OT April/May 2021 – your latest digital edition by TheAOP

Introducing My Lens Life…

Outer covers spread

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Journal of the Association of Optometrists

COVID-Generation Special report Page 35-38

£9.95 REPRO OP

April/May 2021 Volume 61:02

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Starter pack

Email template

Welcome pack

Email template PRODUCTION

Step 2

CLIENT

Step 1

April/May 2021 / Volume 61:02

…the contact lens patient retention programme from CooperVision, designed to help reduce drop out and support remote patient care.

www.optometry.co.uk

Step 3

Information booklet

Series of follow-up follow w up emails

If we can give step-by-step support to new contact lens wearers, we can help reduce contact lens drop out - allowing new wearers to enjoy the freedom provided by contact lenses and live their lens life to the full. My Lens Life is a category programme that provides patient communication tools at every step of the contact lens journey, for all your contact lens patients, regardless of the lenses they are wearing.

THE REMODELLING PATIENT EYE CARE EDITION

mylenslife.uk

GO BEYOND VISION and let your patients Live the ULTRA Life

To find out more please contact your CooperVision Business Development Manager.

coopervision.co.uk/mylenslife

Remodelling eye care for a post-pandemic future / www.optometry.co.uk

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CET Management of the anisometropic child

Spotlight The Education Strategic Review explained

In practice Proactively engaging contact lens wearers

Page 80

Page 08

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Introducing NEW Bausch + Lomb ULTRA® Multifocal for Astigmatism

The latest innovation in reusable contact lenses across a complete family*

1,2,3,4

AVAILABLE

53,55,56,57

IN STOCK

REPRO OP

AND READY TO SHIP

Long hours, long days, lasting performance • Long-lasting moisture retention18,19

HOURS OF COMFORT

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with MoistureSeal® Technology

• Exceptional wettability18,20

Combines the seamless vision presbyopic patients want with the lens stability for their astigmatic needs.2,6

• Superior surface smoothness and durability17,† • Precision optics for sharp vision1,16,23 ART

• Comfort and visual performance day in, day out... month after month1,22,23

Available in stock and ready to ship so you can reduce your patients’ waiting time and fulfil their vision needs sooner.

3-ZONE PROGRESSIVE DESIGN™

OPTICALIGN™ DESIGN

SEAMLESS vision

STABLE

Axis indicator designates axis of cylinder power7 (30˚ example shown)

DISTANCE

PRODUCTION

INTERMEDIATE

NEW

NEAR

APPROVED FOR EXTENDED WEAR

CLIENT

MATERIAL:

FOR PRESBYOPIA

FOR PRESBYOPIC ASTIGMATS

Bausch + Lomb ULTRA® for Presbyopia5

samfilcon A

LENS MATERIAL TECHNOLOGY:

MoistureSeal® Technology

0.5

46%

-0.5

-3.00D High Add

WATER CONTENT: MODULUS:

LENS DESIGN TECHNOLOGY:

Power (D)

0.0

OXYGEN TRANSMISSION:

Orientation mark helps measure rotational stability and assists patients during insertion7

For illustrative purposes only. FOR ASTIGMATISM

70 163 Dk/t @ centre for -3.00D

114 Dk/t @ centre for -3.00D

Aspheric optics to reduce inherent and OpticAlign™ Design with spherical induced spherical aberration aberration control

≤5°on 95% of patients

near, far and in-between1

And our Patient Satisfaction Guarantee for complete peace of mind.

SPHERICAL

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104 Dk/t @-3.00D

3-Zone Progressive Design™ with centre-near aspheric optics

3-Zone Progressive Design™ OpticAlign™ Design

Near

Intermediate

Distance

On-eye clinical results2

Rotation, centration and movement at dispensing ROTATION

CENTRATION

MOVEMENT

-1.0 -1.5 -2.0 -2.5 -3.0 -3.5 -4.0 0.0

0.5

1.0

1.5

2.0

2.5

3.0

0 to 5 Degrees

95%

Excellent

86%

Adequate

100%

6 to 10 Degrees

Good

14%

Excessive

11 to 15 Degrees

Fai r

Insufficient

> 16 Degrees

Poor

Adherence

8.5 mm

8.6 mm

8.5 mm

8.6 mm

DIAMETER:

14.2 mm

14.5 mm

14.2 mm

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CENTRE THICKNESS:

0.07 mm @ -3.00D

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+6.00D to -12.00D (in 0.50D steps above -6.00D)

+6.00D to -9.00D (in 0.50D steps above -6.00D) Available in -2.75D Cylinder

+6.00D to -10.00D (in 0.25D steps including plano)

+3.00D to +1.00D -1.00D to -5.00D in 0.25D steps

Low: up to +1.50D spectacle Add High: from +1.75D spectacle Add

Call now for your Fitting Guide and to order Trial Lenses

-0.75, -1.25, -1.75, -2.25, -2.75

-0.75, -1.25

N 0845 602 2350 E cs.vc.uk@bausch.com D www.bausch.co.uk/ultra-mfa

10° to 180° (in 10° steps)

10°, 90°, 170°, 180°

Orientation mark at 6 o’clock Axis indicator varies with axis

AXES: ORIENTATION MARK / AXIS INDICATOR: VISIBILITY TINT: WEAR SCHEDULE: REPLACEMENT SCHEDULE:

Light Blue Daily wear, up to 7 days extended wear Monthly

* Latest technology in soft reusable lenses across a complete contact lens family. † Vs Acuvue® Oasys®, Biofinity® and Air Optix® Aqua.

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To help reduce the spread of COVID-19, the UK Government has advised that face coverings should be worn whenever social distancing can’t be maintained.

New COVID-19 practice resources for members

3 distinct zones with consistent power in each zone Nimo power profile

SIMPLE EASY TO FIT*, IN STOCK, READY TO SHIP

Our online guidance and practice resources include what reasonable adjustments you could make for patients who are unable to wear a face covering, and a template door poster so you can set out your practice policy on face coverings.

3,4

ADD POWERS:

Keeping your practice safe

Radial Displacement (mm)

BASE CURVE:

CYLINDERS:

Inner covers spread

VERSION

Bausch + Lomb ULTRA®

A condensed and efficient power range addressing some of the most popular powers, providing additional business opportunities for your practice.

* When the ECP followed the fitting guide 1. ULTRA® Comfort Experience™ for Presbyopia Data Analysis Phase 1 + 2. 2017. 2. Bausch + Lomb ULTRA® Multifocal for Astigmatism stabilisation study. 3. Bausch + Lomb, 2013. Perceptions of Bausch + Lomb PureVision® 2 for Presbyopia (#815). Rochester. 4. Bausch + Lomb., 2016. A study to evaluate the product performance of two designs of soft toric lenses (#ROC2-16-016). Rochester. 5. Reindel, W., et al., 2015.Ergonomic Utility of Progressive Multifocal Contact Lenses: A Comparison of Power Profiles Across Near, Intermediate and Distance Zones. AAO Poster Presentation. 6. The 2020 Study of US. Multifocal contact lens market. 7. Hovinga,K.R., 2016. Summary of ULTRA® for Astigmatism Orientation and Axis Markings (#LDR168019). 16. Bausch + Lomb, 2013. A study to evaluate the product performance of a new silicone hydrogel contact lens (#817). Rochester. 17. Merchea, M., Wygladacz, K.A., et al., 2014. Comparative Surface Smoothness Durability of a Novel Silicone Hydrogel Material. Association for Research in Vision and Ophthalmology 2014 annual meeting. 18. Hoteling, A., Nichols, W., et al., 2014. PVP content of a silicone hydrogel material with dual phase polymerisation processing. American Optometric Association Annual Meeting; 2014, Philadelphia, PA. 19. Bausch + Lomb, 2013. 16 Hour bilateral dispensing evaluation of methacrylamide lenses as compared to Air Optix® Aqua, Acuvue® Oasys® and Biofinity® lenses (#ROC2-13-002). 20. Schafer, J., Reindel, W., et al. Use of a novel extended blink test to evaluate polyvinylpyrrolidone(PVP) contact lens containing polymer performance. 22. Reindel, W., Mosehauer, G., et al., 2018. Patient comfort, vision and cleanliness over 12-months of Samfilcon A Lens Wear. Poster presented at AAO. 23. Micromass Communications Inc., 2017. Statistical Analysis of Bausch + Lomb ULTRA® for Astigmatism Lenses Challenge Patient Survey. (n=426). 53. Pence, N.,2014. Contact Lens Design and Materials. Contact Lens Spectrum [e-journal]. https://www.clspectrum.com/ supplements/2014/october-2014/breaking-the-cycle-of-discomfort/contact-lens-design-amp-materials [Accessed 8/12/2020]. 55. Sulley, A., 2005. Practitioner and patient acceptance of a new silicone hydrogel contact lens. Optician 6017 (230), pp 15-17. 56. Barr, J., 2004. An avalanche of products, compliance and the FCLCA. Contact Lens Spectrum [e-journal]. https://www.clspectrum.com/issues/2010/december-2010/product-spectrum [Accessed 15/12/20]. 57. Mack, C., 2008. Contact Lenses 2007. Contact Lens Spectrum [e-journal]. https://www.clspectrum.com/issues/2008/january-2008/contact-lenses-2007 [Accessed 8/12/20] ULTRA, MoistureSeal, OpticAlign and 3-Zone Progressive Design are trademarks of Bausch & Lomb Incorporated or its affiliates. All other product/brand names and/or logos are trademarks of their respective owners. ©2021 Bausch & Lomb Incorporated or its affiliates.

To read the guidance and download the poster visit www.aop.org.uk/facecovering

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Welcome

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ART PRODUCTION Cover: Garry Walton

CLIENT

n 23 March, the country solemnly marked a year on from the first nationwide lockdown. People took to their doorsteps, this time with candles and torches, to offer a quietly moving vigil for all those who have died during the pandemic. As I write this Welcome note in late March, businesses across the country continue to prepare for the gradual easing of lockdown restrictions, while remaining mindful of the government’s watchwords: ‘We are led by the data not dates.’ For our profession, the lights have for the most part stayed on so that the public can continue to receive the eye care they need. This could only be achieved with the dedication of optometrists. Understanding the impact of the pandemic on the profession will take time and careful consideration. For optometry students and preregistration optometrists, whose careers are at their most formative stage, the disruption has been profound. In this edition, OT finds out firsthand what challenges lie ahead for this ‘COVIDGeneration’ – and considers why this cohort will be the most resilient and enterprising yet (page 35). Asking the big questions about the future of optics beyond the pandemic will be key – and the AOP’s policy team are at work on a new long-term plan to crystalise what this future should and can look like. As a front-line primary care service, perceptions of optometry will have evolved both in the mind of the public, and also within secondary care – creating a platform for change. Extended services such as CUES have also changed the landscape, but more discussion about the commissioning of services and the infrastructure to support it is needed – see more on page 59. The importance of finance remains front and centre, and we know from members that the financial pressures of the pandemic have led to new conversations about delivering eye care using more sustainable business models. Meeting the milestone of vaccinating 30 million people (me included, in Salisbury Cathedral) points to a future where COVID-19 does not start and end every conversation. I write in hope.

“Asking the big questions about the future of optics beyond the pandemic will be key – and the AOP policy team are at work on a new long-term plan”

Henrietta Alderman, AOP chief executive

April/May 2021

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Welcome

APRIL/MAY 2021

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Contents

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ART

A look at the making of the cover on page 7

CLIENT

Garry Walton

PRODUCTION

07-25 SPOTLIGHT

Spotlight

AOP SUPPORT

The news in digest Picture this The story behind OT’s latest cover OT reports Exploring five questions about the Education Strategic Review The Edit Optics in 16 stories 100% Optical Previewing the May online event Industry profile Shamir UK’s Russell Bickle Clinical roundup The top 200 optometry researchers Supplier insight The dynamics of the dry eye market AOP roundup The AOP’s latest Council meeting, plus new advice from the professional discipline team

4 www.optometry.co.uk

April/May 2021

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“The AOP legal teams are experts, and we can guide members through the GOC investigation process” Cassandra Dighton, head of professional discipline PAGE 25

27-33 HIT LIST

The trends, launches and looks OT focuses on... Managing patient contact Me and my glasses British Superbike racer, Brad Ray Get the look // Anatomy of a frame With Lizzy Yeowart The shortlist This edition’s selection Behind the brand Eco by Modo Eyewear

35-38 COVID-GENERATION

SPECIAL REPORT

“Graduates need to be able to develop skills to keep abreast of changes and to critically review new technologies as they come into practice” Professor John Siderov, University of Huddersfield

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

35 25

65 CET welcome 66 Primary care assessment and management of macular holes 70 Dispensing children in a special needs school environment 75 Communication essentials: health literacy in practice 80 Management of the anisometropic child 86 Cases of gradual vision loss 88 Instrumentation for anterior eye assessment In this edition of OT, practitioners can test a range of competencies: OPTOMETRISTS // 6 THERAPEUTIC OPTOMETRISTS // 1 DISPENSING OPTICIANS // 5 CONTACT LENS OPTICIANS // 1

43-57 IN PRACTICE

Business insight and career development The roundtable OT and Alcon ask ECPs how they prevent contact lens dropout Becoming a busines owner Sophie Patel How do I... Manage infection control in the practice? What I have learned Optometry’s role in the COVID-19 vaccination programme in Wales Pre-reg focus Peter Grant and Luke McRoy-Jones Life as a locum Sammara Ahmed In conversation With Johnson & Johnson Vision

ONLINE

Cover story

The new renaissance Can eye care rebuild following a global pandemic? From telemedicine in Wales to diagnostic hubs in London, leaders within the profession are thinking in new ways PLUS: Professor Bruce Evans talks with OT about research examining referrals from optical practices to secondary care PAGE 59-64

90-98 ENDNOTES

Jobs The Hakim Group way Last word Readers’ text messages to their former selves pre-COVID-19

OT video highlights

A roundtable on COVID-19 and contact lens dropout Watch the video on

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

April/May 2021

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Contents

CONTENTS

Spotlight, 1 VERSION

Spotlight

REPRO OP

08 OT REPORTS

Five learnings from the GOC's Education Strategic Review

21 CLINICAL ROUND-UP

The 200 researchers leading the way in optometry

24 AOP SUPPORT

The future of optics, policy updates, and professional discipline

SUBS

PICTURE THIS ART

The da Vinci effect

PRODUCTION CLIENT

With the cover story theme, 'remodelling eye care,' the OT team turned to illustrator Garry Walton for the cover image. Drawing inspiration from da Vinci's dazzling renaissance sketches, Garry was able to work in modern themes, including the now synonymous COVID virus, for our tailor-made image.

April/May 2021

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VERSION

EDUCATION STRATEGIC REVIEW:

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FIVE QUESTIONS ANSWERED ON CHANGES TO OPTICAL TRAINING

April/May 2021 Volume 61:02 Issn 0268-5485 ABC certificate of circulation 1 January 2020 – 31 December 2020

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Editor: John White johnwhite@optometry.co.uk Deputy editor: Emily McCormick emilymccormick@optometry.co.uk Senior content editor: Lucy Miller lucymiller@optometry.co.uk Assistant editor: Selina Powell selinapowell@optometry.co.uk

ART PRODUCTION CLIENT

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

Advertising: Richard Ellacott 020 3771 7242 richard.ellacott@thinkpublishing.co.uk Advertising production: aop@ccmediagroup.co.uk Senior designer: Grant Pearce Account director: Anna Vassallo Executive director: Jackie Scully Published bimonthly for the Association of Optometrists by Think Capital House, 25 Chapel Street, London NW1 5DH Printed by Acorn Web, Normanton Ind Estate, Loscoe Close, Normanton, West Yorkshire, WF6 1TW All rights in and relating to this publication are expressly reserved. No part of this publication may be reproduced in any form or by any process without written permission from the AOP or the publisher.

8 www.optometry.co.uk

April/May 2021

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More than four years after the General Optical Council’s (GOC) Education Strategic Review (ESR) was initiated, the regulator has signed off its plan for an overhaul of optical education and training requirements. Through the changes, students will need to achieve a single qualification approved by the GOC, instead of the current two-stage approach. Qualifications will also need to integrate 48 weeks of learning and experience in practice. During the consultation phase of the review, concerns were expressed by the AOP about various aspects of GOC's plans – including how the changes would be funded and maintaining consistency across different education providers. Below OT presents answers from the AOP policy team to common questions about the new requirements.

1 F

unding is still a real risk. Optometry courses are likely to be more expensive for universities to deliver under the ESR, partly because universities will probably arrange and quality-assure the practice-

Are funding concerns still a risk? based learning and experience that most students currently obtain through their pre-reg placement. That will have some benefits for students – for instance, it may reduce the risk of students being left to fend for themselves if a pre-reg placement falls through, as happened in some cases during the pandemic. But it will come at a cost – including to students, who are likely to incur higher student debt in the future because of longer university courses. Initial education and

training for optometry is currently less well funded than for other healthcare professions including dentistry and pharmacy, and the AOP is still concerned that universities may struggle to deliver the ESR without extra funding. The GOC and the sector bodies are now working together to explore options for extra funding for optical professional training. If it seems during the ESR implementation that limited funding to deliver the ESR may threaten the future provision of optometry courses, with implications for patient safety, the AOP will expect the GOC to take whatever steps it can to ensure continued provision of training and safeguard patients.

iven the changes the GOC has made while finalising the ESR requirements in recent months, the AOP does not consider this to be a significant risk. In fact, some of the new features of the GOC’s education requirements should reinforce the

academic status of optometry training. For instance, new optometry qualifications must be set at Master’s level, in line with a recommendation by the Quality Assurance Agency, and any qualification must also be either a recognised

academic award or regulated qualification. These requirements are not included in the current GOC education handbook, and the current College of Optometrists’ Scheme for Registration does not lead to a Master’s level qualification.

WILL THESE CHANGES OPEN THE WAY FOR A DEGREE APPRENTICESHIP IN OPTOMETRY?

t will not be any easier to seek GOC approval for a degree apprenticeship under the new ESR requirements than under the current GOC handbook. If anything, the GOC approval process for future qualifications should be more rigorous. It will be based on an overall assessment of whether the proposal would meet the ESR outcomes and standards, rather than what could be considered the ‘tick-box’ requirements for student experience in the current GOC education handbook. It remains possible that a provider may seek GOC approval for a degree apprenticeship qualification in the future

(although this would now have to be a higher degree apprenticeship at Master’s level). The AOP would oppose any such proposal, for the reasons we set out in our response to the degree apprenticeship consultation in 2019. In its response to the 2020 ESR consultation, the AOP argued that any application to the GOC to approve a degree apprenticeship in optometry should automatically be treated as high-risk and subject to full consultation.

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April/May 2021

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Spotlight, 2

WILL THE ESR CHANGES MEAN FUTURE OPTOMETRY QUALIFICATIONS ARE OF A LOWER STANDARD?

SPOTLIGHT

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HOW LONG WILL THE CURRENT COURSES & THE SCHEME FOR REGISTRATION STAY IN PLACE?

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his will depend on discussions between the GOC, universities and the College of Optometrists. The GOC has said it expects most universities will aim to begin programmes under the new ESR requirements from autumn 2023 or 2024, but that it will work with education providers individually to support them through the transition. It seems possible that some providers will still offer courses under the pre-ESR education handbook in 2023 or beyond, and if so the Scheme for Registration will also need to stay in place. The GOC has said it expects the Scheme for Registration will be required until at least 2030.

ART PRODUCTION CLIENT

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OP members reported that the quality of supervision of pre-reg trainees in the current system, and the support given to their supervisors, is not always good enough. In summer 2020, the AOP ran a member survey on pre-reg supervision experience; a substantial minority of the current and recent pre-reg trainees who took part highlighted that the support they received was either “sometimes adequate and sometimes less than adequate,” or “less than adequate most of the time.” This is a significant concern and demonstrates the need for better funding of clinical

10 www.optometry.co.uk

“Some of the new features of the GOC’s education requirements should reinforce the academic status of optometry training”

WILL THE SUPERVISION OF PLACEMENTS BE GOOD ENOUGH? placements. The same concerns will apply to the learning and experience in practice that will be integrated into new qualifications. Although AOP undergraduate student members report valuing early clinical experience in their studies, and would welcome more of it, the AOP is also aware that it creates cost and complexity for universities. Because of the concerns AOP members have raised about the quality of clinical supervision, the association urged the GOC to include in the new standards a requirement for education providers to ensure that commercial pressures don’t affect the quality of supervision on

placements. The AOP is pleased that the GOC has introduced this important safeguard. However, education and placement providers will only be able to provide highquality supervision if the resources are available for them to do so. This is one reason why it remains vital for the GOC and the sector to manage the risks around future funding for optometry education.

April/May 2021

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Spotlight, 3

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Observe and measure all the main structures and surfaces of the eye Posterior OCT

ART

Anterior OCT OCT-A Angio OCT OCT-B Biometry OCT True colour fundus imaging

“Thousands of [eye clinic] appointments have been missed due to COVID-19 restrictions and practitioners’ capacity difficulties” Spokesperson for the charity Deafblind UK, Simone Moore, described the anxieties many patients are facing during the pandemic. The charity has launched a wellbeing and emotional support service for patients who have missed appointments during the pandemic to “talk through feelings, thoughts and emotions” with trained advisers.

PRODUCTION

“Myopia prevalence is going to nearly double by 2050”

CLIENT

Dr Noel Brennan, a clinical research fellow for Johnson & Johnson Vision’s Myopia Control Platform, spoke to OT about the company’s new myopia recommendations guide, how approaches are changing, and why practices should adopt myopia control.

“I would recommend that anyone considering a new OCT scanner in 2021 seriously look at the Optopol range. I have been very impressed with the scan quality, ease of use and comprehensive functionality of the software” Sundeep Kheterpal MA MRCOphth FRCSEd

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

12 www.optometry.co.uk

April/May 2021

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15.2%

fall in net sales was reported by Safilo Group for 2020. Commenting on the results, Safilo group CEO, Angelo Trocchia, said: “2020 presented the most challenging market conditions we have ever experienced.” The last three months of the year, however, saw net sales grow by 3%. The company’s total online business also “grew sharply.”

Alcon has introduced its new Precision1 daily disposable contact lens in sphere and toric designs, along with a patient support programme powered by augmented reality. Jonathon Bench, Alcon director of professional affairs international – dry eye and ocular health, explained that the immersive platform aims to ensure patients receive the right information, in the right way and at the right time. View the interview on OT’s Youtube page: https://bit. ly/30PpXbe

“The positive impact of optometry was clear during the peak of the pandemic and demonstrated how intrinsic community eye care is to other primary and community services”

Julie Mosgrove, vice-chair of Optometry Scotland and chair of the Expert Working Group for Primary Eyecare Services Report, on a new report presented to the Scottish Government.

LVMH eyewear company, Thélios, has partnered with Mazzucchelli 1849 and materials provider, Eastman, to jointly develop new sustainable acetate frames, exploring eco-responsible formulas and materials. The first collection is set to be released in 2022.

Mazzucchelli

REPRO OP

More than just an OCT

The European Commission has approved EssilorLuxottica’s proposed acquisition of GrandVision. This is conditional on the divestment of some of EssilorLuxottica’s optical retail businesses in Belgium, the Netherlands and Italy – totalling around 350 stores. The Commision said the proposed remedies would address competition concerns. At the time of publication, the transaction is under review in Chile and Turkey.

Getty/ z_wei

INDUSTRY SUPPORT

Spotlight, 4

SPOTLIGHT

THE EDIT 60 DAYS IN 16 STORIES

SCIENCE AND VISION

Pexels/Amarnath Radhakrishnan

Allergan has launched a mobile app to provide education and support for patients with glaucoma. The Glaucoma in Perspective app was developed in consultation with Professor David Crabb from City, University of London, and with guidance from Glaucoma UK. Features of the app include guides, demonstrations and animations. Loughborough University is working to develop a device for the early detection and diagnosis of keratoconus. The research, funded by Fight for Sight and Keratoconus Self-Help and Support Association, aims to create a laser tool that is more compact and portable than existing methods, which would identify localised thinning of the cornea that occurs in earlystage corneal disease progression.

20,945

new registrations from adults and children as being blind or partially sighted were recorded in England in 2019–20, equivalent to 57 new registrations a day. The aggregate information presented by NHS Digital suggested that, as of 31 March 2020, there were 276,690 registrations overall, or five registrations per 1000 people in England.

To tackle a vision screening backlog brought about by the pandemic, the Clinical Council for Eye Health Commissioning (CCEHC) has recommended parents of children who started reception in 2019 or 2020 but missed out on vision screening should be advised to have an NHS sight test if local screening is not imminent. The CCEHC has produced a template letter and guidance on the responsibilities of practices.

“The AOP is honoured to be in its 75th year. We are proud of our AOP community, working with members and for members every step of the way” Henrietta Alderman, chief executive of the AOP, has shared her thoughts on a milestone year for the association. Watch OT’s interview with AOP chair, Mike George, and vice chair, Dr Julie-Anne Little, on the 75th anniversary: https://bit.ly/2OYys10

Pexels/Ylanite Koppens

NHS England rejected proposals to provide further financial support for struggling practices affected by the COVID-19 pandemic. The Optometric Fees Negotiating Committee criticised the decision not to provide further support, commenting that it “shows a lack of regard for the small number of practices that still need help, having struggled to continue to meet eye care needs and provide frontline services throughout the pandemic.”

IN PRACTICE “75% of our staff are still partially furloughed to various extents” Practice owner, AOP board member and past chairman, Kevin Thompson, welcomed the extension to the Government’s furlough scheme until September. The update was included in the Government’s 2021 Budget, which also confirmed the extension of the Self-Employment Income Support Scheme.

Optometrists and business owners, Roshni Dalia and Dr Valarie Jerome, have been recognised in Small Business Britain’s #ialso100 campaign, which celebrates the work of 100 female entrepreneurs. Speaking to OT, Ms Dalia (pictured) said: “I hope to use this platform to inspire young women to follow their dreams, to show that with hard work and determination, anything can be achieved, no matter how impossible it may seem.”

“There are better, brighter days ahead” Holly Higgins, hospital optometrist, reflected on reasons to be hopeful, for OT’s ‘The year that changed optometry’ feature, recognising one year since the first UK lockdown. Ms Higgins highlighted the increased adoption of teleophthalmology as a positive change for the profession, as well as providing greater flexibility for clinics. Read more reflections on the past year on page 98.

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Pixabay/Picjumbo_com

PROFESSIONAL SUPPORT

VERSION

Pre-register as a delegate

REPRO OP

100% Optical’s virtual event will take place between 23–24 May. Pre-register for the event online: www.100percentoptical.com

100% OPTICAL SUBS

Conversations and connections

ART

100% Optical will deliver a virtual event between 23–24 May, offering education and interactive CET, as well as networking opportunities. OT finds out more…

PRODUCTION

This year, 100% Optical will come to screens as a virtual event, connecting exhibitors and delegates for networking, product showcases and education. With the physical show postponed until January 2022, the first day of the virtual event will offer opportunities to network and gather CET points, while the second day will be dedicated to eyewear buyers and business owners. Pre-registration opened in March for delegates to express their interest in the virtual show, receiving an “encouraging” reception, Nathan Garnett, event director of 100% Optical, told OT. The AOP will be delivering a series of online CET sessions during the virtual event on Sunday 23 May, to ensure practitioners can gain interactive points. Dr Ian Beasley, AOP head of education and OT clinical editor, said: “The AOP-led programme at 100% Optical provides an opportunity to update practitioners on key clinical topics while also offering interactive CET points across a range of core competencies.” The first session will be delivered by the AOP’s clinical negligence legal

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team on how to spot the red flag signs and symptoms of intracranial tumours. This will be followed by the importance of OCT imaging for the detection of peripheral retinal disease, while the third session will provide an update on myopia management uptake by practitioners, considering the barriers that have been overcome and the remaining challenges. Another key session will consider the role of the tear film in relation to the ocular surface and contact lens wear. The AOP will also be delivering an extensive range of CET online throughout the year, including webinars and peer discussions with key groups in mind. Making a connection Discussing the virtual event, Mr Garnett said: “Through the platform, exhibitors can share new products and brands, either through videos or face-to-face virtual meetings, or they can hold an education session.” The event is also planning virtual eyewear showcases to display a selection of frames from exhibitors and share what is new on the market.

The event will be hosted on the digital platform, Swap Card, featuring a networking matchmaker powered by artificial intelligence. This tool can suggest which products a delegate might want to look at, the contacts they may wish to connect with, or seminars and CET sessions that they might want to join. Mr Garnett said: “You can set up an agenda, choose your CET sessions, and book appointments with exhibitors – much as you would at the show itself.” Through the platform, seminar attendees will be able to take part in live discussions, and networking rooms will also be set up. The event will be hosting content around business topics, such as how to sell luxury, and store designs, as well as wider conversations around the shape of the industry going forwards. Hybrid potential As well as reuniting the profession virtually, the event could also kickstart a new approach for the event as the platform will remain available. Delegates will be able to revisit the platform after the event to view products, arrange meetings, or view information and videos. It will also host 100% Optical’s newsfeed and Tech Bites virtual series. Mr Garnett suggested this could work in tandem with the event in the future. “I think this is one of the good things that has come out of [the situation],” Mr Garnett said. “It gives us more of a 360-degree approach to the event, allowing the conversations to start earlier and carry on throughout the year.”

Media 10/100% Optical

Exhibitor views: what is your focus for the show? Rogier Lenderink, Charmant head of operations in the UK: "In today’s new business world, opening the digital doors for the two days of the show is an exciting and enjoyable way of interacting with our customers. The platform will facilitate meetings, opportunities to view our latest collections and to catch up on the latest in the world of optics."

Paul Cumber, Essilor Ltd instruments director: “We plan to use the platform to showcase our new Vision Station-700 which is set to launch just ahead of the virtual exhibition. We’ll also be showcasing and reminding attendees about our innovative equipment to diagnose and treat dry eye disease in practice as we recognise this is an emerging growth area.”

Gareth Steer, VP of European sales, Optos: “This is an opportunity for us to showcase the benefits of advanced ultra-widefield retinal imaging technology. We recently conducted research to better understand the challenges as practices reopen fully. We will share these insights and reveal what our poll told us about changing consumer behaviour.”

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INDUSTRY PROFILE // SHAMIR UK

Providing the best solutions for patients

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Adapting to the changes and restrictions brought about by the COVID-19 pandemic has had knock-on effects for the way practices operate, and the way consumers behave. To find out more about some of these key changes and the possibilities for further adaptation, OT spoke with Russell Bickle, general manager for Shamir UK.

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The effects of COVID-19 across the industry have varied as time has gone on and restrictions have changed. It has been interesting to see the resilience of the industry. During the first three months of the pandemic, eye care practitioners (ECPs) quickly moved to protect their staff and many operated on reduced emergency-only cover. This of course led to a dramatic reduction in orders across the UK and across Europe. As we progressed into the summer and cases declined, there was a huge surge across the industry and both the quality and volume of orders were, in fact, above the 2019 level. As a supplier, the huge increase in volume whilst also dealing with a reduction in staffing caused by COVID-19 restrictions led to our manufacturing hubs working in new ways with labs across the globe supporting each other. Issues surrounding mask use and lens fogging became quickly apparent, so Shamir responded by donating over 1000 pairs of safety eyewear with our anti-fog coating to NHS and care home staff. We also increased the production of anti-fog lens coatings. It has been truly uplifting to see the way our customers have risen to the challenge of providing care during these testing times. I have lost track of the number of stories of ECPs going above and beyond, be that with home delivery, out of hours triage, or fast delivery to key workers. We have seen that both patients and practitioners are keen to be as safe as possible. This has increased the demand for digital measuring systems such as Shamir's

“You can have a very successful business and be part of your High Street at a time when support for local business has never been higher in the public mind” 18 www.optometry.co.uk

Above: Russell Bickle suggests an online presence could be an opportunity Left: Shamir labs found new ways of working through the pandemic

'Spark MiTM Up,' which allows you to be up to three metres from the unit. We have also seen an increase in ECPs looking at innovative testing, measuring and diagnostic equipment that enables further distancing and less time needed in the confines of the test room. One of the biggest changes in consumer behaviours we have seen is that patients are willing to have better visual solutions than before, such as with higher quality varifocals. I think it is key that ECPs react to this increased emphasis on personal care and are not afraid to offer the best visual solution to patients. One of the biggest things we have seen through our research is a huge increase in 'blue light protection' searches online, with data from Google Trends of interest over time indicating a spike in searches for this alongside the spikes in COVID-19. We believe this is due to increased screen-time brought about as a result of the pandemic restrictions. People working from home for longer periods are noticing eye strain and are looking for solutions. ECPs are in a great position to educate patients on the available options. Many of these customers can be reached via social media. We have seen several practices offering advice on looking away from screens and providing

ixabay/PhotoMIX-Company/371 images; Shamir

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Russell Bickle, general manager of Shamir UK, on the opportunities he sees for practices to engage patients beyond the pandemic

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Whilst online platforms can be seen by some as a threat, I think that it can represent a great opportunity. By leveraging the advantages of online for customers who want to browse your ranges and get an idea of prices, then I think having a strong online presence can be a real help. We have seen that many practices have managed to increase average sale value by having more time to discuss needs with patients and offer them better solutions due to the reduced volumes caused by the pandemic. I know of one practice that saw three new customers in a week, who had seen frames in the practice’s online shop and wanted to visit for the expert fitting of the ECP. Without that online offering, would they have purchased elsewhere? At Shamir, we support our customers by providing online training sessions for staff to enable them to know how to best match their patients' needs. We are also helping practices with videos and content for their online platforms.

Target the largest audience of eye care professionals in the UK by advertising in OT. To find out more, contact: Richard Ellacott richard.ellacott@thinkpublishing.co.uk 0203 771 7242

CLIENT

If I could share a message with practices I would say: 'be proud of what you do and the products you offer.' By delivering quality testing at a sustainable cost and offering innovative products that address patients' needs, you can have a very successful business and be part of your High Street at a time when support for local business has never been higher in the public’s mind.

A TREND OVER TIME According to Google Trends data, search interest for 'blue light glasses' appeared to spike in April and late August to September last year. Search interest appeared to rise again in January 2021 Data source: Google Trends

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eye care advice, but perhaps they sometimes miss the opportunity to inform potential customers of the solutions they can offer. I think some practices do a fantastic job of promoting the extra services they can provide to patients and clinical commissioning groups, but there is still a vast number of services that the public are not aware of. I think it will become more important to pursue these avenues of patient care for both NHS and private patients in a postpandemic world, when both healthcare and the efficient use of public money will be in greater focus.

3 Feb 2019

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Data represents search interest over time, relative to the highest point on the chart for the given time. Google Trends data is aggregated and anonymous, search interest data is indexed and normalised.

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Clinical round-up

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OT’s Selina Powell reviews the latest clinical news and research papers Ranked: the top 200 optometry researchers

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A new study published in Clinical and Experimental Optometry has analysed research output to assemble a list of the top 200 optometric scholars worldwide. Within the list of 200 researchers, there are 43 scientists who are based in the UK. The study named Professor Konrad Pesudovs from the University of New South Wales in Australia as the top optometry researcher internationally. He has published 303 papers over the course of his career, with his first scientific article going to press in 1992 and his most recent work published in 2020. Professor Pesudovs is followed by Robert Hess, who is based in Canada at McGill University and US researcher Dennis Levi from the University of California, Berkeley. In 16th place, the top-ranked UK researcher is Alicja Rudnicka from St George’s University of London. She has published 170 papers over the course of her career, with her first research published in 1992 and her most recent paper published this year. Responding to her inclusion within the global ranking, Professor Rudnicka described the recognition as a "great honour."

"This significant achievement has arisen because I have had the good fortune to work with excellent researchers. It is a team effort that has resulted in this positive outcome. I am very grateful to all I have worked with, and aim to continue onwards and upwards," she said. Within the list of 200 researchers, 86% work in either the US, UK, Australia or Canada. The University of California, Berkeley has the highest number of researchers included on the list, with 17 scholars making the cut from a single institution. Fewer women than men are included within the list, making up 30.5% of the total.

will undoubtedly impact the lives of millions," he said. The operation was the first time that the artificial cornea has been implanted in a patient. A total of 10 Israeli patients will receive the surgery as part of A 78-year-old man who was a broader multi-national clinical previously blind in both eyes can read trial aimed at securing regulatory and recognise family following the approval for the device within successful implantation of an artificial different international cornea. Surgery to implant the CorNeat “Moments like these jurisdictions. All patients within KPro artificial cornea was are the fulfillment the Rabin Medical carried out at the Rabin of our calling” Center trial are either Medical Center in Israel. not suitable candidates for traditional Professor Irit Bahar, who carried out corneal transplantation or have had one the surgery, highlighted that the results or more failed corneal transplantation of the operation had “exceeded all of surgeries. our expectations.” The CorNeat KPro artificial cornea “Moments like these are the is made from a synthetic porous fulfillment of our calling as doctors. We are proud of being at the forefront of this material that mimics the structure of the extracelluar matrix. exciting and meaningful project, which

ISRAELI PATIENT’S VISION RESTORED FOLLOWING ARTIFICIAL CORNEA IMPLANTATION

The global toll of sight loss

NEWS

A new international report has highlighted that those with poor eye health have a 2.6 times higher risk of mortality than those without sight loss. The Lancet Global Health Commission on Global Eye Health highlights that 1.1 billion people experience sight loss because they do not have access to eye care services. The report states that 90% of sight loss could be avoided, while estimating that sight loss costs the global economy $411 billion USD (£296 billion GBP) per year in productivity losses. Burton et al. DOI: 10.1016/S2214-109X(20)30488-5 HEALTH

Eye nodules reported in patients with severe COVID-19

Scientists have described eye nodules in a small group of patients with a history of severe COVID-19. The researchers, who report their findings in Radiology, analysed the ocular magnetic resonance imaging (MRI) scans of 129 patients who had severe COVID-19 between March 4 and May 1, 2020. Within this group, nine patients (7 %) had one or more hyperintense nodules on the posterior pole of the globe. All nine patients had nodules in the macular region, while all but one had bilateral nodules and two patients had nodules outside the macular region. Lecler et al. DOI: 10.1148/radiol.2021204394 IMAGING

Eyes provide window to heart health

A new study published in EClinical Medicine has described how optical coherence tomography (OCT) scans could be used to detect signs of heart disease. Scientists highlighted that the presence of retinal ischemic perivascular lesions could be used as a biomarker for cardiovascular disease. The study involved assessing the retinal OCT scans of 84 patients with heart disease and 76 healthy individuals. Researchers observed that larger numbers of retinal ischemic perivascular lesions were found in the eyes of patients with heart disease. Long et al. DOI: 10.1016/j.eclinm.2021.100775

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around dry eye, though Mr Bench added that patients do not commonly refer to the issue as ‘dry eye.’ This suggests patients are aware of a change in their ocular comfort and want to do something about it, Mr Bench said, but added: “This will most often be researchbased rather than action-orientated.”

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SUPPLIER INSIGHT

A changing focus on dry eye ART

The impact of the pandemic on many patients’ lifestyles has shone new light on dry eye symptoms, with opportunities available for practices to meet this need

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Setting up a dry eye clinic has been a long-term goal for many practices, but opportunities are ramping up. Nick Atkins, director of marketing and professional services for Positive Impact, told OT: “With lots of research and development into new diagnostic and treatment options, as well as supporting research to help practitioners better manage their patients, this is definitively still a growing sector.” While traditionally seen as an issue affecting older patients and with a female bias, Mr Atkins said: “It is fast becoming a problem for an ever-younger population and with more male sufferers.” Contact lens manufacturer, Alcon, has identified two groups of patients emerging in discussions of dry eye. In a consumer study commissioned in December 2020, Alcon identified a group of patients who were not sure what to do and did very little about dry eye. These patients were less anxious about their eye health and were more relaxed shoppers. Alcon also identified a group of patients they named ‘buyers,’ who are more anxious about their eye health and comfortable to carry on using a product. “Both sets of patient groups blame the increase in screen time as a cause of their dry eye symptoms,” Jonathon Bench, director professional affairs international – dry eye and ocular health at Alcon, said. The company found that patients blame themselves for aggravating the issue, not recognising that they have a condition. 22 www.optometry.co.uk

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The impact of COVID-19 Practices have noted anecdotal increases in patients describing dry eye symptoms during the COVID-19 pandemic. It is thought that lifestyle changes caused by lockdowns could link to the symptoms. Mandy Davidson, optometrist and professional affairs manager at Scope Eyecare, said: “We are all familiar with the impact of reduced blink rates associated with screen use, but this has now spread more widely as children are using screens for home schooling and many of us have significantly increased our screen time as they have become essential for working from home.”

“The future of diagnosis is actually here today” Nick Atkins, director of marketing and professional services for Positive Impact With social interactions also moving online, Ms Davidson said: “It would not be unreasonable to assume that a typical day, from morning until night, could involve screen hopping from one device to another.” Mask Associated Dry Eye could also be a factor in dry eye symptoms and discomfort. Ms Davidson highlighted that these symptoms can extend for some time after the mask has been removed. Alcon has also heard practices referencing an increase in conversations

Hearing the problem Suppliers suggested that there is more opportunity for practices to grasp in the field of dry eye. It is often patients presenting with dry eye symptoms at eye examinations that drives a need for extra investigations, suggested Ms Davidson. “Because dry eye is a multifactorial disease, many practitioners are realising the limitations of fully investigating dry eye as part of a routine examination and are considering inviting patients back to offer a specialist service, if first line recommendations don’t appear successful.” Mr Bench agreed that there is still more opportunity in this space, commenting: “As more eye care professionals are becoming engaged and aware of the impact that dry eye has on quality of life, wellbeing and of course on vision and ocular comfort, they are identifying more dry eye sufferers within their patient base.” Over the past year where patients have been unable to visit a practice, Mr Bench said this has led to “great virtual consultations and perhaps us ‘hearing’ the problem better than ever before, rather than ‘seeing’ it.” “One very interesting opportunity for practices to meet the needs of dry eye sufferers is to be aware of the NHS initiative to drive dry eye into primary eye care and community as part of their plan to reduce spend on prescriptions,” he continued. Alcon has been supporting practices with educational content on dry eye, Mr Bench added, hinting, “we are currently working on some more online and ondemand content.” Investing in equipment “Setting up a dry eye clinic has been on many a to-do list for a number of years,” Nick Atkins commented, but suggested that a minority of practices do run the specific appointments. “The first lockdown of the pandemic

allowed many independents to get off the treadmill of everyday practice business and enabled them to revisit dry eye and other business differentiation and development plans,” he noted. “While there is a glut of new technology, especially for the diagnosis of dry eye, most practitioners are still using dated investigative techniques with low specificity and sensitivity for the disease,” Mr Atkins said. He encouraged investing in the latest instrumentation and software, suggesting there is a first mover advantage available to those who do. Lisa Evans, director of optical supplier Hanson Instruments, suggested it can be challenging to gain compliance from patients with certain dry eye treatments, such as eye drops or eye bags, particularly among younger patients and those who struggle to find the time. With a variety of products and treatments available to address the condition, Ms Evans said investing in equipment to provide treatments such as low-level laser light therapy could differentiate a practice and help to generate income. As this treatment is non-invasive, it also does not need to be carried out by the optometrist, Ms Evans explained, adding that this could be a positive for practices with spare rooms, or that don’t have an optometrist practising every day. Suggesting the sector is on the “cusp” of change, Ms Evans said: “I think today it seems to be the more forward-thinking practices that are seeing the opportunity and the benefits. We’ve been talking about dry eye for years, but it has been heating up in the last couple of years.” Richard Lumley, UK and Ireland vision sales manager for solutions provider, Lumenis, suggests that it is still an early stage for alternative treatments to dry eye in primary care. Intense pulsed light (IPL) has been clinically acknowledged to deliver controlled positive results for dry eye and is a registered alternative method of treatment. Practices have not Solutions such as TearLab can help with dry eye diagnosis

DRY EYE IN THREE STEPS WITH PROFESSOR JAMES WOLFFSOHN The pro-vice chancellor and professor of optometry, life and health sciences at Aston University offers his view

The prevalence of dry eye disease currently in the UK Our most recent study in the UK, which examined 282 people matching the general population profile against the Tear Film and Ocular Surface Society (TFOS) Dry Eye Workshop II criteria, found a reverence of 36.2% – so a little more than one in three in the UK have dry eye disease (DED). Female sex, systemic/ocular health conditions, short sleep duration, and prolonged outdoor leisure time were significant DED risk factors.

The impact of COVID-19 for dry eye symptoms Masks force exhaled air across the ocular surface which will increase evaporation and can cause dry eye, especially in those with pre-existing ocular surface disease from lots of

yet had the time to fully investigate this alternative treatment, Mr Lumley suggests. “But now, optometrists are seeing that with IPL treatment, they can treat dry eye as a first-stage treatment process,” he added. This is something the company is aiming to address. Earlier this year, Lumenis told OT that the company has rolled out a pilot programme to deliver training to optometrists in the UK around its Optima IPL product. Mr Lumley added: “Lumenis is taking the lead to educate optometrists and ophthalmologists to actively promote awareness to new clients and existing patients by supporting them with marketing material to deliver the message of IPL treatment as a primary option.” The way ahead Considering what is next for dry eye management and treatment, suppliers suggested that there is no one-way ahead. Ms Davidson shared: “I think educating patients and practitioners on what the

screen time (due to less and partial blinking). Long-term, the increase of screen time could conceivably increase the prevalence of dry eye. Optometrists could screen for this and open up conversations by having patients complete a standard dry eye questionnaire prior to the consultation.

Approaches to dry eye following the TFOS DEWS II report I think the TFOS DEWS II report is slowly changing clinical diagnosis and management of dry eye in primary care in the UK. The main focus now is to better inform the choice of the most effective treatment based on baseline measures – such as a 2021 paper (Jennifer Craig et al, https:// bit.ly/2P5FFMM) which indicates that symptoms will improve within a month of artificial tear use if they will at all. This allows for better communication to patients about the need for compliance during this period and practitioner knowledge to modify treatment after this period if the patient has not had a marked improvement. patient can do for themselves, in the way of diet and lifestyle, to promote a healthy tear film would be a good start.” Communication is key, agrees Mr Bench: “The first thing to help this is more and greater conversations – listening to what the patient is feeling, asking more questions to better understand, to then be able to make great recommendations.” He suggests there is space for more diagnostic instrumentation to complement the devices available, adding: “We hope to share more in this area in the future.” Investing in new technology will be important for expanding services. Ms Evans said that many of the tools needed are already available; however, a starting point for practices could be equipment to image the meibomian glands to show the patient the issue and what is happening, and measure the effectiveness of treatments. Positive Impact's Mr Atkins suggested: “What we do know is that tear film osmolarity is the only definitive measure to know for sure whether a patient has dry eye or not,” adding that solutions such as TearLab can quickly gather this data. He added: “The future of diagnosis is actually here today.” April/May 2021

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AOP on your side How is the AOP responding to COVID-19?

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The ongoing impact of COVID-19 on practices and considerations for the future of the profession formed the agenda of the March online meeting of the AOP Council (17 March). Introducing a discussion on the impact of COVID-19, AOP policy director, Tony Stafford, shared that the introduction of lockdown restrictions had led to a spike in member enquiries, with the legal and regulatory teams recording 2020 levels of activity dealing with COVID-19 queries. The AOP has been supporting members in accessing the COVID-19 vaccination, and developing new resources, including an updated Infection Prevention and Control Certificate video and CET (read more on page 49). A key concern raised by the Council was the impact of the pandemic

on pre-registration placements. Mr Stafford explained that the AOP had provided feedback for cross-sector work addressing the issue, including highlighting the “massive stress” caused by employers' slow confirmation of placements for students due to graduate. With this year marking the last year of the current CET cycle, Councillors highlighted concerns from members about achieving interactive points. Dr Ian Beasley, AOP head of education and OT clinical editor, explained that more than 60 sessions have been scheduled so far for the year ahead, with 90% of these offering interactive points. Events are released on a quarterly basis, while the AOP’s provision of educational content at the virtual 100% Optical event will also give attendees the chance to obtain their interactive CET points (read more on page 15).

shift in how patients see the profession. AOP chair, Mike George, suggested the prioritisation of the profession to receive the vaccine and introduction of personal protective equipment have helped to “raise our profile with patients that we are frontline healthcare [professionals].” Some highlighted the benefits of an increase in collaborative approaches to eye care services and greater discussions around extended services. In some areas, however, councillors felt progress has been slow, highlighting a need for more discussion around infrastructure in the commissioning of services and communication with secondary care. Councillors also highlighted the financial pressures of the pandemic. Many spoke of discussions within the profession around the sustainability of delivering General Ophthalmic Services. Policy update

Future of optics

Kathy Jones, AOP policy adviser, introduced a discussion on the future of optics, exploring what has changed over the past year, and how this should be reflected in a new long-term plan for optometry. This builds on work carried out by the AOP before the pandemic. Councillors described a

“Things can be more fleeting than one would expect” Mike George, AOP chair

Managing the risks of reform The AOP has responded to NHS England and NHS Improvement’s consultations for reform proposals The AOP has highlighted key risks and potential opportunities for optometry in response to NHS England and NHS Improvement’s consultation on the next steps for developing Integrated Care Systems (ICSs) in England. In February, the Government published a White Paper and recommendations for reforming health and social care with key plans including a proposal to introduce ICSs to every part of England to coordinate services. Responding to the plans, AOP clinical director,

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The AOP policy team delivered updates on policy developments, including the General Optical Council’s (GOC) consultation on ‘Speaking up’ and whistleblowing. The Council also heard updates from Dr Beasley on the GOC’s new CPD scheme, which will be implemented in January 2022. Concluding the meeting, which marked his final session as chair, Mr George thanked the Councillors for their work, adding: “I didn’t imagine, the last time I chaired a meeting in person, that it would be the last time that I would be holding that gavel. Things can be more fleeting than one would expect.”

Dr Peter Hampson, suggested the shift in local commissioning to larger ICS should “open the way for extended eye care services, delivered in optometry practices, to be commissioned on a wider scale, as we have long called for.” However, the AOP has also raised potential risks, such as if the commissioning of GOS was moved to ICSs. This was highlighted in the AOP's consultation response, emphasising the need to ensure the commissioning of GOS remains national. A bill is set to be laid before Parliament later this year.

The AOP’s consultation response can be read in full online: www.aop.org.uk/consultations

Getty/Lena Datsiuk

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A March meeting of the AOP Council raised key areas for the AOP to support practices and optometrists over the coming months

AOP EXPERT

Communications

Legal

Serena Box, PR and media manager

Shutterstock/Lilith.E

Cassandra Dighton, head of professional discipline What does the AOP's substantive hearing and interim orders guidance cover? Once a case referred to the General Optical Council (GOC) is found to meet the acceptance criteria, the registrar will consider if there is any concern that immediate action needs to be taken to protect the public. This is where an interim order might come in, and there are several decisions the panel can make, such as temporarily suspending the individual or putting conditions in place. In a substantive hearing, the fitness to practise panel of the GOC considers whether a registrant’s fitness to practise is impaired to a point that action needs to be taken upon their registration. We receive a lot of questions around these processes. They can be really troubling for registrants, especially if they are denying the allegations.

Why create the new guidance? There seems to be quite a lot of feedback that registrants are scared of the GOC. Because of this, we are working to try and demystify the process. The first step to that is education and making clear materials available. What key message would you have for members? The AOP legal teams are experts with many years of experience between us, and we can guide members through the GOC investigation process. There is no such thing as a silly question when it comes to legal proceedings.

Read the new guidance at: www.aop.org.uk/legal

What can readers expect to see from the AOP this year? At the height of the pandemic our primary focus was on what information members needed from us, and this often translated into updating and disseminating guidance daily. This curtailed a lot of our planned activity for the year but, with a roadmap out of lockdown, we can be optimistic about delivering targeted campaigns in 2021. With so many routine appointments neglected during lockdown, raising the profile of the sight test, and eye health, will be even more important. How are you adapting communications? With an incredibly buoyant news agenda, its essential that our campaigns respond directly to COVID-19 or fill a niche for softer news stories.

This is why our Voice of Optometry project will now take the form of short-snap surveys that gauge members’ views on one topic. We’ll be using findings to design our flagship 2021 campaign. How can AOP members get involved? We want to find out about the issues that are important to members. There will be an opportunity to get involved through the Voice of Optometry surveys. With over 1000 responses vitally important to our media work, we urge members to take part in these short, quick-fire surveys when they land in their inboxes.

More information can be found at: www.aop.org. uk/voice

School of Optometry and Vision Science

Fully funded PhD opportunities in Optometry & Vision Science

ONLINE INFORMATION SESSION

Apply to study for a PhD at the University of Bradford’s School of Optometry & Vision Science. Choose from a broad range of clinical, translational and basic science projects.

Monday 17 May, 19:30

Applicants must be UK-qualified optometrists and hold a minimum 2.1 undergraduate degree and/or relevant Level 7 (Master’s) qualification. REGISTER OR MAKE AN ENQUIRY:

Tuition fees, a generous stipend and payment for undergraduate clinical demonstrations are provided. Funding is available for three years (full-time).

FOR MORE INFORMATION AND HOW TO APPLY:

j.denniss@ bradford.ac.uk

www.bradford.ac.uk/optometry/funded-phd Deadline: 11 June 2021

UOB

PHD OPPORTUNITIES

2021

W W W . B R A D F O R D . A C . U K / O P T O M E T R Y/ F U N D E D - P H D

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Non-contact assessments

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FOCUSES ON... MANAGING PATIENT CONTACT

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Birmingham Optical has partnered with IbisVision to offer its computerbased platform that facilitates noncontact eye assessments, or remote eye examination. The suite includes a variety of tests including Amsler grid, Ishihara colour and visual acuity, with more to be added. The system can be used in the practice, or in the patient’s home, guided by an eyecare practitioner. IbisVision commercial director, Melville Berwick, said the partnership was a positive step for the business as it rolls out the solution. www.birminghamoptical.co.uk

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Hit list

The trends, launches and looks

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Supporting distancing

Grafton Optical has highlighted the Rexxam DR-900 Motorised Refractor Head, with five-metre cables and auto-phoropter to allow for social distancing. The face panel is fully detachable to allow for cleaning. Rexxam has recently introduced a software upgrade to the DR-900 and LCD-1000/P test chart, adding a range of features including a spatial frequency contrast sensitivity test and Pigassou Children charts. Manufacturers have also added a number of functions for the DR-900, such as a dimming function of LED illumination for near tests. www.graftonoptical.com

A faster refraction

Essilor has launched its new Vision-R700 phoropter, aiming to offer a faster and socially distanced refraction. The device can obtain a refraction in three minutes, whilst still gaining accurate and repeatable results, the company explained, incorporating a series of patient-specific smart programmes to shorten the process. The device features the Digital Infinite Refraction process, which automatically compensates for the effect that any changes in sphere, cylinder and axis had on one of the other dimensions. The phoropter can also be operated from up to seven metres away. https://ecp.essilor.co.uk/

Fog-free examinations

Louis Stone Optical has introduced anti-fogging Volk ClearPods to support practitioners dealing with fogging lenses “affecting one’s view and slowing down eye examinations.” The tool incorporates wing and flange features designed to divert warm currents of air away from the lens surface, while accommodating the right working distance. The ledge on the inside is designed to act as a back-stop to guide the lens into the right position. The company suggests the tool enables practitioners to conduct detailed exams “without having to interrupt care.” www.louisstone.co.uk

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LOOK

Q&A ME & MY GLASSES

Optometrist and lifestyle blogger, Lizzy Yeowart, on that spring feeling

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Lighthearted and fun, here are three spring styles that offer delicious pastel shades.

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Aspinal

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Brad Ray

The angular cat’s eye profile is universally flattering and fitted with gradient lenses in this Aspinal frame. This style makes a luxury feature of the hinge componentry, with an etched metallic plate in the shape of the Aspinal shield adorning this beauty in lavender. Aspinal’s ‘Paris’ in colour ‘02’ lavender www.eyespace-eyewear.co.uk

The British Superbike racer on the practice that helped him find the perfect racing spectacles

My parents took me for my first sight test at 18 months old, as my two older brothers needed glasses. It turned out I needed glasses too and I have worn them ever since. I used to have a pair of flexi glasses as I would always break my old pairs playing sports or from being under my helmet, as I’ve been racing since I was four years old.

I first visited Jim Green at Eyesite Opticians in Brighton at the age of 14. We have talked about understanding my vision and glasses as my superpower. Through the support I have received, I probably know my eyes better than anyone on the grid and, really, that assistance from Eyesite has been the difference between having a career and not having a career.

My Oakley racing spectacles are my favourite pair. They are more curved, have silicon behind the ears and wrap around the face more. They have clear arms which gives me a wider field of vision. When I put them on it’s like wearing an old pair of slippers, and they are so comfy that I sometimes forget they are on my face.

When I first put on the personalised racing specs it was almost like seeing again. There was a period where I thought I may not be able to compete professionally, as no-one on the grid even wore glasses, never mind my unique prescription. But since that visit, I have never once thought that my glasses would stop me competing at the highest level.

Stepper The cool spearmint shades of the ‘STS10060’ by Stepper suits ophthalmic and sun lenses alike. The brand’s signature super-lightweight TX5 material makes for supreme all-day comfort. Stepper’s ‘STS-10060’ www.steppereyewear.com

Face A Face The ‘HOLLOW3_2080’ by Face A Face tempers its cute combination of pastel peach and blue with a shot of hot pink on the side. Face A Face’s ‘HOLLOW3_2080’ www.designeyeweargroup.com

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Design Eyewear Group’s Woow Is You has launched a new collection of frames, focusing on the themes of joy and freedom. The frames are large and draw inspiration from the 70s, featuring a colour palette of ‘electric blues, granitas and rainbow gradients.’ The ‘Brightside’ metal frames are available in a lemon or round cat’s eye shape, and combine galvanic and matte effects in colourways of ‘Klein blue’ with galvanic silver, or pink and emerald green with galvanic gold. www.wooweyewear.com

SHORTLIST THE LATEST PRODUCT LAUNCHES

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Sunglasses

Maximum personality

Kaleos Collection

CLIENT

Kaleos has introduced its new eyewear range for spring/summer 2021, with 27 new silhouettes across the collection. Styles in the collection offer a maximalist and retro-feel, with a focus on oversized shapes and utilising a range of acetate and colour options. The brand’s limited edition silhouette for the season is the statement frame ‘Bickle,’ featuring a unisex design and rimless-effect, while the boxy and oversized ‘Creasy’ frame (pictured) is a brand favourite. www.kaleoscollection.com

Sunglasses

Sustainable materials

De Rigo has launched Chopard’s new sustainable collection which uses biobased acetate and lenses. 70% of the acetate is drawn from natural sources including cellulose acetate derived from wood and cotton, while 40% of the nylon lens is from natural sources – a resin produced from castor plants. The collection includes sunglasses and optical frames, with the women’s range taking inspiration from the Ice Cube jewellery collection, and the men’s frames drawing from the Alpine Eagle watch collection. www.derigo.com/eng

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

Contact lenses

Addressing evolving needs

CooperVision has announced the launch of its new Biofinity toric multifocal contact lenses in the UK and Ireland from April. The product extends the designs of the Biofinity toric lenses to presbyopic patients. The contact lens features ‘Optimised Lens Geometry’ to provide stability and predictable orientation, along with ‘Balanced Progressive Technology’ which provides multiple zones of vision correction. The lens also features CooperVision’s ‘Aquaform Technology’ which provides natural wettability and high breathability for comfort. www.coopervision.co.uk/practitioner

Frames

Mythological marvels

Movitra has introduced eight new models, including four sunglass styles and four optical frames – its first optical style offering. The frames, with names inspired by Greek mythology, are produced from acetate blocks made by Mazzucchelli, and feature Movitra’s patented locking system. The optical model ‘Isi’ (pictured) re-interprets a retro style with keyhole bridge and a range of shades including a bright honey colour. www.movitra.it

Frames

Equipmenti

Steel statement

Treating dry eye

Eschenbach Optik has introduced 10 new frames into the Titanflex collection, with a range of hybrid frames that combine lightweight properties with flexibility. The frames ‘820869’ and ‘820870’ use Titanflex stainless steel and acetate for statement features, such as a top bar and double bridge. The ‘823012’ frame utilises Titanflex liquid metal for a rimless and sporty effect. The brand’s existing ‘820515,’ has been reinvented in the new frames, ‘820850’ and ‘820851,’ with a revamped colour scheme. www.internationaleyewear.co.uk

Positive Impact has introduced a new electronic eyelid hygiene device, NuLids, for the treatment of dry eye disease, meibomian gland dysfunction and blepharitis. The device can be used on-site or by the patient at home. An eye cleaning foam is applied over the closed eyelid, before the NuLids is used to massage the eyelid. The rotating disposable silicone soft tip is used for 15 seconds per eyelid, twice, and is timed by the device. www.positiveimpact.co.uk

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Q&A BEHIND THE BRAND

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Giovanni Lo Faro, Modo Eyewear’s European CEO, discusses Eco's sustainable goals

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Eco, a Modo Eyewear brand, plants a tree for every frame purchased, with 2.4 million trees planted so far All Eco packaging and point of purchase material is sustainable, with frames transported in biodegradable bags made out of cornstarch Eco has won two design awards, the IF Gold Award and German Design Award.

Clockwise from left: Left, recycling ocean plastics; Right, 'Lana' frames; Below, 'Tide' frames in ink

What is the latest collection that you have released and what led to this concept? The Eco Ocean collection is made from recycled ocean plastics. We teamed up with Waste Free Oceans, an NGO that works with local fishermen who collect the used plastic. These are processed and extruded into plastic granules that become our ocean frames. The frames are lightweight with a smooth, matte finish in ocean-inspired shades like aqua, ink, and clay, as well as the classic black, olive, and blue. How has the company been affected by COVID-19, and how has it had to adapt? We implemented all the necessary measures to ensure the safety of our teams and to provide continuous support to our customers. Despite a tough lockdown – Milan, where we operate from, was hit hard – we remained active. We did our best to stay beside our customers and offer the flexibility they needed. We have been able to navigate through this storm thanks to our solid distribution. This allowed us to preserve all of our team, which is growing, and to continue to invest in new collections. We feel this approach will reward us in the months ahead, where we finally see the light at the end of the tunnel. What are the brand’s main ambitions for the next 12 months? To consolidate our position in sustainable eyewear. To continue our work in researching new sustainable resources, materials and solutions. Our mission is not only to recycle but to find new materials and new ways to process them in order to have the lowest impact on the environment.

ANATOMY OF A FRAME

Bang on trend 70s styling

Gradient sun lens ‘Chain link’ side detail

OT columnist, Lizzy Yeowart

Mondottica/Ted Baker

Handcrafted acetate

In a nutshell Manufacturer // Mondottica for Ted Baker Frame // ‘Indi TB1616’ Colour // ‘119’

Dk Brown horn colouring

Signature branding at the sides

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NOTICE OF THE AOP ANNUAL GENERAL MEETING 2021

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To all members of the Association of Optometrists. The AGM of the Association of Optometrists will be held virtually, via Zoom, on Wednesday 9 June 2021. The AGM will commence at 10am. All members wishing to attend are invited to register their interest with Liz Routh, lizrouth@aop.org.uk by 12pm, 8 June. Agenda for the Association of Optometrists’ Annual General Meeting 2021

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1. Introduction by the Chairman 2. To receive and approve the minutes of the last Annual General Meeting held on 4 November 2020 3. Roll of deceased members 4. To receive the Chairman’s report 5. To receive the Chairman of Finance Committee’s report 6. To approve the Annual Financial Report and Accounts for the year ended 31 December 2020 7. To consider and, if thought correct, approve the proposal of the Board that BDO LLP be re-appointed as the Association’s auditors 8. Any other business.

By Order of the Directors. Henrietta Alderman, chief executive, 2 Woodbridge Street, London EC1R ODG 1. Please note that a full set of the 2020 accounts will be available at www.aop.org.uk in advance of the AGM. 2. A member entitled to attend and vote at the meeting convened by the notice set out above is entitled to appoint a proxy to exercise all or any of his or her rights to attend and speak and vote in his or her place. A proxy need not be a member of the Association. 3. A form of proxy is available on the AOP website at www.aop.org. uk. To be effective, the instrument for appointing a proxy must be deposited with the Association’s Chief Executive at the Association’s office (janicephillips@aop.org.uk) no later than 3.45pm on Friday 4 June 2021. Completion of the proxy does not preclude a member from subsequently attending and voting at the meeting in person if he or she so wishes.

CLIENT

PEER SUPPORT LINE FROM THE AOP Supporting members during challenging times Throughout 2020 and the COVID-19 pandemic, the AOP Peer Support Line has offered a confidential, free-phone helpline for individuals at any stage of their optical career to call and discuss their problems with a trained, empathetic peer who recognises the pressures of optical practice.

34 www.optometry.co.uk

What the profession told the AOP about the service “I have received invaluable support. Going to a regular counsellor would not have been anywhere near as effective as talking to optometrists who understood me. Due to confidentiality, I couldn’t confide in my friends but I could with these peers. I cannot fathom what state I would have been in had I not reached out” “In my most desperate need someone was there to listen to my problem and help me through it” “This is one of the best things the AOP has done” “This service helped me at my lowest point, and reminded me of my worth when my workplace and managers were against me and bullied me.”

“This is one of the best things the AOP has done”

The Peer Support Line in a nutshell Peer Support Line volunteers are trained AOP members who are dedicated to supporting and strengthening the community of optical professionals Callers do not have to be an AOP member to use the Peer Support Line The line is completely anonymous, so no membership details or full names are requested Calls can be on a range of issues including workplace pressure, bullying, ill health, financial worries, bereavement or anxiety about exams The calls will continue for as long as the caller needs them to Calls will be answered 24 hours a day, by an external answering service, with volunteers on duty to return calls between 8am and 8pm.

A service in need in 2020

64% increase in calls to the Peer Support Line in 2020

50%

increase in calls regarding mental health issues in the past 12 months

All information was collected via anonymous feedback/data sources

To contact the Peer Support Line, call 0800 870 8401

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COVID GEN VERSION

COVID SPECIAL REPORT:

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Getty/ Anastasia Usenko

he last 12 months have been challenging for people in all parts of the optical sector, but we know the pandemic has been particularly disruptive for students and pre-reg trainees,” AOP policy adviser, Kathy Jones, tells OT, reflecting on the impact of the pandemic for young optometrists. This disruption has been felt by several cohorts of pre-registration optometrists and undergraduates. From first year students, who saw their A-level exams cancelled and undergraduate students who have had to adapt to online lectures, to pre-registration optometrists who saw their roles changed, their progress on the Scheme for Registration delayed, or even lost their placements. Luke McRoy-Jones, pre-registration optometrist, AOP council member and chair of the student committee, recognised the “hard work, determination and commitment” of university staff to adapt optometry education to be delivered safely during the pandemic. Despite these efforts, Mr McRoy-Jones suggested: “There are

The pandemic has disrupted the lives of many student and pre-registration optometrists, but has also accelerated trends and created a unique skillset in young practitioners. As part of an online series, OT investigates the bigger picture for the profession

ongoing worries about pre-registration placement availability, the fate of the job market after the pandemic and also worries about being away from home due to lockdowns, and the health and wellbeing of friends and family.” William Holmes, University of Manchester senior lecturer and chair of the Optometry Schools Council, reflected on the “substantial amount of work” that has been required to adapt teaching to be delivered remotely or in a COVID-secure way. As restrictions have changed, Mr Holmes described a “slight sense of a moving target.” With the vaccination roll-out and the roadmap out of lockdown, there is a greater sense of certainty now, though Mr Holmes acknowledged: “It’s fair to say that both staff and

" Optometrists have the expertise, equipment and the capacity to be part of these changes and I wholly believe our profession will step up and evolve swiftly" Luke McRoy-Jones, pre-registration optometrist, AOP council member and chair of the student committee

students probably feel more tired, and just like anyone else in the population, fatigued with everything that has to be complied with.” Striking the balance After more than a year of social distancing requirements necessitating a virtual approach to learning, experts suggest that future approaches will strike a balance between online and in-person delivery. While some aspects of inperson teaching and assessments cannot be replaced, students have suggested that some virtual approaches could be beneficial beyond the pandemic. Giving the example of the Scheme for Registration, Mr McRoy-Jones suggested: “Many competencies at Stage 1 and 2 are knowledge and problem-solving based. Assessing these in a virtual environment alongside in-person assessments of practical elements means that standards are not compromised and there could be a greater level of flexibility for trainees to be assessed, demonstrate competence and progress on the Scheme.” With the possibilities of some continued remote care, and a shift April/May 2021

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" Even from an education perspective, it wouldn’t be difficult to imagine that online platforms for doing tutorials would have been on the way in the next few years" William Holmes, University of Manchester senior lecturer and chair of the Optometry Schools Council

36 www.optometry.co.uk

FACING THE CHALLENGES OF COVID-19 Reflecting on the past year, optometry student, Saira Saleem, told OT: “COVID-19 has had a massive impact on my university life.” Where clinics would usually be a “hive of activity,” Ms Saleem said patient numbers have dwindled as the pandemic progressed, making it more challenging to gain practical experience. Meanwhile, Nkosi Yearwood, a third-year student and pre-registration councillor for Optometry Wales, shared: “I think the main challenge is finding pre-reg placements, and then how to return to ‘normal’ when all you know is COVID-19.” OT has spoken with students, employers, universities and professional bodies to gain their insight into the impact of the pandemic on optometrists at the start of their career journeys. Find the full twopart series and student interviews on the OT website.

necessarily going to happen that wouldn’t have anyway, but it might just happen a little sooner. Even from an education perspective, it wouldn’t be difficult to imagine that online platforms for doing tutorials would have been on the way in the next few years,” Mr Holmes said. Optometry courses have always evolved around new technologies, academics suggest, but core skills will remain as important as ever. Speaking to OT, Professor John Siderov, head of the department for optometry and vision sciences at the University of Huddersfield, commented: “In my experience, working as an optometrist and educator in a number of jurisdictions in Australia, US and the UK, optometry has always been keen to embrace new technologies and I do not see that changing.” Students must be familiar with the newest developments, but Professor Siderov emphasised: “Fundamentally, it is important that we keep a firm basis in the basic and clinical sciences relevant to vision.” “Graduates need to be able to develop skills to keep abreast of changes and to critically review new technologies as they come into practice,” he said, adding, “This type of approach is what will provide future optometrists the ability to adapt to change in a positive way.”

What will drive which elements will be included in the future will depend on the effectiveness of the methods, and how they relate to the student experience. Nick Hillman, director of the Higher Education Policy Institute (HEPI) think tank, observed: “Though some of the academic work going online is fantastic, the social element is what is really missing, and students want that.” Joining an evolving profession For current students and graduates, the disruption caused by the pandemic is expected to have knockon effects, with students highlighting an impact to their confidence. Research by HEPI in spring last year found that many students felt more ‘anxious’ than ‘excited’ about starting their careers, with 28% reporting anxiety as their main feeling. For one-third (29%) of respondents, the pandemic had exacerbated their emotions. Reflecting on these statistics, Mr Hillman, shared his expectation that these feelings will have continued, telling OT: “In a crisis, big transitions, such as from education to the labour market or from schools to university, are what get disrupted. “The crisis has gone on longer than any of us hoped," he said, suggesting, "The longer it goes

Getty/ Anastasia Usenko

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towards shared care schemes and satellite clinics, Mr McRoy-Jones argued: “Virtual elements of learning and assessment earlier on could actually better prepare graduates and create a workforce ready for the advancements of tomorrow.” Reflecting on his own experience of the changes to learning, such as the use of patient simulators and course material delivered online, second-year student, Indy Ghuman, described seeing “more innovative educational learning resources.” As the practice environment has changed during the pandemic with greater emphasis on technologies such as Optical Coherence Tomography (OCT) or virtual consultations, he expects these areas could gain greater significance for undergraduates in the future. University curriculums are constantly kept under review, Mr Holmes pointed out, and as practice developments accelerate, “We’ll probably end up looking a little bit closer at those things as a result.” “I’m not sure anything is

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on, the more worried people will be about making the jump from education to the labour market.” Whilst facing some anxiety about the future, optometry students also see developments in the profession that may create new opportunities. “The COVID-19 pandemic has put further strain on our health services, increasing waiting times and highlighting shortfalls in resourcing, therefore, we are likely to see reforms in health as the country recovers from the pandemic,” Mr McRoy-Jones shared, pointing to the shift towards a greater emphasis on diagnosis and management of patients in the community, as well as the NHS Long Term Plan. With COVID-19 increasing the strain on health services, it is expected that some changes will be accelerated. Considering this, Mr McRoyJones said: “Optometrists have the expertise, equipment and the capacity to be part of these changes and I wholly believe our profession will step up and evolve swiftly. "I think we will look back in 10 years time and see many advancements in the way eye care is delivered in the United Kingdom.” For current graduates considering their future career prospects, one path that may seem less inviting

as a result of the pandemic, is self-employment. Charlie Ball, head of higher education intelligence for the student organisation, Prospects at Jisc, explained that the pandemic had made the locum career path seem “precarious." “After 12 months of a pandemic, people are quite risk-averse in career decision making,” he said, adding however, that finding a good work-life balance will continue to be a driver for exploring self-employment. A uniquely skilled cohort Experts are positive about the skillsets of young optometrists who have experienced the challenges of the past year. Mr Ball told OT, “People have had a very extensive crash course in how to work under pressure and unusual circumstances.” “I think there will be an element to which the class of 2020 will be viewed as an unusual group with a different set of skills and qualities,” he said, explaining: “You will know that the class of 2020 is resilient, and in any frontline healthcare profession, you are going to need people with those qualities.”

OT PO LL

35%

of students and pre-registration optometrists reported feeling ‘somewhat negative’ about the future of the profession in an OT poll of 136 readers

reported feeling ‘both positive and negative’

Businesses have also undergone a vast transformation, Mr Ball noted, with current students and graduates having to become early adopters of the new working practices.

MORE CHANGE ON THE HORIZON While, in the short-term, universities are focused on supporting students and ensuring compliance with revised requirements, discussions are turning to the General Optical Council’s (GOC) plans for the future of optometry education. In February, the council of the GOC approved the new education and training requirements developed through its Education Strategic Review. The GOC has suggested the changes will ensure optical professionals are equipped to “deliver eye care services in a rapidly changing landscape and meet the needs of future patients.” It is also suggested that the changes could provide greater flexibility for students and universities. Some concerns remain however, with AOP policy adviser Kathy Jones, sharing: “We think there are some significant

risks that come with the changes – particularly around whether the funding for universities to deliver them will be available – and these risks will need to be managed closely over the next few years.” New requirements for practical experience also pose a further challenge. Speaking to OT, Mr Holmes commented: “Even if COVID-19 had not happened, a big challenge of the ESR was going to be placement capacity, co-ordinating placements and ensuring variety." In the meantime, the AOP has committed to supporting student and pre-registration members under the current system, “to deal with the continuing challenges of COVID-19 and launch safely into their future careers in optometry.” Read OT's 'Five questions answered on the ESR' – pages 8-10

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" You will know that the class of 2020 is resilient, and in any frontline healthcare profession, you are going to need people with those qualities" Charlie Ball, head of higher education intelligence for Prospects at Jisc

ART PRODUCTION CLIENT

Recognising students' worries about the levels of practical experience, Mr Holmes said, “I can understand students' concerns,” but highlighted that at an undergraduate level, much can be gained from simulations and case studies. This includes experiences that would not be able to run their course in a clinic, such as learning to engage with an angry or upset patient. For those with concerns about the impact of a potential gap in the transition between university and pre-registration, Mr Holmes pointed out that the way many academic years operate may mean students could, in normal years, have had their last clinical session in May, before starting their placement later in the year: “I think there may be a potential bit of extra getting up to speed, but I think it is doable.”

Reflecting on the challenges of the past year, Mr Holmes said: “In many ways, the experience they are getting is arguably going to equip them to be more creative and problemsolving clinicians than perhaps in the past. People are having to think really hard about what needs to be done, and how it should be done." For many students and pre-regs, a clear-eyed commitment to work towards their career goals amidst the challenges is palpable. Mr McRoy-Jones shared that the past year highlighted the importance of “loving what you do,” He added: “This has undoubtedly changed my outlook on my career and the values I will look for in future employers and business ventures, as I look forward to a long, varied, and hopefully enjoyable career in optometry.” Similarly, Mr Ghuman is keeping positive and focusing on consolidating knowledge as best as he can. “At some point in the future, we’re going to be seeing patients and helping them, because that is what we came into optometry to do.” Visit the OT website for more insight on the impact of COVID-19 for training optometrists: www.aop.org.uk/ot/inpractice/career-development

SUPPORTING STUDENTS AND PRE-REGISTRATION OPTOMETRISTS The Peer Support Line offers a free, confidential helpline for optometrists to discuss their problems with a trained peer. The line can be accessed at 0800 870 8401 or found at: www.aop.org.uk/ peersupportline Students and pre-reg members can use the AOP’s Pre-reg register to list their availability for a placement at: www.aop.org.uk/adviceand-support/business/pre-reg-register The education library hosts OT’s skills guides, designed for students and pre-regs, or practitioners training for further qualifications: www.aop.org.uk/otlibrary The AOP’s employment team is available to support and advise AOP members on pre-registration contracts and employment law and can be contacted at employment@aop.org.uk.

38 www.optometry.co.uk

STUDENT VIEW:

THE FUTURE OF OPTOMETRY NKOSI YEARWOOD

“I think COVID-19 has shown the value of clinical skills and as someone who wants to further their education through professional diplomas after I graduate, this is a great step in the right direction.” SAIRA SALEEM

“I think as more pressure is put on the NHS, the optometry profession will have to adapt further and become more skilled to help reduce this pressure. I think this could lead to exciting changes within the profession and more opportunity to be involved in more complex roles.” LUKE MCROY-JONES

“I already had ambitions to consider postgraduate study, but the pandemic has made my plans more imminent, to keep up with an evolving profession and be in a position to offer the best care to my patients and community. The ongoing Welsh Eyecare Transformation project will also shape my plans.” INDY GHUMAN

“I’ve definitely seen the value in the NHS, and it makes me want to be a part of that and work in the hospital eye service. It also encourages me to want to study further, such as in independent prescribing, as that has shown me the value that optometrists can play in primary care, and reducing the need for patients to go to hospital.”

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47 Business owner SUBS

Sophie Patel’s JVP journey – and the challenges of working during the pandemic

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he world of optics has changed over the past 12 months – from increased use of remote consultations to greater numbers of contact lens fits for those tired of finding their glasses impossible to manage alongside a mask or face covering. How can optometrists navigate these new challenges, and what tools are at their disposal to help them do so? In a roundtable discussion hosted by OT and Alcon, three experienced eye care practitioners (ECPs) discussed contact lens dropout, managing the expectations of and supporting the journeys of patients, how the contact lens side of their business has weathered the storm of the previous year, and the place of future technology in contact lens management. Tackling discomfort, vision and handling

Hove-based optometrist Sandip Doshi believes that, with better products, discomfort has become less of a problem. “My philosophy is to optimise your ocular surface and tear film in order to maximise comfort. And that, combined with better products, tends to give me good results.” He also cited regular communication with the patient as a key way to reduce dropout.

49 How do I...

The AOP’s Dr Peter Hampson on infection control in practice during the pandemic

50 What I have learned

Sali Davis and Angharad Bowie insights into the vaccination programme in Wales

51 Pre-reg focus

Peter Grant on being part of patients’ entire journey through the practice

THE ROUNDTABLE

Support, support, support: how to proactively engage contact lens wearers How can practitioners prevent contact lens dropout, and what methods are they using to achieve this? OT and Alcon went in search of answers

Irish optometrist Fiona Kavanaugh finds that, for her patients, comfort is a greater concern than vision. She told the group: “I sometimes put in a lens that I know is not as comfortable first, and then I follow it with a lens that is

much more comfortable, and it gets rid of the price issue because they realise the value of comfort.” She finds that explaining her own experience as a new user of multifocal daily contact lenses, which she now

“My philosophy is to optimise your ocular surface and tear film in order to maximise comfort. That, combined with better products, tends to give me good results” Dr Sandip Doshi, optometrist and clinical consultant

uses for the majority of her daily tasks, helps her patients with any vision issues. She is also aware that there is no magic bullet when it comes to confidence in handling, and has brought patients back as many as four times for coaching sessions, as well as utilising videos to demonstrate insertion and removal. Like Sandip, she has also found that good management of the ocular surface is a “huge” factor, and that encouraging patients to

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IN PRACTICE ROUNDTABLE, 1

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In practice

Business insight and career development

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THE ROUNDTABLE

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use ocular lubricants in the morning and evening has been helpful – “so that you’re putting the contact lens onto a good surface.” Showing patients their ocular surface has also been “fantastic” in reducing dropout, she explained. “When they see the image on the screen, and they can see the red areas and orange areas that are drying, they completely understand why they have to do something. That has been a great help.” Providing patients with heat bags, eye masks and lubricant drops, and encouraging them to think

about omega-3 levels, has also been positive, Fiona added. After a couple of weeks of these actions, she has found more success when they have returned to practice. Former British Contact Lens Association president Keith Tempany agrees that “sometimes you need three or four coaching appointments, especially with kids.” He added: “We do a lot of contact lenses, and sometimes the first visit is just chatting, and showing them the videos, getting to feel a lens, maybe having a go. But then, maybe just let them think on it and watch the videos at home.

OUR ECPs’ THOUGHTS ON PRECISION1TM DAILY CONTACT LENSES…

CLIENT

Fiona: I think PRECISION1TM Daily Contact Lenses are great. We think younger people don’t appreciate the health benefits of contact lenses – but they do, actually. They really like the fact that there’s more oxygen getting to their eye, and the comfort. Parents don’t have a problem with price because they feel it’s a healthier product for their children. The fact it is available in plus, minus and toric form means it’s really the best launch I’ve ever seen, because it gives an opportunity to fit a lot more people with the lens. The minute I say it’s a brand-new product, it’s the latest technology, it’s got extra comfort, extra oxygen coming through to your eye, they want it. Sandip: PRECISION1TM Daily Contact Lenses are good lenses with great handling. My experience has shown that

44 www.optometry.co.uk

it is more comfortable compared to other lenses. The health benefits stand up for themselves. I’ve got a couple of patients trialling at the moment. I like the availability and toric powers, and obviously plus powers as well. We all want the latest smartphone, so why not the latest contact lens? I definitely see it as a tool in the armoury going forward. Keith: The patients I’ve tried PRECISION1TM Daily Contact Lenses on have really found it very comfortable. The fact that it was giving them better vision made a big difference. We should be introducing new technology to our patients all the time. Once you get into that routine of updating people, they get used to it. They want the new technology. I use the analogy, ‘car-wise, you’re running around in a Ford Anglia. Why wouldn’t you like to update?’

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“Contact lenses got us through the first lockdown, in terms of turnover, because we weren’t seeing patients. We did emergencies only. We had a lot of contact lens orders the first two weeks of lockdown” Fiona Kavanaugh, independent optometrist

“In COVID-19 times, the videos are really useful. We email them out to patients before they come in for a teach, so they’ve already got an idea of what’s expected, then we play them again at the start of the session.” He also emphasises the importance of having a quiet area in the practice for the coach, where no one is watching. Ultimately the most important thing, Keith believes, is to “make sure that the patient is confident and competent before they take the lenses home.” “If we aren’t doing the job properly when coaching,” he said, “we’re going to have handling issues.” Managing expectation

For vision, pre-empting any issues is also essential for Keith: “You need to talk to the patient, to tell them that contact lenses will do probably 80–90% of what they want, near vision-wise,” he said. “We call it a visual wardrobe, where you have different balances and prescriptions for different uses. We have different shoes for different outfits and for different things that we do, and it should be very simple

with daily disposable lenses to just explain to patients that one pair of lenses can’t do everything that you want them to.” Keith also pointed out that, for a variety of reasons, patients may not actually tell you that they’re suffering from discomfort. Acceptance of discomfort as normal (“that’s what contact lenses do”) or worries about the lenses being taken away, should be considered. “I think you’ve got to really use your probing question technique at the aftercares,” he said. “That’s where we pick up most of the challenges. You’ve got to choose your questioning carefully to establish the true wearing time.” He added: “I ask them to explain what they do at the end of the day. What’s their routine? What do they do with the case? We check their cleaning habits and their case hygiene, because that can influence the culture of reusable lenses towards the end of their lifecycle.” Sandip believes that there is a tendency to prioritise vision over comfort, and that this needs to change: “We don’t address it enough. I tend to ask patients: ‘Are you getting enough hours of comfortable wear? Do you feel you need more?’ We need to be much, much more proactive in asking those questions.”

throughout that journey, in order to make sure that they know. We’ve got their back.” Fiona asks her patients to score their comfort out of 10, and is dissatisfied with any rating below a seven – something that the other practitioners agree with. Providing support

Keith reiterates that effective follow-up is key to reducing dropout, especially among new patients, who “need a little bit more TLC, whether it’s in sorting out dry eye, or just investing the time.” New wearer support programmes, he believes, can be useful in highlighting problems, “so that patients can then contact you for an appointment to then sort them out. This can help focus on what the issue is, and potentially save time.” For patients, he finds that the journey is a vital factor in whether dropout will occur. He added: “I always think it’s better to under promise and over deliver. You do get patients where they don’t need that TLC, but it’s good to make sure they’re aware that you’re there for them at any point.” Sandip’s focus is also on “support, support, support” – before the fitting to ensure suitability and that the lenses

aren’t too difficult to handle, and during the wearing, particularly with new wearers. He said: “We’ve set up communication that allows patients to get in touch with us. We use WhatsApp Business, because everybody has WhatsApp on their phone. They can ping a message to the practice, and one of three practitioners will pick it up. We’ve been able to support patients literally round the clock with this. The fact that people know that this service is there inspires a lot of confidence.” He emphasises the importance of support continuing as wearers become more experienced, too, so that they know that they can come back regularly for aftercare, to discuss any concerns, “and, in time, to discuss better and newer products as well.” Sandip adds: “We do make a point of letting patients know that there will be discussion going forward: that things change, including products that may be more appropriate for their prescriptions or their requirements. “The key in my opinion is to offer support at all levels

“It is important that you don’t rush them at the coach. I see it as an investment in time that will be rewarded by loyalty and long-term contact lens wear in the future” Keith Tempany, contact lens practitioner

Staying resilient through national lockdowns

For Fiona, the contact lens side of her business “has held up very well” through three national lockdowns. “Contact lenses got us through the first lockdown, in terms of turnover, because we weren’t seeing patients,” she said. “We did emergencies only. We had a lot of contact lens orders the first two weeks of lockdown.” New fits, she has noted, include those struggling to wear glasses with a mask. Sandip also found that his practice’s contact lens scheme and direct debits brought in vital income. He said: “We made a point to get in touch with our contact lens patients to reassure them that, if we were to go into a national lockdown, there would be no issues with getting contact lenses to them.” Practice staff also contacted infrequent wearers, and asked if they would like lenses to be ordered in case a lockdown did take place. “We found a huge uptake on that,” Sandip said. “Lots of people really appreciated the fact that we were being proactive in making sure that they had ample supply to see them through. It was certainly financially a saving grace for us.” Sandip has also taken on contact lens work “with people who are getting fed up with their glasses steam up

all the time, particularly those habitual spectacle wearers who are struggling to get out and about.” Contact lenses in the future

Keith has begun considering how he may be able to carry out a contact lens fit remotely. He believes that new technology, with the ability to video call and assess red eye, “could be an interesting development,” but that it’s currently too early to consider it as a replacement for an inperson contact lens check. Sandip also believes that new technology has its place in the future: “It adds a new dimension, when we are doing virtual consultations with patients, in order to stay in touch, or for them to upload images to be analysed with the software, or to have a virtual consultation. I think digital technology will probably change how we work. I don’t believe it will replace face-to-face consultation, but I think it will help us identify those patients that need a face-to-face consultation, and perhaps prioritise them. “COVID-19 has made us realise that there are different ways to do what we do, and it doesn’t need to be always face-to-face. It may not be in the best interests of the patient; it might not be in our best interests all the time.” OT video To find out more about the PRECISION1TM Daily Contact Lenses launch, watch OT’s video with Chantelle Cook and Jonathon Bench https://www.aop.org.uk/ ot/industry/contact-lenses/2021/03/03/alcon-introduces-precision1-daily-disposable-contact-lenses

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IN PRACTICE ROUNDTABLE, 2

Clockwise from top left: John White, OT editor; Dr Sandip Doshi; Fiona Kavanaugh; Keith Tempany; Eddie Pigott, Alcon Brand Manager – PRECISION1™ and DAILIES TOTAL1®

To watch the roundtable, hosted by OT and Alcon, visit www.youtube.coc/c/ Optometry-Today_ AOP/videos

VERSION REPRO OP

DETECTING DIABETIC MACULA OEDEMA Lorraine Shields, a UK-based retina nurse and consultant to Allergan, tells OT about ways to work collaboratively to ensure that patients receive appropriate diabetes care

SUBS ART PRODUCTION

OT: What is diabetic macular oedema and how is it diagnosed? Diabetic macula oedema (DMO) is caused by disruption of the bloodretinal barrier due to long-term hyperglycaemia, leading to retinal thickening.1 This can increase the risk of vision loss.2 DMO is commonly diagnosed at a retinal screening appointment – a service which diabetic patients are advised to attend.3

CLIENT

OT: How does DMO affect patients? Beyond the physical symptoms, many people living with DMO face the risk of losing their career4 and independence.5 The need to attend regular appointments to receive treatment can increase levels of anxiety for those who must juggle work commitments alongside clinic appointments. This is particularly the case if a patient doesn’t have an understanding employer. Additionally, DMO can impact driving standards6,7, which could result in patients missing their appointments. Regrettably, this results in increased levels of anxiety. As we are able to detect DMO at an early stage, we can improve patients’ prognosis via proactive treatment interventions. OT: Since the pandemic, do you see any opportunities in the clinic, and has there been a change in health care attitudes? In the peak of the pandemic, all nonurgent appointments were cancelled. We saw this as an opportunity to launch

“By working collaboratively, healthcare professionals can better ensure that patients receive appropriate treatment” virtual clinics. Patients had to fit strict criteria to be eligible for treatment; this was difficult for patients that required monthly intravitreal injections as some were not able to receive their treatment. It would be detrimental to their vision to not receive timely injections.8 This highlights the importance of exploring longer acting treatment options for patients as this does not require frequent visits to the clinic. One of the main indirect impacts of the pandemic is a significant increase in the levels of anxiety and depression experienced by many patients. Unfortunately, for those who have been leading an unhealthy lifestyle, their retinopathy has worsened.

OT: What do you think can be done better by healthcare professionals to help improve care for patients with DMO? An important question to ask your patient is “who looks after your diabetes?” In some cases, patients are visiting the eye clinic but do not see another specialist for their diabetes. Herein lies a significant need for healthcare professionals to communicate with one another, especially in the context of multidisciplinary diabetes care. By working collaboratively, healthcare professionals can better ensure that patients receive appropriate treatment.

References

1. LInternational Diabetes Federation. Diabetic Macular Edema (DME). Available from: https://www.idf.org/our-activities/advocacy-awareness/campaigns/54-our-activities/ 562-diabeticmacular-edema-dme.html Accessed March 2020 2.Mathew C, Yunirakasiwi A, Sanjay S. Updates in the management of Diabetic Macular Edema. Journal of Diabetes Research. 2015;2015:1-8. 3. Jiménez-Báez María V, et al. Early diagnosis of diabetic retinopathy in primary care. Colombia Medica, 2015; 46(1):14-8. 4.Psychological, social and everyday visual impact of diabetic macular oedema and diabetic retinopathy: a systematic review. Coope OAE, Taylor DJ, Crabb DP, Sim DA, McBain H. Diabet Med. 2020; 37, 924– 933 5. Cumberland PM, Rahi JS, UK Biobank Eye and Vision Consortium. Visual function, social position, and health and life chances: the UK Biobank Study. JAMA Ophthalmol 2016; 134(9): 959–966. 6. A nine-country study of the burden of nonsevere nocturnal hypoglycaemic events on diabetes management and daily function. Brod M, Wolden M, Christensen T, Bushnell DM. Diabetes Obes Metab 2013; 15(6): 546–557 7. Driver and Vehicle Licensing Agency (DVLA). Diabetes mellitus: assessing fitnesss to drive. Available at: https://www.gov.uk/guidance/diabetes-mellitus-assessing-fitness-to-drive 8. Action on diabetic macula oedema: achieving optimal patient management in treatment visual impairment due to diabetic eye disease. Gale R, Scanlon PH, Evans M, Ghanchi F, Yang Y, Silvestri G, Freeman M, Maisey A, Napier J. Eye (Lond) 2017 May; 31(Suppl 1): S1–S20. Date of preparation: March 2021 Job bag number: UK-NON-2150041

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ALLERGEN ADVERTORIAL

Advertorial produced and funded by

VERSION

BECOMING A BUSINESS OWNER

REPRO OP

“What I wanted to do had finally come to fruition” Optometrist, Sophie Patel, speaks to OT about how she achieved her goal of becoming a practice owner and reflects on working during the pandemic

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hen optometrist Sophie Patel enrolled to study optometry, her longterm goal was to become a practice owner. “I went into optometry wanting to have my own practice one day,” she told OT. Aware that it would take hard work to realise this goal, the optometrist set about developing professionally to ensure that, when the time was right, she was confident enough in her clinical and commercial skills to make the transition. Mrs Patel’s serendipitous moment came just four years after qualification, when in 2018 she was offered the opportunity to become the optometric director of a new Specsavers practice in Portslade, Sussex. Having relocated to the coastal town a year before, the practice was located three miles from her new home. Recalling the moment that she received the keys to the practice, Mrs Patel said it was “completely indescribable.” “I went into optometry wanting to have my own practice one day. So, when I got the keys to the store it was really overwhelming. What I wanted to do had finally come to fruition.” The JVP journey

Mrs Patel qualified in 2014 after completing her prereg at Specsavers in Ealing Broadway. A year post-

qualification, she began to broaden her experience by practising in different practices. “This enabled me to see how things were done differently and gave me ideas about how I would do things,” Mrs Patel explained. While brimming with ideas, as an employed optometrist Mrs Patel felt that she could not contribute as much as she wanted. “It really spurred me on to have the autonomy to do it myself,” she shared. Considering which path to take into practice ownership, Mrs Patel explained that she opted for the joint venture partnership (JVP) route because “you have a lot of support” in areas that optometrists would not normally be trained in. “Having done all of my training with Specsavers, for me it felt like it was the right route,” she added. By 2017, Mrs Patel felt ready to progress in her journey to become a practice owner and registered her interest with her regional manager, who put her forward for the multiple’s business ownership programme Pathway, designed to prepare optometrists, dispensing opticians and retail managers for practice ownership in Specsavers.

“He knew that there would be a new practice opportunity coming up that I would be interested in,” Mrs Patel said, adding: “It was perfect timing.” On completing the programme, practice ownership was imminent for Mrs Patel, who was offered the directorship of a soon-to-open practice in the area she lived in. Recalling the lead-up to opening the practice, Mrs Patel said she was nervous, revealing: “I was having a reoccurring nightmare where I checked the figures at midday, and we had only taken £2. It was ridiculous, as the first day was really successful. Every time we have a good day now, I joke about the £2 nightmare. I can laugh about it now.” Ways to grow

Mrs Patel understands that business ownership will not be for everyone and highlights that it is certainly “an all-consuming passion” for her. “It does take up a lot of your time,” she admitted, adding: “That works for me, but it has also been the biggest challenge.” For anyone thinking of becoming a business owner in the future, the optometrist advised: “Be as selfless as possible when you are employed. Take on as much responsibility and as many roles as possible without necessarily asking for anything in return as in the end it will benefit you to have all of that experience.” She also encourages practitioners to “put yourself

out there. And network as much as possible.” “I still talk to past colleagues, who give me different perspectives for when I want to do something new in my store,” she added. While Mrs Patel’s next challenge is becoming a mother as she prepares for maternity leave, longterm her ambitions are still wide-ranging. “My store is small, so we are growing all the time. Then it’s about becoming a director of a medium store and maybe, eventually, a large store,” she said. “There is a real sense of achievement [to have your own practice], but it is ongoing,” she concluded.

“We have come out the other side”

Sophie Patel admits that being a relatively new business owner during the pandemic has been difficult. “It was a horrible time last March. My first concern was for my team and making sure that everyone was ok.” While initially staff were furloughed, the practice has retained all its employees. Mrs Patel admits that it was “tough at the beginning, but we are now continuing with our expansion plans.” The practice has recently employed its first optometrist and had a third testing room installed. “We have come out the other side and are really thankful,” she added.

Get in touch Share your practice ownership journey. Email emilymccormick@ optometry.co.uk

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business owner

IN PRACTICE

In Practice HDI

VERSION

HOW DO I...

REPRO OP

Manage infection control

AOP resources The AOP has produced a range of policies and posters to support practitioners, which can be found on its website: www.aop.org.uk/ coronavirusupdates

Optometrist and AOP clinical director, Dr Peter Hampson, discusses infection control in practice during the pandemic

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ooking at the basics of infection control, there are a number of areas that are important to creating a safe working environment for you, practice staff and patients. These include personal protective equipment (PPE), ventilation and vaccines.

PRODUCTION

PPE

CLIENT

Everybody should be wearing PPE. This advice has not really changed since the beginning of the pandemic – if you are working with patients within a distance of two metres or less, then you should be wearing the appropriate PPE. While there has been a debate over whether optometry is classified as medium or low risk according to the latest guidance, the medium risk sets out that we should be wearing single use gloves, a single use apron, type 2R fluid resistant masks, and eye protection when additionally required. Many people are asking about a “roadmap” for reducing PPE, but we need to follow the guidance set by Public Health to both

keep people safe, and also to avoid being considered a close contact when wearing PPE. It is worth keeping in mind that wearing gloves doesn’t remove the need for good hand hygiene from all members of staff. In the absence of gloves, good hand hygiene is able to mitigate the risk. If you haven't got any open sores or broken skin, and hand hygiene is maintained, risk can be mitigated as there is no known risk of contracting COVID-19 through intact skin. Wearing face masks is of upmost importance for all practice staff and patients for two reasons, not only can you stop someone breathing out the virus, you can reduce how many virus particles you are breathing in. There will be some patients who cannot wear a face mask for medical reasons, so reducing these interactions and wearing a mask yourself is key. Ventilation

I know lots of practices that have added screens in some areas and that’s

“Consulting rooms don’t normally have any natural ventilation and, in those instances, filtration units with approved HEPA filters can be used to reduce risk”

Three steps to success 1. Don’t get complacent 2. Increase ventilation however you possibly can 3. Have the vaccine when offered. great, but there is some debate about how effective they are in terms of the size of the particles in the air. So, while the screens help when dealing with two metre droplets, they aren’t necessarily great if particles are floating in the air. This is where ventilation becomes key as good air flow can dilute the virus. Ventilation is really important due to the aerosolisation risk associated to the virus. Aerosolised particles have been linked to an increased risk of disease spread as viruses linger in the air. Natural ventilation, such as opening windows, works very well, but is not always possible at all times of the year. However, consulting rooms don’t normally have any natural ventilation and, in those instances, filtration units with approved HEPA filters can be used to reduce risk. Effective filters in filtration units can help reduce the viral load in the air. These types of filters work in the same way that

face masks do. These devices are not overly expensive and may present a sensible way of reducing the viral load in the consulting room. Vaccines

Vaccines are really important as they can protect against infection or disease, so it is important that we mythdebunk about this. While the types of vaccines that are used vary and may work in slightly different ways, they all still stimulate an immune response, which cannot affect DNA, as we have sometimes heard. Although the vaccine is being rolled out, it’s important not to get complacent. At least in the short term we still need to be wearing PPE, and good hygiene and cleaning has always been important, but even more so until we get the all clear. Looking beyond the pandemic, there are a number of processes that I think practitioners will continue with. I certainly think in the future face masks will at least become commonplace on a seasonal basis. New Infection control and prevention certificate The AOP has released a new Infection control and prevention certificate, supported by Johnson & Johnson Vision. Visit www.optometry.co.uk/cet

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WIHL VERSION REPRO OP

have, and they have been able to do that. It has been really great that we’ve been able to mobilise the workforce to deliver the vaccinations, prove that we can do it safely and effectively, and to have that discussion with Welsh Government alongside it.

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“With optometry you can do anything” Optometry Wales chief executive, Sali Davis, and Angharad Bowie, optometrist, give OT an insight into the COVID-19 vaccination programme in Wales

PRODUCTION CLIENT

How are optometrists in Wales involved in the vaccination programme? Sali Davis, chief executive Optometry Wales (SD): It’s

fair to say that the Welsh Government have been quite agile in terms of the inclusion of the profession. From the start, we had agreed a service specification which would include pharmacists, optometrists, dispensing opticians, and dentists to work alongside GPs in the mass vaccination centres. At the moment, we have probably about a third of our workforce, which is made up of about 900 optometrists and dispensing opticians in total, in mass vaccination centres. Some of our practice staff are also helping out with the administration.

Specsavers

What has been involved in establishing this? SD: Before they can deliver

the vaccinations, optometrists have to complete an online training course which takes around half a day. That’s really the only requirement

50 www.optometry.co.uk

that they have had to meet, other than registration with the individual health boards. We have seven health boards across Wales; to date, five are using the profession within the mass vaccination centres and two are ready to come on board. Those two are in quite rural areas, and so coverage hasn’t been needed in the same way. What do you think it means for the profession to take on this role? SD: Throughout COVID-19,

Optometry Wales has been involved in weekly negotiations with the Welsh Government about a contract for the profession in Wales. It was always the intention of the Government to try to use this opportunity to showcase the skillset that optometrists

“I’m particularly used to dealing with people’s fears and anxieties in an optometry setting”

What has been your key takeaway? SD: I have been pleasantly

surprised at how supportive the primary care colleagues have been. I think it has been the perfect opportunity to show that we want to help and stand alongside GPs, pharmacists and dentists, and deliver this work. Everyone has mucked in and I think that is going to be so helpful for us. What made you want to get involved? Angharad Bowie, optometrist at Haverfordwest Specsavers (AB): I was lucky enough

to work throughout the pandemic for emergency and essential appointments. It was nice to be able to work, but I also wanted to give something more back to the NHS. I think the NHS has always been amazing, but especially during the pandemic. When I received the email to tell me that I could help with the vaccinations, it just felt right. What did the training involve? AB: All of the training

was online, apart from one morning which was on manual handling and piercing. There were around eight or nine modules online and once you had completed a module, you took a short multiple choice exam. Then we had a shadow shift. I was assigned to a nurse

who I watched give the vaccinations. She watched a me do a few and then there is an assessment where they sign you off. After my shadow shift I had my first shift. It was completely out of my comfort zone, but I had a great sense of achievement. There were always people asking if I wanted any help. How have your skills in optometry supported you? AB: I’m used to interacting

with, and helping, patients. I’m particularly used to dealing with people’s fears and anxieties in an optometry setting. In a vaccination scenario, people can be even more scared as many don’t like needles. I think there is a compassionate side of optometry that you have to have, and being used to helping people feel at ease has really come in handy when giving the vaccinations. What will you take away from this experience? AB: Now, more than ever, I

really appreciate the hard work and commitment that goes into the NHS. I have felt a great sense of achievement. I find that people believe optometry is quite regimented or limited. But this just proves that with optometry, you can do anything. I think it has broadened my mind outside the test room. It is nice to be able to give something back and I think that’s the way healthcare will go. It will keep opening up those doors. Share your story Get in touch if you would like to share your experience with OT kimberleyyoung@optometry.co.uk

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HIGH

IN PRACTICE VERSION

PRE-REG FOCUS

REPRO OP

“I can be pretty proud of where I am” Pre-reg optometrist, Peter Grant, on how problem solving in practice can have an important impact on patients’ wider health

COVID-Generation

Read OT's report on pages 35-38

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find it hard to believe that I am six months into practising as a preregistration optometrist. University seems like a long time ago, and I feel I have learnt and developed so much since then. Typically, six months in, I would expect to be further along in the Scheme for Registration – but obviously the current circumstances have delayed things. However, I am thoroughly enjoying being in the testing room with patients, day in and day out, doing the job that I have worked towards since A-levels. The role comes with its ups and downs and there have been many challenges along the way, and plenty more to come, but when I take a step back I can be pretty proud of where I am. I am discovering more and more how essential optometry is as a healthcare service, and what a privilege it is to be a part

Luke says…

of that. This profession is so much more than refracting and prescribing spectacles; it involves a lot of problem solving and decision making that directly affects patients’ wellbeing. For example, I examined a patient who was complaining of blurry vision, found to be caused by bilateral posterior subcapsular cataract, who upon referral was diagnosed

managed to reduce my testing time since I wrote my last article. It takes me between 35 to 60 minutes to do a sight test depending on the complexity of the patient and the additional tests required. As I work in an independent, I carry out all additional tests, as well as my own visual field tests and dispenses. I really value being part of the patient’s

“I really value being part of the patient’s entire journey through the practice, and patients tend to appreciate this too” with type 2 diabetes. I also referred a patient for a bitemporal quadrantanopia field defect, who turned out to have had a mini-stroke. These cases highlight the importance of our role in detecting conditions away from the eye. I am well on my way to achieving my patient encounter totals, having

The biggest learning curve has been… testing children. At university, you get fairly limited experience in paediatric optometry. Combined with the gap in clinical experience due to the COVID-19 pandemic, I was apprehensive about this initially. However, developing experience and taking advice from my supervisors has ensured I have become more confident and effiicient in this area.

entire journey through the practice and patients tend to appreciate this too. I am gradually becoming more confident managing patients, but I really value the few minutes I get with my supervisor at the end of each eye examination to discuss any problems or interesting findings. With the recent unveiling

My top priority for the next few months is… to continue to progress through the Scheme by gaining appropriate clinical experience and developing my knowledge and skills as a clinician. I will also need to complete the virtual Hospital Eye Service experience, and I’ve recently started the theoretical learning for Eye Health Examinations Wales accreditation.

of the pathway to easing of lockdown restrictions, I am looking forward to having a more varied work-life balance over the next few months. In the current situation it can feel like all I do is ‘eat, sleep, work, repeat,’ and I know this is the case for everyone. Being able to go for walks with one other person has been great, but I am eager to make the most of time away from the testing room as I believe it is so important to have a balanced lifestyle. In terms of the Scheme for Registration, I have my Visit 2 in April. The weeks leading up to it will involve preparing for the visit by finding the appropriate patient episodes for each competency and organising my evidence so that it is ready to be shared with my assessor. I hope to successfully pass this assessment and continue my progression through the Scheme.

When I'm qualified, I want to... continue my development as an optometrist. I feel this is essential so we can continue providing care in the community, relieving strain on the NHS. I also want to do a Master’s degree and become an independent prescriber.

Luke is a pre-registration optometrist at Merthyr Optical Centre in South Wales

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In Practice Locum

IN PRACTICE VERSION REPRO OP

Then the first lockdown was announced and all of my work was cancelled. I had a few months without any work, but after that, things started to look up.

SUBS

I think there will always be a demand for locums.

ART

After the first lockdown restrictions were lifted, practices had a backlog to catch up on and there was much work available. It’s been a real roller coaster; it’s been up and down. The

PRODUCTION

LIFE AS A LOCUM

CLIENT

“It’s been a real roller coaster” Locum optometrist, Sammara Ahmed, on the instant variety that locuming provides her – and realising she is valued during the pandemic I became a locum in 2018 because of the flexibility that it offers. But while I’ve

always loved this flexibility, the best thing about it is the variety that it unlocks for you in what you get to see. When you work in one practice, you don’t realise how much you are stuck in one routine. You have the same equipment, the same testing times, and, sometimes, the same patient

ABOUT SAMMARA

Qualified: 2016 Previous roles: Employed optometrist at a multiple Based: Across south-east London, Kent, Surrey and Oxford.

52 www.optometry.co.uk

types. Locuming has allowed me to see how different practices run, how different people work and a broad demographic of patients, which I don’t think you get when working in one place. Throughout the pandemic, it has been apparent how vulnerable we are as locums.

I have not had any help in terms of government support. As a locum, you take the risks that are associated with it. The last 12 months have been difficult at times. Work

initially began slowing down in early February last year. Rather than practising four or five days a week, I was only doing two or three.

same thing happened with this third lockdown – there was a cancellation of all of my work. However, as the vaccination programme rolled out and people began to feel more comfortable attending practices, it began to pick up again. I have at times gone from no work for two weeks to being booked up 12 days in a row. I have found it quite a privilege to be considered a key worker. To be able to go

into practice and help people has been very rewarding. As a locum, there is a bit of ‘you come in, you do your work and you go,’ but going back into practices during the pandemic has made me realise how much I am valued, by patients and staff.

My advice to fellow locums is hold on, it has been a

tough year. For new locums particularly, I’m sure it’s been even tougher as they will not have built up connections. If you persevere, I’m sure that things will pick up. Over time you will be able to build locuming around the life you want, but now is the time to keep an open mind.

A DAY IN THE LIFE

6.30am The first thing I do is check the roads for potential traffic, or the trains for delays. I then know what to expect during my journey and can be sure I’m on time. 8.45am Once I arrive, I will introduce myself to the person managing that day. This gives me the opportunity to say hello but also get briefed on the basics of what the procedures are in terms of handovers, pre-screening and referrals. I will also introduce myself to other staff. Once in the testing room, I check that the equipment is working, that it’s all clean and that I’m comfortable using it. 1 pm I always go out for lunch to ensure that I get some fresh air. So I will go for a walk and pick-up lunch, and then go back to the staff room. This gives me the opportunity to speak to staff and get to know them better. 5pm Before leaving, I check that I have packed up all of my equipment. I also ensure that I have signed the GOS forms that need to be signed, and I leave my details in case I am needed for something like a referral. Making sure that I leave my details also means that I can be easily contacted if they want to rebook me in the future.

AOP Locum Register Find out more: www.aop.org.uk/locumregister

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IN CONVERSATION VERSION REPRO OP SUBS

SUPPORTING CONTACT LENS TRIALISTS

ART

BEYOND

PRODUCTION

THE PRACTICE

CLIENT

As lifestyles evolve through pandemic restrictions, the way contact lenses are introduced is also changing. OT finds out how to engage patients and improve conversion

Shutterstock, Getty

OT: What does the market look like for the contact lens sector currently? Jakob Sveen (JS): It’s no secret

that continued lockdowns have impacted the optical retail category and contact lens sector, with 43% of people wearing contact lenses less than before the pandemic. However, as the High Street prepares to open again, we are seeing some encouraging signs from patients. A recent survey commissioned by Johnson &

Johnson Vision found 79% of contact lens wearers in the UK plan to return to their normal frequency of wearing contact lenses after COVID-19. While some patients reduced their frequency of wear over the past year, interestingly 15% of young people said they are actually wearing contact lenses more than they did before the pandemic. In terms of making appointments with their optician, 40% of those surveyed

"ONE OF THE BIGGEST CHANGES WE’VE SEEN IN CONSUMER ATTITUDES TOWARDS CONTACT LENSES IS A SHIFT IN OCCASIONS FOR WEAR" Jakob Sveen, managing director Northern Europe & general manager UK and Ireland April/May 2021

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GIVING PATIENTS A GREAT START REPRO OP

Faye McDearmid, optometrist and professional affairs consultant for Johnson & Johnson Vision, on supporting contact lens ‘considerers’

SUBS ART

We have completed more contact lens fits so far in 2021 than in any other year. I think that is because we are proactive about discussing contact lenses, but also patients have new challenges due to changes in their lifestyles and working environments due to COVID-19.

PRODUCTION CLIENT

Before the pandemic, we might have been able to fit somebody straight away, but now if we don’t know in advance that they are interested in contact lenses, then it needs to be booked separately. Having said that, I think that can be a good thing, because it means we can introduce the idea and gain acceptance from the patient. One thing that we will definitely continue out of COVID-19 is sending hygiene, application and removal information ahead of time, because when they come in, they seem to be so much more at ease. I’ve noticed there are a lot more ‘considerers’ now making the leap. I think this is because of the extra challenges of wearing glasses through COVID-19, such as wearing masks or the new working situations. I think the Acuvue® 21 Day Challenge is great because patients can be a little bit overwhelmed when first trying contact lenses. It is a new skill to learn, and people can be anxious or embarrassed if they don’t learn it straightaway. This will help get them off to a good start. Giving them that good experience is vital to going on to enjoy being a contact lens wearer. We make sure patients are confident before they leave their teach, but then doing it on their own the first time can be a bit daunting. Some might feel embarrassed if they need to ask for help, though we tell them it is okay. The challenge means anybody who needs support, but might be put off asking, can reach out for extra help. We have also become used to doing so much more virtually and people are coming to expect that. Retention is key and if you are offering something like the Acuvue® 21 Day Challenge to your patients, it really shows you care. We put so much time and effort into fitting people and giving them a good experience, so we want to retain them and see them enjoy those benefits of wearing contact lenses. 56 www.optometry.co.uk

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said they had already done so since the beginning of the pandemic, and half said they have no concerns with returning. We believe that continued engagement with current contact lens patients, and reaching out to those who might be open to contact lenses to come in and be fitted for a trial, will help with recovery. Of course, this needs to be done within the guidelines set out for the profession within the Amber Phase. Eye care professionals (ECPs) who have been able to adapt through these times are already paving the way. OT: How have consumer attitudes towards wearing contact lenses changed? JS: One of the biggest

changes we’ve seen in consumer attitudes towards contact lenses is a shift in occasions for wear. Before the pandemic, the most common times for wearing contact lenses

"ALL OF US – LIKE OUR PATIENTS – ARE COMING OUT OF THE PANDEMIC WITH A NEW PERSPECTIVE ON WHAT IT MEANS TO MAKE CHOICES FOR OURSELVES" Jakob Sveen

were special occasions, socialising, travel or dining out. Today it is everything from grocery shopping, to outdoor exercise, being on digital devices, reading and working from home. We believe this is because all of us – like our patients – are coming out of the pandemic with a new perspective on what it means to make choices for ourselves. People are doing what makes them happy – not because they need a reason to, but because they want to. Any occasion can be the occasion for patients to wear contact lenses. If they don’t realise it yet, with our help, they can.

THE PATIENT PERSPECTIVE

Julia Hipkiss, 37, contact lens wearer for 20 years “I’ve been wearing contact lenses for about 20 years, so I would probably never stop. It’s nice not to have something on my face all of the time and I don’t feel quite as dressed up without contact lenses. “At the end of 2019 I had a baby and, as he got bigger, he was always wanting to take my glasses off. So, even if I was just around the house, I would always put my contact lenses in because it was much easier. “Being in our houses more due to COVID-19, there has seemed to be less of a reason to dress up. Early in the pandemic, as my son went to nursery and I went back to work, I felt that I might as well just wear my glasses. As I’ve become more used to working from home though, I have found that sometimes you want to make an effort with your appearance, and so I wear my contact lenses a lot, even if it is just me in the house. “I also like to wear a headset when I’m on calls and having the arms of my glasses behind my ears is not always very comfortable. I’m on the phone so much more now, so contact lenses are convenient.”

JJV

IN CONVERSATION

SUPPORTING PATIENTS & PRACTITIONERS Kamlesh Chauhan, director of professional affairs, UK, Ireland, Nordics and DACH for Johnson & Johnson Vision, shares his view “As we return to a new and hopeful future beyond the pandemic, services from health care professionals – including eye care practitioners – will be in heavy demand. Supporting patients to lead the lives they want is paramount at any time and having the 21 Day Challenge to support opticians’ busy lives is perhaps needed more now than ever.”

just that. It is designed to enhance patients’ experience with contact lenses from their first fit through to successful, ongoing use. Starting when patients sign up for a contact lens trial, the programme delivers a range of content and tips directly to their inbox across a threeweek period. Our account managers will be reaching out to practices from April to talk about the Acuvue® 21 Day Challenge and how to get patients signed up. With the support of our how-to guide, we hope this will be a helpful resource for building relationships and talking about contact lenses in store, driving conversions from contact lens trials to completion, ultimately growing a loyal patient base.

OT: How could the profession's approach to patient engagement evolve? JS: The change in patients’

OT: How does the challenge encourage behaviour change and support new wearers? JS: The purpose of the

perspectives means the way we introduce and talk about contact lenses should change too. Instead of looking only for traditional prompts, such as sports or big occasions, to recommend contact lenses, we suggest considering how everyday occasions might encourage new trials, reduction of drop-outs and re-engagement with lapsed wearers.

Acuvue® 21 Day Challenge is to complement the instore experience, helping contact lens patients by providing support after they leave the practice, and improving our collective chance of supporting a firsttime trialist to become a confident and loyal contact lens wearer. Part of the inspiration behind the Acuvue® 21 Day Challenge is that we know it takes time to form a new habit. There are plenty of proven case studies, from exercise, to smoking cessation, which demonstrate that providing useful, timely content and positive nudges can help make a big GL╬HUHQFH ZKHQ SHRSOH ZDQW difference when people want to make make aa change. change. to we are are focusing focusing on on So, we So, WKRVH ¿UVW IHZ FULWLFDO ZHHNV those first few critical weeks contact lens lens trialists. trialists. for contact for

OT: How is the Acuvue® 21 Day Challenge designed to support practices in engaging patients? JS: We want to support

ECPs with their contact lens patients to help reduce drop-outs and improve The Acuvue Acuvue® conversion. The conversion. Day Challenge Challenge is is aa 21 Day 21 new behaviour behaviour change change new programme that that ECPs ECPs can can programme share with patients to do

KEEPING THE MOMENTUM GOING Melanie McDowall, contact lens optician and professional affairs consultant for Johnson & Johnson Vision, on supporting long-term successful contact lens wear from the start I’m privileged to be in a practice where we have the capacity to see contact lens patients, though we are trying to speak with as many as we can over the telephone or through remote consultation where it is suitable. We are increasingly seeing more patients, and their confidence to come in has also grown. I feel there is more demand for new fits of contact lenses. This increase has happened organically, with patients getting in touch with us. Particularly those who have been considering contact lenses for some time and have found their glasses have been bothering them, are deciding that now is the time to try. Prior to their trial, we are sending patients links to contact lens teach videos so they have a visual understanding of what to expect and can practise their technique without the lens before they come in. It has been working phenomenally well and is something I will continue going forwards. It helps reduce the amount of time that the patients are in the store and it gives them a starting point and a bit of confidence that they know what to do. I think the digital support available through the Acuvue® 21 Day Challenge is amazing. I have a degree in science and management of exercise and health, so I know that the 21 day behaviour change psychology is important to getting into a new habit. Certainly, I have experienced this firsthand when I have tried similar challenges, such as exercise apps, that provide a lot of online support. For contact lens wearers, the challenge can help to support them through those early days, which can be very challenging because it is like learning a new behaviour. Getting regular reminders and constant support is really going to keep the momentum going, reduce any insecurities and hopefully turn them into long-term successful contact lens wearers. This is ultimately why they have come to us in the first place. In a new teach, contact lens wearers are given a lot of information. The challenge can help to support their learning and reduce any anxiety. To have a tool that can keep them in contact and support them further is helpful for the patient, the practitioner and practice.

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CLIENT

A year after the first UK lockdown, how can eye care rebuild? From a telemedicine drive in Wales to commercial offices repurposed as a diagnostic hub in London, OT finds out how leaders within the profession are charting a path forward

driver can pull up to a car park on the outskirts of Guildford in the rain, sunshine or snow and ferry a paper bag home on the passenger seat. This is not a fried chicken craving or quick burger fix, but one of the many ways that eye care professionals have responded to provide care for their patients in the face of challenges posed by a global pandemic. Since January, more than 400 patients have been seen each week through Royal Surrey NHS Foundation Trust’s drive through glaucoma service. April/May 2021

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seemed like a “natural step” after similar services were set up for pharmacy, cardiac and maternity patients, Mr Lindfield highlighted. He added that glaucoma is a potentially blinding disease which is often symptomless. “Eye pressure is the risk factor but patients have no awareness of it like with blood pressure. There are lots of elements of the testing that we can’t do through the drive through, but we can check eye pressure through a car window. This allows us to measure this key risk factor and keep our patients safe,” Mr Lindfield said. He added that the service has identified five patients with “dangerously high” eye pressure – all of whom were unaware of their potentially sight-threatening condition. “This alone makes it all worthwhile. These patients would not have been found if we ran a purely telephone outpatient service or if their appointments were

“Patients seem to be happy to go to the post office to post a parcel or to the shop and buy some milk but they don’t want to come door” through the hospital doorî Dan Lindfield

Patients drive through a designated one-way lane, have their eye pressure checked through the car window and are able to get their eye drops changed if needed in aa portacabin. portacabin. Glaucoma consultant, Mr Dan /LQG¿HOG WROG OT that the the whole whole Lindfield, told OT that SURFHVV WDNHV OHVV WKDQ ¿YH PLQXWHV process takes less than five minutes for for some some patients. patients. As well as the convenience (all but one patient showed up for drive through appointments following a bout of heavy snow that would have traditionally seen attendance plummet), being tested through a car window has helped to relieve some of the anxiety that patients currently feel about entering a hospital. “Even though hospitals are meticulously cleaned and safe, some patients don’t feel confident stepping through the door,” Mr Lindfield explained. “To be in their own car with their family and just have a hand coming through the window keeps patients within their comfort zone,” he said. Establishing a drive through service for glaucoma patients 60 www.optometry.co.uk

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further delayed,” Mr Lindfield emphasised. Although Mr Lindfield does not envisage a drive through glaucoma service outlasting the pandemic, he highlighted that the hospital eye service needs to work more efficiently to deal with a backlog of patients that has built up during national lockdowns. The glaucoma service currently has a virtual clinic reducing the number of clinicians seen by a patient and speeding up the process. Allied health professionals are involved in the care of patients alongside consultants. “We are definitely moving away from the traditional model of seeing a doctor after your tests, which is inefficient,” Mr Lindfield shared. He added that there are further opportunities to refine the patient pathway. “To have a clinic that just does glaucoma in high volume and efficiently before feeding that data into a senior decision maker would allow the clinician to see more patients. It is just securing the investment, having the bravery to do it and implementing the IT systems,” Mr Lindfield said.

A FORMIDABLE BACKLOG

Provisional data from NHS England shows that in December 2020 there were 23,000 patients who had been waiting more than a year for ophthalmology treatment. In the same month the year before, only 40 patients had been waiting for that length of time. Mr Lindfield believes that a key hurdle to overcome in addressing the backlog is making sure that patients feel safe to return to the hospital. “Patients seem to be happy to go to the post office to post a parcel or

Feature

to the shop and buy some milk but they don’t want to come through the hospital door. They see it as a COVID-19 hotspot – which is not true. It is trying to dispel that myth,” he emphasised. Another issue to address in a post-pandemic health service is that of crowded waiting rooms, Mr Lindfield added. “Eye clinics nationwide and probably worldwide are guilty of having patients wait two or three hours sometimes for their appointments. That has got to change. It really has to stop.”

CUES: FIT FOR THE FUTURE?

The task of clearing out hospital waiting rooms could be aided by treating more patients within community optometry practices. Data from Primary Eyecare Services shows that since the establishment of the COVID-19 Urgent Eyecare Service (CUES) in

DIGITAL AND DYNAMIC

Moorfields Eye Hospital has launched a department of digital medicine, building on previous projects such as video appointments and an online A&E service. Moorfields' medical director, Louisa Wickham, said: "This new department will help us to continue to make big strides in utilising the latest technologies to transform the way in which we deliver ophthalmic care."

April last year, more than 64,000 patients have contacted the service in England. Within this group, 6% were redirected through telephone triage to a more appropriate service or received advice on how to selfmanage their condition. Of the patients receiving treatment through the service, more than 80% were managed within primary care optometry with only 12% of patients requiring urgent referral to a hospital eye service. Interim clinical lead at the Local Optical Committee Support Unit (LOCSU), Zoe Richmond, highlighted that although CUES was originally developed in response to COVID-19, it is an initiative that will continue to support ophthalmology through the recovery phase of the pandemic. “If we can manage more people in primary care and fewer people need to be seen in the hospital then that is going to benefit the recovery of health services and help with the backlog. There are huge pools of experience in primary care as well as equipment. This is a chance to deliver care differently,” Ms Richmond said. Across England, 76% of the population now has access to urgent eye care through an optometry practice – either through CUES or through a Minor Eye Condition Service (MECS). As well as the convenience to patients of receiving care in their neighbourhood rather than in hospital, Ms Richmond highlighted the benefits for practitioners of CUES and MECS. “For practice staff, they are able to fully use the scope of the skills that they have – not just in terms of core competency but also the skills that optometrists have gained through additional qualifications,”

CUES

by the numbers

64,000 PATIENTS CONTACT THE SERVICE

RECEIVE ADVICE FROM OPTICAL PRACTICE OR SIGNPOSTED TO MORE APPROPRIATE SERVICE

80%

OF PATIENTS WHO ENTER THE SERVICE CAN BE FULLY MANAGED WITHIN CUES WITHOUT ONWARD REFERRAL

12%

WILL REQUIRE URGENT REFERRAL TO THE HOSPITAL EYE SERVICE

Source: Primary Eyecare Services (the largest provider of CUES and MECS services across England)

Ms Richmond said. A priority moving forward is to make sure that independent prescribing optometrists are able to practise to the full extent of their ability, she added.“CUES recognises the skills April/May 2021

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of optometrists with independent prescribing, but it hasn’t necessarily been all that easy to get them the FP10 pads. Although they have the skillset, a number of IP optometrists are having to send their patient through to the GP to get access to prescription medication. That is an unnecessary step to the pathway,” Ms Richmond highlighted. A year after CUES was first introduced, the environment in which clinicians are operating is shifting. Ms Richmond noted that services are being evaluated at a local level to check what is working and what might work in the future. “We made some ambitious changes as a response to COVID-19 but on reflection, this care pathway is fit for the future. From my point of view, this is a long-term solution to delivering urgent eye care to people in the local area,” she said. Ms Richmond emphasised the need for NHS England to work with optometrists to ensure that people have equal access to eye care. “I think as a professional group we have demonstrated that we can be incredibly agile and responsive at a

“There are huge pools of experience in primary care as well as equipment. This is a chance to deliver care differently” Zoe Richmond

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time of crisis. We could do so much more to help. There are pockets of excellence across England but we need some way of ramping it up so that every practitioner has the same opportunity to meet the needs of their patients,” she said.

THE VIEW FROM PRACTICE

Alongside working as an optometrist at Specsavers practices in Chesterfield and Matlock, Alex Howard is a clinical governance and performance lead for Primary Eyecare Services. Mr Howard, who helped to design and coordinate the roll out of CUES in Derbyshire, highlighted that being involved in CUES gave him a sense of purpose during the initial stage of the pandemic. “It is about having the chance to contribute in some way during a time when our services were most valuable to people,” he said. “At the beginning, it was scary. You almost forget how scary it was didnít know what because we just didn’t the virus was was or or whether whether we we were were the virus ourselves at at risk. risk. II feel feel putting putting ourselves really proud about the way that a lot of people stepped up to the the plate.” plate.î up to +H KDV VHHQ D VLJQL¿FDQW He has seen a significant increase in the the number number of of increase in practices that are involved in CUES or MECS in over the the course course Derbyshire Derbyshire over of the pandemic. Being involved in the service gives practitioners practitioners service gives variety variety within within their their working day, Mr Howard noted. “There ìThere is a feeling feeling that that everyone everyone is working together together is working towards something bigger.” CUES gives gives CUES

patients an option for accessing eye care locally at a time when many patients have reservations about attending hospital appointments. Mr Howard shared the example of a patient who was seen through CUES after developing flashers and floaters just before Christmas. After an examination revealed a retinal detachment, he was urgently referred to hospital for treatment. The same patient developed new symptoms and was referred to hospital again through the service in February with a retinal tear in the other eye. “In that case, we had a gentleman who, without any intervention, would have permanently lost vision in both eyes,” Mr Howard shared. Turning to the future of urgent eye care, Mr Howard would like to see equal access to care. “Different patients receiving different care depending on their postcode is really simply not fair. I think more services should be comparable between areas. There should never be gaps in provision,” he said. Mr Howard also believes that practitioners should be trusted

within the service specification to make decisions about what degree of care is best for their patient. For example, telemedicine is a core element of CUES at present. “It doesn’t necessarily need to be mandatory in my mind. Some cases are dealt with really well through telemedicine and it definitely has its value, but there are other occasions where you know that the patient just needs to be seen face-to-face. I think the practitioner should have the autonomy to decide over that,” he highlighted. Following the pandemic and subsequent lockdowns, a shift to home working saw office blocks empty as staff shifted to home working. On the back of this trend, Moorfields Eye Hospital has trialled using commercial office space to offer care to more patients. The eye hospital network has opened a series of diagnostic hubs – including within former office space in Hoxton, London. Patients take a series of tests within a 45-minute visit which are reviewed virtually by a consultant. They then receive a letter informing them of the outcome of tests and are offered a video or telephone appointment to discuss particular results. Patients are only asked to attend a hospital appointment if the consultant sees something that requires urgent or personal attention. Moorfields Eye Hospital divisional director and deputy medical director, Dilani Siriwardena, highlighted that expanding the use of diagnostic hubs helped to provide care to more patients. “We hope that the diagnostic hubs format can be applied in

UNIVERSAL EYE CARE

An expert working group has concluded that Scotland should build on universal, NHS-funded eye care by improving access to eye care in home settings and rural and remote communities. After spending three months examining primary care optometry services before and during the pandemic, the group concluded that co-ordination with third sector and social and community care organisations could also be improved. Julie Mosgrove, working group chair and Optometry Scotland vice chair, said: “Scotland is the only part of the UK to provide universally funded NHS eye examinations. It is clear we have a real opportunity to now build on this and establish a service that is truly world class.”

other settings to meet the needs of patients in the safest, most efficient way possible,” she said.

WELSH OPTOMETRISTS EMBRACE TELEMEDICINE

In Wales, telemedicine is one tool that optometrists are using in the wake of the pandemic to enhance access to eye care. More than 300 practices accredited to the Eye Health Examination Wales Service have been supplied with a USB webcam and two USB headsets as part of efforts to bolster the NHS Wales Video Consulting Service. Virtual consultation platform Attend Anywhere was offered to all optometry practices across Wales from the end of 2020, with more than 100 practices signing up to the platform by the end of February. Clinical co-lead of the Eye Health Examination Wales Service, Sharon Beatty, shared that feedback on the initiative had been “very positive.” “It is an opportunity for practitioners to offer healthcare

services in a safe and secure way via a video appointment, rather than seeing patients in person. This has benefits for patients, especially those who are unwell, self-isolating, are in full-time work or who have mobility or transport challenges,” she said. Full training on using the technology is provided to all staff members when practices sign up to the service. When the technology is rolled out at a practice, patients need to provide the practice with permission to use Attend Anywhere. “A link containing an appointment time and date is then sent to the patient’s email address or mobile phone. Clicking on the link then takes the patient to the virtual waiting room, where they would wait for the practitioner to join them. Full records must still be maintained by the practitioner of the video consultation as per a normal face-to-face consultation,” Ms Beatty explained. April/May 2021

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Return to sender:

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IMPROVING REFERRALS

PRODUCTION CLIENT

Professor Bruce Evans talks with OT about research examining referrals from optical practices to secondary care eferrals from community optometry to secondary care are a key part of the puzzle when it comes to transforming eye care in the recovery phase of the pandemic. A study funded by the Association of Optometrists and the Central Local Optical Committee Fund has investigated the appropriateness of referrals to secondary care and the proportion of referrals that receive a response. Professor Bruce Evans, who led the study, told OT that an audit of 905 hospital referrals from optometry practices in Scotland and England found that more than 90% of referrals were necessary. “We did not find over-referral to be a major problem,” he said. In both England and Scotland, Professor Evans and his research team found that some optometry practices routinely received replies from the hospital eye service following a referral while other practices received responses infrequently. Professor Evans noted that while the study revealed some variation in the appropriateness and accuracy of referrals, the main problem they LGHQWL¿HG ZDV WKH ODFN RI D WZR ZD\ identified was the lack of a two-way ¡RZ RI LQIRUPDWLRQ flow of information. ìThe “The absence of referral replies means the optometrist does not know whether the patient has been 64 www.optometry.co.uk

seen in the HES or what was found, and, in some circumstances, is obligated to re-refer. This may mean a wasted NHS appointment and additional anxiety for the patient,” Professor Evans said. He added that good-quality replies are important not only for clinical care and to prevent unnecessary re-referrals, but also to serve as feedback that improves the standard and appropriateness of referrals. Professor Evans noted that, as a profession, optometrists have become acclimatised to not receiving replies but this needs to change in the context of a pandemic where optometrists are managing patients previously seen within the hospital eye service. “In the context of this closer integration with the NHS, the paucity of replies to optometric referral letters seems increasingly inappropriate,” he said. In terms of steps that optometrists working in practice can take to make their referrals more effective,

Professor Evans recommends including a request for a reply to the referring optometrist within the referral letter. If a reply is not received and it would be useful for future clinical care, the optometrist can write to the clinic where the patient was seen asking for a report. The next step would be to approach the hospital eye service clinical lead. Professor Evans noted that online platforms are increasingly being used for referrals. “I would suggest that, as a profession, we should only agree to adopt such systems if replies, and/or access to summary HES information, are built into the system.”

“In the context of this closer integration with the NHS, the paucity of replies to optometric referral letters seems increasingly inappropriateî inappropriate” Bruce Evans

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Education and training for the eye care practitioner

SUBS

Primary care assessment and management of macular holes

ART LEARNING OBJECTIVES

• Be able to explain to patients

PRODUCTION

with macular holes about the management options • Be able to manage patients presenting with macular holes LEARNING OBJECTIVES

• Be able to explain to patients

CLIENT

with macular holes about the management options • Be aware of the management options for patients with macular holes

Dispensing children in a special needs school environment

in a special needs school environment • Be able to take facial measurements from children in a special needs school environment

Communication essentials: health literacy in practice

LEARNING OBJECTIVES

• Be able to communicate

effectively with patients taking into account their health literacy status

LEARNING OBJECTIVES

• Be able to communicate

effectively with patients taking into account their health literacy status

Management of the anisometropic child

LEARNING OBJECTIVES

• Be able to dispense suitable

frames and lenses for children with specific needs • Be able to adapt the testing and dispensing routine for children in a special needs school environment LEARNING OBJECTIVES

• Be able to dispense suitable

CET INTRO

CET IN THIS ISSUE

LEARNING OBJECTIVES

• Be aware of the factors that need to be taken into account when dispensing optical appliances to children with anisometropia

LEARNING OBJECTIVES

• Be able to clinically justify the use of contact lens correction for children with anisometropia by taking an evidence-based approach

Cases of gradual vision loss

LEARNING OBJECTIVES

• Be able to interpret the

presenting signs and symptoms for a range of gradual vision loss cases

I nstrumentation for anterior eye assessment

LEARNING OBJECTIVES

• Be able to recognise and

understand the use of instruments for assessment of the cornea • Be able to recognise and understand the use of instruments for assessment of the tear film • Be able to recognise and understand the use of instruments for assessment of the anterior chamber LEARNING OBJECTIVES

• Be able to assess the anterior

LEARNING OBJECTIVES

• Be able to clinically justify the use of contact lens correction for children with anisometropia by taking an evidence-based approach • Be aware of the factors that need to be taken into account when dispensing optical appliances to children with anisometropia

segment using appropriate techniques

optical appliances for children

THE CET EXAMS WILL EXPIRE ON:

EXAM QUESTIONS & REFERENCES Under the enhanced CET rules of the GOC, MCQs for OT’s CET exams appear online at www.optometry.co.uk. The CET exams will expire on 2 July 2021. Exams cannot be submitted 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. AOP members and subscribers will then need to log into the CET portfolio by clicking on ‘MyGOC’ on the GOC website (www.optical.org) to confirm points. Visit www.optometry.co.uk, and click on the ‘Related CET article’ title to view the article and accompanying ‘references’ in full.

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Primary care assessment and management of macular holes Guy Negretti MA, MB, BChir, FRCOphth

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This article provides an overview of the presentation, clinical examination and management of macular holes.

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Introduction

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Macular holes can be classified into three groups – full thickness macular holes (FTMH), lamellar holes (LMH), and pseudoholes – the pathology and treatment of which differ. This article summarises current management of these conditions, helping the primary care optometrist to understand when and how urgently to refer to secondary care, along with providing the tools to explain to patients what to expect when they reach secondary care.

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Clinical symptoms

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Pseudoholes Pseudoholes are not true holes in that there is no retinal tissue loss. They are caused by the centripetal contraction of epiretinal membranes (ERM) which leads to retinal tissue becoming bunched around the fovea giving the impression of a hole on examination (see Figure 3, page 68).

All three types of macular hole can be asymptomatic binocularly and picked up incidentally on a routine sight test when each eye is tested independently. When patients do experience symptoms they may complain of blurred central vision and/or distortion of their vision (metamorphopsia). This distortion might manifest as straight-lined objects, such as mirror frames, picture frames and text, appearing wavy. Patients may report diplopia as they are unable to fuse the distorted image from one eye with the normal image from the fellow eye. When seeing a patient with a suspected macular hole, it is important to understand how symptomatic they are. Patients who are asymptomatic may not require any surgical intervention.

Epidemiology

The prevalence of FTMH varies depending on the population studied and has been reported to range from 0.02% to 0.8%.4-8 FTMH are more common with age and are three times more common in females compared to males.9 The prevalence of LMH ranges from 1.1 to 3.6%.10-11 The prevalence of pseudoholes was found to be 0.1% in a 2018 study of 1531 patients with normal glucose metabolism.10

Pathogenesis

FTMH FTMH are defects that involve the entire neural retina (see Figure 1). They are most commonly primary (without secondary cause) and arise due to tangential and anteroposterior traction from the vitreous at the centre of the fovea.1 Vitreous traction at the centre of the fovea is thought to initially result in an intraretinal split that evolves into a cystic space and then into disruption of the outer retinal layers thus forming a full thickness hole. FTMH can sometimes occur secondary to other causes such as major trauma, laser injury or retinal detachment.

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LMH LMH are partial thickness holes in which there is a defect in the inner retina, but the retinal photoreceptor layer remains intact (see Figure 2). They can be split into those caused by vitreomacular traction (VMT) and those caused by inner retinal degeneration. The first description of LMH was by Gass in 1975. It was associated with chronic cystoid macular oedema in which the cysts had degenerated to form a partial retinal defect.2

Figure 1

242 um

Figure 1 Full thickness macular hole

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Figure 2

Figure 2 Lamellar hole

Clinical examination

Visual acuity (VA) is an important initial test. Patients with FTMH tend to have significantly reduced VA while those with partial thickness holes often have nearnormal VA. Macular holes can be diagnosed with fundoscopy using a high magnification stereo fundus lens. On examination of the macula there is a visible central retinal defect. FTMH often have a cuff of subretinal fluid surrounding the hole and drusenoid deposits at the base of the hole. At the base of a lamellar hole, the foveal reflex gives the impression of a residual retinal layer. If a pseudohole is suspected, then an ERM will be seen surrounding the hole (see Figure 3). On fundoscopy, the appearance of ERMs can vary from a subtle sheen on the macula, best seen with the red-free (green) light on the slit lamp, to obvious fibrous white scar tissue. The Watzke-Allen test can be used to distinguish a FTMH from partial thickness holes. To perform this test, a beam of light from the slit lamp is projected over the hole and its margins and the patient is asked whether the central portion of the slit-beam is missing. If it is missing, this means there is loss of the photoreceptors in the hole and thus the hole must be full thickness. The best way to diagnose macular holes is using optical coherence tomography (OCT), which allows easy distinction between the types of macular hole (see Figures 1-3).

Natural history

The majority of FTMH do not regress without treatment but instead increase slowly in size leading to a drop in VA and reduced potential for visual improvement with surgery; 11% of FTMH smaller than 400ųm with no posterior vitreous detachment (PVD) do regress naturally when a PVD occurs.13 Pseudoholes, like ERMs without pseudoholes, do not tend to progress or regress with time.14 The chance of a lamellar hole increasing in size will depend on whether there is still an active disease process causing the lamellar hole. For example, if the lamellar hole is secondary to degeneration caused by cystoid macular oedema (CMO) and that disease process is ongoing, the lamellar hole may well increase in size. Patients with a FTMH are understandably often concerned about the risk to their fellow eye of developing a macular hole. This risk will depend on whether a PVD is present. A 2011 prospective study demonstrated an 11% risk over five years of FTMH development in the fellow eye of patients with a FTMH where the vitreous is not detached.12 Where the vitreous is detached in the fellow eye, patients can be reassured that the risk of FTMH development is close to zero.

Classification of FTMH

A classification system for FTMH is important as it helps to guide treatment decisions and informs patients about the likely chance of treatment success

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with the patient in detail with a decision made on an individual basis. The other group of patients with FTMH that might not go for surgery are those who are asymptomatic binocularly, who have a PVD in their fellow eye, so are at minimal risk of developing a hole in that eye, and who have multiple medical comorbidities meaning that surgery could be a risk to their general health. These patients also need to understand that if they decline surgery initially their chance of a successful outcome if they change their mind later will reduce. Patients with asymptomatic lamellar and pseudoholes would not be considered for surgery. Indeed, these patients can be seen annually by their primary care optometrist rather than being referred into secondary care, providing the optometrist is confident in the findings and there is a mechanism for monitoring in their area.

Figure 3

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Figure 3 Pseudohole

for their hole. Gass produced his classification of FTMH in 1988; this was based on clinical examination and commonly used until the widespread use of OCT led to the OCT-based classification system of the International Vitreomacular Traction Study Group (see Table 1). This system is widely used by vitreoretinal surgeons and it is a good predictor of the chance of a successful outcome with surgery. When measuring the size of the hole, the caliper function on the OCT is used to measure the narrowest hole width in the mid retina with a line roughly parallel to the retinal pigment epithelium (RPE) (see Figure 1).

Treatment

Observation In patients with FTMH, observation may be reasonable for a short period of time if the hole is small and there is no PVD present; this is because the hole has a small chance of closing spontaneously although this has to be weighed up against a slightly less successful outcome if surgery is delayed. These conflicting issues need to be discussed

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Surgery For patients with FTMH who want intervention, the mainstay of treatment is pars plana vitrectomy with induction of PVD, peeling of the internal limiting membrane (ILM) and gas tamponade. Vitrectomy and ILM peeling are thought to relieve traction on the macular hole while the gas acts as a tamponading agent pushing the edges of the hole flat and allowing glial repair of the retinal defect. Vitrectomy for FTMH was first described by Kelly and Wendel in 1991 who had a closure rate of 58% for macular holes.15 With modern techniques, closure rates of greater than 90% have been reported.16 Closure rate depends on the size of the macular hole and the length of time it has been present. The vast majority of surgery for macular holes is done as a day case and is performed under local anaesthesia with a sub-Tenon’s or peribulbar injection of local anaesthetic providing akinesia as well as anaesthesia. Surgery is performed through three small ports that are either 23, 25 or 27 gauge which are inserted through the ciliary body’s pars plana (3.5 to 4mm posterior to the limbus). The vitreous is then removed using a vitrector with a high cut-rate in one hand and a light pipe, providing illumination, in the other. Following vitrectomy, a dye, such as Brilliant Blue G (Fluoron GmbH, NeuUlm, Germany), is used to stain the ILM. The membrane can then be grasped with micro-forceps and gently peeled from the surface of the macula. At the end of the surgery, the eye is filled with an inert gas such as sulphur hexafluoride (SF6) or perfluoropropane (C3F8). SF6 gas will last for two to three weeks in the eye and C3F8 will last for six to eight weeks, during which time the patient will experience blurred vision.

Summary of management of macular holes in primary care

Table 1 Classification

Subclassification

Size

Small (≤250μm) Medium (>250-≤400μm) Large (>400μm)

Status of vitreous

With vitreomacular traction Without vitreomacular traction

Cause

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Primary or secondary

Table 1 The International Vitreomacular Traction Study Group Classification of full thickness macular holes

The surgery for pseudoholes is very similar to that for FTMH except that the ERM is peeled rather than the ILM and gas is not required. The criterion for when to operate on pseudoholes is exactly the same as for ERMs: only when the patient has significant symptoms. For LMH, even when the patient has symptoms, surgery may not be beneficial. If there is a significant amount of vitreous traction associated with the lamellar hole or if there is a significant ERM, then vitrectomy surgery using the same techniques described above can be beneficial. Ocriplasmin Ocriplasmin (Jetrea, ThromboGenics, Belgium) is a truncated form of human plasmin manufactured using recombinant DNA technology. It is an option for the treatment of FTMH but not lamellar or pseudoholes. It cleaves laminin and fibronectin between the vitreous cortex and ILM and thus induces a PVD. A multicentre randomised control trial using Ocriplasmin demonstrated FTMH closure rate for small and medium holes of 40.6% compared to 10.6% in the control group.17 Despite this result, it is not used widely among vitreoretinal surgeons. One of the main reasons for this is the very high macular hole closure rate and low risk associated with surgery. There is also concern about possible side effects with the use of Ocriplasmin. Up to 12% of patients have been noted to get a reduction in their vision in the seven days post injection.18 In a small subset of these patients, the visual loss was permanent. This loss of vision is thought to be due to intraretinal cleavage of laminin.

History The history needs to ascertain the symptoms the patient is experiencing and how these are affecting their quality of life. Is the patient getting significant metamorphopsia in particular? Examination VA and the Watzke-Allen test will help to distinguish between the three hole types. OCT examination, if available, is the definitive test required for the diagnosis of macular holes. Who to refer FTMH

In general, all FTMH should be referred to secondary care unless the patient is adamant that they do not want surgery and understands the consequences of delaying surgery. Pseudoholes These do not need to be referred to secondary care unless the patient is symptomatic and would like to have vitrectomy and ERM surgery to try and improve these symptoms. LMH These do not need to be referred to secondary care unless the patient is symptomatic and would like to have vitrectomy surgery. Urgency None of these conditions need to be seen as an emergency. Pseudoholes and LMH can be referred routinely, with appropriate warnings on what action to take if symptoms change. A FTMH is more urgent in that if surgery is delayed too long then outcomes can be worse, and optometrists should follow any local protocols in their area.

About the author n Guy Negretti graduated from Cambridge University in medicine in 2009. He completed all of his ophthalmology speciality training in London including two fellowships in vitreoretinal surgery at Moorfields Eye Hospital. He currently works as a consultant vitreoretinal surgeon at Surrey and Sussex Healthcare NHS Trust.

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Dispensing children in a special needs school environment

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Mitchel Reuben FBDO, SMC (Tech), Cert Ed and Martyn Howlett FBDO SUBS

This article outlines ways to support successful spectacle wear for children with learning disabilities. The role of dispensing in a multidisciplinary special school eyecare team is discussed.

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Introduction

PRODUCTION CLIENT

The authors are dispensing opticians who work for SeeAbility as part of their Special Schools Eye Care Service campaign. They visit nine special needs schools in the Greater London area alongside a specialist optometrist and currently manage the eyecare needs of over 1500 children. The schools are populated by children with varying degrees of learning disabilities (LD), which can be part of, or sit alongside, other conditions such as autistic spectrum disorder (ASD), Down syndrome (DS), cerebral palsy (CP), as well as other syndromes or brain injuries. These conditions are shown to exhibit increased incidence and magnitude of vision impairment.1 Children with learning disabilities are 28 times more likely to have eye or vision problems compared to children without LD,2 with half of the special school population having a significant visual deficiency and 31–50% needing spectacle correction.1,3 Among this cohort are significant numbers of children with cerebral visual impairment (CVI), which is a visual function deficit caused by damage to the retro-chiasmal visual pathways in the absence of any major ocular disease; it is the most common reason for unavoidable visual impairment in children in the developed world.4 Mencap defines a learning disability as ‘a reduced intellectual ability and difficulty with everyday activities… which affects someone for the rest of their life.’5 Profound and multiple learning disability (PMLD) is when a person has a severe LD and other disabilities that significantly affect their ability to communicate and be independent.6 Approximately 120,000 children with LD in England attend special schools.7 With the exception of the nine schools visited by SeeAbility, the authors are not aware of similar schemes in other areas. Successful compliance with and adaptation to spectacle wear for children with LD is often low,3 even though it has been shown that a comprehensive ocular examination followed by spectacle dispensing significantly enhances the visual function for children with LD,8 as well as improving behaviour and active participation in class;9 this is also true for children with CVI.10

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Figure 1

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Figure 1 SeeAbility’s About your child and their eyes form which is sent to parents/carers prior to the school visit

As part of the NHS Healthy Children Programme, Public Health England recommends that all children aged four to five years should be screened for anomalous vision by an orthoptic led service.11 It appears that the provision is patchy and produces geographical inequalities.12 Vision screening has also been shown to be inappropriate for the special school population1 and Public Health England recommends a full assessment as outlined by the Framework for Special Schools Eye Care.13 This framework was developed by SeeAbility in association with ABDO, BIOS, the College of Optometrists, LOCSU Eye Care Wales and the Royal College of Ophthalmologists, which recommends comprehensive routine eye care, including refraction at least annually and spectacle dispensing, fitting, support and repairs to be provided in the special school environment. SeeAbility has shown that only 10.7% of children attending special school have ever visited a community optical practice and 43% have no reported eyecare history so uptake of GOS sight tests in this group is low.1 Reasons for this are multifactorial but parental misconceptions around accessibility of sight tests plays a part.11

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such as speech and language therapists (SaLTs), occupational therapists (OTs), physiotherapists, school nurses, paediatricians and educational audiologists. Communication with the child and everyone involved in their support and education is the lynchpin to a positive outcome. Understanding how a person with a LD might process the information around them should inform the way the practitioner presents themselves and the tasks at hand. Providing continuity of care allows the practitioner to build rapport and develop an understanding of a child’s needs and Figure 2 Dispensing a student in the classroom. Note the relaxed environment behaviours. First time meetings can be more challenging. The practitioner As part of its 10-year plan, National Health Service needs to acquire information relating to the child’s England has pledged to deliver a fully funded eyecare condition and review previous eye care reports, provision that reaches all children educated in special if available. Equally important is establishing the schools.14 The development of a nationally recognised child’s likes, dislikes and triggers; a conversation with accreditation for working with children with LD is someone who knows the child well, such as a parent, proposed and this should become mandatory for all teacher, carer or TA, will help greatly in this regard. An professionals working in a special school ophthalmic invaluable tool is a pre-assessment questionnaire which team.13 can help to prioritise aspects of the examination and allow some discussion prior to the child’s arrival for The role of the DO their assessment. SeeAbility has created an easy read In a special school environment, the DO is on hand form which is sent to parents/carers before a child is to provide well-fitting spectacles with the latest valid seen in school (see Figure 1). prescription, as per community practice and to provide support to ensure that spectacles are worn as needed. Figure 3 The fitting of spectacles might involve manipulation of frames to account for other devices such as hearing aids, wheelchairs and communication aids. The role of the DO may stretch beyond the dispensing process by taking an active part in many aspects of the continuous eyecare needs of an individual. For instance, the practitioner will often communicate with parents, teachers, qualified teachers of the visually impaired Figure 3 Miraflex design with soft, flexible material (QTVIs), teaching assistants (TAs) and other disciplines Figure 2

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Cardiff Contrast Sensitivity Test Ulster-Cardiff Accommodation Cube Colour Vision Testing Made Easy (Waggoner) Lang Stereo Test I and II Frisby Stereo Test.

Figure 4

SUBS ART PRODUCTION CLIENT

Having a DO on hand during the test is useful. Aside from noting non-verbal cues and subtle gestures that may otherwise be missed, the DO can observe eye movements during field of view tests or perhaps note that a missed letter/symbol was due to a distraction or loss of interest. The aim during assessment is to a achieve a positive outcome; this does not necessarily mean every aspect of the eye examination is completed and requisite spectacles are happily dispensed in a timely fashion. Circumstances might mean that not all elements of the test are completed during a single appointment and the child may need several visits over time. Perhaps on a single visit, only VA is measured due to the child no longer being comfortable or able to comply with instruction. If it has been possible to gather additional information since the previous visit, then a positive outcome has been achieved. Dispensing could be done at a later date and a useful strategy is to give the TA some frames for the child to try on in the classroom later on.

Figure 4 Centrostyle design with skull grip sides

Additional tasks for the DO will depend very much on the set up of the testing facility including the location, frequency of visits, who is attending and primarily, the specific needs of the individual being seen. The test room may vary in size and invariably is not set up for testing. The room location may vary from one visit to the next so vision testing and dispensing equipment must be portable. The optometrist and DO plan the setting, consider the position of seating, make best use of available light and create easy access to the test equipment. Although the test might not follow standard routines, the transition between each element should be smooth. Unnecessary clutter should be removed as some children might find extraneous objects distracting. Children with ASD might also suffer from sensory overload so background noise should be minimised as far as possible. Practitioners should communicate directly with the patient. The child may be non-verbal, but this must not create a barrier to an eye examination, or a spectacle dispense. Children are often excellent at relaying messages through gestures or types of sign language such as Makaton and Signalong or it may be necessary to be guided by someone who knows the child well to interpret what they are communicating. It is important to be sensitive to non-verbal communication cues, and in particular, being responsive to signs of distress. The DO often assists the optometrist during the sight test. It may be as simple as being a large animated point of focus or a spare pair of hands, aiding with recording visual acuity (VA). To that end, DOs need to be familiar with specialist acuity charts and assessment tools such as: Kay Picture Test crowded and singles (LogMAR 3m and near test) Keeler Acuity Cards for Infants Lea Gratings Paddles/Teller Acuity Cards Bradford visual function box Peekaboo Vision app Cardiff Acuity Test

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Dispensing

Dispensing and fitting may take place in a dedicated room, in a classroom, or indeed, any space where the child is at ease (see Figure 2). Due to the nature of the role, there is a limit to the number of frames that the DO can bring to the school, so it is essential that the range and sizes are well thought out in advance. Although colour choice is important, frames can be selected from a catalogue once a good fit is established. First and foremost, the spectacles must be designed to minimise potential injury, which Figure 5

Figure 5 Tomato Glasses which come with options for interchangeable parts

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means no sharp or rough part and end tips must not be special schools service for registered providers are easily removable. Care must be taken when dispensing currently being established. Where possible, the child frames with pads or removable bridges as these can should have input with the choice of frame. They may present a risk of choking. The frame must be durable have a LD, but they will more often than not have an and needs to exhibit some rigidity to form a platform opinion on the style they desire. Usually, colour is the for housing lenses in a stable position and yet be flexible influencing factor but older students (this could include enough to maintain comfort and add to strength. those up to the age of 25 years) can be tuned in to current It is inevitable that this cohort of spectacle wearers will and popular frame styles.12 Interpupillary distance (PD) measurements can be break or damage their spectacles more frequently than challenging to obtain accurately in some cases. Many others and sometimes there needs to be a compromise on children in a special school setting do not like an rigidity if a child continually breaks their frame. In these invasion of their personal space, for instance, having cases, a rubberised or soft nylon frame, such as a Miraflex a ruler held near them, while others, particularly design (see Figure 3) may be appropriate although due to its softness, the lenses might pop out more frequently, or those with ASD, do not like direct eye contact. With the front might curve with the face form causing contact experience, it is possible to make an approximation of with eye lashes. Other frames offer strength and many of the PD by simply looking at the overall facial features them use varieties of TR90 (a nylon-based polymer). The although this approach should be avoided with high Centrostyle range (see Figure 4) offers designs with scull prescriptions. Judgement is needed as to how much grip sides that can be supported with silicone straps or error might be involved versus the power of the lens. frame locks. Some models have silicon laminated TR90 Practitioners should aim to take the measurement sides that offer extra comfort and strength. Tomato Glasses quickly and then retreat. If the child is compliant, (see Figure 5) and Swissflex Eyewear (see Figure 6) use a second attempt may give better accuracy. Other high quality materials with interchangeable parts that give strategies include limbus-to-limbus measurements scope for fitting a multitude of face shapes, accounting for (remember to subtract 1mm due to the eccentricity of the variance in facial features. Specialist metal frames such as pupils) or canthus-to-canthus (be mindful that this may Erin’s World are designed for patients with DS and their be inaccurate due to epicanthal folds). The gold standard specification is aligned with findings from a study on the is measuring pupil centre to pupil centre and also facial characteristics of these children;15 they have a low recording monocular PDs while blocking fusion; this set bridge, shorter sides and end pieces made of a flexible also provides a chance to observe eye movements, which alloy. may serve as a basic alternative to the cover test. Where High specification frames are expensive with the indicated, and if possible, near centration distances cost exceeding the claimable value on the NHS optical (NCD) should be measured rather than assumed; this voucher. In 2016, the Optical Charges and Payments also gives another basic assessment of eye movement, Regulations were amended to allow the Special Facial such as smoothness of movement and convergence Characteristics (SFC) supplement to be claimed by ability, which can all be fed back to the optometrist. GOS contractors in primary care. The supplement is payable where a frame Figure 6 has to be custom made, specially adapted, or has been designed and manufactured with appropriate modifications. Where the SFC supplement is being applied, there must be a clinical need for the specialist frames.16,17 SeeAbility proposed that all children should be provided with a spare pair due to the high frequency of breakage and loss and that this is essential for the continuity of wear as the periods between DO visits may lead Figure 6 Swissflex Eyewear which come with options for interchangeable to delay in repairs and replacements. parts Mechanisms for funding within the

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Figure 7

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Figure 7 A student using Eye Gaze communication equipment

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PDs are generally the only facial measurement taken by the authors in this environment with frame fitting measurements taken from the frame once it has been completely fitted. The need to record specific measurements may depend on the frame type. For instance, it may not be necessary to record the angle of side on a plastic frame, where no alteration has been made. As a minimum, it is advisable to record length to bend/tangent, head width, temple width and distance between pad centres for a pad-on-arm frame. For frames that offer interchangeable parts, it is prudent to record the size, type and position. Lens selection in a special school setting is, on the whole, simpler than in community practices and the Hospital Eye Service. Children needing complicated lens solutions are usually seen under a consultant within the HES. DOs are trained to make appropriate lens choices in this instance, satisfying their professional competencies as laid out by the General Optical Council.18 Of course, consideration to vertex distance is still relevant and care must be given to segment top positions and fitting heights

for multifocal (MF) designs. Accommodative insufficiency is found in 80% of children with DS,19 57% with CP20 and 17% with ASD.21 The DO will help decide whether single vision lenses would be more effective than MFs once the student has been observed in their regular environment. In relation to lens strength, the authors generally consider that CR39 is adequate for normal spectacle wear. However, more impact-resistant material such as Trivex, polycarbonate or high index plastic (1.67 index is preferred as it is less brittle than 1.74) for monocular children or if there is evidence of extra risk such as head banging. For high minus prescriptions, it is wise to request a heavy safety chamfer and avoid ordering a knife edge surfaced positive lens as the thin edge of the lens is weak and if the lens pops out a sharp edge is exposed. Minimum edge substance should be no less than 1.5mm. Multi anti-reflection (MAR) coatings are given when there is a specific need. One such need is if a student uses the Eye Gaze communication system (see Figure 7) for communication and studying, as in the authors’ experience, uncoated lenses can impede the use of these devices. Critical to this whole process is the continuous and habitual wear of the optical appliance; therefore, a frequent follow up regime must be in place. Follow ups at one, four and 12 weeks after the supply of spectacles is advised. This gives the DO an opportunity to observe the child in their regular environment and the chance to discuss progress with carers and teachers and also to implement strategies to aid compliance and make any necessary adjustments or repairs.

Conclusion It is essential that children with special needs can access regular and appropriate eye examinations congruent to their needs, which crucially includes the supply and maintenance of suitable spectacles and promote habitual and beneficial wear. It is key that the DO aids in decision making as part of a multidisciplinary team for an eyecare plan that enhances a child’s quality of life.

About the authors n Mitchel Reuben completed his ophthalmic dispensing and technician course at City and Islington College, returning later to teach as a part-time lecturer until 2013. He completed his pre-registration year at Moorfields Eye Hospital and has continued to work there on a part-time basis for the last 15 years. Mitchel is also part of SeeAbility’s vision team which allows him to contribute to the comanagement of eyecare for children with special needs.

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n Martyn Howlett qualified as a dispensing optician in 1989 and has worked in optics in the UK, and overseas, where he undertook a varied role, which included serving the needs of embassies and their diplomatic staff. Martyn is now based with SeeAbility as part of the team and also works as a locum in High Street practice.

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Communication essentials: health literacy in practice

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

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SUBS

This article describes health literacy, its relevance, challenges and outcomes. Communication interventions to promote health literacy in healthcare practice are suggested.

ART

Introduction

PRODUCTION

Health literacy (HL) is central to effective health communication. Health service responsiveness to HL challenges promotes patient understanding and compliance with healthcare management recommendations, fostering long-term health and wellbeing outcomes.1,2 This article aims to enhance eyecare practitioner recognition of the manifestations and consequences of poor HL and the practical interventions that can be adopted to promote HL in practice, in accordance with professional standards relating to communication in practice (see Table 1, page 76).

CLIENT

What is health literacy?

The World Health Organisation (WHO) Health Literacy Toolkit1 describes HL as: ‘The personal characteristics and social resources needed for individuals and communities to access, understand, appraise and use information and services to make decisions about health. HL includes the capacity to communicate, assert and enact these decisions.’ This description may be extended to include listening, writing, numeracy and everyday technology use to access information and communicate in order to navigate health services.2,6-8 Poor HL is often associated with a low level of general literacy, but the converse does not necessarily hold true. Healthcare providers often over-estimate patient literacy levels,9 as some well-educated and highly literate people may have a low HL level.6,7 The findings of studies into the prevalence of HL challenges are summarised in Table 2 (page 77). Poor HL is often associated with the following factors: age; poor health; disability; disadvantaged socioeconomic status; lower educational attainment; immigration status; and ethnic minorities.2,6,14 There is a dearth of research on HL levels of patients with specific ocular diseases, but a recent study showed high rates of poor HL in patients with age-related macular degeneration (65%), diabetic macular oedema (73%) and retinal vein occlusion (63%).15 A further study showed that 30% of glaucoma patients have marginal or inadequate literacy skills.16 This suggests that HL inadequacies may impact many eyecare service users.

Types of health literacy

The three main types of HL as recognised by the Royal College of General Practitioners (RCGP)7 and the National Health Service (NHS)17 are: Functional – this describes a person’s ability to perform basic reading, conversational and numerical tasks to the extent that these are understood sufficiently to enable them to function in a healthcare environment through application of this knowledge6,7,17 Interactive – this describes a person’s ability and confidence to engage in collaborative discussion of their health condition and management options with their practitioner, forming the basis for patientcentred decision-making2,7,17,18 Critical – this involves a higher level of cognitive skills, which when combined with social skills, facilitate a person in taking control over wider health determinants; this includes the identification of health barriers,7,18 with this information being used to exert greater control over life events and situations.17

Health literacy as the basis of a patient-centered approach

HL is optimised when the expectations, preferences and skills of both health service users and providers are aligned,19 forming the basis of participative healthcare decision-making.8,20 It is multi-faceted, as it depends not only on individual personal capabilities, or the nature of the healthcare system, but also on the effortful interaction between the person, health practitioners and the dynamic health and social care environment (see Figure 1, page 78).1,2,6,19-21

Consequences of poor health literacy

Low levels of HL are closely related to poorer physical and mental health outcomes2,7,19,20 and higher national healthcare costs. Poor HL is associated with reduced comprehension of medical information, lack of understanding of diagnosed medical conditions and appropriate care for those using preventative health services, poor medical advice compliance

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Table 1

SUBS

GOC Standards of Practice for Optometrists and Dispensing Opticians3 2.1 Give patients information in a way they can understand. Use your professional judgement to adapt your language and communication approach as appropriate

ART

2.4 Ensure that the people you are responsible for are able to communicate effectively with patients, their carers, colleagues and others

PRODUCTION

7.1 Conduct an adequate assessment for the purposes of the optical consultation, including where necessary any relevant medical, family and social history of the patient. This may include current symptoms, personal beliefs or cultural factors

CLIENT

10.1 Work collaboratively with colleagues within the optical professions and other healthcare practitioners in the best interests of your patients, ensuring that your communication is clear and effective

CORU Standards of Proficiency for Optometrists4 and Dispensing Opticians5

2.1 (Optometrists; Dispensing opticians) Be able to communicate diagnosis/assessment and/or treatment/ management options in a way that can be understood by the service user 2.2 (Optometrists; Dispensing opticians) Be able to modify and adapt communication methods and styles, including verbal and nonverbal methods to suit the individual service users considering issues of language, culture, beliefs and health and/ or social care needs 2.3 (Optometrists; Dispensing opticians) Recognise service users as active participants in their health and social care and be able to support service users in communicating their health and/or social care needs, choices and concerns

Table 1 Professional standards regarding communication in practice

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rates and increased use of emergency services and hospitalisation. Poor HL can also lead to unhealthy lifestyle behaviours, such as a poor diet, smoking and lack of physical activity, leading to an increased risk of morbidity and premature death.2,6,19

Advantages of improved health literacy Public Health England suggest that improved HL may lead to:2 Reduced disease severity Improved mental health Improved confidence and self-esteem Increased health knowledge Improved adherence to medical instructions Adoption of healthy lifestyle changes Improved engagement in health decisions Empowerment of patients to effectively manage long-term health conditions Reduced burden on health and social care services.

Best practice health literacy guidelines

Healthcare staff may need to adapt their oral, printed and web-based communication style, tone and techniques to meet patients’ needs.17 Table 3 (page 79) summarises resources that include practical tools and techniques that practitioners can adopt to effectively support people with low levels of HL.

Oral literacy Oral literacy encompasses listening and speaking skills.1,20 Patients with low HL find processing verbal communication difficult.24 Cognitive abilities, such as memory and the ability to understand relationships between multiple pieces of information, underpin the comprehension of spoken information.1,20 Oral communication recommendations for practitionerpatient dialogues include: Speaking slowly19,20 Assessing the patient’s current knowledge with open-ended questions25 Encouraging the patient to ask questions19 Linking new information to existing knowledge25 Avoidance of excessively technical terminology and jargon, replacing this with plain, non-medical language19,20 Showing or drawing pictures to enhance patient understanding and recall19,20 Limiting the amount of information given at each visit – and repeating it19,20 Creating a shame-free environment by being respectful, caring and sensitive6,20

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Table 2 Reference

Countries

Findings

Sørensen et al10

Austria, Bulgaria, Germany, Greece, Spain, Ireland, Netherlands, Poland

One in 10 (12%) respondents exhibited insufficient HL. Almost one in two (47%) respondents had limited (insufficient or problematic) HL

Rowlands et al7,11

England

43% of participants were below the HL threshold for text-based information only. 61% of participants were below the HL threshold for information presented in both text and numerical form

MSD and the National Adult Literacy Agency (NALA) 12

Ireland

20% of respondents were not fully confident that they understand all the information they receive from their healthcare professional

Scottish Government13

Scotland

26.7% of respondents had literacy levels suggestive of occasional day-to-day literacy challenges. 3.6% of respondents had literacy levels so limited as to cause serious challenges in their daily lives

Table 2 Poor health literacy in numbers

Checking patient understanding by providing feedback opportunities using the teach-back, chunkand-check, and show-me methods.2,7,17,19,20,25 The teach-back method involves asking a patient to repeat back the information they have just heard.2,19 The show-me method involves asking the patient to demonstrate a technique that they have been instructed on.20 The chunk-and-check method is used to break down information into small chunks, interspersed with breaks to check understanding.17

Numerical literacy Numerical literacy (‘numeracy’) is the ability to manage the mathematical demands of day-to-day living. Complex mathematical concepts such as risk, probability, likelihood and norm are commonly used in healthcare communication, making it more difficult for the patient to engage in healthcare decision-making. The Health Service Executive (HSE) and NALA (2009)19 recommendations in relation to numeracy include: Assume that most people are not comfortable understanding complex quantitative concepts Focus on one idea at a time – do not overwhelm the patient with information Avoid the use of decimals. For example, avoid telling a patient that a measurement or likelihood is ‘0.3’ Risks should be presented in absolute terms (for example, three out of a 1,000 will have a stroke),

rather than relative terms (for example, there is a 50% higher chance of having a stroke). As little as 50% of what a patient hears during a healthcare consultation can be recalled accurately. It is, therefore, helpful to provide patients with welldesigned print material to supplement oral patient instructions.24

Print and document literacy During a routine eye examination and spectacle dispensing, eyecare practitioners use text-based testing charts for vision and visual function measurement. Patients need a certain level of print literacy – the ability to read and comprehend the written language – to engage with these charts. It has been shown that the reading levels demanded by near point vision assessment charts are not necessarily compatible with the literacy abilities of patients in an optometric setting.26 Document literacy – the ability to locate and use information in documents20 – is required to understand prescription labels, consent forms, educational leaflets, fact sheets, procedural instructions and web-based information.19,25 A mismatch between these materials and the patient’s reading level may negatively impact on the examination itself. For example, a HLcompromised patient’s struggle to read a near visual acuity chart may erroneously be interpreted as a

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Figure 1

SUBS

Patient

ART PRODUCTION

System

Practitioner

CLIENT

Figure 1 Health literacy as an interaction between patient, practitioner and system

need for a higher near spectacle addition.26 Healthcare professionals need to be alert to any deficiencies in the patient’s ability to read or understand instructions relating to visual assessment and subsequent management. Adults may try to hide their limited literacy skills, or they may not realise their literacy limitations or consider this to be problemactic.19 Strategies that may be used by patients to hide literacy problems include responses such as: 6,19 I forgot my reading glasses I’ll read through this when I get home I’d like to discuss this with my family first I have hurt my hand, so I can’t write now. Direct questioning about a patient’s reading level may cause shame and embarrassment for the patient.6,11,19,27 Instead, it might be useful to ask your patient to read a prescription label or to present written material upside down, while observing whether the patient turns this the correct way round.6 Confident readers scan a piece of text, subconsciously processing visual clues to extract its meaning. Less

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confident readers read every word, relying on visual clues like capital letters, correct punctuation, text layout and appropriate images to be able to identify groups of words and their meaning.19 Most patients, regardless of literacy level, prefer simple, easy-to-read materials.6 Ophthalmic patient education materials are often written at a level too advanced for many patients to understand.28 Printed healthcare materials should: Be written in plain language19 Be written for the expected reading level of a nineto-12-year old29 State the purpose of the publication in the title or introduction19 Avoid the over-use of bullet-pointed information, which is harder to understand because the words have often been removed from their context. Instead, using prose format facilitates HL as the meaning of the word can often be deduced from adjacent words19 Limit information to no more than four points25 Have paragraphs no longer than six sentences19 Have sentences no more than 15-20 words long19 Omit unnecessary words that increase sentence length without adding meaning14 Use an active voice and conversational style25 Use ‘I’, ‘we’ and ‘you’ as much as possible to personalise the material’s content14 Avoid full words in capital letters, which may distort the shape of words, making them more challenging to read14 Increase white space and limit dense text on a page.25 Guidelines that apply to both oral and written communications include: Avoid excessive technical terminology and jargon, replacing these instead with plainer alternatives14,19,20 Define essential specialist terms, acronyms and abbreviations the first time they are used14,19 Avoid concept words and phrases describing a general idea or abstract reference. For example, ‘normal range’; this should be followed with an example of what is considered to be ‘normal’19 Avoid using value judgement words describing amounts, such as ‘excessive’, ‘regularly’ or ‘adequate’ because their meaning is context-based. If used, they should be accompanied by more specific clarifications.19 These guidelines also apply to web-based information. Edmunds et al concluded that 83% of patient-oriented websites concerning ocular disease were of ‘difficult’ readability.29 Huang et al showed that most of the

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Table 3 Organisation

Resource name

Website

NHS22

The Health Literacy Place

healthliteracyplace.org.uk

NHS17

Health Literacy ‘How To’ Guide

healtheducationenglish.sharepoint.com

NALA23

Health Literacy

https://www.nala.ie/health-literacy/

World Health Organisation (WHO) 1

Health Literacy Toolkit

https://apps.searo.who.int/PDS_DOCS/B5148.pdf

American Medical Association (AMA) 20

Health Literacy: A Manual for Clinicians

http://lib.ncfh.org/pdfs/6617.pdf

Table 3 Health literacy resources

339 online patient education materials (compiled by major US ophthalmologic associations) were written at a reading level too advanced to facilitate adequate understanding of health materials.30 The assessment of the readability of eyecare-related documents and web pages can be measured using a range of validated measures, including the Flesch Reading Ease Score (FRES),25,29,30 Flesch-Kincaid Grade Level (FKGL),28-30 Simple Measure of Gobbledygook (SMOG) and Gunning Fog Index (GFOG).29,30

Visual illustrations ‘Easy read’ refers to information which is written using simpler words and phrases, supported by images, symbols or photographs, facilitating easier understanding of documents.17 A pictogram is a symbol or picture representing an object or concept;31 these are used in patient education materials to enhance communication effectiveness for those with limited literacy, relying on nonwritten forms of communication to gather information.6 Pictogram-containing patient education materials for those with low literacy levels have been shown to increase patient adherence to post-operative cataract extraction medication regimens.31 Others recommend that patient educational materials should contain illustrations to promote HL of glaucoma patients.16 The images used must be relevant to the information being communicated as unrelated images may create confusion for the service

user.16,25 Photographs should be free from irrelevant background information. Stick figures should be used to represent people, as they are culturally neutral.19

Conclusion Medicine and healthcare systems are becoming increasingly more complex, demanding higher levels of HL from patients.19 There is a growing recognition that governments, health and community service providers, researchers and consumer groups are all accountable for the promotion of HL.1 Healthcare settings should adopt HL optimisation guidelines to be considered as safe, caring and non-judgemental places, where healthcare providers are knowledgeable, approachable and compassionate in relation to HL challenges.

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

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Management of the anisometropic child

REPRO OP

Jo Mackenzie BSc (Hons), MCOptom, PG Cert TLCP, DipTP(AS), DipTP(SP), DipTP(IP), PG Cert HCL SUBS

This article will discuss the incidence, types and visual optics of anisometropia, its impact upon amblyopia, the optical effects which anisometropia may cause and suitable management options.

ART

Introduction

PRODUCTION CLIENT

Anisometropia is a condition where a difference exists between the refractive error of each eye and is generally defined as having an inter-eye difference of at least one dioptre.1 The difference can be general or meridional; its cause can be refractive or axial and the type of anisometropia that exists will have a bearing on the type of optical problems which the patient might experience and the subsequent management of the condition. The term refractive ametropia is used if the axial length is within the ‘emmetropic’ range and it is, therefore, one of the refractive components of the eye which is causing the ametropia. For an eye with axial ametropia, Figure 1 shows the relationship between the change in refractive error expected for a given change in axial length, such that 1D of myopia is brought about by an axial length increase of 0.371mm. For the majority of the population, the refraction of fellow eyes is typically similar to each other.2 Different studies show various estimations for the prevalence of anisometropia and age influences this. Deng and Gwiazda found a mean difference of 0.11D between the refraction of each eye in a population of 1190 six-month old children and a prevalence of anisometropia (defined as ≥1D in any meridian) in 1.96% of the participants.3 When they examined an older population of five-year-old children, the mean inter-eye difference was greater at 0.28D; however, there was a lower incidence of anisometropia at 1.27%. Anisometropia may cause the two eyes to have disparate retinal image sizes and this is called aniseikonia, which literally means ‘not equal images.’ This disparity becomes perceptible if those images fall on noncorresponding points of the retinae. Such disparate images typically result in sensory adaptation to give suppression, thereby avoiding aniseikonic effects, diplopia or confusion and so if not managed carefully from an early age, anisometropia may leave a patient with an amblyopic eye and impaired binocular vision. Using pattern reversal visual evoked response (VER), Katsumi et al looked at the effect of aniseikonia on

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POINT

binocular function by inducing aniseikonia using size lenses in individuals with good binocular function. The study found that at 3% retinal image size difference, binocular summation started to decrease and at 5% retinal image size difference there was no significant binocular summation taking place. Beyond this level, binocular summation was replaced by binocular inhibition.4 These results are particularly significant for patients who develop anisometropia later, after the so-called plastic period ends as they will experience reduced visual function.

Anisometropia and amblyopia Congenital anisometropia may easily go undetected if one eye is all but emmetropic, as the child will be able to see to focus on most things, will be unaware that others see differently to them and their parents and carers will not notice any difficulty in their ability to carry out most tasks. Someone with congenital anisometropia will have never been (fully) binocular and will not, therefore, be used to high degrees of stereopsis nor will they realise that others have, for example, a greater field of clear view. Symptoms such as a lack of fine motor skills, difficulty stacking building bricks, poor hand-to-eye coordination, especially when trying to catch a ball, may be mistaken for a degree of dyspraxia rather than binocular vision problems. Uncorrected anisometropia can lead to amblyopia.5 Von Noorden defined amblyopia as ‘reduced visual acuity (VA) without ophthalmoscopically detectable anomalies of the fundus or without visible organic cause.’6 One prerequisite for the normal development of vision is a clearly focussed image. In an attempt to determine what level of uncorrected anisometropia was necessary for amblyopia or decreased binocular function to occur, 361 patients with anisometropia and 50 non-anisometropic control participants, examined over a 42-month period, with no history of treatment for refractive error, amblyopia or other

CET

Figure 1 The lens equation can be written as n’ − L = F (equation 1.0) − l’ Where n’ = refractive index of the vitreous, F is the equivalent power of the eye and L (=1/l) is the vergence of the object, conjugate to the retina of the eye, relative to the first principal plane. l’ is therefore the axial length. If the axial length increases by an amount l’, this will give a change in vergence of L in the object vergence Differentiating equation 1.0 and then re-arranging to describe the change in length gives: 2 l’ = - Ll’ (equation 1.1) n’

For an unaccommodated emmetropic eye, to form a clear image on the retina l = infinity (∞) and so equation 1 becomes n’ n’ = F which can be re-written as l’ = −F − l’

Substituting this into equation 1.1 gives l’ = - Ln’ F2

Which can be re-arranged to describe the change in vergence, giving L = - l’F2 n’

The change in vergence, L, is of course known to us as the refractive error Re Taking the standard emmetropic eye of Fe = +60.00D and a vitreous humour refractive index of 1.336, after Gullstrand and considering axial length in mm, we have Re = -2.694 l’ D or l’ = -0.371 Re mm Figure 1 Calculating the effect of axial length change on refractive error

ocular pathological characteristics were evaluated in a study by Weakley.7 He found that spherical myopic anisometropia (SMA) of >2D, spherical hyperopic anisometropia (SHA) of ≥1D and cylindrical myopic anisometropia (CMA) or cylindrical hyperopic anisometropia (CHA) of >1.5D was found to give a significant increase in the incidence of amblyopia when compared with non-anisometropic patients. Further work by Weakley8 showed a deterioration of binocular function, as measured by the rate of monofixation and decreased stereoacuity, with anisometropia and at the same magnitudes of the different anisometropias as in his previous study. It has been shown in several studies that a patient with an amblyopic eye is at least three times at risk of serious vision loss in the fellow eye compared to the general population.9 It is important, therefore, to detect children with such refractive errors from an early age in order to reduce any amblyopia and binocular vision deficit and enable them to reach their full visual potential. Unfortunately, not every child is taken for an eye examination where such refractive errors could be detected at an appropriate age and the screening programmes for young children, typically administered at age four to five years in the UK, only carry out distance acuity testing and not near acuity. The Northern Ireland Childhood Errors of Refraction (NICER) longitudinal study has been one of the first of its kind in the UK to look at the incidence of refractive errors in large numbers and one of their papers investigated VA as a tool for identifying significant

refractive error, concluding that uncorrected distance logMAR acuity is poor at detecting refractive errors other than myopia.10 As both hyperopia and astigmatism are risk factors for amblyopia and may occur unilaterally they may, therefore, be missed by school screening programmes which only measure distance vision. The greater the degree of anisometropia, the greater the incidence of amblyopia has been shown to occur, demonstrated in a study of 639 anisometropic patients which found that 100% of those with anisohyperopia of ≥3.50D had an amblyopic eye as did myopic anisometropes of ≥6.50D.11 However, a paper published in 2013 extensively discusses the relationship between amblyopia and anisometropia, posing in particular, two very interesting questions: 1 – is it the higher level of anisometropia which leads to deeper amblyopia; or 2 – does the amblyopia occur first and prevent emmetropisation, thereby resulting in greater anisometropia?12 Meridional anisometropia is a special case which may not always result in decreased stereopsis despite poor VA, depending upon the orientation of the astigmatism. Being emmetropic in the horizontal meridian, a simple hyperopic astigmat having against-the-rule astigmatism will form clear retinal images of vertical lines but the images of horizontal lines will form behind the retina, leaving blurred images of those lines on the retina, decreasing acuity for horizontal lines but not for vertical lines. Horizontal line acuity has been shown to have little

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VERSION

Figure 2

Myopia

REPRO OP

Apparent object position wearing spectacles

Near object K=

SUBS

Contact lens-wearing myope converges MORE

Fsp 1-dFsp

K’ = F + Fe

this gives KH’ = +60.00D and Kv’ = +63.96D Relative magnification is found using RM =

Distance PD

K Fsp

Fe K’

ART

Near object

Hyperopia

For the right eye in the vertical meridian = +3.96 +3.75

+60.00 +63.96

=0.99x

PRODUCTION

For the left eye, RM =

Apparent object position (spectacles)

-0.25 -0.25

+60.00 +59.75

=1.005x

Contact lens-wearing hyperope converges LESS

CLIENT

Distance PD

Figure 2 Convergence in myopia (top) and hyperopia (bottom)

effect on stereopsis with only the horizontal disparity of vertical lines being used for stereopsis, for which clear vertical lines are required.13 Peli describes a young adult patient with the following refraction:14 RE +3.75DS/-3.75DC x 80 20/50-1 LE Plano/-0.50DC x 150 20/10-1 The patient was orthophoric at distance with an intermittent near exotropia of 10Δ, present 50% of the time, yet the patient was able to achieve 40” stereopsis with the Titmus Fly Test and 20” with the Randot Stereogram. Another factor here affecting tolerance of the anisometropia is that this anisometropia will not bring about significant aniseikonia. Although this will not hold true for every case, a good rule of thumb is that if the anisometropia is >2D then it is likely to be axial whereas if it is only meridional or is <2D then it is likely to be refractive. In reality, all ametropias are probably a combination of both elements. In the case of Peli’s patient, taking a back vertex distance (BVD) of 14mm, using:

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The ratio for the relative magnification on the vertical meridian would therefore be 0.99: 1.005 which gives 1.49% difference between the image sizes and so there would be no perceptible alteration in shape or size to objects viewed with the right eye compared to the left, thus as long as the astigmatic correction is worn from an early enough age, in the absence of strabismus, good VA and binocular vision would be expected to develop.

Optical considerations in spectacle correction Paediatric refractive error has been traditionally corrected by spectacles and various studies have shown that any improvement in VA through spectacle wear alone in those under seven years of age tends to plateau after 12 weeks of wear. Chen et al showed that only 45% of amblyopia resolved with spectacles alone and those subjects had a better starting VA and lower degree of anisometropia.1 It is beyond the scope of this article to go into the details of the formation and perception of aniseikonic effects and how spectacle lens form can be manipulated to significantly reduce those, but suffice to say that tip and tilt, disorientation, diplopia and altered perspective may all occur in the presence of disparate retinal image

CET

plane has an accommodative demand of RE +3.89D and LE +4.49D to view that object Asymptomatic male, four and a half-year-old failed vision screening RE 6/6 LE clearly. Therefore, the amount of 6/24 accommodative effort required Titmus Fly gross stereopsis only by each eye in the spectacleCycloplegic refraction: RE +1.00DS LE +5.75DS full Rx prescribed, wearing anisometrope is possible benefits of CL discussed unequal. In contact lenses, the Normal ocular examination, appears orthophoric vergence L2 would be equal for VA after 6/52: RE 6/6 LE 6/12 each eye and the eye rendered VA after 12/52: RE 6/6 LE 6/12+2 stereopsis 140” of arc emmetropic at the corneal Fitted with one T74 lens LE 8.30/13.00/+5.00D excellent adaptation and handling plane, thereby eliminating VA improved to 6/6 with lens alone, no occlusion the unequal accommodative At age eight, refitted with Balafilcon A with aspheric optics LE 8.60/14.00/+4.75D demand. By age 10, RE 6/5 N4 LE 6/5 N4 stereopsis 40” of arc However, studies have shown that the accommodative effort exerted by each eye Figure 3 Case study of a child with anisohyperopia fitted with one contact lens in unaided anisometropia is not usually equal and so an sizes and shapes. By equalising the image size and shape accommodative lag in the most ametropic eye may not of retinal images, fusion may then become possible in the always be manifest. Toor et al describe one such study of young child; however, prismatic differential between the anisohyperopes where 81% of participants demonstrated two eyes will still occur. asymmetrical accommodation, also finding that almost Let us consider a child in a library with a spectacle one in four demonstrated ‘anti-accommodation,’ prescription of RE +1.00DS and LE +6.00DS. Looking at whereby the distance accommodation was greater than the shelf on eye level, there is no prismatic effect from the near accommodation when unaided, but which their correctly centred spectacle lenses. If the child now resolved upon wearing the spectacles.16 In assessing the effect of accommodation on astigmatism and looks up to the shelf above and uses a point 12mm above anisometropia, a study of 236 12 to 26-year-olds also the optical centres, then a vertical prismatic differential showed unequal accommodative responses such that the of 6Δ base down in the left eye occurs. Vertical fusional amount of anisometropia reduced upon accommodation reserves are much smaller than horizontal fusional in the majority of high anisometropes.17 reserves and have been typically found to be 3Δ break point and 2Δ recovery point for both base up and base Children and contact lenses down prism,15 so this amount would result in vertical diplopia. In looking down to the shelf below eye level, this Fitting children with contact lenses is (usually) fun! Children are typically eager to please and like to be will swing to 6Δ base up in the left eye, which would be ‘grown up,’ which, given that contact lens wearers very disconcerting for the child. they know are more likely to be adults, succeeding at In the horizontal meridian, the prismatic effect is wearing contact lenses can allow them to feel ‘grownresponsible for an unequal convergence demand in up.’ Being cheerful and positive towards the child spectacles, which can be eliminated by contact lens wear, and about the lenses will help to instil confidence. as show in Figure 2. It can be useful to allow the patient to handle a lens Accommodation in anisometropia before applying one to the eye, so that they can feel the Ocular accommodation (AOC) is given by the equation: texture and not be afraid of it. One approach is to tell AOC = K – L2 the child that the lens will feel wet and cold and that where K is the ocular refraction and L2 is the vergence they will know that something is on the eye, but that of light from a near object measured in the plane of the it will not hurt, just as you would feel your hand was cornea. in a glove, but it would not hurt. Being able to handle From this, we can calculate that a spectacle wearer the lenses themselves will give the child confidence having a prescription RE +1.00DS LE +6.00DS worn at to wear them, with a feeling of being in control and 14mm, viewing an object 25cm in front of the spectacle able to do something about it should the lens become Figure 3

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CET 4, 3 VERSION REPRO OP

Figure 4

SUBS ART

Six-year-old boy, very compliant with spectacles RE +3.00/-0.50 x 80 6/6 LE +5.25/-0.50 x 95 6/12 BVD 13mm Appears straight on cover test, LE no further VA improvement for four months having worn glasses 12/12 Stereopsis 140”, Mallet Near Unit suppression under dichoptic conditions LE reads 20’ letter, under monocular conditions LE reads 15’ letters, indicating 5’ foveal suppression If axial ametropia, an image size difference of 0.7% would be expected but in refractive, 3.2%, at which point binocular summation is known to break down4 Measurements show unexpected keratometry readings RE 7.65mm LE 8.00mm. Contact lenses discussed Fitted with contact lenses. By eight years old had improved to RE 6/5, LE 6/5, stereopsis 40”, no suppression

PRODUCTION

Figure 4 Case study of a child with anisohyperopia fitted bilaterally with contact lenses

CLIENT

uncomfortable. Children’s fingers are typically small and dexterous and they, therefore, tend to handle lenses more easily than many adults. At least one parent should also be able to handle the lenses and must understand the dos and don’ts of contact lenses as well as the cleaning and wearing regimen. Figures 3 and 4 show two case studies of children wearing contact lens(es) in anisometropia. In addition to the optical benefits, many children benefit from greater confidence and self-esteem when wearing contact lenses instead of spectacles. Walline and colleagues demonstrated this in a 2007 questionnaire-based study of 169 children and teenagers who were neophyte contact lens wearers, concluding that the reported improved quality of life shown by contact lens wear indicated that lenses should routinely be offered to children requiring a refractive correction.18 As well as dramatically improving how children and teens felt about their appearance and participation in activities, contact lenses also led to greater visual comfort. Some practitioners may rightly be concerned about the safety of contact lens wear in children; however, improvements in materials, lens design, manufacturing processes and the efficacy of contact lens care products have reduced the overall risk involved in contact lens wear and several studies have shown that there is not an increased risk in children. The Contact Lens Assessment in Youth (CLAY) study found that the use of soft contact lenses in young patients aged eight to 15 years was associated with a lower risk of infiltrative events compared with teens and young adults.19 The multi-centre study had charted 14,305 visits from 3,459 soft contact

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lens wearers aged eight to 33 years old, observing a total of 4,663 soft contact lens years with 187 corneal infiltrative and inflammatory events (CIE) in 168 wearers. More recently, with the increased numbers of children wearing contact lenses, much more published safety data exists. Bullimore reviewed 16 prospective studies representing 1800 patient years of wear in seven to 19-year-olds with none reporting any incidence of microbial keratitis.20 Three retrospective studies found no events in the younger age group and an incidence of 15 per 10,000 patient years in 13 to 17-yearolds from 1372 contact lens years. Overall, the review concluded there was not an increased incidence of microbial keratitis or infiltrative event and again that this may indeed be lower in children.

Conclusion

Practitioners should not be afraid of fitting children with contact lenses; it is rewarding and fun and can contribute greatly to the development of the child’s full visual potential as well as their self-esteem. Uncorrected anisometropia generally leads to amblyopia, but it is possible for a good level of VA and binocularity to be attained by a patient with significant anisometropia by wearing spectacles in certain circumstances. As this article has described, retinal image size is not the only factor in anisometropia and there are other reasons as to why contact lenses might be a better, more visually comfortable option for the anisometropic patient, even if at first glance it appears the retinal image size difference may be larger.

About the author n Jo Mackenzie graduated from UWIST in 1986 and was a hospital optometrist for the majority of her 30-year career, taking an extended role in glaucoma clinics before becoming senior lecturer at Portsmouth University in January 2016 and returning to the NHS in 2019. She took the independent prescribing qualification in 2009 and regularly facilitates peer discussion sessions for the College of Optometrists. She was awarded the Giles Van Colle Memorial Award in 2005 for her research into The Use of Contact Lenses in the Management of Anisometropic Amblyopia, an award given for the most significant contribution to paediatric optometry.

April/May 2021

BLACK YELLOW MAGENTA CYAN

91OPTAPR21155.pgs 25.03.2021 16:12

VRICS VERSION

Cases of gradual vision loss

CET

POINT

REPRO OP

Prashant Shah BSc (Hons), MCOptom, PGDipOphth, DipClinOptom SUBS

This VRICS presents four cases of gradual vision loss. Readers are invited to review the images and access additional resources where necessary to answer the questions.

Image B

Image A ART PRODUCTION CLIENT

A 47-year-old female patient presents for routine examination with fundus findings as shown in the image. She mentions that a family member has the same condition. 01 Which of the following symptoms might the patient complain of? a) Poor night vision b) Glare c) Reduced peripheral vision d) All of these options 02 Which of the following features is not typically associated with this condition? a) Bone spicule pigmentation of the peripheral retina b) Waxy pallor of the optic nerve head c) Retinal blood vessel attenuation d) Nuclear sclerotic cataract 03 Which of the following statements with regard to this condition is false? a) The most frequently inherited type is autosomal recessive b) Reduction of the scotopic rod response is typically the first electroretinography (ERG) sign c) Cone function is primarily affected in this condition d) Choroideraemia is a potential differential diagnosis

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April/May 2021

BLACK YELLOW MAGENTA CYAN

An 18-year-old patient presents for his first sight test. Visual acuities are R 6/24 and L 6/6. 04 What clinical presentation is most likely in this case? a) Inferior paracentral corneal steepening in keratoconus b) Corneal ectasia due to laser refractive surgery c) Pellucid marginal degeneration d) Rigid contact lens induced corneal warpage 05 Which of the following is the least likely to be a risk factor for this type of presentation? a) Family history b) Chronic eye rubbing c) Atopy d) Soft contact lens wear 06 Which of the following is not a potential management option? a) Scleral contact lenses b) Corneal graft surgery c) Topical steroid drops d) Corneal crosslinking

Image C

A 70-year-old male patient has a visual field result for his right eye as shown in the image. The left visual field result is normal. Intraocular pressures are R 26mmHg L 23mmHg with non-contact tonometry. Visual acuities are R 6/7.5 L 6/6. 07 Which of the following is most likely to be observed on examination of the right optic nerve? a) Superior rim thinning and retinal nerve fibre layer loss b) Inferior rim thinning and retinal nerve fibre layer loss c) Temporal rim thinning and retinal nerve fibre layer loss d) Nasal rim thinning and retinal nerve fibre layer loss 08 Based on the history, what would be a reasonable initial diagnosis? a) Branch retinal vein occlusion b) Optic neuritis c) Primary open angle glaucoma d) Posterior communicating artery bleed in the visual cortex 09 Which of the following tests would be least useful in supporting the diagnosis? a) Optical coherence tomography scan of the optic nerve and retinal nerve fibre layer b) Corneal topography c) Gonioscopy d) Van Herick test

VRICS

Image D

An 80-year-old female patient presents with symptoms of gradual difficulty recognising bus numbers. Her last sight test was more than 10 years ago. Visual acuities are R 6/24 L 6/24 10 What imaging modality was used to take the image shown? a) Fundus autofluorescence b) Fluorescein angiography c) Indocyanine green angiography d) Ultra-widefield 11 Based on the image and history, what is the most likely diagnosis? a) Choroidal melanoma b) Choroidal neovascular membrane c) Geographic atrophy d) Central retinal vein occlusion 12 Which of the following is not a risk factor for the condition? a) 60 years age and over b) Hypotension c) Positive immediate family history d) Current smoker

About the author n Prashant Shah is an optometrist and CET author with postgraduate diplomas in ophthalmology and in clinical optometry.

April/May 2021

www.optometry.co.uk 87

91OPTAPR21156.pgs 25.03.2021 16:25

VRICS 1, 1

Pathology & diagnostics

VRICS VERSION REPRO OP

Instrumentation for anterior eye assessment

CET

POINT

Dr Louise Terry PhD, MCOptom, FHEA and Dr Neema Ghorbani Mojarrrad PhD, MCOptom, MBCLA, Prof Cert Glaucoma, Low Vision Dip SV, FHEA

SUBS

This feature presents a range of instruments designed for anterior eye assessment. Practitioners should use their clinical knowledge and access additional resources where necessary to complete the questions.

ART

Image A

Image B

PRODUCTION CLIENT

Image courtesy of No7 Contact Lenses

Image courtesy of WOPEC

01 Which of the following could this device not be used for? a) Ortho-k contact lens fitting b) Monitoring corneal profile changes in keratoconus c) Measuring corneal thickness pre-LASIK d) Evaluating tear breakup time

04 Which of the following is not possible to assess with this attachment? a) Lipid layer regularity b) Non-invasive tear breakup time c) Tear meniscus regularity d) Meibomian gland structure

02 Which of the following is not an advantage of this device? a) Measurements are not influenced by tear film integrity b) Observer subjectivity is minimised by automated measurements c) The entire cornea can be mapped using composite scans d) Subsequent scans can be used to produce a time-series

05 Which of the following statements about tear breakup time is false? a) The median of three readings should be taken b) Readings from invasive and non-invasive methods are not directly comparable c) Patients should be asked to stare wide to maximise corneal exposure during measurement d) Readings can be affected by humidity and air movement

03 Instruments such as this are principally used to directly measure: a) Elevation b) Corneal thickness c) Anterior corneal curvature d) Posterior corneal curvature

06 A normal reading of non-invasive TBUT: a) Is typically shorter than the fluorescein TBUT b) Should be over 25 seconds c) Does not rule out dry eye disease d) Should be in the range five to 10 seconds

88 www.optometry.co.uk

April/May 2021

BLACK YELLOW MAGENTA CYAN

Image C

Image courtesy of TearLab 07 Which of the following is true regarding the parameter this device measures? a) It is included in the TFOS DEWS II definition of dry eye disease b) All patients with a high reading will be symptomatic c) It is not correlated with dry eye severity d) An interocular difference of 5mOsm/L is considered abnormal 08 Which of the following is false? a) This measurement should be taken before fluorescein breakup time b) It is sufficient to measure one eye only at each visit c) The test cards used with this device are single use only d) Electronic check cards should be used daily to check proper function of the device 09 Which of these readings is the most likely to indicate mild to moderate dry eye? a) R 307 mOsm/L L 307 mOsm/L b) R 295 mOsm/L L 307 mOsm/L c) R 308 mOsm/L L 304 mOsm/L d) R 299 mOsm/L L 305 mOsm/L

VRICS

Image D

10 Which of the following statements about the instrument shown in the image is false? a) Images can be assessed both qualitatively and quantitatively b) The attachment shown enables anterior segment imaging on a conventional spectral-domain OCT device c) Image averaging usually improves signal-to-noise ratio at the cost of spatial resolution d) Assessment using this instrument should replace gonioscopy in assessing suspect glaucoma 11 Which of the following structures is not visible in ~25% of eyes when using this instrument? a) Scleral spur b) Descemet’s membrane c) Trabecular meshwork d) Corneal endothelium 12 The optimal wavelength for imaging the deeper anterior chamber structures is: a) 510µm b) 840µm c) 1050µm d) 1310µm

About the authors n Dr Louise Terry is a lecturer at Cardiff University where she leads the third year contact lens lectures and clinics. She also teaches on WOPEC’s Management of tear film disorders and Contact lenses postgraduate modules. She completed her PhD in 2017 on ocular imaging and her other research interests include contact lenses and myopia management.

n Dr Neema Ghorbani Mojarrad is a lecturer at the University of Bradford where he is a module leader on the contact lens practice module and teaches in the third year contact lens clinics. He finished his PhD at Cardiff University in 2020, investigating the genetics of myopia. His current research interests include the genetics of refractive error, understanding the causes of myopia development and myopia management.

April/May 2021

www.optometry.co.uk 89

91OPTAPR21157.pgs 29.03.2021 11:52

VRICS 2, 1

Anterior eye, diagnostics & instrumentation

Jobs VERSION REPRO OP

Jobs

www.aop.org.uk/ot/jobs

SUBS

MY CAREER ADVICE

Zach Hughes, recruitment marketing executive at the Hakim Group, explains what those applying for jobs at the company should know

PRODUCTION

What role do you take in the hiring of new staff members?

CLIENT

My role is to attract the right talent to our family of independent practices at Hakim Group. I’ve also been involved in helping the team ensure that we provide our candidates with the best experience possible both during, and after, the recruitment process.

What advice would you give to someone who wants to work in the Hakim Group? They need to be committed to a high standard of eye care. Many of the independents within Hakim Group operate longer testing times, offer the latest technology, and have an ongoing programme of professional training. Independents often have multigenerational loyalty with their patients. Building a positive relationship with the community is just as important as giving them the level of care that they have come to expect.

What’s the first thing you look for when shortlisting candidates? We look for people who are joining the team for the right reasons. As a values-driven business, it’s important to us that the people we bring into practice are honest, ambitious, kind and hardworking, with attention to detail.

Is the cover letter essential? We see many applications, and there needs to be something in a cover letter that really makes it memorable. Optics is all about people, and we’re genuinely interested to get to know you: what gets you out of bed in the morning? What Netflix show are you bingeing right now? Are Jaffa Cakes biscuits?

What’s the biggest mistake that can be made in an interview? Turning up without doing your research is high on the list. It only takes a couple of probing questions to figure that out. Likewise, not asking questions and not showing a genuine interest is a mistake. The interview is your chance to give the practice a grilling. Don’t forget that recruitment is always a two-way process!

A new employee is preparing for their first week at a Hakim Group practice. What are your tips for a successful start? Start to connect with your new team mates. We’re a friendly bunch, so this should be easy enough. Also, don’t hesitate to connect with me or any of my colleagues at HQ – there is a lot of support available to those who join our independent practice teams.

WHAT STEPS DOES HAKIM GROUP TAKE TO ENSURE THAT THE HIRING PROCESS IS FAIR? All of our candidates are pre-screened by the recruitment team before they get to interview at practice. Our team are very experienced and are constantly reviewing feedback to ensure that our assessment criteria is fair and balanced. We also do our best to ensure our independent practices are prepared for interviews. We support them with our knowledge, providing questioning tips or even sitting in on the interviews if they would like us to. So far, we’ve had a near 100% success rate with our Joint Venture Partners, with little to no attrition over the last 10 years. Once our partners join, they don’t leave – which is testament to the relationships that we build and the time we take to ensure that we get the fit right for both parties.

Shutterstock

ART

”APPLICANTS NEED TO BE COMMITTED TO A TRULY HIGH STANDARD OF EYE CARE”

“Building a positive relationship with the community is just as important as giving them the level of care that they have come to expect” 90 www.optometry.co.uk

April/May 2021

BLACK YELLOW MAGENTA CYAN

91OPTAPR21176.pgs 29.03.2021 11:10

Secret Life

LAST WORD VERSION

TEXT MESSAGE

REPRO OP

TO MY PRE-PANDEMIC SELF

To mark one year since the first UK lockdown, OT asked optometrists what text message they would send themselves on 23 March, 2020

SUBS

CHRIS EVANS

HOLLY HIGGINS

HOSPITAL OPTOMETRIST

ART

The next year is going to be tough – there’s a lot of change coming, you won’t be getting married this year and you’ll watch more Netflix than ever before. It will take time, but things will become the ‘new normal’ and you’ll just have to go along with the change. Also… invest in loungewear!

DIRECTOR OF GWYNNS OPTICIANS The next month is going to be hard, but you’ll get used to it. Talk about how you’re feeling. Tell your friends and family that you love them. Wear a mask.

PRODUCTION

SHAMINA ASIF CLIENT

OPTOMETRIST & DUDLEY LOCAL OPTICAL COMMITTEE CHAIR

Mate… this is not going away anytime soon – it will be more than a year before you have any normality. Get on and plan effectively so you manage to do everything you thought you never had time to do; the books, Islamic lectures and trying to cook new dishes.

BRIAN TOMPKINS

DIRECTOR OF TOMPKINS KNIGHT & SON OPTOMETRISTS

Hey Brian, just giving you a heads up to say don’t delay – get that dog you have been talking about. Makes days at home and exercise options a lot more fun. Oh, and buy shares in a company called Zoom – they’re set to be pretty big this year.

REBECCA RUSHTON LOCUM OPTOMETRIST

Enjoy and make the most of your free time now and don't worry about the future.

DR JOHN GURNEY

DR EILIDH MARTIN

VISION SCIENCES LECTURER AT GLASGOW CALEDONIAN UNIVERSITY

It's ok to have a wobble for absolutely no reason; there is no right or wrong way to deal with such a strange situation. Oh, and subscribe to Hello Fresh now!

98 www.optometry.co.uk

INDEPENDENT PRESCRIBING OPTOMETRIST Stay calm, try not to worry – we will get through this. Focus on the important things in life and not the trivial moans and concerns. Look after your family, keep in contact with your friends as best you can, protect the business and tell your staff how much you value them. We will have learnt a lot from this pandemic, and we will be stronger for all of this going forward.

April/May 2021

BLACK YELLOW MAGENTA CYAN

91OPTAPR21120.pgs 25.03.2021 11:34

Introducing NEW Bausch + Lomb ULTRA® Multifocal for Astigmatism

The latest innovation in reusable contact lenses across a complete family*

1,2,3,4

AVAILABLE

53,55,56,57

IN STOCK

REPRO OP

AND READY TO SHIP

Long hours, long days, lasting performance • Long-lasting moisture retention18,19

HOURS OF COMFORT

SUBS

with MoistureSeal® Technology

• Exceptional wettability18,20

Combines the seamless vision presbyopic patients want with the lens stability for their astigmatic needs.2,6

• Superior surface smoothness and durability17,† • Precision optics for sharp vision1,16,23 ART

• Comfort and visual performance day in, day out... month after month1,22,23

Available in stock and ready to ship so you can reduce your patients’ waiting time and fulfil their vision needs sooner.

3-ZONE PROGRESSIVE DESIGN™

OPTICALIGN™ DESIGN

SEAMLESS vision

STABLE

Axis indicator designates axis of cylinder power7 (30˚ example shown)

DISTANCE

PRODUCTION

INTERMEDIATE

NEW

NEAR

APPROVED FOR EXTENDED WEAR

CLIENT

MATERIAL:

FOR PRESBYOPIA

FOR PRESBYOPIC ASTIGMATS

Bausch + Lomb ULTRA® for Presbyopia5

samfilcon A

LENS MATERIAL TECHNOLOGY:

MoistureSeal® Technology

0.5

46%

-0.5

-3.00D High Add

WATER CONTENT: MODULUS:

LENS DESIGN TECHNOLOGY:

Power (D)

0.0

OXYGEN TRANSMISSION:

Orientation mark helps measure rotational stability and assists patients during insertion7

For illustrative purposes only. FOR ASTIGMATISM

70 163 Dk/t @ centre for -3.00D

114 Dk/t @ centre for -3.00D

Aspheric optics to reduce inherent and OpticAlign™ Design with spherical induced spherical aberration aberration control

≤5°on 95% of patients

near, far and in-between1

And our Patient Satisfaction Guarantee for complete peace of mind.

SPHERICAL

163 Dk/t @ centre for -3.00D

104 Dk/t @-3.00D

3-Zone Progressive Design™ with centre-near aspheric optics

3-Zone Progressive Design™ OpticAlign™ Design

Near

Intermediate

Distance

On-eye clinical results2

Rotation, centration and movement at dispensing ROTATION

CENTRATION

MOVEMENT

-1.0 -1.5 -2.0 -2.5 -3.0 -3.5 -4.0 0.0

0.5

1.0

1.5

2.0

2.5

3.0

0 to 5 Degrees

95%

Excellent

86%

Adequate

100%

6 to 10 Degrees

Good

14%

Excessive

11 to 15 Degrees

Fai r

Insufficient

> 16 Degrees

Poor

Adherence

8.5 mm

8.6 mm

8.5 mm

8.6 mm

DIAMETER:

14.2 mm

14.5 mm

14.2 mm

14.5 mm

CENTRE THICKNESS:

0.07 mm @ -3.00D

0.10 mm @ -3.00D

0.07 mm @ -3.00D

0.11 mm @ -3.00D

SPHERICAL POWERS:

+6.00D to -12.00D (in 0.50D steps above -6.00D)

+6.00D to -9.00D (in 0.50D steps above -6.00D) Available in -2.75D Cylinder

+6.00D to -10.00D (in 0.25D steps including plano)

+3.00D to +1.00D -1.00D to -5.00D in 0.25D steps

Low: up to +1.50D spectacle Add High: from +1.75D spectacle Add

Call now for your Fitting Guide and to order Trial Lenses

-0.75, -1.25, -1.75, -2.25, -2.75

-0.75, -1.25

N 0845 602 2350 E cs.vc.uk@bausch.com D www.bausch.co.uk/ultra-mfa

10° to 180° (in 10° steps)

10°, 90°, 170°, 180°

Orientation mark at 6 o’clock Axis indicator varies with axis

AXES: ORIENTATION MARK / AXIS INDICATOR: VISIBILITY TINT: WEAR SCHEDULE: REPLACEMENT SCHEDULE:

Light Blue Daily wear, up to 7 days extended wear Monthly

* Latest technology in soft reusable lenses across a complete contact lens family. † Vs Acuvue® Oasys®, Biofinity® and Air Optix® Aqua.

BLACK YELLOW MAGENTA CYAN

To help reduce the spread of COVID-19, the UK Government has advised that face coverings should be worn whenever social distancing can’t be maintained.

New COVID-19 practice resources for members

3 distinct zones with consistent power in each zone Nimo power profile

SIMPLE EASY TO FIT*, IN STOCK, READY TO SHIP

3,4

ADD POWERS:

Keeping your practice safe

Radial Displacement (mm)

BASE CURVE:

CYLINDERS:

Inner covers spread

VERSION

Bausch + Lomb ULTRA®

A condensed and efficient power range addressing some of the most popular powers, providing additional business opportunities for your practice.

To read the guidance and download the poster visit www.aop.org.uk/facecovering

UMT.0016.IE.21

91OPTAPR21101.pgs 25.03.2021 23:27

Introducing My Lens Life…

Outer covers spread

VERSION

Journal of the Association of Optometrists

COVID-Generation Special report Page 35-38

£9.95 REPRO OP

April/May 2021 Volume 61:02

SUBS ART

Starter pack

Email template

Welcome pack

Email template PRODUCTION

Step 2

CLIENT

Step 1

April/May 2021 / Volume 61:02

…the contact lens patient retention programme from CooperVision, designed to help reduce drop out and support remote patient care.

www.optometry.co.uk

Step 3

Information booklet

Series of follow-up follow w up emails

THE REMODELLING PATIENT EYE CARE EDITION

mylenslife.uk

GO BEYOND VISION and let your patients Live the ULTRA Life

To find out more please contact your CooperVision Business Development Manager.

coopervision.co.uk/mylenslife

Remodelling eye care for a post-pandemic future / www.optometry.co.uk

BLACK YELLOW MAGENTA CYAN

CET Management of the anisometropic child

Spotlight The Education Strategic Review explained

In practice Proactively engaging contact lens wearers

Page 80

Page 08

Page 43

91OPTAPR21100.pgs 26.03.2021 12:36