking on â&#x20AC;&#x2DC;MyGOCâ&#x20AC;&#x2122; on the GOC website (www.optical.org) to confirm your points.

CET

References Visit www.optometry.co.uk, and click on the â&#x20AC;&#x2DC;Related CET articleâ&#x20AC;&#x2122; title to view the article and accompanying â&#x20AC;&#x2DC;referencesâ&#x20AC;&#x2122; in full.

About the author Q Dr Katrina Schmid is associate professor in the School of Optometry and Vision Science, Queensland University of Technology. Her research interests include assessment of the ocular surface, including meibomian gland dysfunction, dry eye and its treatment. Her current research in this area involves use of Optimel honey, intense pulsed light, and omega 3 as treatments for dry eye.

Course code: C-75145 Deadline: 4 September 2020

Learning objectives Q Be able to explain to patients about meibomian gland dysfunction (Group 1.2.4) Q Be able to identify and manage cases of meibomian gland dysfunction in contact lens patients (Group 5.2.1) Q Be able to assess cases of meibomian gland dysfunction and recognise the importance of early intervention (Group 6.1.4) Q Understand the natural progress of meibomian gland dysfunction and recognise the importance of early detection and intervention (Group 1.1.1) Q Be able to consider the options and instigate treatment for meibomian gland dysfunction (Group 2.1.6) Q Be able to discuss the options and importance of managing meibomian gland dysfunction with patients (Group 3.1.7) Q Be able to explain to patients about meibomian gland dysfunction (Group 1.2.4) Q Understand the management of patients with meibomian gland dysfunction (Group 8.1.3) Q Be able to explain to patients about meibomian gland dysfunction (Group 1.2.4) Q Be able to identify and manage cases of meibomian gland dysfunction in contact lens patients (Group 5.4.1)

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Sight support in schools REPRO OP

Cirta Tooth BSc, Prof Cert LV, Higher Cert LV, Prof Cert Paed Eye Care SUBS

This article describes the impact of visual impairment on educational needs for young children and how this can be managed.

ART

9,1&<3 9LVXDO LPSDLUPHQW WHQGV WR DÂ?HFW DFFHVV WR information, social interaction and mobility and it can be helpful to assess patients with this in mind. The cases that follow will illustrate this approach highlighting certain aspects in each.

Optometrists Dispensing opticians

Case one: oculocutaneous albinism PRODUCTION

Introduction

CLIENT

The leading causes for severe sight impairment (SSI) and sight impairment (SI) registration in children are showing a changing trend with less preventable or treatable sight loss and more sight loss with an (as yet) untreatable cause.1 The commonest cause of SSI and SI in England and Wales in 2009/2010 was cerebral visual impairment (CVI) (21.8%), followed by optic nerve disorders (18.5%), hereditary retinal disorders (16.7%), and congenital globe anomalies (21.2%).2 Besides the evolving nature of sight impairment causes, the author has also observed a change in the management of such cases. In the past, WKH IRFXV ZDV RQ SURYLGLQJ PDJQLĂ&#x20AC;HUV ZKHUHDV QRZ WKH DSSURDFK LV PRUH KROLVWLF DQG DLPHG DW Ă&#x20AC;QGLQJ solutions to improve functional vision. For instance, in Scotland, children are no longer considered for SSI and SI registration and are managed through the Visual Impairment Network for Children and Young People

1 CET POINT

Table 1 Case one clinical findings

LogMAR distance vision (no significant refractive error)

R 0.80 L 0.70 Binocular 0.66

Reading (Maclure reading test)

N6 binocularly at 20cm

Cover test

Minimal exophoria near and distance

Eye movements

Manifest horizontal nystagmus with null point in straight ahead position and downgaze. Nystagmus significantly increased in upgaze and moderately increased with right and left gaze. No strabismus

Other

Photophobia

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Primary school children with oculocutaneous albinism (OCA) are typically referred to the low vision clinic by WKHLU SDHGLDWULFLDQ TXDOLĂ&#x20AC;HG WHDFKHU IRU WKH YLVXDOO\ impaired (QTVI), or their ophthalmologist. OCA is a rare genetic condition with a worldwide prevalence of around 1:17,000.3 The prevalence in western society, including Europe, is around 1:10,000-20,000. Although the numbers are low, this condition frequently leads to reduced visual acuity, typically in the range of 6/18 to 6/120, congenital nystagmus and photophobia,3 and these patients often require input from the low vision service. This case scenario serves as an example of how typical symptoms can be managed in a classroom environment. Table 1 VXPPDULVHV WKH NH\ FOLQLFDO Ă&#x20AC;QGLQJV Access to information In order to access information in a classroom, a child needs to be seated in an optimal location for learning.

7KH PDJQLWXGH RI Q\VWDJPXV D FRPPRQ Ă&#x20AC;QGLQJ LQ OCA,3â&#x20AC;&#x201C;5 RIWHQ YDULHV LQ GLÂ?HUHQW GLUHFWLRQV RI JD]H ,QWHQVLĂ&#x20AC;HG Q\VWDJPXV UHVXOWV LQ SRRUHU YLVLRQ DQG DÂ?HFWV FRQFHQWUDWLRQ VR RQH QHHGV WR DVVHVV ZKHQ WKH nystagmus is minimised and then explain this to the SDWLHQW DQG WKHLU FDUHUV ,Q JHQHUDO Q\VWDJPXV LQWHQVLĂ&#x20AC;HV when the person carries out a visually demanding task,6 and tends to be worse in children with more obvious strabismus and poorer visual acuity.7 The child in this case has reduced acuity and a null point in the straight DKHDG SRVLWLRQ 7KH Q\VWDJPXV LV SDUWLFXODUO\ LQWHQVLĂ&#x20AC;HG when looking up and sideways. Therefore, the best position in the classroom is at the front, in the middle, on a chair (not the carpet). Sharing textbooks needs to be avoided. If the child struggles to see small details on the smart board, a tablet could be a better alternative (depending on local funding) and the use of a monocular

CET

Figure 1

children prefer binoculars as the nystagmus tends to be diminished when both eyes are used together.

Figure 1 Dome magnifier. Image courtesy of Associated Optical

telescope or binoculars may be helpful. In the case of photophobia, it is important to avoid placing direct light sources in front of the child, such as projector lights, ceiling and task lights and sunlight through windows.

The child needs to be encouraged to wear a hat and sunglasses both indoors and outdoors when needed.

Next, the reading performance needs to be addressed.

While visual acuity may improve during the early school years in children with nystagmus,5 the visual demand also increases with more reading tasks and smaller print size; this can impact negatively on reading performance.

Furthermore, accommodative amplitude typically GHFOLQHV IURP DURXQG WR ' DW Ă&#x20AC;YH \HDUV RI DJH WR to 12D at 10 years of age,8 which impacts on sustained reading, especially when reading material is held close.

A working distance of 20cm requires an accommodative demand of 5D and practitioners should consider prescribing reading glasses to aid sustained reading in these cases. If we assume that the patient in this case has JRRG UHDGLQJ Ă XHQF\ XS WR 1 SURORQJHG UHDGLQJ RI VPDOO SULQW VL]H ZLOO UHTXLUH FRQVLGHUDEOH HÂ RUW 'RPH (see Figure 1 DQG EDU PDJQLĂ&#x20AC;HUV DUH SRSXODU VROXWLRQV DV they are not very obtrusive and easy to use. Furthermore, the childâ&#x20AC;&#x2122;s teacher needs to be advised to allow extra time for schoolwork to be completed.

Mobility Mobility training can be arranged through the QTVI where needed. Monocular telescopes can be provided IRU VHHLQJ URDG VLJQV DQG WUDÂ?F OLJKWV DOWKRXJK VRPH

Social interaction The low vision practitioner plays a role in ensuring that the patient is looked after in terms of social and emotional impact of sight loss, nystagmus,9 and other aspects of albinism. It is helpful for practitioners to familiarise themselves with local after school clubs and sports clubs for visually impaired children, along with forums such as Haggeye and national organisations such as Blind Children UK and the Albinism Fellowship. Finally, when key information is explained to the child and carer(s), with consent, it is important to also provide this to third parties involved in the care of this child, particularly the schoolteacher and the QTVI; this is applicable to all children who present to the low vision clinic, irrespective of the underlying cause of the visual impairment.

Case two: hemianopia Hemianopia can be caused by a variety of neurological conditions, some of which are accompanied by inattention or other cerebral visual impairments (CVI). This case scenario serves as an example of how hemianopia can be managed. It concerns the case of a primary school child attending the hospital eye service (HES) with a history of left-sided hemianopia.

Table 2 (page 76) outlines the key clinical information.

When a low vision practitioner encounters a child with KHPLDQRSLD LW LV LPSRUWDQW WR GHWHUPLQH LI WKH Ă&#x20AC;HOG GHIHFW LV DFFRPSDQLHG E\ LQDWWHQWLRQ 9LVXDO Ă&#x20AC;HOGV DUH assessed with both eyes open in order to understand the functional impact. Hemi-neglect, competitive DWWHQWLRQ DQG ORZHU Ă&#x20AC;HOG GHIHFWV DOO QHHG WR EH FRQVLGHUHG ZKHQ DVVHVVLQJ YLVXDO Ă&#x20AC;HOGV ,W LV RXWVLGH WKH scope of this article to discuss investigative techniques.

However, it is important to establish the nature RI WKH Ă&#x20AC;HOG LPSDLUPHQW DV LW KDV DQ LPSDFW RQ UH

habilitation. This case concerns hemianopia as a result of a primary pathway lesion and is not accompanied by inattention or any other features of CVI. In terms of

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Table 2 Case two clinical findings

Table 3 Case three clinical findings

REPRO OP SUBS

LogMAR distance vision (minimal uncorrected hyperopia)

R 0.40 L 0.12 Binocular 0.10

LogMAR distance R 0.70 vision (with small L 0.50 hyperopic correction) Binocular 0.50

Reading (Maclure reading test)

R N14 L N8 Binocular N8 at 40cm

Reading (Maclure reading test) with glasses

Binocular N20 Improved to N14 when surrounding text covered

Visual field

Left-sided homonymous hemianopia

Contrast sensitivity (Mars)

Noticeable loss

Visual field

General field constriction in all quadrants with competitive attention to the left side requiring a left body turn for optimal scanning. Inferior fields grossly intact

scanning techniques, the child can scan the surroundings in the classroom and outside with simple eye and head movements. Scanning techniques need to be discussed with the patient and a referral for mobility training can be FRQVLGHUHG LI QHFHVVDU\ 7KLV LV RIWHQ GRQH via WKH 479,

ART PRODUCTION

Access to information It is a prerequisite that the child needs to be able to see the learning environment and the learning materials in order to access the school curriculum. Hemianopia, when not well managed, can prevent a child from accessing this information adequately. Learning walls, furniture, other pupils and the teacher may all be invisible if they DUH ORFDWHG LQ WKH DUHD RI WKH Ă&#x20AC;HOG GHIHFW :LWK D OHIW VLGHG KHPLDQRSLD LW LV HVVHQWLDO WR RSWLPLVH WKH VHHLQJ Ă&#x20AC;HOG RQ the right side, which can be achieved by positioning the child in the classroom with the wall on the left.

CLIENT

Reading Hemianopia tends to slow down reading speed, even LI WKH YLVXDO DFXLW\ LV JRRG 7KLV EHFRPHV D SUREOHP particularly when a child moves up through the school \HDUV DQG HQFRXQWHUV JUHDWHU UHDGLQJ GHPDQGV :LWK D OHIW VLGHG KHPLDQRSLD LW FDQ EH GL FXOW WR Ă&#x20AC;QG WKH beginning of the next line on the page. One way to RYHUFRPH WKLV LV WR URWDWH WKH WH[W WKURXJK Â&#x201D; DQG UHDG from bottom to top (see Figure 2). A vertical line at the beginning and end of the column can be helpful to DYRLG VHDUFKLQJ H\H PRYHPHQWV ZKHQ WU\LQJ WR Ă&#x20AC;QG WKH QH[W OLQH )ROORZLQJ WKH WH[W ZLWK D Ă&#x20AC;QJHU IXUWKHU DLGV WH[W QDYLJDWLRQ 7\SRVFRSHV DQG EDU PDJQLĂ&#x20AC;HUV ZLWK a reading line (see Figure 3, page 78 FDQ EH EHQHĂ&#x20AC;FLDO to some. Various programs have been developed to WUDLQ UHDGLQJ Ă XHQF\ DQG H[SHULPHQW ZLWK GLJLWDO WH[W presentation, such as Read-Right13 and LOOK. Mobility :LWK WKH VHHLQJ Ă&#x20AC;HOG RQ WKH ULJKW WKH FKLOG LQ WKLV FDVH ZLOO EHQHĂ&#x20AC;W IURP ZDONLQJ QHDUHVW WR WKH OHIW ZDOO ZKHQ navigating around the school, the playground and beyond. If door frames and other obstacles are causing frequent collisions, it may be helpful to mark the doors with a bold contrasting colour and remove unnecessary obstacles. Marking of doors and stairs can be arranged WKURXJK WKH 479, 'H FOXWWHULQJ DQG RUJDQLVLQJ storage as well as the use of contrast and lighting can further improve the visual scene and optimise visual performance, both for mobility and for visual search.

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Social interaction +HPLDQRSLD D HFWV YLVXDO VHDUFK ZKLFK OHDGV WR WKH child not spotting their friends and consequently not acknowledging their presence. Friends may suddenly disappear and reappear in the middle of a conversation and facial expressions can be harder to see when only one half of the face is seen. Explaining these issues can make D UHDO GL HUHQFH 3HHU VXSSRUW DQG FOXEV IRU YLVXDOO\ impaired children can be invaluable.

Case three: cerebral visual impairment Cerebral visual impairment (CVI) is an umbrella term for several types of visual impairment, related to GDPDJH WR WKH EUDLQ HDFK ZLWK GL HUHQW V\PSWRPV DQG presentations.15 3UDFWLWLRQHUV QHHG WR LGHQWLI\ WKH VSHFLĂ&#x20AC;F impact of these impairments for each individual case.

In order to do this, a medical history and any previous scans may be helpful as well as clinical investigations and a detailed appraisal of symptoms and behaviours.

Once the condition is understood, the practitioner can H[SODLQ WKLV WR WKH SDWLHQW DQG WKHLU FDUHU V DQG R HU FRPSHQVDWLRQ VWUDWHJLHV 7KLV FDVH VFHQDULR FRQFHUQV a child who has just moved up to secondary school with a history of premature birth. A detailed question inventory15 LGHQWLĂ&#x20AC;HV GL FXOWLHV ZLWK FURZGLQJ simultanagnosia, dyskinetopsia, reduced overall visual DWWHQWLRQ DQG YLVXDO Ă&#x20AC;HOG LPSDLUPHQW 3RRU H\HVLJKW DQG SHUFHSWXDO GL FXOWLHV LPSDFW XSRQ VRFLDO LQWHUDFWLRQ access to information and mobility.16 7KLV VFHQDULR ZLOO H[SODLQ WKHVH GL HUHQW DVSHFWV DORQJ ZLWK VRPH SRVVLEOH interventions. Table 3 summarises the clinical details for this patient.

Social interaction &KLOGUHQ ZKR KDYH GL FXOWLHV ZLWK FURZGLQJ RIWHQ UHSRUW WKDW LW LV GL FXOW WR Ă&#x20AC;QG WKHLU SDUHQWV LQ WKH SOD\JURXQG 7KLV SUREOHP FDQ EH HDVLO\ RYHUFRPH E\ DJUHHLQJ D VSHFLĂ&#x20AC;F ORFDWLRQ RQ WKH SOD\JURXQG IRU SLFN XS times and by wearing a brightly coloured scarf or other SLHFH RI FORWKLQJ WR PDNH WKH SDUHQW VWDQG RXW 7KH SDUHQW

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Figure 2

Figure 2 Reading with hemianopia.11 Image courtesy of AH Lueck and GN Dutton

should also be encouraged to wave to their child. Friends FDQ EH GL FXOW WR UHFRJQLVH LQ D FURZG DV ZHOO DQG D FKLOG can be helped by trying to remember friends by their clothing and by asking them to call out to assist. Reduced contrast sensitivity together with low acuity can make it harder to see peopleâ&#x20AC;&#x2122;s faces and facial expressions, which LV PDGH HYHQ PRUH GL FXOW LI D FKLOG KDV G\VNLQHWRSVLD (impairment of motion perception) and canâ&#x20AC;&#x2122;t easily REVHUYH IDVW PRYLQJ IDFLDO H[SUHVVLRQV &KLOGUHQ EHQHĂ&#x20AC;W from actively listening out for changes in tones of voice to understand what is being said and felt. '\VNLQHWRSVLD DOVR D HFWV VSRUWV DQG JDPHV &KLOGUHQ may report that they canâ&#x20AC;&#x2122;t seem to catch a ball or follow where teammates are going when they run too fast or GLVDSSHDU LQWR D Ă&#x20AC;HOG RI LQDWWHQWLRQ :KHQ DV D FKLOG LV unable to see the scene as a whole (simultanagnosia), they can experience isolation and frustration. A ringing ball can help locate the target of interest. Individual sports, such as judo may be suitable alternatives. *RDOEDOO 8. R HUV VSRUWV FOXEV IRU SHRSOH ZLWK D visual impairment; these include sessions for the entire school class to experience playing sports blindfolded, which leads to better understanding from peers. Scope provides information about a range of disability sport organisations.17 Access to information In the classroom, the child needs to be optimally SRVLWLRQHG WR PDNH XVH RI WKH Ă&#x20AC;HOG RI DWWHQWLRQ 7KH\ need to understand that, in order to access the side RI LQDWWHQWLRQ D ERG\ WXUQ LV UHTXLUHG DV WKH Ă&#x20AC;HOG RI inattention is related to body position rather than eye or head position. Scanning techniques need to be discussed.

7KH FKLOG PD\ Ă&#x20AC;QG LW GL FXOW WR VHH WKH VPDUW ERDUG GXH

to low visual acuity and depressed contrast sensitivity.

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CET4, 2

Low vision

CET4, 3 VERSION

Figure 3

About the author

REPRO OP

Q Cirta Tooth is an optometrist with a special interest in visual impairment. After several years working in community optometry, she is now primarily based in a hospital setting where she works in paediatric, macular, and low vision clinics. She has developed strong relationships with healthcare professionals, local support groups and voluntary organisations. She recently completed postgraduate education in low vision and paediatric optometry. She is involved in teaching optometrists, orthoptists, ophthalmologists, paediatricians, QTVIs, RNIB staff and postgraduate students.

SUBS

Exam questions

Figure 3 Bar magnifier with a line. Image courtesy of Associated Optical ART PRODUCTION CLIENT

mobility outside and indoors. In the home environment, one can de-clutter the rooms and put a systematic storage system in place to allow for better navigation and visual search.

It is outside the scope of this article to discuss all possible interventions. In a clinical setting the author tends to use a question inventory, followed by a lengthy discussion with the child and their carer(s). The family also receives written advice that they can pass on to the school and any other professionals involved in the care of the child. Depending on the situation, direct referrals and reports are sent to third parties, providing that the patient gives consent.

The author has found that it is particularly important IRU FKLOGUHQ ZLWK &9, WR XQGHUVWDQG WKHLU VSHFLÀF YLVXDO impairments, so that the behavioural features resulting from this are understood. This tends to empower the patient (and their carer(s)) and gives them the tools to develop their own strategies.

Conclusion There are over 25,000 visually impaired children aged 16 years and under in the UK.18 Many of these children attend mainstream schools and, therefore, specialist support is required to allow them to access the curriculum. However, education services for visually impaired children varies between areas.19 Provision depends on factors, such as the nature and severity of the visual impairment, the level of support the child will require, parental choice and the availability of services within the local authority. This article has shown that good communication among professionals and cohesive management is a key factor in helping children to reach their learning potential. Furthermore, good communication with the child and their carer(s), including explanation of the condition and coping VWUDWHJLHV EH\RQG WKH PHUH SURYLVLRQ RI PDJQLÀHUV LV essential. Practitioners can play an important role in supporting children with a visual impairment and their families.

78 www.optometry.co.uk

Under the enhanced CET rules of the GOC, MCQs for this exam appear online at www.optometry.co.uk. Please complete online by midnight on 4 September 2020. You will be unable to submit exams after this date. Please note that when taking an exam, the MCQs may require practitioners to apply additional knowledge that has not been covered in the related CET article.

CET points will be uploaded to the GOC within 10 working days. You will then need to log into your CET portfolio by clicking on ‘MyGOC’ on the GOC website (www.optical.org) to confirm your points.

References

Visit www.optometry.co.uk, and click on the ‘Related

CET article’ title to view the article and accompanying ‘references’ in full.

Course code: C-75238 Deadline: 4 September 2020

Learning objectives Q Be able to communicate effectively with children with visual impairment Group 1.2.4) Q Be able to provide information to all relevant parties involved in the care of children with visual impairment to ensure that they receive appropriate support (Group 2.2.5) Q Be able to provide advice on optical and non-optical interventions to support the needs of children with visual impairment (Group 4.2.1) Q Be able to communicate effectively with children with visual impairment (Group 1.2.4) Q Be able to provide information to all relevant parties involved in the care of children with visual impairment to ensure that they receive appropriate support (Group 2.2.5) Q Be able to provide advice on optical and non-optical interventions to support the needs of children with visual impairment (Group 6.3.1)

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91OPTJUN20168.pgs 03.06.2020 18:07

VRICS VERSION

1

Anterior eye

CET POINT

REPRO OP

Drew Thompson BSc (Hons), MCOptom SUBS

This visual recognition feature presents a series of anterior images for practitioners to interpret using additional resources where required to answer the questions.

ART

Optometrists Image B

Image A

PRODUCTION CLIENT

01 What can be seen in the centre of this image? a) Striae b) Hydrops c) Keratoconus d) Damaged contact lens

04 What can be seen in the slit lamp beam? a) Dellen b) Keratic precipitates c) Subepithelial white cells d) Munsonâ&#x20AC;&#x2122;s sign

02 What has caused the grey perpendicular lines emanating from the limbus? a) Refractive surgery E 3KDFRHPXOVLĂ&#x20AC;FDWLRQ VXUJHU\ c) Keratoconus d) Corneal dystrophy

05 Which of the following is a predisposing factor for this condition? a) Poor hygiene b) Upper respiratory infection c) Visits to an eye clinic d) All of these options

03 Which of the following is a complication that can result from this? a) Wound rupture b) Iatrogenic ectasia c) Glare d) All of these options

06 What is the generally accepted treatment for this condition? a) Chloramphenicol b) Fluorometholone (FML) c) Diclofenac d) Polyhexamethylene biguanide (PHMB)

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Image C

Image D

07 What can be seen in the image? a) Vitreous bleed b) Asteroid hyalosis c) Tobacco dust d) Vitreous cells

10 What has caused this appearance? a) Anterior uveitis b) Hyphema c) Rose bengal staining in dry eye d) Posterior polymorphous dystrophy

08 What treatment should be considered? a) Gas bubble b) Vitrectomy c) None d) Topical steroids

11 What underlying ocular condition could have caused this? a) Fuchsâ&#x20AC;&#x2122; endothelial dystrophy b) Pseudoexfoliative glaucoma c) Central retinal vein occlusion d) Exposure keratopathy

09 What other condition might be associated with this finding? a) Diabetes b) High cholesterol c) Hypertension d) All of these options

VRICS

12 What is the future risk associated with this underlying condition? a) Glaucoma b) Cataract c) Corneal scarring d) All of these options

About the author Q Drew Thompson is an independent practice owner in Lytham, Lancashire and has extensive experience in anterior segment disease for hospital clinics. His main interests are corneal disease and complex contact lenses.

Exam questions Under the enhanced CET rules of the GOC, MCQs for this exam appear online at www.optometry.co.uk. Please complete online by midnight on 4 September 2020. You will be unable to submit exams after this date.

Course code: C-74886 Deadline: 4 September 2020

Learning objective Q Be able to manage patients presenting with anterior segment pathology (Group 6.1.5)

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VRICS 1, 1

Anterior eye

VRICS VERSION

1

Macular marvels

CET POINT

REPRO OP

Jaspreet Sajjan B(Optom)Hons, MCOptom, ProfCert MedRet SUBS

This VRICS feature presents a series of retinal images for practitioners to interpret and answer the accompanying questions, referring to additional resources where required.

ART

Optometrists

Therapeutic optometrists Image B

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PRODUCTION CLIENT

01 What finding is displayed in the image?

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82 www.optometry.co.uk

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Image C

07 What complication is displayed in the image?

D 3UROLIHUDWLYH GLDEHWLF UHWLQRSDWK\ E 'LDEHWLF SDSLOORSDWK\ F 'LDEHWLF PDFXODU RHGHPD G 'LDEHWLF NHWRDFLGRVLV 08 What treatment is most appropriate for this patient?

D $QWL 9(*) WUHDWPHQW E ,QWUDYLWUHDO FRUWLFRVWHURLGV F 3KRWRG\QDPLF WKHUDS\ G 3DQUHWLQDO SKRWRFRDJXODWLRQ 09 Which of the following forms part of the treatment inclusion criteria in these cases?

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About the author Q Jaspreet Sajjan is a specialist optometrist at Leicester Royal Infirmary. She has nine years’ experience in hospital optometry and has a wide range of clinical interests including medical retina and uveitis.

Exam questions Under the enhanced CET rules of the GOC, MCQs for this exam appear online at www.optometry.co.uk. Please complete online by midnight on 4 September 2020. You will be unable to submit exams after this date.

VRICS

Image D

A patient is being treated with hydroxychloroquine (HCQ) for a systemic condition 10 What finding is displayed in the image?

D %XOO·V H\H PDFXORSDWK\ E 0DFXODU VFKLVLV F 0DFXODU WHODQJLHFWDVLD G 0DFXODU GHJHQHUDWLRQ 11 Which of the following is not included in the criteria for ophthalmology HCQ screening?

D $QQXDO VFUHHQLQJ LI RQ +&4 IRU ÀYH \HDUV E %LDQQXDO VFUHHQLQJ IRU SDWLHQWV RQ FKORURTXLQH IRU !RQH \HDU F 3DWLHQWV ZKR KDYH VWRSSHG WDNLQJ +&4 GXH WR WR[LFLW\ G 3DWLHQWV SODQQLQJ WR EH RQ ORQJ WHUP ! ÀYH \HDUV

+&4 IRU EDVHOLQH H[DPLQDWLRQ ZLWKLQ VL[ PRQWKV 12 Which of the following tests is useful but not mandatory in screening of HCQ patients?

D +XPSKUH\ YLVXDO ÀHOGV E 3XSLO GLODWLRQ F 2&7 DQG ZLGHÀHOG IXQGXV DXWRÁXRUHVFHQFH LPDJLQJ G &RORXU YLVLRQ H[DP Course code: C-75202 Deadline: 4 September 2020

Learning objectives Q Be able to identify a range of retinal abnormalities (Group 6.1.5) Q Be able to interpret clinical images and identify the clinical abnormality for a range of retinal conditions (Group 2.1.2)

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VRICS 2, 1

Diagnostics

I can't live without, 1

VERSION REPRO OP

Jobs

www.aop.org.uk/ot/jobs

SUBS ART

QUESTIONS

Career counsellor at CV Writers, Michelle Hiseman, advises on competency-based questions

PRODUCTION

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ompetency-based interviews are used to demonstrate that you have the right skills for the role by using examples based on prior experience.

They often start with: Give me an example of a time when...

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Your decision-making process Reasons for choosing your course of action How you interacted with people How you overcame the challenges.

When answering a question related WR FRQĂ LFW \RX FRXOG VD\ ´, WROG KLP to calm down and explained what the problem was.â&#x20AC;? However, there is not 8VLQJ H[DPSOHV LGHQWLĂ&#x20AC;HG LQ \RXU enough detail in this answer. Instead, preparation, alongside the Context, you should highlight the reasons behind Behaviour, Impact (CBI) technique, your action, how you spoke and your gives structure to your answers. course of action. For example: â&#x20AC;&#x153;I could see he was irritated so I asked him gently Context to tell me what the problem was. By %ULHĂ \ GHVFULEH WKH VLWXDWLRQ WDVN allowing him to vent his feelings, he goals, main challenges and the reason quickly calmed down. I for undertaking the task.

For example: â&#x20AC;&#x153;Due to a â&#x20AC;&#x153;You should focus then explained my own merger, I was made area not just on â&#x20AC;&#x2DC;whatâ&#x20AC;&#x2122; point of view, emphasising WKH LPSRUWDQFH RI Ă&#x20AC;QGLQJ manager. The branches you did but also a solution that suited us were used to working â&#x20AC;&#x2DC;howâ&#x20AC;&#x2122; you did itâ&#x20AC;? both. We scheduled a XQGHU WZR GL HUHQW meeting toâ&#x20AC;Śâ&#x20AC;? systems, and due to poor communication, morale was low. Teams consistently under-performed on the Impact targets to upsell products and services.â&#x20AC;?

Explain the outcome, what you accomplished, the contribution it made, and what you learnt. Use statistics if Behaviour SRVVLEOH SOXV UHĂ HFWLRQV RU LQWHUHVWLQJ Explain what you did to achieve the insights. For example: â&#x20AC;&#x153;The impact of the outcome. This is where the most detail restructure resulted in a 20% increase of should be. You should focus not just on VDOHV LQ WKH Ă&#x20AC;UVW IRXU PRQWKV DQG ZH DUH â&#x20AC;&#x2DC;whatâ&#x20AC;&#x2122; you did but also â&#x20AC;&#x2DC;howâ&#x20AC;&#x2122; you already on target to exceed this in the did it, including:

BONUS TIP: BE PREPARED Always prepare and practise mock questions before an interview. The internet is a great resource to use for your research. Just by keying in the words â&#x20AC;&#x2DC;competency-based questions for optometry,â&#x20AC;&#x2122; you will find several sites with practice questions and advice. Use the job description to identify the most relevant questions for the role you are applying for.

Practise your answers out loud. This is more effective than thinking about them. Ask a trusted friend or family member to perform a mock interview with you, and give you honest feedback about your performance. A note of caution, though: avoid overrehearsing. You need to come across naturally in the interview, plus have the flexibility to adapt your answers to the actual questions being asked.

next three months. Plus, there has been an improvement in morale. As a result, the new team structure is being rolled out across the entire organisation and I am acting as an adviser to other area managers. I am proud of this project EHFDXVH LW ZDV P\ Ă&#x20AC;UVW PDQDJHPHQW UROH DQG , KDYH JDLQHG D ORW RI FRQĂ&#x20AC;GHQFH LQ my leadership abilities.â&#x20AC;?

Shutterstock

INTERVIEW SKILLS:

CV Writers offers career counselling and interview coaching, as well as support with CVs, LinkedIn profiles and cover letters. They also provide a free CV review service via their website www.cv-writers.org.uk

84 www.optometry.co.uk

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Marketplace 1

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Marketplace Services and products for the practitioner

SUBS

WEBINARS & WHATSAPP

ART PRODUCTION CLIENT

chat, which contains all of the practice partners in the Hakim Group as well as HGHQ members. We do that Jill Heath, partner at Heath Optometric in Stoke-onso we have the most up-to-date Trent and Newbold Optician in Market Drayton information and can start the day I COUL D feeling informed. The messaging hen in times of extraordinary NOT LI V group is thoroughly professional E challenge, itâ&#x20AC;&#x2122;s useful to know that W ITHO UT... and practice team members VRPHRQH KDV \RXU EDFN LV Ă&#x20AC;JKWLQJ \RXU share their experiences, advice and corner, and is keeping you in the loop. guidance on any and all situations, but Thatâ&#x20AC;&#x2122;s why during the the COVID-19 particularly relating to COVID-19 at the pandemic, two communication moment. Itâ&#x20AC;&#x2122;s a great forum where you platforms became vital to our remote are able to pose questions to those in a working life: webinars and WhatsApp. similar situation and get almost instant My husband James Heath and I have responses. two practices that are part of the Hakim Group, so we have been lucky enough Knowledge sharing to attend regular webinars hosted by For young optometrists who have CEO Imran Hakim and other members been landed with COVID-19 so early of the team. Theyâ&#x20AC;&#x2122;ve been amazingly in their careers, especially if theyâ&#x20AC;&#x2122;ve LQIRUPDWLYH DQG LQ WKH Ă&#x20AC;UVW ZHHN RI â&#x20AC;&#x153;Communication with only recently taken over a practice as a the â&#x20AC;&#x2DC;lockdownâ&#x20AC;&#x2122; these webinars were partner, to have this backup of group almost a daily occurrence, which was so other practices has been knowledge must be incredibly valuable. important at that time. It was reassuring really importantâ&#x20AC;?

If youâ&#x20AC;&#x2122;re new to partnership, the WR NQRZ WKDW VRPHRQH ZDV Ă&#x20AC;JKWLQJ Instant responses structure of the Hakim Group means our corner every day of the week and Geographically, as practice owners that someone who does have that keeping us updated. weâ&#x20AC;&#x2122;re all apart from one another and experience is just a message away. As a we canâ&#x20AC;&#x2122;t meet up for obvious reasons, dispensing optician it can also be very Adapting communications so webinars are one way of keeping us KHOSIXO LI \RX¡UH ORRNLQJ IRU D VSHFLĂ&#x20AC;F We certainly wouldnâ&#x20AC;&#x2122;t say that we used all in the loop. What weâ&#x20AC;&#x2122;ve really found frame or lens advice. The WhatsApp webinars regularly a few months ago, useful has been the interaction during groups are ideal sources of mass EXW ZH KDYH GHĂ&#x20AC;QLWHO\ EHHQ FRQYHUWHG the webinars, in the comments section. information.

The webinars have covered a number The communication with the other Both communication tools allow RI LVVXHV LQFOXGLQJ D ZHHN Ă&#x20AC;QDQFLDO practices has been really important, the Hakim Group HQ team to blueprint for all the practices, which is because everybody runs their own communicate with all partners at incredibly useful moving forward.

SUDFWLFH YHU\ GL HUHQWO\ ZLWKLQ WKH once, rather than sending out lots of One of the most important webinar Hakim Group and the exchange of ideas individual messages. Crucially for topics has been in relation to our team KDV JLYHQ ULVH WR GL HUHQW YLHZSRLQWV XV LW JLYHV XV WKH Ă H[LELOLW\ WR UHFHLYH PHPEHUV 6WD DUH WKH PDLQVWD\ RI D These group discussions can make you important information, whilst we work business and the priority is to keep YLHZ WKLQJV GL HUHQWO\ DGGLQJ PRUH remotely, on very accessible platforms. them happy. There were concerns knowledge and possibly changing your The core message from the Hakim around whether it would be safe for own decisions. When the webinars are Group during this time has been VWD WR FRPH LQWR WKH SUDFWLFHV EHIRUH playing itâ&#x20AC;&#x2122;s been fantastic to be able to #StrongerTogether, and the way weâ&#x20AC;&#x2122;ve the lockdown and before we had bounce back ideas. been able to communicate has been personal protective equipment (PPE), Shared information and learning with crucial for that mantra to come true. especially if they had older family other independent partners is also why As an independent practice, life members or others at risk at home. The ZRXOG KDYH EHHQ D ORW PRUH GL FXOW webinars have given useful guidance on WhatsApp has been so vital. When James and I wake up in a morning, the without the support we have received KRZ EHVW WR SURWHFW RXU VWD VHFXULQJ Ă&#x20AC;UVW WKLQJ ZH GR LV FKHFN RXU JURXS from our wider network. their jobs and the business as a whole.

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Last word, 1

LAST WORD VERSION

MY T SECRE ...

S LI F E A

My secret life

REPRO OP

Do you have a hobby to share with readers?

Get in touch with selinapowell@ optometry.co.uk

SUBS ART PRODUCTION CLIENT

While trial lenses are functional objects for optometrists, they are a tiny canvas for artist and treasure hunter, Andy Poplar

“It is circular. I give one piece new life and then find the next one to work on” 90 www.optometry.co.uk

M

y background is not in optics, although my sister is an optician. When she was at university, she would test my eyes with an old set of lenses.

It has been in the periphery of my life. I was out taking my daughter for a walk one morning in Harrogate and I had this idea about etching on to glass.

I taught myself how to etch and it went a little bit viral on the internet through social media.

My company, [vinegar & brown paper], grew from there and it has now been going for eight years.

I’m based in Yorkshire between Harrogate and Leeds.

I used to write commercials and I liked the idea of taking a piece of glass and imbuing it with

meaning. Because you can see through glass, it is almost as if you are writing a message on the world.

I spend my life walking around looking at things that I could etch. I especially like working with vintage glass. The optician lenses are perfect. I have had quite a few commissions from optometrists asking for name badges. , ÀQG WKH OHQVHV DOO RYHU the place, in vintage shops, at antique fairs and on eBay. I pick them up as and where I can. When I exhibit at shows, I do have quite a few optometrists come up to me.

I think they can see the lenses from a distance, and they’re drawn to them. I have had R HUV IURP RSWRPHWULVWV WR source sets of lenses for me because they no longer meet the criteria of what the practice needs. Everything I make, I always think I could make it a little bit better. I guess I am a perfectionist, but that drives you on as well. You keep improving incrementally.

I have collected things since I was in my teen years but now I make my living from it too.

My job is perfect. I spend half my time going around treasure hunting and half the time etching it and selling it on.

It is circular. I give one piece QHZ OLIH DQG WKHQ ÀQG WKH QH[W one to work on.

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