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February/March 2021 / Volume 61:01
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Make a difference to the future of optics THE LENS TO START IN AND STAY IN
Regional representatives from our geographical constituencies 14 designated posts for optometrists working in core areas of practice and for optometrists working in Scotland, Wales and Northern Ireland.
“I urge every optometrist to take their professional development seriously”
THE FITNESS TO PRACTISE EDITION
We’re looking for members to join our Council
If you’re passionate about the profession and representing your peers, we’d like to hear from you. No previous experience required. Nominations open 10 February.
Find out more www.aop.org.uk/elections LONG-LASTING COMFORT 1
EASE OF HANDLING1
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£9.95
Biofinity® toric multifocal
www.optometry.co.uk
Prescribe freedom for your astigmatic patients with presbyopia.
/ www.optometry.co.uk
Mike George, AOP Council member
IN THEIR SHOES
“When I got the letter from the GOC, I thought: this is judgement day”
PRE- AND POST-FIT SUPPORT
Rise above the social media noise and help to shape the future of our profession with evidence, consideration and healthy debate on the AOP Council
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Hitlist Bio-acetate eyewear
February/March 2021 Volume 61:01
INTRODUCING
PRECISE VISION1
Outer covers spread
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Journal of the Association of Optometrists
What optometrists need to know about facing professional conduct proceedings and how they can strengthen their practice
“I didn't share what had happened with anyone when the complaint first came in, out of embarrassment and pride”
Reliable fit, exceptional vision. Optimised Toric Lens Geometry™ for a stable and reliable fit.
“I never thought I would find myself in the position that I did”
success rate on initial lens fitting.1
Balanced Progressive® Technology for exceptional vision at all distances. patients preferred their vision with Biofinity® toric multifocal over Proclear® multifocal toric contact lenses.1*
Powered by Aquaform® Technology for natural wettability, high breathability and proven comfort.1 Available in over 200,000 custom prescription options.2
CET How to talk to your patients about AMD
Perspectives COVID-19 and the impact on domiciliary optometry
In practice Teleoptometry and contact lens care
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1. CVI Data on file 2018. Non-dispensing, subject masked, randomized, bilateral, cross-over short-term clinical evaluation. 27 subjects at 2 sites (UK & US) fitted using CVI fit guide. *70% vs 15%; subjective vision assessed approximately 1 hour post-insertion. 2. CVI data on file 2019. Based on total number of prescription option combinations manufactured (for sphere, cylinder, axis, and add–including D & N combinations). Aquaform® Technology, Balanced Progressive® Technology, Biofinity®, Optimised Toric Lens Geometry™ and Proclear® are registered trademarks and trademarks of The Cooper Companies Inc. and its subsidiaries. © CooperVision 2020.
91OPTFEB21101.pgs 03.02.2021 13:07
A GREAT PROGRAMME
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Combining Biofinity® toric and Biofinity multifocal optical designs for a reliable fit and exceptional vision.
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Optimised Toric Lens Geometry™
Balanced Progressive® Technology
for a stable and reliable fit
for exceptional vision at all distances
A GREAT LENS
ART
Two distinct optical designs Unique back surface curvature Reduces on-eye movement to support stable lens positioning.
D lens Distance vision
PRODUCTION
Spherical central zone
Intermediate vision Progressive zone
Large toric optic zone
Near vision
Helps provide good vision performance.
Spherical zone
CLIENT
N lens
Uniform horizontal ISO thickness
Near vision
Improves lens stability and reduces rotation for better visual acuity.
Spherical zone
Intermediate vision Progressive zone
SEE WHAT HAPPENS WITH PR ECISION1 ™ CONTACT LENSES
Distance vision Spherical central zone
Optimised ballast toric design
A GREAT PROGRAMME designed to reduce contact lens drop out by providing patients with a virtual experience, supporting them on both their pre- and post-fit contact lens journey.
Provides a stable comfortable fit.
A GREAT LENS to meet the needs of new and current wearers seeking precise vision,1 long-lasting comfort1 and ease of handling.1 PRECISION1TM contact lenses feature SMARTSURFACE® Technology, a permanent, microthin layer of moisture on the lens surface that exceeds 80% water.2 This is designed to provide longer-lasting lens surface moisture stability3-5* and a more stable tear film for precise vision and long-lasting comfort.2
In a recent clinical evaluation, Download the OptiExpert™ app today.
of lenses were within 10 degrees of the desired orientation position.1
Talk to your Business Development Manager today. coopervision.co.uk
The CooperVision OptiExpert™ app helps prescription accuracy and speeds up contact lens selection, for a fitting process that is efficient and effective for astigmatic presbyopic patients.
PRE-FIT SUPPORT Attract new wearers with a unique virtual PRECISION1TM experience, in practice material, social media content and more
DURING FIT Providing virtual contact lens application and removal support to maximise patient success during the first stages of handling lenses
POST FIT Supporting new PRECISION1TM wearers through their early lens wearing experience with 24/7 virtual support PRECISE VISION1
*Compared to 1-DAY ACUVUE^ MOIST, clariti^ 1 day, 1-Day ACUVUE^ TrueEye^, ACUVUE^ OASYS 1-DAY, Biotrue^ ONEday, and MyDay^ contact lenses. Based on in vitro studies wherein wettability was measured using the iDDrop System. ^Trademarks are the property of their respective owners.
LONG-LASTING COMFORT 1
EASE OF HANDLING1
Contact your Alcon® representative to find out more.
References: 1. Cummings S, Giedd B, Pearson C. Clinical performance of a new daily disposable spherical contact lens. Optom Vis Sci. 2019;96:E-abstract 195375. 2. PRECISION1 (DDT2) Lens with Smart Surface study; Alcon data on file, 2019. 3. Tucker B, Leveillee E, Bauman E, Subbaraman L. Characterization of the Surface Properties of a Novel Daily Disposable Silicone Hydrogel Contact Lens. Poster presented at the American Academy of Optometry Annual Conference, October 23-26; Orlando FL. 4. IDDrop Comparative Study DACP and BioTrue ONEday Report; Alcon data on file, 2019. 5. IDDrop Comparative Study Oasys 1 Day and TruEye; Alcon data on file, 2019. Please refer to relevant products IFU for complete list of indications, contraindications and warnings. Find at: ifu.alcon.com PRECISION1, Alcon and the Alcon logos are trademarks of Alcon Inc. 14602 © 2021 Alcon Inc. 01/21 UKIE-PR1-2100013
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Also found in MyDay® toric and Avaira Vitality™ toric
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Welcome
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ART PRODUCTION Cover: Grant Pearce
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fter a year unlike any other, what should we expect from 2021? It is a question with layers of complexity. But, as your professional membership organisation, the AOP remains at your side to find answers to the questions that matter, represent your interests, and defend your ability to practise safely. The COVID-19 pandemic poses conflicting concerns that are painfully difficult for our profession to reconcile. Patients are suffering avoidable sight loss due to cancelled and missed appointments; businesses are facing financial jeopardy as the lockdown keeps patients out of practice; members are in need of protection from the virus, minimising risks to their health. This is why we issued a statement in January, stating that if a practice continues to offer routine care at this time, stringent measures must be maintained to manage the risks of COVID-19 infection, and this should include the use of longer appointment times. It is also why we called on employers to put appropriate measures in place to protect all staff working in optometry practices. And why, as a member of the Optometric Fees Negotiating Committee, we have continued discussions with NHS England on potential additional support that is urgently required for optical practices affected by the new restrictions. The situation is evolving rapidly, and we will continue to update our guidance on the coronavirus advice pages of the AOP website and send targeted emails to make sure you never miss the information you need. In this edition of OT, we profile the work of the AOP legal and regulatory team, with a focus on GOC fitness to practise investigations. The support that the team provides, in what is a highly distressing time for members, continues to be a source of pride. After eight years as chief executive, this will be my last at the AOP as I retire in the summer. To represent, support and defend members is a privilege and an honour – and I, along with all my colleagues at the AOP, thank you for choosing us to be with you throughout your career.
“The support that the AOP team provides, in what is a highly distressing time for members, continues to be a source of pride”
Henrietta Alderman, AOP chief executive
February/March 2021
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Welcome
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GIGI Studios, Bolle, Jonah Krznaric, Getty
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07-25 SPOTLIGHT
Spotlight
Multifocal contact lenses
The news in digest Picture this The art of microscopy OT reports Five lessons from a long-running fitness to practise case The audit Optics in 16 stories 100% Optical Moves to 2022 Industry profile Inspecs Group’s Steve Tulba Clinical roundup Vision changes linked to cognitive decline in Parkinson’s patients Suppliers respond The expansion of the multifocal contact lens market AOP roundup Launching the Council elections, plus AOP events in 2021
4 www.optometry.co.uk
“It is estimated that 83% of our patients will have some stage of presbyopia by the age of 45” Dimple Zala, Bausch + Lomb PAGE 22
27-33 HIT LIST
The trends, launches and looks
February/March 2021
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OT focuses on... Sustainable eyewear Me and my glasses Eyewear designer, Caron Kraitt Get the look / Anatomy of a frame With Lizzy Yeowart The shortlist This edition’s selection Behind the brand Lumenis
35-39 PERSPECTIVES
Voices from optics and beyond Perspectives Shamma Masud, Paul ChapmanHatchett, Rebecca Bartlett My vision British sailor, Luke Patience
“Our housebound and vulnerable patients deserve our empathy and kindness more than ever before” Paul Chapman-Hatchett, PAGE 36
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CET 67-89 Education and training for the eye care practitioner
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67 CET welcome 68 How do you talk to your patients about AMD? 72 Be safe and savvy with social media 76 Tear breakup time: are all methods created equal? 80 Using fixation disparity curves in clinical practice 84 Features of diabetic retinopathy 86 Anterior eye abnormalities 89 CET Q+A: Dr Liat Gantz
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In this edition of OT, practitioners can test a range of competencies: OPTOMETRISTS // 5 THERAPEUTIC OPTOMETRISTS // 3 DISPENSING OPTICIANS // 4 CONTACT LENS OPTICIANS // 1
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Business insight and career development The roundtable OT talks teleoptometry with with eyecare practitioners Pre-reg focus Luke McRoy-Jones and Emily Mather How I got here Dunfermline-based optometrist, Michael O’Kane What I have learned Understanding the principles of cultural awareness How do I... Make my practice dementia friendly?
ONLINE
Cover story
Trial and error Could a simple mistake during the working day see an optometrist face criminal charges? OT examines the use of the criminal law against healthcare workers in the UK – and whether change is needed PLUS: the Chartered Institute of Professional Development on how to apply diversity and inclusion principles in the workplace PAGE 57–65
90-97 ENDNOTES
OT video highlights
A roundtable on COVID-19 and teleoptometry 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
Jobs What to include in a cover letter I cannot live without ”The Pentacam,” writes Emma Bolger Secret life Yair Neuman transforms spectacle lenses into works of art
Like us on Facebook OptometryTodayJournal Follow us on Instagram @optometry_today
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Spotlight
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08 OT REPORTS
Five lessons from the Honey Rose fitness to practise case
21 CLINICAL ROUND-UP
24 AOP SUPPORT
Vision changes in Parkinson’s patients and community optometry in Wales
The 2021 AOP Council elections unpacked, and AOP events plans for the year ahead
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Micro beauty
Images courtesy of Zeiss
From mouse hair follicles to convallaria, Zeiss has showcased the applications of its new compact microscope, the Zeiss Primostar 3, which launched in January. The microscope is designed for digital teaching and routine lab work for tissue and sample examination, and aims to make entry into microscopy “as easy as possible.”
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HONEY ROSE: FIVE LESSONS FROM THE GOC CASE
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Editor: John White johnwhite@optometry.co.uk Interim deputy editor: Lucy Miller lucymiller@optometry.co.uk Assistant editor: Selina Powell selinapowell@optometry.co.uk
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Senior reporter: Kimberley Young kimberleyyoung@optometry.co.uk Web content and social media executive: Leah Boyle leahboyle@optometry.co.uk Clinical editor: Dr Ian Beasley ianbeasley@optometry.co.uk Clinical editor for multimedia: Ceri Smith-Jaynes cerismithjaynes@optometry.co.uk Video production editor: Laurence Derbyshire laurencederbyshire@optometry.co.uk CET enquiries: 020 7549 2076 CEThelp@optometry.co.uk AOP membership and OT subscription team: AOP, 2 Woodbridge Street, London, EC1R 0DG subscriptions@aop.org.uk
Advertising: Richard Ellacott 020 3771 7242 richard.ellacott@thinkpublishing.co.uk Advertising production: 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.
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The 2016 conviction of a UK optometrist of gross negligence manslaughter caused many practitioners to examine their own practice There was a fear that optometrists might face criminal proceedings for a lapse in judgement or a moment of inattention at work. The Court of Appeal later quashed the conviction, highlighting that the case was one for the regulator to decide rather than the criminal courts. Optometrist Honey Rose received a ninemonth suspension order from the General Optical Council in November 2020. However, in January, the Professional Standards Authority lodged a High Court appeal against the decision. What can the wider profession learn from the case? The AOP’s head of clinical and regulatory, Henry Leonard, shared his thoughts on how optometrists can strengthen their daily practice.
1 The GOC fitness to practise committee considered that the failure to conduct an adequate internal eye examination was the most serious aspect of the case against Ms Rose. Mr Leonard shared that reasonable efforts should be taken by the practitioner to overcome any challenges to completing an internal examination of the eye. If the view is limited,
3
Conducting an adequate internal examination is a key part of any sight test this should be clearly explained at the time, and practitioners should consider what steps they can take to mitigate the risk of missed pathology. If a child is having difficulty maintaining
fixation on the test chart for example, it may be helpful to enlist the help of their parent or guardian to gain the
child’s attention, Mr Leonard noted. Mr Leonard also highlighted that in February 2019 NHS England sent an ‘avoidance of doubt’ letter to GOS contractors in England. This sets out NHS England’s expectations of practitioners when examining clinically challenging patients, and confirmed that a GOS fee can be claimed, even when it was not possible to complete the sight test. However, this only applies when “...a reasonable attempt has been made to examine the patient, appropriate records of this are kept and any legal obligations are met.”
Getty/ grivina
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February/March 2021 Volume 61:01 Issn 0268-5485 ABC certificate of circulation 1 January 2019 – 31 December 2019
If an internal eye examination cannot be completed for a good reason, then optometrists should record this – including their reasons for not completing the examination and what, if any, steps they have taken to mitigate the risk of missed pathology.
Mr Leonard noted that this may include viewing retinal images instead. In this situation practitioners should take extra care to ensure the images they are looking at belong to the right patient, and relate to the correct date. If an adequate view is not possible,
3
2 practitioners should consider rebooking the patient on another day, or recommending an earlier recall than usual.
RECORD FINDINGS FOR EACH EYE SEPARATELY & AVOID AMBIGUITY
The importance of clear, detailed records was a reoccurring theme in the fitness to practise proceedings against Ms Rose. Mr Leonard emphasised that optometrists should record their findings for each eye separately. “In the case of written records, it’s not a good idea to record findings such as monocular visual acuities across both lines to indicate that each eye was the same, because this method of recording is ambiguous and could be misinterpreted as a binocular finding,” he highlighted. Mr Leonard added that practitioners also need to be clear about whether ocular muscle balance for distance and near has
“If a practitioner hasn’t recorded something of significance, which they later seek to rely on, it may be assumed that it didn’t take place”
been measured with or without correction. If records are called into question, the test that will be applied is whether a reasonable body of optometrists would have recorded the result in the same way; it is not sufficient that a reasonable body of optometrists would be able to interpret a particular recording. Ambiguous marks should be avoided. Mr Leonard highlighted that ticks are not an adequate way of recording normality in relations to structures such as the cornea, optic disc or macular. He added that ticks should generally be avoided in written records except in limited circumstances where a ‘yes/no’ response is appropriate. Complete and accurate records are often crucial to a successful defence, he said. “If a practitioner hasn’t recorded something of significance, which they later seek to rely on, it may be assumed that it didn’t take place,” Mr Leonard explained.
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Henry Leonard
February/March 2021
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IF AN INTERNAL EYE EXAMINATION IS NOT POSSIBLE, RECORD THIS
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When reviewing retinal images, make sure the picture is of the correct patient from the correct date and time. This is particularly important if an internal examination of the eye is unable to be completed for any reason.
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Avoiding auto-pilot:
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MAKE SURE YOUR RECORDS ARE NOT MISLEADING Optometrists should ensure that each result they record is supported by the necessary test or observation. Mr Leonard shared with OT that practitioners working in primary care will spend a lot of time observing normal results in most of the patients they see. “These practitioners are at particular risk of inadvertently recording that a structure has been examined and is normal out of habit or because they are working on auto-pilot, even when the examination was not normal, or has not been performed,” he said. In the case of Ms Rose, she recorded the periphery as normal even though she had not seen it. Mr Leonard emphasised that
practitioners need to ensure that their records are not misleading – either intentionally or unintentionally. “In situations where practitioners are relying on retinal photographs alone, it’s important not to record that the peripheral retina, or more accurately the mid-peripheral retina, has been examined, unless the images were taken using a wide-field camera,” he said. Practitioners should not record that a structure is normal on the basis of an absence of signs and symptoms without actually examining the structure. “For example, whilst abnormalities of the peripheral retina are rare in children,
“Whilst abnormalities of the peripheral retina are rare in children, practitioners should not record normality simply because the patient was asymptomatic” Henry Leonard 10 www.optometry.co.uk
practitioners should not record normality simply because the patient was asymptomatic, unless they have actually examined this part of the eye,” Mr Leonard observed.
Getty/ grivina
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ENSURE YOU ARE LOOKING AT THE CORRECT IMAGE OF THE CORRECT PATIENT
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More than just an OCT Observe and measure all the main structures and surfaces of the eye Posterior OCT
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The medical start-up, Occuity, announced plans to launch a handheld non-contact optical pachymeter this year. The company suggests the new device will make it quicker and easier for optometrists to take corneal thickness measurements, and “revolutionise the detection of glaucoma.” An advanced prototype of the device is undergoing in-house testing, with a production version undergoing clinical trials and CE marking in early 2021.
Occuity
INDUSTRY SUPPORT
“We know from our research that the current pandemic and lockdown is having a particularly harsh effect on those living with eye conditions and sight loss.” Sarah Campion, Fight for Sight director of engagement, on the launch of the charity’s survey into how the continued lockdown restrictions in the UK have been affecting those with sight loss and eye conditions.
OCT-A Angio OCT OCT-B Biometry OCT
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Consultant paediatric ophthalmologist, Professor Rachel Pilling, has been appointed the first professor in special needs and learning disability eye care in the UK, taking on the role in the School of Optometry and Vision Science at the University of Bradford. The professorship is a result of her role in driving clinical support for children with learning disabilities, as well as her research on tools to detect and act on vision loss in people with learning disabilities.
CLIENT
“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
63%
of optometrists in an OT poll of over 330 readers said they felt “much less” or “somewhat less confident” about practising during the third lockdown introduced in January, compared to the first national lockdown in 2020. Meanwhile, 15% felt “somewhat more confident” and 6% felt “much more confident.” A further 5% said they would not be practising during the lockdown.
Smart contact lens company, Mojo Vision, has formed a development partnership with Menicon. The start-up aims to develop an augmented-reality smart contact lens, with early applications intended to support people with vision impairments. Haag-Streit UK has launched its new optical coherence tomography system, the iVue80 SD-OCT, in the UK. The system offers faster scans and new functions, along with a wider field-of-view, and a streamlined interface. The iVue80 OCT is three times faster than the original iVue model, the company suggests, offering 80,000 A-scans per second.
The Aston Villa Foundation teamed up with Aston University and Essilor to develop a programme delivering eye health education in communities in Birmingham. Essilor fitted a mobile eye care vehicle, the Villa Vision van, which will be used to perform eye examinations and help spread awareness.
February/March 2021
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Mojo Vision
True colour fundus imaging
SPOTLIGHT, 4
SPOTLIGHT THE AUDIT
SCIENCE AND VISION
“By understanding the real-life experiences of our glaucoma patients, we can understand the efficacy of their treatment and support more effective glaucoma management.” Getty/ljubaphoto
Dr Andrew Tatham, consultant ophthalmic surgeon at Princess Alexandra Eye Pavilion, on a survey of glaucoma patients conducted by Santan EMEA that illustrated how factors such as treatment side effects and negative experiences can increase non-adherence.
A new treatment for wet age-related macular degeneration (AMD) has been approved for NHS use in England and Wales. Brolucizumab, which has been brought to market by Novartis, could see patients receiving as few as four injections a year, with more than 50% of patients in clinical trials able to maintain vision on 12-weekly dosing intervals. It is thought the drug could help to minimise the treatment burden and hospital visits for patients.
A retrospective study has found very low complication rates in children who wear soft contact lenses. The Adverse Events Rates in the Retrospective Cohort Study of Safety of Paediatric Soft Contact Lens Wear is expected to offer realworld information to help counsel parents considering myopia management options. The work was launched to support CooperVision’s regulatory submissions of the MiSight 1 day product.
Following the introduction of new national lockdowns in January, optical bodies confirmed that optometrists formed part of a priority group for access to the COVID-19 vaccine. To support members, the AOP created editable letter templates for practice owners to evidence that optometrists and practice staff are eligible. These are available at: www.aop.org.uk/ coronavirus-updates/covid-19vaccine-faqs
The General Optical Council (GOC) encouraged registrants to take part in the United Kingdom Research Study into Ethnicity and COVID-19 Outcomes in Healthcare Workers. Marcus Dye, acting director of strategy for the GOC, said: “It’s vital that optometrists and dispensing opticians participate in the research to reflect the experience of our sector and to ensure that the important learnings will help us to better support our BAME colleagues.”
Getty/Anastasiia_New
University of Oxford, John Cairns
PROFESSIONAL SUPPORT
The Department of Health and Social Care (DHSC) and NHS England agreed to cancel planned GOS support payment deductions in order to offset the PPE costs of contractors. In a statement, the Optometric Fees Negotiating Committee called the move a “fair and simple solution” to reimburse practices for PPE costs incurred before the DHSC PPE portal was made available.
IN PRACTICE “Amid the chaos, I have achieved something great and have a focus for the upcoming months. Besides, if we can learn to practice optometry through fogged lenses imagine how good we will be when the masks are off.” Steph Bowen, pre-reg optometrist, Bowen Opticians, shared her thoughts on completing the Bradford University optometry conversion course for OT’s ‘2020 Wins’ article.
Three optometrists were recognised in the Queen’s New Year Honours List 2021. Tanjit Singh Dosanjh, founder and chief executive officer of the Prison Opticians Trust, was awarded an OBE for services to optometry in prisons and reducing re-offending. Ruth Perrott (pictured), managing optometrist for VisionCare Optometry, was awarded an MBE for services to people with sight impairments in Africa. Asda superintendent optometrist, Sarah Joyce, received a British Empire Medal for services to primary optical care during the COVID-19 response.
“We’re very rarely given an opportunity to stop the hamster wheel, to stick a spoke in it and restart under our terms.” Nicholas Rumney, chairman of BBR Optometry, spoke to OT on joining the Hakim Group, the impact of COVID-19, and business models for optical practices. Read more online: https://bit.ly/3q3L3xw February/March 2021
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100% Optical will be held on 29-31 January 2022 REPRO OP
The AOP’s events and education calendar can be found at www.aop.org. uk/events-and-education/events
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Worth the wait ART
As restrictions look likely to extend into spring, 100% Optical has been postponed until January 2022. OT speaks to event director, Nathan Garnett, about the decision
PRODUCTION Laurence Derbyshire
CLIENT
Event organisers behind 100% Optical, Media 10, have made the decision to postpone the show until January 2022. Despite efforts to ensure the optical profession would be able to meet again at 100% Optical in 2021, with the country in lockdown in January, Media 10 said the possibility of restrictions continuing into spring had become increasingly more likely. The organisers explained that running the event with limited attendance, and with the potential for travel restrictions, would not be in the best interest of clients or delegates. Speaking to OT about the decision to postpone the event, director of 100% Optical, Nathan Garnett, said the response from exhibitors had been positive: “Like us, they are incredibly disappointed not to be going ahead in May, but we can plan with more certainty for next year, and for what we can do digitally as well.”
partner, to ensure some of the education content planned for the event would still be delivered in May, in order to support members to achieve points required in the final year of the CET cycle. Sharing the AOP’s plans for education, Dr Ian Beasley, head of education and OT clinical editor, added: “Although the ability to deliver education in a face-toface environment remains uncertain, the AOP will continue to adjust its programme of CET to meet member demand in the third year of the cycle. “An extensive range of interactive CET will be available online throughout the year, offering webinars and peer discussions with key target groups in mind, including locums, independent practitioners and therapeutic prescribers,” he continued.
Securing CET The AOP has supported the show since its launch as its official event partner and education provider, with OT the official media partner. Commenting on the announcement, AOP chief executive, Henrietta Alderman, said: “We are very disappointed not to be able to deliver the event in May as planned, but we know this is the right decision for visitors and exhibitors.” The AOP confirmed it would continue to work with Media 10 as the official event
In place of the physical show, organisers are planning a one-day virtual event for May, set to offer an opportunity for networking, meeting suppliers and to gather CET points. Mr Garnett explained: “I believe virtual events can perform a vital function of connecting suppliers with buyers, whilst we wait for shows in January 2022.” Discussing the virtual event, Mr Garnett told OT that they will be looking at how to enable those meetings to happen successfully on
Bigger and better Organisers hinted that the 2022 run of 100% Optical is expected to be one of the largest optical events staged in the UK “for at least a decade.” While the event was always planned as a time to bring the profession together, this took on new meaning when the Federation of Manufacturing Opticians (now the Optical Suppliers Association) announced its backing for the event. Media 10 said this assured the profession of one major annual exhibition, with the full support of the major optical bodies. “The advantage is that we now have another year to plan the event,” Mr Garnett said. “We had a really good lineup for 2021, and now that we have extra time, I think we can get in even more companies.” “When we launched this show nearly eight years ago, people talked about how big they thought the optical show would be for the sector, and I still don’t think we are there yet,” Mr Garnett said. “We’ve now got a real opportunity to make it the big showpiece that the industry wants.” Ms Alderman echoed this sentiment: “We know that the year ahead will still challenge us, but through our continued partnership we are confident that the next event will be our best yet." Mr Garnett concluded: “It will be worth the wait; 100% Optical 2022 is going to be a very large celebration indeed.”
Taking 100% Optical online Nathan Garnett shares plans for a virtual event a digital platform. AOP members will receive information on how to register for any virtual events through AOP emails. Mr Garnett recommends registering early to get booked in. Media 10 hopes to make the events as interactive as possible for attendees. Mr Garnett explained: “There might be some networking events. It is never the same as meeting in person, but some informal meetings would be nice to enable people to catch up.”
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A hopeful future for those who continue to adapt
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As we continue to explore the challenges faced through the pandemic across the optical sector, Inspecs Group’s Steve Tulba, managing director for the Inspecs divison, speaks to OT about the hurdles eyewear companies have overcome, and the opportunities that remain
SUBS ART
To adapt to this, at Inspecs we launched a B2B e-commerce platform in order to help our independent practices, enabling salespeople to engage with their customers remotely. It is still very important to get that personal touch across, despite being behind a screen, and this is why we launched our platform, so each customer feels they are receiving the right personal approach tailored to their needs and expectations. Through this platform, we have tried to provide options, so that regardless of how they wish to approach the procedures of dealing with COVID-19 at a retail level, we are there to service them.
PRODUCTION CLIENT
Eyewear brands were among some of the optical suppliers to see the sharpest impact of the coronavirus (COVID-19) pandemic, with lockdowns and subsequent restrictions reducing sales. In its 2020 report, Euromonitor International predicted the outbreak of COVID-19 would lead to a reduction in eyewear value and volume sales through the year, but suggested e-commerce would see a “dramatic increase” in value share. “The UK eyewear industry is expected to start to record volume growth again in 2021,” the report authors suggested, adding that wearers would still need to buy their corrective spectacles. Despite the rocky year that many suppliers have had, the frame manufacturer and distributor, Inspecs Group, has identified opportunities for growth, taking on the manufacturing operations of Norville, and announcing the conditional acquisition of German eyewear supplier Eschenbach Holding in November. Steve Tulba, recently named managing director of the company’s Inspecs division, walked OT through the current landscape of the eyewear market.
With the shift to a more remote way of working, this has allowed manufacturers and suppliers to be more creative in their ways of serving customers by finding digital-focused solutions to substitute in-person meetings. In the future, we anticipate there will be a growing omnichannel approach, whereby customers may wish to view and order collections online, but with a salesperson talking them through. While some may want to do that entirely independently, others might prefer to see a salesperson and look at a product face-to-face. This is an unprecedented time for everyone, and we must continue to adapt to the current climate and remain flexible and responsive to our customers’ needs.
There is no doubt that 2020 was a challenging year for many retail industries, including the eyewear industry. The uncertainty of the pandemic meant eyewear manufacturers have needed to be flexible and adapt to ever changing circumstances. This past year presented many challenges for the eyewear industry as a whole. With face-to-face meetings becoming difficult to organise due to the COVID-19 pandemic, the industry has had to shift to a more remote model. For manufacturers and suppliers, we have had to switch to supporting our practices remotely and rethink how we could best support our customers and respond to circumstances accordingly.
“This is an unprecedented time for everyone, and we must continue to adapt to the current climate and remain flexible and responsive to our customers’ needs” 18 www.optometry.co.uk
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Inspecs
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INDUSTRY PROFILE // INSPECS GROUP
The eyewear industry is in a very good position to keep growing, innovating and moving forward in these uncertain times. Whilst challenges in some channels, such as travel and traditional sunglass retail, have been extremely difficult during the pandemic, other areas, including e-commerce channels, have continued to grow rapidly in the current climate. [At the time of writing] Optical practices, depending on the country, can still serve patients. With people spending more time at home, reading and in front of screens, the need for eye health, innovation and regular eye tests will only continue to grow. I believe that there is hope and a bright future for all companies in the industry that can adapt quickly and keep offering great product solutions as well as high service levels to their customers.
ASKS
THE NUMBERS...
CASH FADES INTO THE BACKGROUND AS E-COMMERCE ACCELERATES Over the past year, researchers have seen a shift in the behaviour of consumers, with lockdowns limiting where and how the public can shop. A YouGov survey, carried out on behalf of the ATM network Link of more than 2000 people, looked at shopping behaviours and attitudes to cash going into 2021.
75%
felt COVID-19 would continue to affect their use of cash in 2021
48%
felt they would use cards more
37%
36%
said they would shop more online
will rely more on contactless and mobile payments
ONLINE SHOPPING IN 2021 In the UK, e-commerce accounted for over a third of total retail sales in 2020, a key trend expected to continue in 2021
67.2%
1/3+
Optical website specialists, OptiCommerce, recorded an increase of 67.2% in visitors since spring last year
Paul Clare, co-founder and director of OptiCommerce, commented: “We see the day-to-day of this evolution. It is being driven by patients demand for online services to compliment the optometry in-practice services. It’s the practices who are investing in e-commerce to complement their instore offerings that are remaining resilient in the current climate and nurturing their patient base.”
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Industry Outlook
The global eyewear industry remains a very fragmented market and I am sure we will continue to see consolidation as companies look to grow their market share and expertise. Our stated strategy at IPO (initial public offering) was to grow the business, organically and through accretive acquisitions, as we build our market share. In 2020 we pressed ahead with this strategy and made the most of opportunities as they presented themselves. During the pandemic we acquired two businesses, Norville and Eschenbach Optik, which will see the Inspecs Group grow significantly in what is a fractured market. We will be able to expand our operations into key markets, acquire bigger global licenses as a more attractive partner for larger global brands, and broaden our customer base. Investment in the company’s future remains a priority into 2021 and we will continue to press ahead with our plans for the year. We will be launching a new ‘house brand’ made from fully sustainable and recycled materials.
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GLAUCOMA
University of Birmingham researchers combat fibrosis
Clinical round-up
REPRO OP
OT’s Selina Powell reviews the latest clinical news and research papers Vision changes linked to cognitive decline in Parkinson’s patients
SUBS ART PRODUCTION Getty/FG Trade
CLIENT
Studying the vision of patients with Parkinson’s could enable scientists to identify those with a higher risk of dementia 18-months ahead of cognitive decline. The findings by University College London researchers are outlined in papers published in Communications Biology and Movement Disorders. The Movement Disorders research revealed that in a group of 77 people with Parkinson’s disease, simple vision tests could predict who would go on to develop dementia within a period of 18 months. The Communications Biology study involved 88 people with Parkinson’s disease. Within this group, 33 people had visual dysfunction and were thought to be at higher risk of developing dementia. MRI scans of the brains of these patients were compared to the scans of 30 healthy adults. Scientists found that there was a higher degree of decoupling across the brains of those with Parkinson’s than healthy adults. Those with visual dysfunction and Parkinson’s had more
decoupling in some areas of the brain, particularly in regions associated with memory in the temporal lobe. Dr Zarkali highlighted: “The two papers together help us to understand what’s going on in the brains of people with Parkinson’s who experience cognitive decline, as it appears to be driven by a breakdown in the wiring that connects different brain regions.” A senior author on both the papers, Dr Rimona Weil, said that vision tests could be used to identify who should be targeted for new treatments to slow the progression of Parkinson’s. “Ultimately, if effective treatments are found, then these simple tests may help us identify who will benefit from which treatments.”
WELSH STUDY EXPLORES ROLE OF COMMUNITY OPTOMETRY number of outpatient episodes of any A project that investigates the role of specialty within the NHS. community optometrists in monitoring “As a result, a number of new and managing eye disease has received approaches have developed across the a substantial funding boost. UK. Here in Wales, we have primarily The collaboration between researchers and healthcare professionals concentrated on upskilling primary care optometry,” Dr was awarded a Research “New approaches Anderson said. for Patient and Public She noted that Benefit grant from have developed services provided by Health and Care across the UK” optometrists within the Research Wales. community differ across each region The project is being led by Professor in Wales, partly because of lack of Barbara Ryan, from Cardiff University, evidence supporting the best approach and includes representatives from to take. primary and secondary eye care. Hospital to Community Dr Pippa Anderson and Dr Mari Collaboration Cymru has developed Jones, from Swansea University, are the project to better inform decisions part of the multidisciplinary team. Dr taken at health board and Welsh Anderson highlighted that since 2017, government level. ophthalmology has had the highest
NEWS
New research by University of Birmingham scientists has highlighted the potential of low molecular weight dextran-sulphate (ILB) in treating fibrotic diseases – such as open angle glaucoma. The study, which was published in npj Regenerative Medicine, found that ILB normalised matrix deposition and lowered IOP in a pre-clinical model of glaucoma. “Our studies provide proof of concept that ILB has potential as a novel disease-modifying therapy for the treatment of POAG and other acute and chronic fibroproliferative conditions,” the study authors concluded. Hill et al. DOI: 10.1038/s41536-020-00110-2 DRY EYE
Manuka honey eye drops ease dry eye symptoms
A new study has investigated the effectiveness of manuka honey eye drops in the treatment of meibomian gland dysfunction. The research, published in the British Journal of Ophthalmology, involved randomly assigning 59 dry eye patients either regular lubricating eye drops or Optimel 16% manuka honey eye-drops. The study group concluded that the manuka honey eye drops were an effective alternative treatment for meibomian gland dysfunction. Li Al et al. DOI: 10.1136/ bjophthalmol-2020-317506 HEALTH
Rising levels of brain pressure disorder
A new study published in Neurology has highlighted an increase in the number of patients suffering from idiopathic intracranial hypertension. The increasing incidence of the condition corresponds with growing obesity levels. Researchers also found that, for women, the risk of developing idiopathic intracranial hypertension may be associated with socioeconomic factors such as income, education and housing. The study involved analysing data collected through a national health database in Wales over a 15year period between 2003 and 2017. Miah et al. DOI: 10.1212/WNL.0000000000011463
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Clinical roundup
SPOTLIGHT
Suppliers VERSION REPRO OP
would be open to trials. The first group are existing contact lens wearers, agreed Ian Pyzer, professional affairs manager for Johnson & Johnson Vision, followed by, “The nine million emmetropes who, newly presbyopic, would be looking for alternatives to glasses – the ‘Ex-2020 Visioners.’” The largest group, at 2.5 million patients, are those who find their spectacles inconvenient at times. Mr Pyzer suggested: “An ‘optical wardrobe’ approach offers practices an opportunity to provide a variety of vision correction solutions to meet their presbyopes’ everyday needs.”
SUBS
SUPPLIER INSIGHT ART
Room for growth
PRODUCTION
Multifocal contact lenses represent a growing segment of the market, with experts identifying a vast potential for further expansion
CLIENT
Described as a steadily growing market, the numbers of multifocal contact lenses being prescribed is increasing, with a vast scope of opportunity still to grasp. Painting a picture of the scale of this potential, Dimple Zala, professional affairs manager, UK/Ireland & Nordics, for Bausch + Lomb, shared that almost 50% of the European population falls within the presbyopia candidate age range. She said, “83% of our patients will have some stage of presbyopia by the age of 45.” With research suggesting contact lens wear drop-out between the ages of 45 and 55 coincides with the onset of presbyopia, Ms Zala added: “This clearly shows that we have a huge opportunity still to tap into and serve the unmet needs of our presbyopic patients.” Manufacturers agree that a key group of patients to approach for multifocal contact lenses (MFCL) are those already wearing contact lenses.
Getty/ shapecharge
What’s next for... multifocal contact lenses? Menicon, Neil Retallic: “If the presbyope’s natural uncorrected near vision is poor, this can make initial handling more challenging. Multifocal lenses utilising Smart Touch technology would overcome this issue.”
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Sarah Weston, CooperVision senior marketing manager, UK and Ireland, said: “There is a familiarity with the benefits of contact lens wear, together with experience of wearing and handling.” But research also revealed a need to speak to patients about presbyopia early. CooperVision head of professional services, UK and Ireland, Krupa Patel, highlighted a study by Hutchins and Huntjens (2020) which showed that prepresbyopic contact lens wearers were generally more open to the idea of contact lenses for presbyopia, but reported not having received any information on this. “It feels like a huge opportunity to support these patients,” Ms Patel said. Exploring prescribing trends, insights from Johnson & Johnson Vision suggest that ECPs are more likely to fit a mature, or older presbyope, with a multifocal contact lens, but the manufacturer has identified three groups of younger presbyopes who
Bausch + Lomb, Dimple Zala: “We have come so far with the technology in design and material to serve presbyopic patients. It is up to all of us to be communicating the benefits that these lenses offer and recognising what a huge impact they can have in our patients' lives.”
Untapped potential Research suggests this is a growing segment of the market, with insights from the International Contact Lens Prescribing 2019 report in Contact Lens Spectrum indicating that multifocal contact lenses accounted for 22% of soft fits in the UK. The share of weekly or monthly soft multifocal contact lenses has continued to grow in the UK market over the last five years, from 5.6% to 9.8% at the end of 2019 (according to GfK, Jan-Dec 2019). “There is still an enormous amount of untapped opportunity,” Ms Zala shared. “The number of potential presbyopes in the UK is around nine million people (people aged 45-54 years; ONS 2017) and with around 77% of this group requiring vision correction (Vision Needs Monitor 2013), this means there is the potential to fit around almost seven million people with multifocal contact lenses,” she said. Menicon professional services director for Europe, Neil Retallic, too, saw a vast potential for the segment. He said, “Although prescribing of soft multifocal lenses has increased over the years, it is estimated that globally around half of presbyopic soft fits are with a non-
CooperVision, Krupa Patel: “More research to help eye care professionals understand how individual designs will perform across different patients, to help with initial lens selection, would be well-received, as well as more insight and best practice on communicating effectively.”
Johnson & Johnson Vision, Ian Pyzer: “The impact of tear film stability isn’t one that only affects comfort but can have a significant effect on vision too. Materials that can improve this will bring additional benefits to wearers on top of those delivered by advanced and unique multifocal designs.”
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“We have a huge opportunity still to tap into and serve the unmet needs of our presbyopic patients”
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Dimple Zala, Bausch + Lomb professional affairs manager, UK/Ireland & Nordics
ART PRODUCTION CLIENT
presbyopic lens, revealing the extent of market opportunity that still exists.” The increasing trend in soft multifocal prescribing is one expected to continue, he said, particularly with the introduction of more daily disposable products. CooperVison’s Ms Weston identified “significant growth” in the segment, sharing: “Our data shows that MFCLs are the fastest growing segment across the UK and ROI, and indeed, Europe.” Much of the growth can be attributed to wearer movement, Ms Weston suggested, from existing single vision contact lens wearers progressing to multifocal, or monthly wearers switching to the daily disposable variant. Growth is also coming from new wearers, but is currently a less popular route. Ms Weston added: “Our research has picked up on the ‘COVID-effect’ with one of the top reasons for consumers moving to MFCL being that they are fed up with their glasses steaming up.” Creating a positive story The consulting room experience is allimportant for engaging presbyopes in the possibilities that MFCL could offer. Addressing barriers to fitting MFCL, CooperVision plan to deliver education and training programmes through the online Learning Academy. Ms Weston said:
Menicon's 1month multifocal contact lens High design before application
“ECPs have a key role in communicating to patients the benefits of contact lenses and in addressing consumers’ concerns, so building a positive story around presbyopia and MFCL is the key to success.” CooperVision launched its ‘My Lens Life’ programme in 2020 to reduce the number of new contact lens wearers who drop out in the first year. The programme is set to incorporate a multifocal element this year. Planned initiatives regarding multifocal contact lenses include two new pieces of ECP and consumer research into the communication and understanding of presbyopia. It is hoped that this insight will help to identify new ways to address barriers to wearing MFCL, Ms Weston suggested, “growing the segment of the category as we go.” In April, CooperVision’s Biofinity toric multifocal contact lenses will become available, aiming to keep wearers that are astigmatic in contact lenses as they become presbyopic. Fitting calculators are simplifying the selection of contact lenses, also helping to reduce the time spent in the practice – particularly important in the pandemic. Last year, Menicon launched its Multifocal Calculator to improve the possibility of achieving first fit success, something that can be particularly challenging for a first-time wearer. The company has also recently launched educational tools for practices. Neil Retallic explained that the e-learning modules help ECPs to ensure their staff have all the information they might need about Menicon’s lenses, facilitating those conversations in the practice. Supporting eye care professionals through continuing education and development has also been on the agenda for Bausch + Lomb in supporting the UK launch of its Ultra Multifocal for Astigmatism. The company has created practical tools for optometrists, Ms Zala explained: “We are supporting practices throughout their patient journey by providing tools, like social media content, patient email templates, bundle deals with lens care solution, as well as a subscription and home delivery service.” Meanwhile, Johnson & Johnson Vision has been working to support greater understanding of presbyopic patients’ needs, Mr Pyzer explained. “We have
Multifocals in the spotlight with Professor Philip Morgan The head of optometry and director of Eurolens Research at The University of Manchester discusses prescribing trends “With multifocal contact lenses it’s a bit of a mixed picture, but it is one that is getting better. A relatively small number of presbyopes use any sort of contact lens, and an even smaller number wear multifocal contact lenses. “I think we should be offering multifocal contact lenses more proactively to presbyopes. The opportunity is right in front of us. “In a recent study, we looked at what happens if a practitioner makes a low-key recommendation of contact lenses to all suitable presbyopes. We offered patients the opportunity to wear multifocal contact lenses to aid spectacle frame selection, and found there was a big uptake for this offer overall. Ultimately, we found that this simple suggestion doubled the number of presbyopes purchasing contact lenses."
5% to 10% of presbyopes wear contact lenses, and about half of those use multifocal contact lenses, depending on the country Of all contact lens wearers, the number of presbyopes has increased from about 20% to over 30% during the past 15 years Of presbyopes who use contact lenses, the proportion using either a multifocal or a monovision correction has increased from approximately 30% to 50%. always tried to make reaching out to their patients as easy as possible for ECPs, so we have created a range of digital materials that they can use to engage their presbyopic patients,” he said. “During the last couple of years, we also invested in raising patient awareness about multifocal contact lenses and how they can improve their vision experience,” Mr Pyzer said. “We will continue to drive consumer awareness into 2021 with our new media campaign and PR activities.”
A list of references can be found at: www.aop.org.uk/ot/industry/contactlenses/2021/02/01/room-for-growth
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Suppliers
SPOTLIGHT
AOP on your side
AOP Council 2021
How is the AOP… changing its Council in 2021? REPRO OP
The AOP has revised the structure of the Council from 2021, creating new opportunities to represent members. OT found out more
SUBS ART PRODUCTION CLIENT
The AOP Council elections will be held this spring, with new opportunities to represent the views of optometrists. Nominations opened in February and voting will take place in March. With the Council elections paused in 2020 as a result of the pandemic, the AOP took the opportunity to consider a refresh. Speaking to OT, AOP policy officer, Jacqueline May, explained: “The previous structure of AOP Council had been in place since 2015 and we felt that now was the right time to make changes." The number of Councillors will remain the same, though there will be a greater proportion of designated positions and new positions have also been created. “The changes will help to ensure that Council continues to make a strong contribution to our policy development and other work, and adequately represents our diverse membership and its range of needs,” Ms May added. AOP Councillors help to ensure that member’s views are represented in policymaking. They can refer members within the AOP for
advice and support and are involved in encouraging membership. Reflecting on the role of the Council, Ms May shared: “From the policy team’s perspective, responding to consultations and creating guidance, in a way that brings benefit to our members and ensures the AOP stays relevant, would be impossible without input from Councillors. “Councillors have told us that being part of the AOP Council is a rewarding experience, with opportunities to develop new skills, network and to help bring about positive change to the future of the profession,” Ms May said. Get involved
Nominations opened on 10 February and close on 1 March. More information on vacancies and how to apply can be found on the AOP website. This is available at: www.aop.org.uk/elections. “We are looking for passionate members to put themselves forward. No previous experience is required,” Ms May said. Voting will be open from 12–26 March and results will be announced in May. The designated Council positions also opened in February. The AOP Appointments Committee will appoint a Councillor for each of these positions from among the applicants. Ms May said: “One of the best ways to participate in the AOP is to use your vote.”
AOP responds to the GOC’s COVID-19 statements Shortly before Christmas, the AOP submitted its consultation response The AOP has submitted its response to the General Optical Council’s consultation on its regulatory statements issued in response to the COVID-19 pandemic. The response indicates four of the COVID-19 statements where the AOP felt that the GOC should change its approach, including those on contact lens aftercare, electronic service of notices, verification of contact lens specifications, and infection prevention and control. Reviewing the statement on contact lens aftercare, the association emphasised the potential safety implications of relying on remote aftercare consultations for an extended period. The AOP recommended the statement should highlight this risk and should also include a recommended maximum interval of no more than two years between in-person consultations in pandemic conditions. The AOP also highlighted the statement on contact lens specifications during the emergency as one in which the GOC should 24 www.optometry.co.uk
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There are nine elected posts in England, one in Wales and two in Scotland open for nomination. There are 14 designated positions.
Elected posts East of England East Midlands London North East England North West England South East England South West England West Midlands Yorkshire and the Humber Wales Scotland (two seats) Designated posts Undergraduate student Pre-registration optometrist New hospital optometrist (alongside the chair of the Hospital Optometrists Committee) Newly qualified & early career IP optometrist Domiciliary care optometrist Locum optometrist Director multiple Employee multiple Director independent Employee independent Optometrist for Scotland Optometrist for Wales Optometrist for Northern Ireland More about the available positions and eligibility criteria can be found at www.aop.org.uk/elections
change its approach. The AOP recognised the need for flexibility where routine care is suspended, but highlighted concerns over the effect of removing the requirement. The AOP highlighted “serious concerns” with taking a blanket approach to the electronic service of notice to registrants, and emphasised a need for the GOC to make appropriate arrangements to provide physical notices in cases where it does not have explicit consent to send them electronically. While the statement on infection prevention and control during the emergency was found to be helpful in setting out the responsibilities of businesses and individuals, the AOP suggested a “more robust” approach was needed to ensure the responsibilities of employers were carried out effectively – particularly in enabling appropriate time for infection control measures between appointments. To read the AOP's consultation response on the GOC's COVID-19 statements in full, go to the 'Our Voice' section of the AOP website, or visit www.aop.org.uk/consultations
Getty / mitay20
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Education
Shutterstock
Ian Beasley, head of education and OT clinical editor How did the AOP adjust its education delivery in 2020? It seems a lifetime ago that around 10,000 visitors attended the AOP’s flagship event, 100% Optical, in January 2020. Then, in a matter of weeks, our carefully laid plans for face-to-face education delivery throughout the calendar year were torn into shreds as the implications of the pandemic unfolded. In those early days, there was an anxious period of negotiation to cancel education venues across the UK as we set about adapting our model, greeting all that Zoom had to offer with open arms. Delivering education in the virtual space allowed us to adopt a nimble approach to disseminate important clinical, regulatory and employment updates to members. The convenience of being able to use a virtual platform to access interactive CET, along with a range health and
wellbeing content, has been warmly received by members against the backdrop of the dayto-day challenges of practice. What will your focus be for the months ahead? It is clear that providing education virtually offers a convenient solution for our members and we will continue to adopt this approach throughout 2021. Our plans include virtual peer discussions, and clinical webinars, tailored support for students, along with targeted education for locums and independent practitioners in partnership with Johnson & Johnson Vision. OT will also continue sharing tailored and informative content. In our last issue, we produced a locum optometrist’s toolkit, and a CPD guide on contact lenses for younger patients, with articles from these supplements now available to read online.
Events
Liz Routh, events manager
How was the events schedule adjusted in 2020? As soon as the first lockdown came into place, we started converting many of our events into virtual activity. We also provided over 70 webinars and peer discussions across the year, for over 23,000 delegates. Virtual sessions focused on clinical content and nonclinical topics, and covered subjects such as myopia, legal updates, glaucoma monitoring, health and wellbeing, hospital optometry and meibomian gland disease, to name a few. What is your focus for 2021? We will continue to meet the needs of our members by covering a range of topics tailored to different areas of the optical sector including locums, independent eye care professionals, students, therapeutic prescribers and hospital optometrists.
What will the AOP’s event plans look like in the next few months? We will be continuing with a programme of webinars and peer discussions that will take place virtually, until we’re advised that we are able to run live events that are safe for members to attend. We will be staggering our activity over the year to ensure that the content is relevant to our members’ changing needs. With it being the last year of the current CET cycle, we will be putting on a variety of peer discussions and recommend that our members attend these at their earliest opportunity. More information on the events programme is available at www.aop.org. uk/events-and-education
52%
of AOP members use OT as their primary way of finding their next job.
To discuss how you can target ambitious professionals, contact: Richard Ellacott richard.ellacott@thinkpublishing.co.uk 0203 771 7248
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Back to the roots
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Bird Sunglasses has launched a limited edition collection featuring real leaves. The ‘Pluma’ frame is made through a 15-day process to bring out the structure of a leaf using only water. After drying, the best leaves are arranged by hand in sheets of bio-acetate. Speaking to OT, Bird Sunglasses founder, Ed Bird, said: “We’re passionate about reframing what matters, pioneering beautiful eyewear that makes a difference and leaves little impact on the world. Our Pluma frame embodies a love of nature in a functional form.” www.birdsunglasses.com
FOCUSES ON... SUSTAINABLE EYEWEAR
SUBS ART PRODUCTION
Hit list
The trends, launches and looks
CLIENT
Bio-based design
Neubau launched its fully bio-based line of frames in 2020. For 2021, the brand is focusing on ‘Changing the perspective,’ drawing inspiration from the four elements. The new styles aimed to capture the “paradox of nature’s resilience and fragility.” The collections will include a mix of sunglasses and optical frames, featuring sustainable materials such as the brand’s naturalPX (65% bio-based) and natural3D (100% bio-based) materials. The ‘Water’ line was released in January with others to follow throughout the year. www.neubau-eyewear.com
Natural materials
Hemp Eyewear has released a new optical frame using organic hemp and turmeric. The designers utilised the vibrant spice as one in a range of natural pigments used in its collection, from blueberries to beetroot. Sam Whitten, founder of Hemp Eyewear, said: “We wanted to push the boundaries of our sustainable technology and develop exciting new combinations. Turmeric was the perfect choice for a bright, vibrant colour with a positive impact on the planet.” www.hempeyewear.com
Planet positive
Last year, Coral Eyewear launched its ‘Endangered Collection’ of sustainable eyewear. In February 2021, the sustainable brand is launching a new limited-edition frame, designed in collaboration with the Formula E racing driver, Alexander Sims. The new style updates the brand’s ‘Albacore’ frame, with red UVA/UVB polarised lenses, in a nod to Mr Sims’ team, Mahindra Racing. The frame is made from Econyl, pellets of recycled nylon made from discarded fishing nets and fabric scraps. www.coraleyewear.com
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Q&A ME AND MY GLASSES
Optometrist and lifestyle blogger, Lizzy Yeowart, takes inspiration from a trending colour
SUBS
Pantone’s ‘Ultimate Gray’ and ‘Illuminating,’ taken in combination, make the Pantone Color Institute’s ‘colour of the year’ 2021. Practical and rock solid, warming and optimistic, this union is one of strength and positivity.
ART PRODUCTION
Bright statement
CLIENT
Caron Kraitt
This black, grey and yellow clubmaster frame from Area98 will suit all face shapes and makes a confident, funky statement. Area 98, ‘Kaos’ KK473 in colour 020 www.area98.it/collections/kaos
Eyewear designer and owner of Caron Eyewear talks style influences, and launching during the pandemic
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I would say I own between 15 and 20 pairs of spectacles and sunglasses. My favourites evolve over time and with fashion. I tend to choose frames with a beautiful shape and structure. I am a fan of bright colours or, better still, bright accents against a dark frame. This makes for a versatile piece, but with that oh-so important personality.
Eyewear is the perfect accessory. It reflects your mood, it describes your style, it can be tailored to an occasion. I have never understood those willing to spend thousands on their wardrobe but neglect their eyewear. People wear a different outfit every day, so why not have different eyewear? A quality frame can be the finishing touch to a stylish look.
I have over 20 years of experience in optical design and a background in optical dispensing, so everything I create is beautiful, but also wearable. I felt that now was the time to bring my skills to my own brand, inspired by modern women who are unafraid to celebrate their femininity alongside their strength and independence.
Launching in a pandemic could be seen as a gutsy move. The launch was delayed but during that initial lockdown, I used the time to introduce my brand directly to the independent market and build awareness. It became clear to me that the independent market was looking for something more than mainstream fast fashion.
A ray of sun
Kirk & Kirk sunglasses are handmade in France from a custom acrylic. This vibrant earthy shade of yellow is an excellent choice for a modern individual. Kirk & Kirk, ‘Martina’ in colour Earth 1 www.kirkandkirk.com/product/martina
Glossy glow
This fabulous frame is inspired by the world of make-up: shiny glosses, eyeliners and varnishes, and features distinguished corners. These fine lines in epoxy add feminine, feline flair. Boz by J F Rey, ‘Koraly’ BZKORALY4050, www.jfrey.fr/en/produit/boz/koraly
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Simplicity and industrial twists
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The independent Italian label, Tree Spectacles, has expanded its collections with two new series; the Light Series and Block Series. The Light Series features women’s models, ‘Eve,’ ‘Chimera,’ and ‘Grace’ which are all crafted from Japanese titanium. The Block Series features the ‘Aubis’ (pictured), ‘Serse,’ and ‘Ramsete,’ unisex models that feature block titanium with beta-titanium and acetate. The sides design features an external/internal titanium construction technique, while the acetate covering offers comfort. www.treespectacles.com
SHORTLIST THE LATEST PRODUCT LAUNCHES
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Frames
Welcome to the 60s ART
Gigi Studios has presented its 2021 collection with 18 models. The new silhouettes in the collection are inspired by the “opulent, oversized” shapes of the 1960s and 70s. Twelve of the frames – six optical and six sunglasses – have been designed and created completely from acetate. The ‘Kaia’ (pictured) features an over-sized, hexagonal design made from acetate with thick sides and a triangular metallic detail on the end piece. www.gigistudios.com
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Drops
Multitasking dry eye relief
Children
Secure fit
For 2021, the Michael Pachleitner Group has introduced Spect Eyewear’s first frame for children. The frame features the brand’s Wing DTS system, which comprises a subtle slider for extendable temples to ensure a secure and comfortable fit. The company suggests this technology guarantees the best grip when cycling, running, playing or at school. The ‘Blossom’ and ‘Brave’ models are available in five colours and are made of TR90 for a light-weight but robust structure. www.michaelpachleitnergroup.com
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In January, Visufarma launched what it described as the first innovative multitasking eye drop for the relief of evaporative dry eye. The VisuEvo contains Omega-3 fatty acids, which the company suggests helps to reduce excessive evaporation of the tear film. The Omega-3, along with vitamin D and phospholipids within the VisuEvo, also help to protect the eye and aid in restoring the tear quality. The eye drop has a preservative-free formulation containing natural components, making it a contact lensfriendly option. www.visufarma.co.uk
To feature in OT’s Hit list, contact kimberleyyoung@ optometry.co.uk
Occluder
Hands-free visual assessment
Grafton Optical has launched the Optishield, a flexible optical occluder to help provide a hands-free approach to conducting the visual assessment. The occluder is CE-approved and made of a soft medical-grade silicone which fits onto the spectacle lens and is available in black or frosted white. According to a formative usability study completed by the Medical Devices Technical Evaluation Centre at Birmingham University Hospitals, the product has a high level of acceptance from optometrists. www.graftonoptical.com Lensi
Myopia solution
Hoya confirmed its plans to begin rolling-out its Miyosmart lens for myopia management in the UK from February. The spectacle lens features patentprotected Defocus Incorporated Multiple Segments technology (D.I.M.S technology), which offers both sharp vision and a treatment effect for children. The lens has been shown to slow the progression of myopia on average by 60% based on the results from a two-year clinical trial, the company said. The lens has been made from an impact-resistant material with a specific anti-reflection coating, and can be used in combination with any type of frame. www.hoyavision.com/uk
Frames
Evergreen frames
Stepper Eyewear marked 50 years by revisiting some of the brand’s earliest styles with a range of new colour options. In the ‘Stepper Eyewear First Collection’, the retro SI-20073 style is now available in a selection of modern colour options, with founder, Hans Stepper, calling the frame “evergreen.” The company can now draw on materials such as TX5, titanium and betatitanium for its frames. www.steppereyewear.com
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HITLIST SHORTLIST, 1
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REPRO OP
LUMENIS
Sergio Solarino, MD
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Q&A BEHIND THE BRAND
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Paris Hatzianastasiadis, Lumenis sales and marketing director, Vision, for EMEA, on a new pilot programme
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LUMENIS
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Lumenis is a 50-year-old company that started in ophthalmics and expanded to dermatology, aesthetics and surgical solutions
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In 2020, Lumenis was acquired for $1.2 billion
CLIENT
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Lumenis' developments include the argon laser photocoagulator, selective laser trabeculoplasty system and the first intense pulsed light technology
ANATOMY OF A FRAME
Clockwise from left: Lumenis Optima IPL; the treatment in use; Paris Hatzianastasiadis
Can you tell us about Lumenis? Lumenis started with ophthalmic solutions and then ventured outward, and has set the pace for one of the major diseases of our time – dry eye. We have the golden standard in dry eye treatment through our platform, Optima IPL. What is Lumenis’ dry eye pilot programme for optometrists? We believe that most major procedures done by ophthalmologists have to start on a healthy cornea. To have a healthy cornea, the first thing you have to take care of is dry eye. We created reference centres in the Greater London area that provide training and education. If an optometrist wants to buy the technology, they would be able to go to that site, get trained and certified and then be able to use the solution safely. The optometrist can then prepare the patient by taking care of the dry eye and delivering them on to ophthalmology for their surgical procedures. We have seen that by operating this way, outcomes are significantly better. How was Lumenis affected by COVID-19? COVID-19 was something that nobody was able to predict and was a major shift in everyone’s way of business. The major shift, I think, was in sales. The traditional sales process was that you had a face-to-face with your contact. What we have seen now is that marketing plays a huge role in lead and demand generation. In 2021, we are going to continue using the new tools that we gained through this experience.
Quilted stitch and sophisticated patterns, reminiscent of chic, glamorous underwear
Couture details carried out by French artisans
OT columnist, Lizzy Yeowart
J F Rey
In a nutshell Manufacturer // J F Rey Frame // ‘The Lova’ Colour // Raspberry and fuchsia
Thin and refined metalwork pieces
One-piece face
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Perspectives Voices from optics and beyond
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“You are not alone. There is an emotional toll to the fitness to practise process – and this needs to change”
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Shamma Masud
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espair.’ ‘Anxiety and stress.’ ‘Retirement is the only way out for me.’ Having gone through a General Optical Council’s fitness to practise (FtP) proceeding, these comments are some of the firsthand views that AOP members have shared with me and other members of the legal team. In my role as a solicitor, I support AOP members who suffer emotional trauma and sometimes long-term mental and or physical health implications following an investigation – even if no action is taken by the regulator. This comes in addition to the financial impact and reputational damage that an FtP investigation can cause a registrant. The public needs to be protected, and a fundamental aspect of this is to investigate FtP concerns – but this must be fair, proportionate and support those practitioners under investigation. Interim order hearings, for example, must be prioritised and heard punctually where there is a risk to the public, the registrant, or is in the public interest – not several months after the incident concerned is reported. It is also important that registrants who are ill are treated, not punished. An investigation can often feel punitive, even if that is not the intended purpose. Regulatory sanctions are all aimed at protecting the public and upholding the public interest. Suicide is a risk that needs to be addressed by the system in addition to the rising complaints of mental health conditions being found in registrants subject to an FtP investigation. I am committed, along with my colleagues at the AOP, to continuous education in mental health and recognising the signs of
poor mental health and/or mental illness. What is your view? AOP members frequently cite feelings of acute Email OT with anxiety, stress, depression and avoidance, and your comments the legal team frequently hear statements to newsdesk@ the effect of, ‘I’ve not been able to read the optometry.co.uk correspondence I receive because it causes me such dread and anxiety.” In turn, and during FtP hearings, committees are now hearing an increase in mitigation concerning a registrant’s health status, which has been instigated or exacerbated by the duration of the investigation. This is the case for registrants who are legally represented, but the impact on registrants without legal representation or legal assistance is even more concerning and should not be underestimated. The regulatory system is already under strain – and it is unable to routinely adjust for registrants with mental health conditions either during the investigation or the hearing process. This was the situation both pre and “The regulatory during COVID-19, and we in the AOP team system is under are seeing greater anxiety and stress being strain – and voiced by members given the uncertainties it is unable regarding employment, health and finances. to routinely It is worth noting that complainants and witnesses in the FtP referral process also adjust for report that the investigation and hearing registrants with process can be protracted, difficult, and mental health isolating. I highly recommend that AOP conditions” members contact us as soon as possible after they receive a GOC notice of investigation. Unfortunately, my casework experience suggests that most complaints could have been dealt with by employers at a local level, but are not, and are then escalated prematurely to the GOC and the NHS. This prevents matters being settled amicably outside of the regulatory setting to all the parties’ satisfaction. The advent of remote hearings in 2020 creates further considerations to be mindful of. Signs of stress can be missed over a remote link. Potential for change My experience reveals practitioners have no confidence in the regulatory processes. Hearings
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Peer support The AOP Peer Support Line is a confidential, freephone helpline for members and nonmembers 0800 870 8401
are viewed as highly contentious, public, dragging on for months, even years, and this can have a tremendous impact on mental health and have a longstanding impact on a practitioner’s reputation. As far back as 2016, the GOC’s own research revealed that some registrants often reported being in fear of the GOC. What, then, needs to change to reflect and respond to these concerns? The Department of Health’s Promoting professionalism, reforming regulation consultation in 2017 sadly highlights how the approach of regulators needs to adapt: “A strong focus on fitness to practise and conducting cases in an adversarial way affects the outlook and culture of the regulatory bodies. The legalistic and defensive nature of the regulators can make them seem unapproachable and bureaucratic to both complainants and registrants.” The GOC has recently acknowledged that demystifying its FtP processes and procedures can help lessen anxiety amongst registrants and it has published its first FtP newsletter, which is aimed at providing all registrants crucial information about their regulator – read more on page 65. One of the first practical steps a registrant can take to empower themselves is to find out more about how the GOC fitness to practise procedures work through reading the bulletin and other guidance and the AOP’s guidance on GOC investigation and fitness to practise proceedings. Data released in 2019 by the Professional Standard Authority’s performance review of the General Optical Council also shows that cases were open for 112 weeks on average, noting: “The GOC’s performance against the dataset remains among the slowest of the regulators we oversee.” The GOC has designed new strategies to try to resolve this issue for example, producing acceptance criteria for fitness to practise referrals and implementing its triage process aimed at transitioning cases more quickly and efficiently. However, at the AOP we will continue to challenge unreasonable delays in investigations and hearings. For those members reading this article who are feeling stressed by a GOC investigation, your AOP solicitor is on hand to talk through your concerns. To feel daunted and helpless is understandable; the AOP Peer Support Line provides a confidential service if you need it, and the Samaritans also provide expert assistance.
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Shamma Masud is a solicitor for the AOP
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“When we encounter patient hostility, it is not about the domiciliary service we provide” Paul ChapmanHatchett
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uring the pandemic, and particularly during the second lockdown, the Care Opticians team has noticed a significant change in the mental health of many of our patients who we see in a domiciliary care setting. Patients are quicker to be critical of our service and to verbalise this. As an employer that sends colleagues into people’s homes, this is an increasing concern. As an example from December, I arrived 25 minutes early to an appointment with a couple in their late eighties living in their own home. The Care Opticians team have visited them on several occasions over the last six years. As the door opened, the husband advised me how totally unacceptable it was to arrive so early. I politely suggested that I wait in the car until the correct time. However, this suggestion exacerbated his bad mood further. I made the decision not to set up my testing kit, but just to listen to him. We chatted about the new world we found ourselves in, as his wife with advancing dementia came in and out of the lounge. Prior to March, he explained to me, he used to have regular respite care several times a week, but this had stopped during the pandemic. I completed the eye tests on both of them and prescribed him with some intermediate glasses so that he could see his computer screen more clearly, which had been his lifeline with family over the last eight months. As I went to leave, I turned to say goodbye and the atmosphere at his door could have not been more different to my arrival. He looked at me and said, ‘do you know, you are the first person I have had a chat to, outside of my family, in eight months.’ The price the elderly and more vulnerable members of our society have paid during this pandemic has been huge, especially on their mental health. As a domiciliary optometrist, the ability to listen has become an even more important part of our role to our patients.
Our housebound and vulnerable patients deserve our empathy and kindness more than ever before. We should be mindful that, when we encounter this hostility, it is not really about us or the service we provide. Hard as it is, we should not take these outbursts personally. I am experienced enough to process what happened in this anecdote; my reason for sharing is that I hope this serves as a source of encouragement to my peers who may be less experienced and less resilient when faced with this scenario. It is likely to be a factor in domiciliary care for some time. Paul Chapman-Hatchett is CEO and clinical director of Care Opticians
“To achieve such a seismic change in the certification of a vision pathway in Wales is no small feat” Rebecca Bartlett
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he Certificate of Vision Impairment plays an important role in the life of a person with vision impairment. Certification enables collection of data on the prevalence and causes of sight loss to inform the effectiveness and planning of services, and in England has an additional role as a public health indicator. It is the precursor to Registration of Vision Impairment with the local authority – a process which ensures access to support and services for people with a vision impairment. The Low Vision Service Wales (LVSW) is the national primary care-based rehabilitative service, provided across Wales by accredited practitioners (optometrists and dispensing opticians) who hold the College of Optometrists professional certificate in low vision. Annually, over 10,000 LVSW assessments are performed. Many of the people seen within the service have a vision impairment that would warrant certification. However, despite this, the majority of people report not being certified. Professionals who provide low vision rehabilitation will know that this is not an unusual situation. Many people with low vison do not routinely attend the hospital eye service.
Therefore, certification often necessitates a referral to secondary care – something which people are not always keen to accept. This situation is compounded by the fact that hospital eye service clinics are busy, and people can experience long waits. Driving change Currently, only consultant ophthalmologists are able to complete the certification process. A solution to ease the burden on secondary care is the expanded role of the low vision optometrist in the certification process. The benefit to patients would be access to certification in a timely manner, closer to home. A study I co-worked on sought to assess the agreement between LVSW optometrists and a consensus panel, in identifying patient eligibility for certification, relative to the agreement between ophthalmologists “A certification and the consensus panel. pathway The findings were supportive of introduced into the clinical decision-making ability of LVSW optometrists in the certification primary care of vision impairment and provided must meet the evidence in support of policy change needs of people to allow low vision optometrists to with a vision certify individuals with atrophic AMD. impairment, and As a result of the research, the Wales be deliverable by Eye Care Services committee, which oversees delivery of primary eye care LVSW optometrists in Wales, instructed a task and finish in a manageable group to be established – the aim of way” which was to explore how certification could be offered for people with atrophic AMD, within the primary care setting. To achieve such a seismic change in practice is no small feat. The process of certification is engrained in the role of the consultant ophthalmologist, and in Wales, a Welsh Health Circular outlines the role of the consultant ophthalmologist in this process. A certification pathway introduced into primary care must meet the needs of people with a vision impairment, be deliverable by LVSW optometrists in a manageable way, and the quality of data collected as part of the process, which is so valuable in informing our knowledge regarding causes and prevalence of Read more The findings of sight loss, must be maintained. Rebecca Bartlett is optometric advisor for the Hywel Dda University Health Board, and clinical lead of the Low Vision Service Wales
February/March December 2021 2017
Rebecca et al’s study appear in Eye www.nature.com/ articles/s41433020-0860-x
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At the 2020 Annual General Meeting of the Association of Optometrists on 4 November, the roll of AOP members that have died from May 2019 to October 2020 was commemerated.
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Mr Brian Airey, Varen Mr Ramesh Amarnani, Wednesbury Ms Jeanette Andrews, Wigan Mr David Armitage, Halifax Mr Emmanuel Ascher, Pinner Mr Michael Atkinson, Colchester Mr Malcolm Bailey, West Midlands Mr Ivor Baker, Oxford Mr Keith Bennett, Bradford Mr Maxwell Bernard, Watford Mr Malcolm Broad, Stoke-on-Trent Mrs Shirley Cameron, Johnstone Mr David Cameron-Davies, Waterlooville Mrs Jill Cheney, Walsall Mrs Elizabeth Coghlan, Cuckfield Mr Stephen Cohen, Newcastle-upon-Tyne Mr Joseph Cohen-Setton, Beckenham Mr Colin Collett, Sidcup Mrs Valerie Collier, Tredegar Mr Matthew Collins, Abergele Mr Michael Cooper, Enfield Mr Peter Critchley, Musselburgh Mrs Jennifer Cross, Rickmansworth Mrs Judith Cryer, Malaga Mr Timothy Davies, Cardiff Mr Stuart Docherty, Alexandria Mr John Doris, Downpatrick Mr Ronald Dyer, Bristol Mr A Egginton, Sheffield Mr John Ellis, Coventry Mr Kenneth Ellis, Ferndown Mr David Evans, Guildford Mr Roger Farnsworth, Hove Professor Robert Fletcher, High Wycombe Mr Charles Frydman, London Mr John Gardiner, Cardiff Mr Erick Gratrix, Tetbury Mr Robert Green, Morpeth Mr John Gunton, Blaenau Ffestiniog Mr Thomas Hair, Glasgow Mr Munirali Haji, Birmingham
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Mr William Holley, Coleraine Mr Andrew Hulme, Solihull Mr Peter Jacques, Isle of Lewis Mrs Andrea Jenkins, Chesterfield Mr John Keay, Goole Mr Kenneth Kennell, London Mr D Lockyer, Dorset Mr C MacPherson, Aberdeen Mr R Mallett, Brentwood Mr Cyril Marks, Orpington Mr John Moore, Canterbury Mr R Morgan, Worcester Park Mr Rashiklal Morjaria, London Mr Vishnuthavan Naidoo, Newcastle-upon-Tyne Mr Daniel O’Hara, St Austell Mr Frank Oldaker, Nuneaton Mr Meurig Pari-Jones, Doncaster Mr Malcolm Parris, Sevenoaks Mr Jonathan Partridge, Shrewsbury Mrs Nynisha Patel, Blackburn Mr David Paulsen, West Sussex Mr Roger Payne, Bath Mrs Madeleine Pennington, Blanchland Mrs Anna Pestell, Wokingham Mr L Powell, Ilkley Mr T Purce, Newtownabbey Mrs Anne Sergeant, Forest Mr Amil Shah, Middlesex Mr James Smith, Leicester Mrs Isobel Tarshis, Edgware Mr Gordon Turner, Guildford Mr Hyman Wexler, London Mr John Wheeldon, Knutsford Mrs A Wieland, Cambridge Mr Glyn Williams, Westcliff-on-Sea Dr G Williams, Swansea Mr Leslie Woodhouse, Blackpool Revd David Woods, Penzance Mr Kenneth Worden, Chester
Gerda Goldinger: a tribute A WARM, WISE AND SUPPORTIVE COLLEAGUE WHO WENT THE EXTRA MILE FOR AOP MEMBERS The AOP has paid tribute to Gerda Goldinger, former director of legal and regulatory, who has died suddenly of cancer. AOP’s chief executive, Henrietta Alderman, said that during Ms Goldinger’s 11 years at the AOP, she “did all she could to keep AOP members safe. She had an eye on protecting the future provision of AOP legal services by enabling members of her team to thrive. Gerda had a complete understanding of what it means to serve members – guiding, supporting and giving excellent advice. Our members knew she would go the extra mile for them and absolutely fight their corner.” Ms Alderman added that Ms Goldinger built strong relationships and was well respected within the sector and outside. “For those of us fortunate enough to work with her, Gerda was thoughtful and kind, with a lovely sense of humour. All our thoughts are with her family,” she said. Ms Goldinger joined the AOP as legal and regulatory director in January 2008, having worked at Collins Solicitors for over seven years. Former AOP chair of the board, Trevor Warburton, told OT that he remembered his first meeting with Ms Goldinger well. “As the AOP chair at the time, I was on the interview panel for the role of legal and regulatory director. There were three or four candidates, but Gerda was the most suitable by a country mile.
“She was lovely, very approachable and always concerned for our members, whether with general advice, or those under investigation by the GOC,” Mr Warburton said. Former colleague, and current AOP director of legal and regulatory, Ella Franci, told OT that she had the pleasure of working with Gerda for 10 years as both a manager and as a friend. She said: “Gerda was an extremely warm, wise and supportive colleague, who fought extremely hard for AOP members in many different forums, including at the GOC before fitness to practise committees. In doing so, she earnt a great deal of respect, not least from me, and I know that those AOP members who were fortunate to have her fighting her corner will be very sad to hear of her passing. My thoughts continue to be with her family and friends at this sad time.” She is survived by her second husband, David Craig, whom she married in 2019, and her two sons, Daniel and Sam, from her first marriage. Gerda Goldinger former AOP legal and regulatory director; died 16 November 2020
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MY VISION REPRO OP
“Vision is where everything begins” Luke Patience
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If you go into the detail of our sport, one of the hard ailing has been my sport since I was seven years old things is that the wind – our engine – is invisible. When and I am 33 now. I have spent a long time on the water, being exposed to direct sun and its reflections. I look out at the ocean, I don’t just see water. I am trying to assess tiny differences in colour, to see if the ripple or I had started to see slugs diving across my vision and waves are slightly higher in some places than others. when I looked at my eyes in the mirror, I saw that there Those minute variations tell me if there is more wind. It was a wee lump on the white part of my eye. I had an is the water painting a picture for you. Reading the ocean eye test and the optometrist told me that my vision was is a skill that you get better at. You just need to have the fine, but I had to be really careful and wear my sunglasses patience to really look – not just to glance – but to stare because I had UV damage. and see the differences. Sunglasses are my best The best thing about protection. When I am sailing is the creativity out racing my boat on the and the adventure of it. water, it might be quite It is such a wonderful an overcast day, and you thing. There are no lines could think, ‘Well there written in the water like is not much glare, I don’t there are on a tennis need to wear my sunnies.’ court or a running You absolutely do because track. It is for you to there is still glare through carve your way through clouds. You can still get however you think is UV damage. best. It was that that What is really good hooked me in the first is having a selection of place. I became addicted different lenses. I need to the sport because of to wear the right lenses creative it felt. on the right days. Some “There are no lines written in the water like how I spent more time off enhance the light and there are on a tennis court or a running the water during the some are darker, and the track. It is for you to carve your way first lockdown than I polarized lenses allow me through however you think is best” had since I was six years to see contours when there old. I was in the North is a huge amount of glare. West of Scotland on an island called Tiree, which has a Vision is where everything begins. It is colour; it is how population of around 650. I had dreams about sailing. you interact with people and read. I couldn’t imagine It was weird to suddenly stop something that has been a world where I couldn’t see. A lot of vision loss is such a normal part of life. preventable. I am really hoping that I don’t look back on The highlight of my career so far is my Olympic medal these years if I am not able to see anymore and think ‘I in London 2012. There were many years’ work that went wish I could have done more.’ into that. The opening ceremony is the memory that I Sailing is almost entirely a decision-making sport. We will return to; the power of being in the tunnel at the gather our information for decision-making visually, stadium. We heard people stamping their feet and calling through our eyes. We have to assess what we see, out ‘Team GB.’ When we came out of the tunnel there make a decision and act on it. If we have bad races it is was this explosion of confetti. That is a memory I will fundamentally because we didn’t gather enough facts to never forget. make a good decision.
Patient leaflets The AOP has produced a series of downloadable eye condition leaflets www.aop.org.uk/patients
British sailor, Luke Patience, won a silver medal at the 2012 Olympics and was selected for the 2020 Tokyo Olympics (now postponed until 2021). He is a sailing ambassador for international eyewear brand, Bollé. Bollé is also an official supplier to the British Sailing Team.
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My Vision
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Discussion VERSION REPRO OP
In practice 47 Pre-reg focus
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Luke McRoy-Jones discusses his typical day, four months into his pre-reg placement
49 How I got here
Optometrist Michael O’Kane on his passion for fighting sight loss with technology
Business insight and career development
51 What I have learned
How creative responses to professionalism and cultural awareness can aid understanding
53 How do I...
Implement dementia awareness training in practice? Raj Gill explains how he did it
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here is no doubt that the way optometrists manage patients has changed over the past year. From remote consultations and PPE, to delivering replacement spectacles to those who are shielding, the profession has had to adapt in ways that would have seemed unthinkable at the start of 2020. Optometry did adapt, though, finding ways to address both existing issues and those that were not apparent pre-pandemic. Going remote, for many, was a key way they found to continue serving patients What of the future, though? Will teleoptometry become a staple part of day-to-day practice? OT and CooperVision asked a group of experts about their experiences, and what they think the future of teleoptometry will look like.
PRODUCTION CLIENT Getty/Anastasia Usenko
Before the pandemic
The panel described a landscape that was undeniably varied at the outset of last year – from practices that had been using aspects of remote consultation and care for years, to those that had never encountered a need for it. Lynne Fernandes, an IP optometrist and Bristol-based practice owner, explained that pre-pandemic she “wasn’t in the remote care mindset at
THE ROUNDTABLE
Teleoptometry, the pandemic and beyond Experts from across the optometry spectrum discuss their experiences of the last 12 months, and what they think teleoptometry’s place will be in the future
all… I wasn’t looking for any advances in technology.” At the same time, she was aware that there was often a reluctance for contact lens patients to visit the practice, especially if they didn’t feel
they had any pressing issues to discuss. In Scotland, Julie Mosgrove, Duncan and Todd’s retail director, believes that “remote triaging, to an extent, was already there.”
“If you ask the same things that you would if that patient was sitting in front of you, you’re gathering the same data” Vijay Anand, deputy head of optometry at Moorfields
As the first port of call for emergencies since October 2019, Julie was already used to triaging over the phone when COVID-19 hit. The same was true of multiples, according to Helen Thompson, a contact lens optician and practice manager at Boots Opticians: “We had triages over the phone, so our clinicians were already experienced at reviewing
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“We’ve learned to lose the guilt that every piece of working time has to be spent in front of a patient” Nick Rumney, BBR Optometry
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details taken down by colleagues,” she explained. “Anything else was kind of unheard of.” Nick Rumney, owner of BBR Optometry, described using “NHS.net, where we had been regularly asking for consultant opinions,” for eight or 10 years. Vijay Anand, deputy head of optometry at Moorfields, echoed this collaboration as something that had been “happening quite considerably for a number of years in medical retina and in glaucoma clinics.” He also identified the Pando app, used by ophthalmologists, which allows photographs to be distributed for specialists to respond to. In January 2020, the app was being used at Moorfields to avoid consultants having to be called, and while staff were in urgent care clinics or A&E. Contact lens focus
Helen said that Boots has been “able to keep a huge number of patients in contact lenses safely” through the use of teleoptometry. “We know that some of our contact lens patients aren’t as compliant as we would like, or as they might say,” she told OT. “If we had stopped lens supply because we were unable to see them, what would they have done?” She envisaged a situation where patients would dig out old glasses as a solution, use the wrong contacts, or
44 www.optometry.co.uk
go online and find a supplier outside the UK. “I think it was vital for everybody to find a way to look after our patients so that they could safely wear lenses,” Helen said. “That was our biggest thing: to make sure we could look after them safely if we couldn’t see them physically. That was our driving force.” In Bristol, Lynne had success implementing a remote aftercare clinic for her contact lens patients using Advanced Ophthalmic Systems (AOS). She said: “Every single patient that’s due has remote aftercare, in our remote aftercare clinic, where we have patient after patient. They can send in images and videos of their eyes, which we can then grade, create a report, and send back. It’s a 15-minute appointment… it’s really streamlined.” Whilst hugely useful, Lynne doesn’t believe that in-person contact lens care will ever disappear completely. “We’ll still get them in every two years if they’re not having any problems and we’re not worried about anything,” she said. “For aftercare for those who have been fitted with contact lenses, rather than getting them in at the end of their trial, we’ll use the AOS software instead.” Julie said that communication was key for contact lens patients at Duncan and Todd. They were
“quite surprised to hear from us,” she said, and “delighted that they could speak to someone about their contact lenses. They were relieved to know that their supply wasn’t getting stopped; that was a worry for a lot of people.” Patient communication
Vijay explained that, at Moorfields, the communication concern came from the complexity of cases that would usually be seen. With 70–80% of patients rigid gas permeable (RGP) wearers, there were worries that reduced corneal sensitivity would make patients less likely to notice irritations that soft lens wearers might pick up on immediately. “Those are the
ones that you tend to find when they come in and say ‘oh, but there’s nothing on my lens,’ and you look at the eye underneath and it’s an unhappy eye,” Vijay said. “That was the sort of thing that we were worried about.” So, how was this risk mitigated? Vijay told OT that his department contacted 4000 of their contact lens patients over a four-month period, offering virtual aftercare and then triaging them into high, medium and low risk categories to determine how long it could be before they were seen again. A similar process was enacted for new referrals. A positive of this new approach, Vijay said, was “the sense of gratitude that these patients had – that
OVERCOMING THE CHALLENGES OF TELEMEDICINE Julie: “We were worried about how patients would respond: would they want to do this over the phone? But it quickly came clear that they wanted to give us as much information as they could.” Vijay: “In the hospital, anything that we do has to have either a standard operating procedure or we have to have the governance behind it, and obviously all of this had to happen and get signed off very quickly. That was probably the biggest challenge to get over.” Helen: “Our patients were surprised that we were willing to do something over the phone for them, which then turned into really grateful and understanding patients. It was a two-way conversation, and they felt really quite relaxed to talk about things.”
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they didn’t feel that they’d been lost in the system somewhere.” Often, solutions to improve the management of contact lens patients remotely can be remarkably simple. Lynne, Julie and Helen all reported that follow up calls three to five days after a fit improved the rate of wear in their contact lens patients. When on a call, Lynne said that she directs patients to video guides on the CooperVision website, as well as to her practice’s own YouTube channel, because “people forget what they’re doing almost instantly when they leave the practice.” She also recommends the use of My Lens Life – www.coopervision.co.uk/ practitioner/my-lens-life – and improved success in new contact lens wearers, which offer daily reminders and advice, so that patients are coached through the first weeks of wear. Helen emphasised the importance of a practice website, especially in the management of younger contact lens patients. “Lots of them would come in for their appointment knowing what to expect, having watched videos on how to apply and remove a lens, and be really confident with it,” she said. “And we’ve found that children are much better at learning that way than adults.” Quality conversations
Safety is a continued priority in 2021, Lynne emphasised, with her perspective shifting away from one that assumed “proper aftercare” only meant patients coming
into the practice. There are still things to work out, she acknowledged: “It’s not perfect, there are teething issues… But it’s safe, and it’s secure, and you get that good two-way conversation. Patients love the convenience; they love the time saving.” At Boots, Helen has also seen patients feeling increasingly comfortable with remote rather than inperson consultations. She noticed that “they felt relaxed enough to ask questions that they might not have done in practice, where they can feel intimidated or that they need to get on to the next thing.” She added: “I think the quality of the conversations were just as good as if we were seeing them face to face. We had that opportunity too – if the patient is worried, or if we’re worried about what they’re telling us, we can bring them in. I think patients feel that they can be more honest; they aren’t feeling like they’re being judged.” Remote consultations, Lynne believes, are likely to completely rewrite the system of contact lens patient care in the future. For new or lapsed patients, she said, “we need to be sending information before appointments – for example videos on what to expect when popping your lenses on and off your eyes. The appointments are going to be shorter, because we’re trying to minimise contact time. You need as much information as you can beforehand.” She listed clear communication on when and how patients will be contacted, the setting up of
“We need to be sending information before appointments” Lynne Fernandes, Lynne Fernandes Optometrists
remote aftercare clinics across the practices, and using technology to keep close contact generally as key aims for the future. Stepping up
Julie foresees huge benefits for patients in the longer term. She said: “The patients love virtual consultations; I think we’re going to really struggle to get them back into the test room.” She believes that dropouts will reduce, “because we’re able to talk to them more, get more of an understanding, or tweak things.” Vijay also envisages a future where certain contact lens patients can be seen in person less frequently. He imagines patients, once stable with their lenses, having their interim appointments via videocall, with an inperson appointment booked if needed. He hopes that this system will increase appointment capacity, reducing the time that patients might need to wait. “If you’ve got a daily disposable lens wearer that wears lenses for sports once or twice a week for a couple of hours, then coming
in yearly is probably not suitable,” he said. “Actually, a two-yearly check is probably fine.” Nick believes that a shift in mindset is needed. “We’ve learned to lose the guilt that every piece of working time has to be in front of a patient,” he said. “There are things that you can do in terms of planning, staff, education processes, even administration, that make a difference to the efficient running of the practice. “But there are practitioners who think that all they have to do is turn up to see a patient for however many minutes, do their normal examination, and everything will stay the same. Well, the only thing that’s sure is that nothing will stay the same. We will see some practices fade away because they can’t cope. But we’ll also see practices jump forward.” Vijay also believes that optometry needs to step up its game in 2021. “I don’t think we would have got as far as we will do without these last months having taken place,” he said. “It’s going to be a real eye opener for people. I think everything’s really changed.” For practices that haven’t taken on teleoptometry, he advises taking “a step back and seeing the other things that the medical professions are doing. See that you can do all of these things without actually physically being in front of the patient.” OT video To watch the roundtable, hosted by OT and CooperVision, visit www.youtube.com/c/OptometryToday_AOP/videos
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“My day doesn’t stop when the practice closes”
OT skills guidesI Get in touch to tell us about your own experience – email: lmiller@aop.org.uk
Pre-reg optometrist, Luke McRoy-Jones, on balancing work and study and preparing for his first assessment
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he end of 2020 marked the end of an incredibly challenging year for society and the profession. What was supposed to be the year of vision quickly turned out to be a year of disruption, restrictions and for some, loss, as we faced the biggest challenge of our lifetimes. As I write this, hope lies ahead for 2021 thanks to the incredible scientific effort to get vaccines developed. Despite all of the disruption, I was grateful to be able to start my preregistration placement at Merthyr Optical Centre in September. The end of the year marked the end of my first three months in practice. At the time of writing my last piece, I was seeing around four patients per day. Over the past few months, I’ve gradually worked up to seeing up to eight patients per day and I’ve now accumulated over 300 eye examinations, as well as over 150 dispenses. My typical day usually starts with some preparation.
Emily says…
When I first get in, I prepare the consulting room, change into my scrubs and PPE, and then spend some time going through the patient records for the day. This begins with looking at some basic aspects, such as the patient age and if they are presenting early or on time for their eye examination, before analysing in more detail to determine any health conditions, ocular history and the outcome of their last eye examination. I find this massively helpful as it means I am more organised and fluent with the patient. It allows me to start to build up an idea of what questions I’ll want to ask during the history and symptoms and what clinical tests may be necessary. Furthermore, it also provides the opportunity to identify certain conditions, medications or symptoms that I may want to read up on, or ask my supervisor about, ahead of seeing the patient. I now get around 50 minutes to perform an eye examination and dispense, if required. In addition to I’ve prepared for the start of my pre-reg by… packing up everything that I might need, and moving it all to London. It's hard because I feel like I’ve been out of practice for a while, since leaving university in March last year. I’ve tried to read around a bit, but it’s difficult to know what I need to know. Hopefully I’ll get into the swing of things.
routine eye examinations, I also perform contact lens fits and aftercares, as well as some acute appointments through Eye Health Examination Wales (EHEW). At the end of the day, I get some administration time blocked out, which allows me to catch up on some of the extra tasks that have cropped up in the day, such as writing non-urgent
it’s helpful to stay on top of the administrative tasks and revise a little every day. This means that tasks don’t mount up, which could be overwhelming. I also think it’s important to maintain a work/life balance and reward work with recreation, such as going for a walk or playing on the Xbox (as our recreational choices are fairly limited at the moment.)
“Over the past few months I’ve gradually worked up to seeing up to eight patients per day, and I’ve now accumulated over 300 eye examinations” referrals, completing GP reports as part of the EHEW scheme, and completing my logbook. However, my day doesn’t stop when the practice closes. On arriving home, I usually have some admin left to complete, in addition to any revision that I want to do. This can be challenging, especially after a full, tiring day in clinic. Nevertheless, I tend to find
I am yet to take any formal assessment as part of the Scheme for Registration. While the College allowed us to register and start gaining clinical experience, it wasn’t until recently that we were formally enrolled. As I look ahead to my first assessment, I look forward to making some progress on the Scheme for Registration and, hopefully, to an exciting year ahead.
I’m planning to balance work with study by… using my free time in the evenings to make notes and revise. I also plan to use the weekends to consolidate everything that I’ve learnt at the hospital during the week.
right at home here in London, as quickly as possible. I also can’t wait to start getting back into testing and can’t wait to see and learn about interesting pathology in the hospital setting.
The first thing I hope to achieve and learn is… that I get into a proper routine and feel
Emily Mather is a preregistration optometrist at Moorfields Eye Hospital
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“I think the Scottish optometry system is above anywhere else. I’m really proud to be part of it”
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HOW I GOT HERE
“I think it’s a brilliant career choice” PRODUCTION
Practice owner at Specsavers Morningside, Michael O’Kane, on how a fascination with technology has shaped his career
CLIENT
I remember being fascinated by a programme on the Discovery Channel when I was a teenager. It showed
the concept of attaching a camera to the brain of a visually impaired person, helping them see again. That embedded an interest in vision and research for me. I was accepted to study human cybernetics at Reading University, but I realised that the technology was in its infancy. I decided to study vision, and then come back to the technology aspect when it became more of a reality. I did my degree at Glasgow Caledonian, then my pre-reg in Boots at Princes Street in Edinburgh. Halfway through my supervisor moved to the Gyle, so I followed her to the Boots Opticians there. After I qualified, Boots asked me to work in Manchester.
I didn’t want to be away from my girlfriend, who is
now my wife, so I looked into surrounding opticians. I submitted my CV to a lot of independents, and worked at one of those. I had also bought my own equipment, because I was offered domiciliary work as a locum. I went on to work in a prison for a while. I was then offered regular employment with Dolland and Aitchison (D&A). My wife and I were looking to buy a home, and we found a three-bedroom house in Dunfermline for the same price as a one bedroom flat in Edinburgh. We moved to Fife and commuted an hour each way. Then Specsavers offered me work in Dunfermline, five minutes’ walk from my house. I went for an interview and was pleasantly surprised when I got there. The
independents that I had worked for, as well as Boots and D&A, had me believing
that there wasn’t the same level of professionalism or patient care in a large organisation. There is, and to be able to do it consistently and with such quantity of patients speaks volumes about the calibre of the optometrists that work at Specsavers. The directors enabled the staff to be the best they could be. While I’d been managed by good people, I’d never received that sort of leadership before. It was a delight, especially coming from cultures where I had to present a business case to get an Amsler chart replaced. I studied my IP at Glasgow Caledonian, and my professional certificate in paediatric eyecare at the University of Ulster.
I did them after work, booking holidays off for exams. When I studied for my professional certificate in medical retina at UCL, I travelled down to Moorfields a couple of times for faceto-face tutorials. My son was born in 2012 and then my daughter was born prematurely, so I had to put my IP on the back burner twice. The hospital could only offer half days, which meant a year of clinical experience before I was eligible to sit the final exam. I’d always aspired to have my own business. Given my
desire for all the clinical tech,
I had expected that I’d have to have a boutique optician to cover the overheads. But working at Specsavers, I realised that actually I could be the clinician that I wanted to be. I was accepted to do my PhD with Aston University, then the opportunity to open a branch in Morningside came up. I decided to seize the opportunity. I was working six, sevenday weeks for the first four or five years. My practice has never had a test time shorter than 30 minutes; at present I’m doing 45-minute appointments due to PPE and COVID-19. In Scotland, we have a first port of call system where GPs won’t see you; everybody has to go to the opticians if there’s a problem. Often, I prescribe medications for emergency walk-ins. I want to contribute to vision research in the long term, and help people with a severe visual impairment see again with the help of technology. I’ve started my
journey: I’m studying my master’s in investigative ophthalmology and vision research, and intend to do a PhD in vision research and neuro-development. I think the Scottish optometry system is above anywhere else. I’m really proud to be part of it. That’s part of the reason I became vice chair of Optometry Scotland. It’s world-leading. I want to be part of that.
Get in touch Share your career journey with OT. Email lucymiller@ optometry.co.uk
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wanted to trial it in optometry education. I wanted students to develop creativity and divergent thinking.
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Could you tell us about your creative project? Jonah Krznaric (JK): Every
WHAT I HAVE LEARNED
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“Cultural awareness is a very important skill to have”
PRODUCTION
Senior lecturer at The University of Melbourne, Dr Kwang Cham, and students, Jonah and Tiffany, share how creative responses to the topic of cultural awareness can enhance understanding
CLIENT
Can you tell us about your creative module? Dr Kwang Cham (KC): The
University of Melbourne offers a four-year postgraduate Doctor of Optometry programme. This project is embedded in the first year of the programme and requires each student to develop a creative piece that relates to professionalism and/or cultural awareness.
Jonah Krznaric
How important is cultural awareness to the patientpractitioner relationship? KC: As an optometrist, being
culturally aware will facilitate communication and allow trust and rapport to be built more effectively with patients. Rather than learning on the job, or, via informal interactions, it should be taught and assessed formally. These core attributes are often overlooked due to the emphasis on optometric skills and knowledge in an
already crowded curriculum. The teachings of it should be integrated and scaffolded across the programme. The learning of these attributes is continuous and it will take time for students to develop them. Areas that require further exploration include how to assess these areas and how students translate the learnings into practice. How does a creative approach help learning? KC: Prior to the pandemic,
students would undertake an object-based learning project. This concept came from my collaboration with Professor Helen Chatterjee and Dr Thomas Kador from University College London, and Dr Heather Gaunt, a curator at the Percy Grainger Museum at the University of Melbourne. The benefits of object-based learning on clinical education is well-established and I
individual has a unique perspective that has been formed from their own experiences and culture. As optometrists, we need to first be aware of cultural differences, and be sensitive to them. Then we can provide a service where cultural safety can be achieved for everyone. For my piece (pictured), I created nine eyes using different techniques to represent a variety of patients that I could potentially meet. Tiffany Lim (TL): The optometrist in my comic regards her patient with prejudice. However, on examining his fundus, something strange happens, and she sees the things that he has seen. The images were inspired by the experiences of my parents, who migrated to Australia having escaped the Cambodian Genocide. From these images, the optometrist in the sketch is able to gain some understanding of the patient’s life and the part that she plays in it. My comic was meant to emphasise the importance of letting empathy and awareness lead interactions with patients of all cultures and backgrounds. How do you feel the module has helped to prepare you for a career in optometry? JK: I think that being aware of
and sensitive to the different
cultures of the patients I will see in the future will help them to be comfortable and to trust us to provide the best care possible. Cultural awareness is a very important skill to have, especially in a profession such as optometry. I would like to think that in the future, this learning experience will have helped me to recognise cultural diversity in my patients so that I can give them the highest standard of care, no matter who they are or where they are from. TL: I have gained an
appreciation of the mental transition that must be embarked on from being a student to being a professional. I am reminded that solely theoretical and practical knowledge and skills aren’t sufficient to operate in a professional sphere which demands we engage with people and situations that do not follow any given formula or rulebook. When I practise in the future, I think these learnings will translate to an ability to access different approaches in order to practise patientcentred care. They are also preparing me to enter a wider healthcare landscape that goes beyond optometry and encompasses aspects such as collaboration with other areas of the community and other aspects of healthcare, but also the inequities. Share your story Get in touch if you would like to share your experience with OT kimberleyyoung@optometry.co.uk
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Make my practice dementia friendly?
AOP advice Read the AOP's guidance on obtaining consent from patients with dementia www.aop.org.uk/adviceand-support/clinical/clinicalgovernance/obtaining-consentfrom-patients-with-dementia
Raj Gill, co-owner of Specsavers Keighley, on how he rolled out dementia awareness training for staff across his two practices
SUBS ART PRODUCTION
Using resources at hand
Getty/Elena Volf
CLIENT
As with all practices within the group, our staff could utilise the dementia-friendly training from Specsavers, which comes in the form of online modules. The training was developed from information created by the Alzheimer's Society. Specsavers stores can find it by searching ‘dementia’ on ilearn; everyone who completes it receives a ‘dementia friend’ badge. For those not with Specsavers, the Alzheimer's Society has updated its training in light of the COVID-19 pandemic. The Alzheimer’s Society Learning Hub will offer courses in areas including supporting customers with dementia and creating dementia-friendly environments. Courses can be bought separately or in bulk. Dementia awareness training is also now available virtually for groups of up to 15. As a complement to this, I would recommend using other resources where possible. For example, we are
in a shopping centre, which has a care unit that allows carers to be able to do some shopping. We had staff from the unit brief our team as part of the training. Once the COVID-19 situation allows, you could also invite members of the team and/or customers with personal experiences to speak. People quite quickly switch off if you're throwing facts at them; stories tend to mean so much more. They give context and meaning, and I think that's important. Deployment of training
We found it effective to plan blended training. As the majority of training took place before lockdown, we had people coming into the store to share their stories.
“From a business perspective, if you open your doors to a wider audience, that's surely a winner”
There were sessions delivered by our in-store trainer, taken from the online content. We also had the Specsavers online modules, which we directed staff to. Between the two stores we've got over 100 staff. It took four weeks to get through the online modules. But it doesn't end there – it's something that's constantly reviewed. It’s an ongoing process. Dementia-friendly training is something that we now do as part of the induction process. Financing
The online modules are free via Specsavers, and the individuals that we had in to speak all volunteered. Prices on the Alzheimer’s Society Learning Hub start at £19 per module, and there are different lengths of training available to suit all needs. Modules can be as short as one hour, while virtual delivery courses are three or six hours. ‘Train the trainer’ sessions, allowing staff to train others, take up to two days. Practice owners will know whether or not this is a cost and time commitment that they can undertake. As we've become more inclusive, we are able to see people from broader backgrounds. We see more patients, and our team are better equipped to see these patients, which ultimately will pay for itself.
Making sure training sticks
It’s helpful to have an end of day huddle, where you go through what's worked well and what hasn't. We're always going to come across situations that we haven't experienced before. It’s helpful to highlight gaps. It’s important to get every staff member accredited. As the customer comes through the practice, they'll come into contact with lots of different people. Everyone needs to be ready to help.
Resources from the Alzheimer’s Society The Alzheimer’s Society Learning Hub helps learners recognise the signs of dementia, and provides practical skills to support people living with the condition. Short modules and half and full day virtual training is available. For information email dementiatraining@ alzheimers.org.uk The free Dementia Friends initiative aims to raise awareness and change perceptions of dementia, giving an understanding of the condition and encouraging people to take the actions that can make a difference to those affected. www.dementiafriends. org.uk
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“NO MATTER HOW GOOD YOU ARE, SOMETIMES THINGS GO WRONG”
SUBS ART PRODUCTION CLIENT Shutterstock
What one optometrist learned from facing a General Optical Council investigation
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raditionally, keratoconus patients were managed in practice as much as possible, but in 2013 corneal crosslinking was approved by the National Institute for Health and Care Excellence. I was unaware of this until I completed a CET on keratoconus in 2017. I had seen a patient with keratoconus twice since 2013 and didn’t refer him. The patient was seen in 2018 by an optometrist at another practice when his vision had deteriorated to the point where it was too late to have corneal crosslinking done. I became aware of the complaint when the patient’s mother called my practice just to get the clinical records. I changed the record cards on two occasions – when I first learned about the complaint and a few months later when the patient’s mum threatened legal action. Shortly afterwards, she complained to the GOC. It was a real shock when I got the letter from the GOC. I thought: ‘This is judgement day. I’m in really big trouble here.’ The GOC knew about the keratoconus and the clinical failings but they didn’t know about the record card changes. When I sent through the information they requested, I typed up a letter saying that I had made changes to the record card. At both points when I changed the record cards, I thought erasure was the inevitable consequence of missing pathology. That is not true. It highlighted the fact that I had no 58 www.optometry.co.uk
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IT WAS A REAL SHOCK WHEN I GOT THE LETTER FROM THE GOC. I THOUGHT: ‘THIS IS JUDGEMENT DAY. I’M IN REALLY BIG TROUBLE HERE’ clarity about the fitness to practise procedure and how the GOC work. I made the situation worse by doing something that potentially could get me struck off the register. I urge every optometrist to take their professional development seriously. The whole problem stemmed from my lack of clinical knowledge on this particular subject – keratoconus. I thought I was committing sufficient time for my professional development. Clearly it wasn’t enough. This whole experience has highlighted this. CET keeps optometrists in the know about what is going on and recent developments. It is vital. I ensure I commit at least a few hours every week to professional development. This would include, for example, gaining at least one CET point and reflecting on recent clinically challenging sight tests I may have conducted. I would subsequently search and read current or previous CET and watch online presentations on the knowledge and skills I feel I can enhance or refresh. One can’t eliminate the risk of being subject
to fitness to practise proceedings, however, with the myriad of clinical information and resources easily available, this risk can be minimised. No matter how good you are and how much professional development you do, sometimes things do go wrong. It is important for optometrists to realise this and ensure they are prepared. Unfortunately, most of my learning has been done in retrospect as a result of my experience. I didn’t share what had happened with anyone when the complaint first came in, out of embarrassment and pride. That was a big mistake. I only told my wife when I got the GOC letter so it was a complete shock to her as well. It is important to establish a support network – whether that be family, friends or colleagues – who you know you can go to no matter how small the issue is. It makes things so much easier and means you’re less likely to do something silly. You have that reassurance saying ‘don’t panic. Whatever happens, we will get through this.’ In my
Shutterstock
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An optometrist who was the subject of a fitness to practise case after he failed to refer a patient with keratoconus shares his story with OT
FEATURE, 2
case, my emotions got the better of me. I think I would have greatly benefited from sharing what had happened with anyone – a colleague, my wife or family. When I told the people closest to me about what had happened, they were all sympathetic and extremely supportive. Throughout the experience, the AOP has been really understanding. They have been honest and frank with me. They have been kind and I have felt that I haven’t been judged. I felt that they genuinely wanted to help. What I have come to realise and what I would urge optometrists to understand and appreciate is how important ethics are. Being dishonest cannot just harm yourself and your qualification – it is about the harm you are doing to the patient potentially and to the reputation of the profession; all the colleagues who work so hard to become optometrists and continue to work hard to serve their local communities. It has farreaching consequences. It is really important to keep in mind the GOC’s Standards of Practice. These are a set of values that are the cornerstone of our profession. Every decision that we make, every action and reaction, needs to be aligned with these principles. When things go wrong, you can’t deviate from those values. What I would say to all optometrists is that if you find yourself in the position that I was in, consider these standards and hopefully you will do the right thing. I never thought I would find myself in the position that I did.
TRIAL AND ERROR
The conviction of a UK optometrist of gross negligence manslaughter in 2016 had a far-reaching effect on optical professionals. Although the charge was later overturned, practitioners were left wondering if a simple mistake during their working day could see them face criminal charges. OT examines the use of criminal charges against healthcare workers in the UK
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wo hours on 15 February 2012 came to define the following eight years for locum optometrist Honey Rose. In the morning, she performed sight tests on two young patients and their mother. Both children had free retinal images taken (the receptionist told them their eyes ‘looked like Mars'), with the youngest child sitting on her mother’s lap as she was not tall enough to use the equipment unassisted. The retinal image software in Ms Rose’s room was not working so she asked another member of staff to bring up the images in the pre-screening area. When she asked for Vincent Barker’s retinal image, she was shown a picture of a healthy retina. This gave her a sense of reassurance when she later had difficulties performing ophthalmoscopy. However, Ms Rose had viewed the wrong image. If she had seen the correct image she would have observed, as an expert witness
described in the GOC hearing, “barn door papilloedema. You are never going to miss this in a month of Sundays.” Ms Rose immediately recognised the condition when later shown the images during a police interview. When asked what she would have done if she had viewed this image during the hearing, Ms Rose said: “I would have referred him straight away to the hospital.” But she did not view the correct image. In addition, she omitted to record the fact that she had been unable to complete ophthalmoscopy and also recorded the periphery of the retina
HONEY ROSE ON… THE AOP
“I had really good support during my case from the AOP. Without them, I don’t think I would have made it this far. You can trust that they will be with you throughout your career – during the ups and downs. They will support you during all of the hard times”
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as normal – even though this was not shown on the retinal photograph. On 13 July 2012, Vincent Barker died at home after becoming unwell at
school earlier in the day. The cause of death was later determined to be hydrocephalus.
The criminal trial Ms Rose was convicted of gross negligence manslaughter following a nine-day trial at Ipswich
Crown Court in 2016. However, this decision was overturned at the Court of Appeal with the court finding that the judge had misdirected the jury on the legal test that should apply to foreseeability. One of the three judges hearing the appeal case,
ART PRODUCTION
“AS HUMAN BEINGS, WE ALL MAKE MISTAKES” AOP solicitor, Emma Brindley, details the role of the Association during proceedings against Honey Rose
CLIENT
The AOP has supported Ms Rose since she first contacted us in September 2012. As is the case with many of our members who become the subject of a fitness to practise investigation, this was Ms Rose’s first ever complaint, and her first experience of the GOC. In the initial stages of any investigation, a large part of our role involves explaining to members what happens next and the procedural steps involved. More than that, however, we want our members to know that they are supported, and that they are in safe hands. The AOP’s legal team has spent nearly 600 hours on Ms Rose’s case alone. This is not a factor unique to Ms Rose’s case; the team devotes a huge amount of time and attention to each and every one of our members’ cases, often going above and beyond to ensure that our members feel supported every step of the way. Not only does the AOP legal team have a wealth of experience to draw on, but we take the time to understand our members’ individual situations and work tirelessly on their behalf to ensure the best possible outcome. It cannot be underestimated the amount of professional and personal investment that goes into these cases. During my time working on Ms Rose’s case, I made sure never to forget the emotional impact that the proceedings must be having on her. To that end, we made sure to hold regular conferences, ensured that she always had a point of contact, and encouraged her to contact us if and when she had any queries or concerns.
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Sadly, Ms Rose’s case only serves to highlight the pressures that our members face on a daily basis. Whilst there is absolutely no detracting from the devastating loss that the Barker family have suffered, the errors Ms Rose made on 15 February 2012 were momentary, inadvertent and not at all representative of her usually high standards of practice. Yet, it is those errors that have resulted in Ms Rose being suspended from practice for the best part of a decade, and those errors which Ms Rose will, undoubtedly, carry with her for the rest of her life. The key lesson that I have learnt from Ms Rose’s case and during my time at the AOP generally is that healthcare professionals are not infallible; as human beings, we all make mistakes. The important thing is to learn from those mistakes, remedy your practice and look to the future. When something goes wrong, it is very easy to forget all the things that you did right.
“When something goes wrong, it is very easy to forget all the things that you did right”
Sir Brian Leveson, explained: “All a reasonably prudent optometrist would have known is that, if he or she did not carry out a proper examination, signs of potentially life-threatening conditions might be missed. But this is a very different matter from knowledge that such signs in fact existed and that there was a 'serious and obvious risk of death'.” The Court of Appeal determined that the issues raised in the case were for the regulator rather than the criminal courts to decide.
GOC hearing
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A General Optical Council fitness to practise committee conducted a virtual hearing over 34 days in July, August and November this year. The committee ultimately found that Ms Rose failed to carry out an adequate internal eye examination, and aspects of her record keeping were substandard, inadequate and dishonest. She received a ninemonth suspension order. The committee concluded that her failings were “spontaneous and momentary,” relating to two hours on a single day. On the question of impairment, the committee found that Ms Rose had remedied the specific clinical failings identified and she was fit to practise “from a personal perspective.” However, the committee found that the registrant’s fitness to practise was impaired on public interest grounds. In January this year, the Professional Standards Authority announced that it would challenge the GOC decision in the High Court on the grounds that the sanction against Ms Rose was not sufficient to protect the public.
The broader impact Regardless of the outcome of professional conduct proceedings,
PEOPLE WERE SCARED JUST TO DO THEIR JOB AND THAT AFFECTS THEIR DECISIONMAKING PROCESS Dr David Nicholl the criminal charges against Ms Rose had a sobering effect not only on the optical community but on all UK healthcare workers. Ms Rose’s criminal case came two years after junior doctor, Dr Hadiza Bawa-Garba, received a suspended sentence for gross negligence manslaughter. Surgeon, Mr David Sellu, served 15 months in jail following his conviction for gross negligence manslaughter in 2013. The conviction was quashed on appeal in 2016. Although Ms Rose’s conviction was later overturned, optometrists were left wondering whether errors at work could leave them facing criminal proceedings. The use of criminal investigations against healthcare workers was examined through a rapid policy
review published in June 2018. Sir Norman Williams, who led the review, highlighted that healthcare workers were worried that simple errors could result in gross negligence manslaughter charges – even in the context of broader organisation and system failings. “There was a concern that this fear had had a negative impact on healthcare professionals being open and transparent should they be involved in an untoward event,” Sir Norman highlighted. Sir Norman noted that the death of a patient due to error has a profound effect on the healthcare worker – both psychologically and in terms of their confidence. “Such effects can then be compounded by an investigation that seeks to blame, rather than February/March 2021
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understand the factors that have led to the tragedy so that lessons can be learned to prevent further incidents,” he highlighted.
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In a system where individuals are held responsible, some groups are singled out more often. The Williams review highlighted that Black, Asian and Minority Ethnic (BAME) professionals faced a disproportionate number of both criminal and regulatory investigations. The General Optical Council is not immune to this trend, confirming in its annual report for 2018/2019 that BAME registrants were more likely to be referred to the regulator. The atmosphere of caution that followed Ms Rose’s criminal trial had a tangible impact on the number of referrals that optometrists made to secondary care. Research published in Journal of Neurology, Neurosurgery &
Psychiatry found that referrals for optic disc swelling increased threefold after 2016. “This was primarily due to a large increase in the number of referrals from opticians, which correlates chronologically with the case of missed papilloedema resulting in a [later quashed] criminal conviction,” the authors highlighted. Birmingham neurologist, Dr David Nicholl, launched a petition in 2016 expressing concern that the Crown Prosecution Service was taking a harder line against healthcare professionals. Speaking with OT in November 2020, Dr Nicholl highlighted that criminal cases involving healthcare workers can result in over-referrals. “When you have these cases, they do change the behaviour of healthcare professionals, and not necessarily for the better,” he said. “There is very real risk that patients with treatable problems end up experiencing delays because we are over-diagnosing conditions,” Dr Nicholl said. At present within UK healthcare, individuals rather than organisations are more likely to bear responsibility when adverse events occur. Turning to optometry specifically, during the past five years, there have been four occasions where a business registrant has appeared before a General Optical Council fitness to practise committee. A financial sanction was issued
by the GOC on two occasions. Over the same period, 166 substantive hearings involving individual registrants were conducted, with a sanction or warning issued in 114 cases.
Trying times Dr Nicholl is a member of the Doctors’ Association UK and part of the Learn not Blame Team, which works towards developing a just culture within healthcare. The inclination to overlook systemic factors when things go wrong is particularly worrying in the context of a pandemic, Dr Nicholl highlighted. “The big worry at the beginning of the pandemic was whether doctors were going to have to make very challenging ethical decisions – for example if they only had two ventilators and three patients who needed them,” he said. Doctors, nurses and optometrists are working within a system where resources are stretched and waiting
ARE YOU JUDGING YOUR COLLEAGUE AND THE CARE OF THAT PATIENT IN A FAIR WAY BASED ON PUTTING YOURSELF IN THEIR Dr David Nicholl SHOES AT THAT TIME?
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lists are growing. HALT is an acronym used to describe factors that can increase the risk someone will make a mistake. “When you are hungry, angry, late or tired you are more likely to make errors,” Dr Nicholl explained. “I suspect there is probably a lot of HALT at the moment – people are stressed out. Staff sickness means there are fewer staff to deal with a larger number of patients and therefore the potential for error is increased,” he shared. Dr Nicholl emphasised his view that healthcare workers should face criminal charges when it is justified – but this should be the “absolute exception.” As well as looking at the system a healthcare professional was working in when an error occurred, Dr Nicholl highlighted the importance of only judging their actions based on the information and skills they had at the time. “There is a very real risk of hindsight bias. If you know that the patient comes to harm, you are more likely to review what has happened in an adverse way,” he shared. A study published in the Clinical Medicine Journal in 2019 asked 93 clinicians to review three case studies online. Each case study had one of two outcomes randomly assigned – either the patient made
a full recovery or died shortly after discharge from hospital. In two of the three cases (a headache and swollen leg) clinicians exhibited “marked hindsight bias.” “In some cases, clinicians are markedly more critical of identical healthcare when a patient dies compared to when a patient survives,” the authors highlighted in their study. What changes would Dr Nicholl like to see in the approach to investigating healthcare errors? “It is being aware both of the system errors that can lead to mistakes and also being aware of your own cognitive bias when reviewing the records,” he said. “Are you judging your colleague and the care of that patient in a fair way based on putting yourself in their shoes at that time?” Dr Nicholl added. Expert witnesses are often used in regulatory proceedings to give committees a view on what a reasonable practitioner might have done in similar circumstances. But their level of skill and experience is often very different to that of the registrant facing investigation. Ms Rose’s representative, Ian Stern, QC, highlighted this point during the fitness to practise hearing. Ms Rose had been working as an optometrist for
around three years and held a locum role, while both expert witnesses had several decades of experience and held established positions. “You need to look at the level of confidence she may have had and the way that she reacted on that day,” Mr Stern told the committee. Dr Nicholl highlighted that “without a shadow of a doubt” Vincent Barker’s death was devastating. “It would be horrifying if that happened to a member of my family. Anyone who has suffered a tragedy like that wants to know what happened and ensure that it doesn’t happen again.” But Dr Nicholl believes that when efforts to attribute responsibility result in a three-fold increase in referrals and potential delays in patient care “there is something very wrong with the system.” “People were scared just to do their job and that affects their decision-making process. They are more likely to over investigate or test to cover their back. I don’t think that is healthy for society,” he said. Sir Norman Williams emphasised in his review of gross negligence manslaughter that healthcare workers go to work to alleviate suffering rather than add to it. “They work in complex, highrisk environments, invariably as part of a team, and when things go wrong it is rarely the result of one individual’s error,” he observed.
NHS Improvement has published A Just Culture Guide, which encourages managers to treat staff involved in a patient safety incident in a consistent, constructive and fair way (improvement.nhs.uk/resources/ just-culture-guide/). February/March 2021
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“IT IS SO IMPORTANT THAT WE HAVE GOOD QUALITY, HONEST CONVERSATIONS”
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CIPD research adviser, Melanie Green, speaks to OT about sensitive ways to apply diversity and inclusion management in the workplace
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What is an inclusive workplace – and how do we take the right steps to build one? OT spoke to the Chartered Institute of Professional Development (CIPD) to explore the issue.
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OT: What, in a nutshell, is diversity and inclusion? Melanie Green (MG): Diversity and inclusion are complex areas, and knowing where to start can be quite difficult. The main thing to recognise is that diversity and inclusion spans a huge range of topics, so it's good to try understand the problem first to recognise where we are and how businesses might take action. A good place to start is hard research. At the CIPD, we created a report in 2019 called Building inclusive workplaces which maps out some of the core areas that businesses can look at to understand how to move inclusion and diversity forward in their workplaces. Thinking about the healthcare setting, in terms of the data and work the CIPD has carried out, what would you say are the key challenges? I can't comment on specific sectors, but what we do know is that there are issues of diversity, inclusion
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and equality across society, and that's reflected in all our workplaces. An example of this is representation. NHS government data highlights that in healthcare generally there's more diversity at junior levels than there is at senior levels – and that's an issue that is not confined to healthcare. Increasing diversity within the healthcare sector means improved access to patient care, and widening the patient-clinician conversation too. Are there any particular professions where the CIPD has noticed interesting work when it comes to building inclusion and diversity? When we have spoken to organisations about what works and what doesn't, which is what we did in a piece of research in 2019 called Diversity management that works, the key theme that came through are the businesses prioritising getting the right data – this means understanding your organisation and what that looks like, to understand how to progress from there. Successful organisations also get buy-in for their work in diversity and inclusion. This means being crystal clear as to why it is important for your employees and your business. In addition, it is important to note that different sexes have different challenges, and no onesize-fits-all approach is necessarily
going to fit the bill. Taking an evidence-based approach using data is important, so map out issues before jumping to the solutions; this is a really good starting point to taking concerted and targeted action. Is there a degree to which some difficult conversations need to happen but it is something that businesses are slightly afraid of? I think we know that we need to have these conversations, but I think we also recognise that they can be really sensitive. It is important that we talk openly. That is something we've been doing in CIPD a lot recently, especially when it comes to topics like anti-racism, supporting businesses to have those conversations. We recognise that they have not happened in the way they should have before. Is progress in the workplace being made quickly enough and how optimistic should we be? It's clear that there is a huge focus on diversity and inclusion at the moment and rightly so. But it's also clear that more needs to be done, so I think this is a point in time where organisations need to make a commitment to take action and drive change. It needs to be an organisational priority, especially as the challenges of COVID-19 are impacting organisations. It's important that we keep banging the drum and prevent it from sliding down the agenda.
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Since joining the GOC, I’ve spoken to various groups, including registrants, professional bodies, education providers and witnesses, about their experience of fitness to practise (FtP). Not much of what I heard was positive. One of the main takeaways from these conversations was that registrants were fearful of the FtP process and consequentially of us as their regulator, so it was clear that we needed to increase awareness of what we do and why we do it. We wanted to make sure we could reach all of our registrants, and that’s how FtP Focus – a learning bulletin published quarterly by the GOC – was born. From reading FtP Focus, I hope registrants get a clearer understanding of the FtP function and how it fits into our broader role of protecting the public and upholding standards.
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Registrants worry about the punishing nature of the FtP process, and the time it takes to investigate. I’ve heard this a lot and we’ll be addressing this over the next few editions as we share the work we’re doing to improve our timeliness. One of our biggest challenges was the volume of cases that we were investigating at any one time. It’s important that only the most serious concerns that could have an impact on the health or wellbeing of the public reach the investigation stage. That hasn’t always been the case due to the prescriptive nature of our legislation. The introduction of our revised acceptance criteria and enhanced triage process in 2019 has helped us filter out concerns that could be better addressed through mediation, for example. As a result, we’ve reduced our caseload by over 40% since August 2019 and have enabled our investigation teams to work more quickly through their cases.
“WE’LL WALK READERS THROUGH THE FTP PROCESS” Dionne Spence, director of casework and resolutions at the General Optical Council, tells the story behind the launch of the regulator’s new bulletin, FtP Focus
We have been looking at the differential impact of FtP on BAME registrants. Our volumes at the GOC are quite low to draw any firm inferences from, but we are aware that this variance cuts across many of the healthcare regulators. A group of us are currently working through some options on commissioning some cross-regulatory research to give each of us greater quantitative datasets that we may be able to drill down some local qualitative data from. We have a quarterly decision review group, attended by an independent FtP representative from another healthcare regulator, to review referred outcomes where concerns such as these may be raised and consider if any lessons can be learned.
REGISTRANTS WERE FEARFUL OF THE FTP PROCESS AND CONSEQUENTIALLY OF US AS THEIR REGULATOR
Additionally, we commission an annual independent audit of our decisions to determine if we can draw any specific impacts from here and I’m pleased to say that this has not yet indicated any bias in decision making throughout the process. There are other FtP topics we hope to tackle in 2021. As well as walking registrants through the end-to-end process, we’re planning a student edition – we are unique across the statutory healthcare regulators in our registration of students and we think there would be a benefit in addressing that fear factor from the earliest stage. We’re also considering doing an interregulatory edition to show how similar FtP is across healthcare. We aim to publish FtP Focus each quarter, with the next edition focussing on the investigation stage. This is due out in early 2021 and will be followed by editions on our case examiner function and our hearings and fitness to practise committees.
The GOC is open to feedback and suggestions on what registrants want to know more about. To email the GOC, contact: focus@optical.org
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Education and training for the eye care practitioner
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How do you talk to your patients about AMD?
conduct in online environments in both personal and professional settings
LEARNING OBJECTIVES
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• Be able to use online platforms LEARNING OBJECTIVES
• Identify and respond
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appropriately to the fears, anxieties and concerns that patients with AMD may have about their visual welfare • Give patients with AMD information in a way they can understand, adapting language and communication approach as appropriate
to communicate effectively to patients about eyecare matters • Be able to maintain appropriate conduct in online environments in both personal and professional settings
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Tear breakup time: are all methods created equal?
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appropriately to the fears, anxieties and concerns that patients with AMD may have about their visual welfare • Give patients with AMD information in a way they can understand, adapting language and communication approach as appropriate
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Be safe and savvy with social media
LEARNING OBJECTIVES
• Be able to use online platforms
to communicate effectively to patients about eyecare matters • Be able to maintain appropriate
Using fixation disparity curves in clinical practice
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• Understand the clinical application
and assessment of fixation disparity curves in clinical practice
LEARNING OBJECTIVES
• Understand the clinical application
and assessment of fixation disparity curves in clinical practice
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Features of diabetic retinopathy
LEARNING OBJECTIVES
• Be able to assess patients
presenting with diabetic retinopathy using appropriate techniques • Be able to identify features of diabetic retinopathy and decide on the appropriate management LEARNING OBJECTIVES
LEARNING OBJECTIVES
• Identify and respond
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• Be able to assess patients with
LEARNING OBJECTIVES
• Be able to undertake tear
film assessment using a range of techniques • Be able to manage the investigation of patients presenting with dry eye LEARNING OBJECTIVES
• Be able to appraise different
techniques for tear film assessment using an evidencebased approach
diabetes and grade the severity of retinopathy • Be able to undertake differential diagnosis of diabetic retinopathy and decide on the appropriate course of action
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Anterior eye abnormalities
LEARNING OBJECTIVES LEARNING OBJECTIVES
• Be aware of different methods for assessing the tear film LEARNING OBJECTIVES
• Be able to manage patients
presenting with anterior segment pathology
LEARNING OBJECTIVES
• Be able to undertake tear film assessment using a range of techniques
• Be able to assess cases of anterior segment pathology and manage the patient accordingly
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 7 May 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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Richard Edwards BSc, MCOptom and Sarah Oakley
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Introduction
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Foresight report indicates a UK population of 64 million with 14.7 million aged 60 and above, and by 2030 this is projected to be 20 million. Projected growth in the over 65 age group from 2010 to 2030 is 50%, while for over 85s it is 100% and as much as a seven-fold increase in centenarians. On top of which the UK population could also have risen by 10% to 71 million.6 What acts as a ‘multiplier effect’ behind this raw data is ‘healthy life expectancy‘ in this rapidly growing demographic. Readers of this article will be well aware of the increasing expectations presenting every day in practice NHS capacity – ophthalmology is one of the largest outpatient specialisms in the NHS with nearly 8 million appointments attended between the period of April 2018 to March 2019.7 The capacity to absorb growing demand in this area is a challenge which will increasingly redefine the role of optometry in the management of eye conditions in the future. Demonstrating our skills in being able manage chronic conditions to ophthalmology colleagues and health policy makers will be critical. This capacity constraint also amplifies the challenges we create if we adopt safe optometry and potentially over referral into an already stretched system Treatment – the pace of change in how AMD is managed and treated is advancing and it is beholden on all practitioners to keep abreast of this. However, we Figure 1
Demographics
Optometry
NHS capacity
The Macular Society supports those with macular degeneration and their families and carers by offering counselling and other services, as well as funding crucial research into disease. The organisation also works with the optometric sector to support improved diagnosis and management of macular disease. The Optical Consumer Complaints Service (OCCS) is funded by the GOC to mediate complaints in the UK optical sector. The OCCS has recorded an increase in concerns raised by the public regarding the communication and management of age-related macular degeneration (AMD). Driven by demographics, advances in technology and increased quality of life expectations, this area will place greater demands on the profession and how we diagnose, manage and communicate our findings. This article uses two scenarios to highlight the typical concerns that the OCCS encounters to illustrate some key points in improving communication in the management of AMD. While the remit of the OCCS falls primarily in consumer issues, a number of complaints are received each year relating to clinical matters. The OCCS 2019 annual report highlighted an increase from 21 to 38 such cases in that year.1 Set against the scale of the UK optical sector this is still small, but within the group was a noticeable increase regarding how optometrists manage the communication of various stages of AMD. Given the demographics at play, this is likely to be an ever-increasing challenge for the profession and as such the OCCS and the Macular Society have started to collaborate on a number of CET initiatives around the human factors in this arena, which will be critical in delivering better outcomes and experiences for patients.2,3 The important external factors that will shape the approach in this area can be summarised as follows: (see Figure 1): Demographic effects – there are approximately 600,000 people in the UK already with vision affected by AMD;4 this aligns with predictions made by RNIB in 2009.5 Office for National Statistics (ONS) data in the
Technology/OCT
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This article outlines two scenarios highlighting how to communicate effectively to patients with AMD, thereby avoiding the potential for complaints.
Evolving treatments
Figure 1 Forces shaping optometry in AMD management
CET
Case study 1
My mother has been diagnosed with macular degeneration. She has lost sight in her left eye and is having injections in her right eye at Moorfields to save the vision. My mother had an eye examination in August 2018 and previously in May 2015 at your practice. No mention of the term macular degeneration was ever diagnosed, only a cataract. We chose to go to another practice to have an eye examination in May 2019 as my mother was complaining about her poor vision. We both thought it might be due to the cataract. The optometrist at the new practice explained the dry macular degeneration would probably have been apparent for many years and certainly in August 2018. If we had known about it then we would not have waited to get it looked at and treated. As such my mother has now must also be cognisant of taking a holistic approach to managing maculopathy by utilising the excellent social and support systems that a patient can access Technology – the evolution of optical coherence tomography (OCT) is a step change in the ability to diagnose; however, it also brings increased expectation from patients and fellow clinicians in our ability to interpret the results of OCT data, to articulate these results to patients and refer to colleagues appropriately. In order to bring to life the challenges that practitioners face, outlined below are two scenarios based on those typically seen at the OCCS. The OCCS recommends using the ‘AERO’ model for complaint management, which consists of four stages:8 Apologise – an authentic apology is the first step in rebuilding trust to help build a resolution. An apology is not an admission of liability but without this first step it can prove difficult to secure positive engagement Explain – whatever the origin of the complaint there will always be an element of explaining what happened that led to the situation. Be honest and candid, and if appropriate, outline the steps that have been taken to prevent recurrence Reassure – the patient doesn’t know what we know. Fear of unknown consequences can often be the emotional trigger for a complaint so providing reassurance is key. Whether that is emphasising the measures taken to prevent recurrence or explaining that the situation will bring no lasting harm, this must be done in a caring, empathetic and jargon-free way Over deliver – what would it take to really turn this around? What needs to be done to delight this patient? Ending the interaction on a positive note, going the extra mile – practice teams who do this are the ones who turn their complainers into evangelists. So, let’s look at two complaint scenarios to illustrate some key points in how we manage our communication around AMD.
lost confidence and the vision in left eye due to wet macular degeneration. Moorfields have said there is nothing more they can do for that eye and she is currently receiving injections in her right eye to save the sight she has. In addition to the upset, there is a cost for cabs to take her to and from the hospital in addition to time off work for my brother and I to support her. This we gladly do but it could have been prevented if we could have acted more quickly. I had never heard of macular degeneration so did not know what I should have done. I would like an explanation of why they did not pick it up and how they will ensure this does not happen again.
Case study 1 Imagine you are a practice owner who receives a letter of complaint (see panel above). How would you manage this situation and what action would you take? Clinical background Aged 81, non-driver and non-smoker Attended for routine examination at the practice in 2018 She was asymptomatic with uneventful history and symptoms Comprehensive clinical records indicate mild nuclear cataract and early drusen Amsler chart – normal R and L RVA 6/7.5 LVA 6/7.5 (Binocularly 6/6 and N6 @ 35cm). The patient was advised of early cataract and drusen, neither of which required any action. A 12-month recall was recommended along with advice to return sooner with any concerns. How the response played out The OCCS was able to secure consent from the patient for correspondence with the complainant. As the practice was a multiple, the concerns were escalated to head office who undertook a full investigation and responded in writing. Remember that if you are an independent practitioner, your professional representative body can help with such correspondence. The good news is that the records were comprehensive and the decision making and advice seemed cogent. Visual acuities were good and the patient was asymptomatic. Equally helpful was the fact that the complainant, the daughter, appears to be making a genuine request for reassurance; this is not always the case and a number of these complaints that come to the OCCS are looking for compensation or regulatory sanction. While the OCCS cannot
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advise on such action, they will often try to better inform complainants about their condition, the clinical management and decision making to date and, as such, have some calibration around the likely outcome of any subsequent action; this can often de-escalate a complaint. In this case, a comprehensive letter was constructed, mapped to the AERO model referenced earlier. The response started with an apology: “Firstly, I am extremely sorry for the time it has taken to come back to you with our detailed response…” This is an excellent way to engage the complainant as it outlines the extensive work undertaken to compose the letter. Nothing in the apology suggests any shortcoming in the clinical decision making but it does engage the recipient in a commitment to acknowledge their concerns. A detailed explanation then followed, explaining the good near acuity (often an early victim of maculopathy) consistent with distance acuity: “In determining whether the appropriate tests were carried out by the optometrist and whether you should have been referred to the hospital at this time, it is our considered opinion that the tests were carried out according to best practice professional guidance and there were no concerns noted by the examining optometrist that would indicate the need for referral for further examination at the hospital. The contemporaneous records from the time of the examination also reflect this. Vision in both eyes was of a good standard and the optometrist observed small drusen in both eyes and noted on the record ‘Amsler chart – no distortion’ for both eyes. The Amsler chart test is done specifically to check the integrity of the macula.” The letter also reassures on the subject of cataract and explains the concept of thresholds for referral of such. With the benefit of hindsight, a more detailed explanation of such decision making may have helped but again this is difficult in a letter: “The optometrist noted the presence of mild cataract; however, this was not at the level that would necessitate referral at that time.” The response goes on to reassure that the records indicate the patient was advised about the early drusen and cataract at the time of the examination and that the specific term of macular degeneration was not used. The sensitivity used in this section of the response is particularly helpful: “Our sincere apologies if this was not communicated as clearly as it could have been at the time.” The authenticity should be reinforced by both a personal reflective practice review by the clinician involved and also a reassurance that regular audits are performed by the business and no other concerns relating to the optometrist have been identified. This element must be done well as the OCCS has seen cases where complainants push back by saying, ‘I don’t care about other cases; they missed my
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mum’s condition.’ In this case, perhaps a combination of a genuine desire to understand, which was reflected in the tone of the complaint and the detailed authentic and comprehensive response in the letter assuaged the concerns and reassured the daughter. On the subject of the ‘over deliver’ part of the AERO model, it would be for individual practitioners to judge appropriate options, but this can be difficult to put across when responding in writing. Indeed, letters such as this are notoriously hard to craft. The author’s instinct would be to manage this complaint by inviting mum and daughter into the practice to discuss the matter. The opportunity to apologise, explain and reassure in person is much more likely to secure a positive outcome. Subliminal impacts around the tone of voice and body language are well recognised as being more influential than the mere words we speak or write. Meeting in person also opens up the option of whether to or how to potentially ‘over deliver.’ In this case a reimbursement of travel costs as a goodwill gesture may be appropriate and this can be judged during that conversation. Making offers in writing without prior discussion can explode either as being under generous ‘insult’ or over generous ‘what are they hiding?,’ triggering suspicion of a cover up. As a final reflection in cases like these, as the daughter had not heard of macular degeneration, it would have been helpful if some supporting literature was issued after the examination. The Macular Society has an extensive range of helpful booklets and factsheets, which are available to order or download as a PDF from their website along with short videos to view.9 The AOP has a suite of patient leaflets in its ‘For patients’ section online.
Case study 2
If the first scenario is indicative of the most common complaint the OCCS team encounter relating to maculopathy, then the following (see panel opposite) is the emerging challenger to that position. How would you respond to this correspondence? Clinical data Aged 64, attended routinely as a new patient in practice Retired police officer, driver, non-smoker with no personal or family history of eye disease Taking a mild sedative following the recent death of his wife and medication for hypertension Ophthalmoscopy revealed early drusen at both maculae The optometrist recommended an OCT scan, the results of which aligned with ophthalmoscopic findings RVA 6/5 LVA 6/5 N5 @ 40cm.
CET
Case study 2
I wish to complain about my father’s experience at your practice earlier this year. He had recently lost mum and was understandably anxious about healthrelated matters at the time. The impact of the conversation and referral regarding his eyesight was significant and incurred a lot of expenditure to seek a private ophthalmological opinion at which he was assured he was not in imminent danger of going blind - the overriding impression he got on leaving your practice. For a man in his sixties to lose his partner was bad enough but the devastating impact of thinking he would then go blind and a sense that nothing could be
done was overwhelming. While relieved to have secured reassurance from the ophthalmologist, it will take some time before dad has truly developed a sense of perspective about the message he received. What is perhaps more galling is that the whole scenario of diagnosing this condition was driven by the use of some new equipment, a test for which dad had to pay an additional fee on top of his eye examination. I would be grateful of you could write and apologise to my dad and also assure our family that appropriate training in the use of new equipment has taken place to ensure similar misfortune does not befall another family.
A referral letter for further investigation for early macular degeneration was also in the records. No detail of the conversation with the patient was recorded.
The scenario in this case resonates for two reasons. Firstly, it plays to the increasing expectations we create with ever-more sophisticated technology in practice. It is imperative that practitioners are well versed in how to interpret OCT scans and articulate their findings appropriately. In this case, the optometrist may have felt they had conveyed their findings appropriately, but was the patient’s understanding checked before he left the room? Could the Macular Society resources, such as their booklet and video on ‘Early age-related macular degeneration’ have helped.8 Secondly, it plays into something that is occasionally seen at the OCCS – the potential mindset that defensive optometry is the safe option. While in this case the patient chose to undergo a private consultation, at a broader level over referral inhibits access to one of the busiest outpatient specialties in the NHS. At an individual level, over referral can erode trust of ophthalmology colleagues in the optometrist’s clinical judgement.
Managing this effectively This case concerns how we communicate our findings. It is exacerbated here by the particularly difficult timing of the conversation, but the overarching premise of a low risk scenario being perceived as ‘I am going blind and there is nothing I can do‘ is one with which the Macular Society is familiar.10 In addressing the complainant’s concerns, the good news here is that their requests are within the practitioner’s remit. It seems a cogent and reasonable request – one of the regular insights at the OCCS is how much can be gleaned from the tone of a complaint and what is the desired outcome. It is important to remember that the practitioner has no right to discuss this patient’s clinical condition with the family member without his consent. Applying the AERO model here, the authors would suggest inviting the patient in for a discussion along with a member of the family. The practitioner can then listen to their concerns, apologise for the situation, explain exactly what was seen and why the action was taken. Reassurance in this case will need to cover both the patient’s condition but also the broader point of actions to improve the service to others. As we saw in Case 1, action to improve service delivery to others can be a powerful reassurance to address a concern.
Conclusion As the demographic time bomb ensues, then our role in managing chronic eye conditions, built on a foundation of trust with the ophthalmology profession, will become increasingly important. Against a backdrop of ever-changing expectations, practitioners must be able to consistently demonstrate their ability to make proportionate decisions and manage conditions and be brilliant at how they communicate.
About the authors n Richard Edwards qualified as an optometrist in 1987 and was director of professional services at Boots Opticians before launching OPTOMiSE Consulting in 2014. He is professional adviser to OCCS, chairs the Optical Confederation education committee and is a member of the GOC companies committee. Richard also works on a consultancy basis for the GOC policy team and lectures internationally in the area of complaint resolution.
n Sarah Oakley worked in the services team at the Macular Society from 2014 to 2020 following a career in the private sector in marketing and operations management. As head of national programmes, her remit included the society’s advice and information service, ensuring more than 16,000 people each year receive the information and advice they need.
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Be safe and savvy with social media REPRO OP
Elizabeth Yeowart BSc (Hons), MCOptom SUBS
This article offers guidelines about maintaining professional boundaries and standards when using social media and advises how individual practitioners, businesses and the profession as a whole can benefit from its smart use.
ART
Introduction
PRODUCTION
Social media describes websites and applications that enable users to create and share content and communicate with others.1 Examples include blogs, podcasts and forums, along with social networking sites such as Twitter, LinkedIn and Facebook. Social media can offer personal and professional benefits to practitioners and bodies corporate, but it is important to be aware of the potential risks involved. This article offers practical and ethical advice on the pitfalls and positives of using social media.
CLIENT
Ethical responsibilities and social media
Patient confidentiality Social media through forums and blogs can provide a space within which professional colleagues can discuss their experiences in practice. Such discussions of patients and clinical experiences can be educational and informative. However, optometrists should avoid informal discussion and refrain from using personal or derogatory comments, even if posting anonymously. The potential impact that such comments could have on the whole profession must be considered.2 Guidelines from the College of Optometrists support the sharing of anonymised patient information on practitioner-only sites.1 However, material published on the internet exists in the public domain; therefore, practitioners should exercise caution when discussing details relating to any specific case or patient. Registrants have a legal and ethical duty to protect patient confidentiality. Individual pieces of information alone may not be enough to identify a patient, but the sum of published information might be, which could lead to a breach of patient confidentiality. Sharing identifiable information about patients in an internet chat or forum even if it is on a site not accessible to the public constitutes improper disclosure and could give rise to a legal complaint. Practitioners must not discuss individual patients or their care with anyone, including the patient themselves, on publicly accessible social media.
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Professionalism and privacy Optometrists are bound by duties set out in the GOC guidelines.3 Breaches of these standards while using social media, such as improper disclosure of patient information, represents a clear case of professional misconduct that can call into question their fitness to practise. There are also ‘unwritten’ standards that lie outside the scope of these guidelines. These principles have evolved within the profession over time, and while not legally binding, they represent those standards of conduct broadly expected of practitioners by their peers and by society. Although the way optical professionals use social media in their private lives is a matter for their own personal judgement, they should consider whether the content they upload could compromise public confidence in the profession. Irrespective of whether it is done in a personal or professional capacity, online posting is the same as publishing text and is subject to the same laws of copyright as other written or verbal communications. Defamation is the act of making an unjustified statement about a person or organisation that is considered to harm their reputation and can apply to any comments posted online. If an individual makes a statement that is alleged to be defamatory, it could result in legal action against the individual and the organisation they represent.2 Communication with colleagues and fellow professionals via social media is usually more informal and less precise than those via a more formal means of communication; this can lead to miscommunication. Social media sites can lack context and posts can be misinterpreted. Practitioners who work for any organisation should make it clear that any views are personal ones and not necessarily those of their employer. All social media users should review their privacy settings on a regular basis. However, irrespective of these settings, social media sites cannot guarantee confidentiality. It is important to be aware that patients, colleagues and other contacts might be able to access personal information.1 Remember that information about location can be embedded within photographs and other
content posted by others. Once information is published online it cannot be removed completely, other users can distribute it more widely or comment on it. Online information can be easily accessed by others and even anonymous content can be traced back to its point of origin.1 The College of Optometrists advises those who identify themselves as an optometrist and who give optometric advice or post comment on a publicly accessible site, to identify themselves by name. Any material written by an author representing themselves as an optometrist is likely to be taken on trust.1 Maintaining boundaries Social media can blur the line between an individual’s personal and professional lives. Although practitioners might choose to divulge personal information about themselves during an eye examination, they are able to control this type of disclosure.2 If a patient makes contact for professional purposes via a practitioner’s private profile, the practitioner should indicate that they are unable to respond privately and redirect them to a professional profile. Any patient contact on social media sites should be done only in a professional context. Friend requests from patients to a personal account should be politely declined.1 Relationships between optometrists and patients that are not based around clinical care can raise ethical issues. Because of the power imbalance that can exist in a practitioner-patient relationship, it is important that a professional boundary exists to maintain trust and to protect patients from the possibility of exploitation. It is possible, and in smaller communities probable, that the optometrist will have friends who are patients. In these circumstances, they should be aware of the boundaries that need to be set and be sensitive to the need to maintain a professional relationship in the practice. The erosion of the private-professional boundary can have a negative impact on the relationship between an individual and their employer and the rest of the practice team.2
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Conflicts of interest Eyecare professionals who post material online (as individuals rather than when representing their business for example), should be open and upfront about any conflict of interest and declare any financial or commercial interests in healthcare organisations, companies or any other factors that may be perceived to influence their opinion.1 According to the Competition and Markets Authority (CMA), the public needs to know if ‘influencers’ have been paid, incentivised or rewarded to endorse or review something in their social media posts;4 this includes when a product or service has been given to them for free. The disclosure must make it clear when a product, brand or service is tagged, linked or endorsed in any way. Failure to do so might break consumer protection law and the individual could face enforcement action from the CMA, local authority trading standards services or the Department for the Economy in Northern Ireland. These regulations apply equally to anonymous posts.3
The benefits of social media It is imperative for every business to have an online presence. A social media profile is like an extensive business card. Patients are consumers and can choose which optometrist they entrust their eyecare. A website might be their first encounter with the practice, so a positive first impression is vital.5
Website A website is a virtual shop window and should make it easy for the patient to find what they are looking for. Ways to book an appointment (by telephone, email or a contact form), the full address, the opening hours along with information about parking and access should be immediately visible, preferably on the homepage or just one click away if not. It is useful to have a photograph of the exterior of the practice there too. A gallery with images of pre-test and dispensing areas and consulting rooms will familiarise new patients with the interior. Photographs and a brief description of additional
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equipment, such as an optical coherence tomography (OCT) machine, visual field unit or dispensing device, when in use are useful so patients know what to expect. For easy navigation, divide the website into pages or tabs. Post 40% educational content (eyecare, healthrelated) and 60% local or practice-related news, announcements, community and charity events, birthdays and anniversaries and ‘light-hearted’ stories.5 A ‘meet the team’ page builds familiarity and enables patients to put names to faces before they attend. There is still a lot of confusion surrounding the difference between an optometrist and an ‘optician,’ so a brief description of each role is a useful addition to this part of the website too. A strong profile of professional team members will establish credibility and trust. Optometrists and dispensing opticians should include their alma mater,
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work experience, additional qualifications and special interests within the field. Providing additional informal information about a practitioner’s hobbies, sporting interests or pets is usually well-received and relatable. 5 A ‘clinical’ page might include descriptions of common eye conditions along with an overview of additional services offered, for example, dry eye clinic, colorimetry or sports vision testing; this can help to differentiate the practice from its competitors. An ‘eyewear’ page should include all brands stocked in the practice. Lifestyle or model images are more aspirational and applicable than cut out images of a frame. If a celebrity has been spotted in a specific style, search for a royalty-free image and caption it with the frame style and number. Encourage patients to submit a success story, or alternatively, find a clutter-free
backdrop in part of the practice and ask if they mind being photographed there upon collection of their new eyewear. Patient reviews can be useful but potential drawbacks should be considered. More than 80% of people trust a review over a personal recommendation. A similar percentage will look up a practice online before booking an appointment. Excellent reviews increase the length of time a patient will spend online. In contrast, more than 20% of potential consumers will be driven away by a single negative review. The most effective way to collect such feedback is with an automated patient feedback request system.5
Additional social media platforms Social media is time-consuming but necessary. In larger practices it might be wise to delegate the responsibility to a designated member of staff. Issue written guidelines for the frequency and tone of posting and instructions on how best to reply to comments and queries. For most practices, Facebook and Instagram will be the two most useful platforms. YouTube is a useful addition for those wishing to post educational videos. Twitter and LinkedIn are, in most cases, better suited to individuals. Regardless of which social media a practice or individual uses, the aesthetic, logo, branding and the handle should be consistent. Keep the ratio of content the same as on a website: 40% educational and 60% light-hearted posts. The latter will encourage engagement. Publishing at least twice a week and sticking to a schedule will also help with engagement. Facebook posts can be scheduled directly and there are numerous applications available to schedule Instagram (for example, Planoly), Twitter posts and Facebook (for example, Buffer and Hootsuite). There is no need for lengthy social media posts or articles as these platforms should provide ‘snackable’ content that is easily consumed. Visual content such as memes, graphics interchange format (GIFs) and images is proven to be more eye-catching and interactive than plain text.6 Engagement It is important to remember that this is social media. Engagement, rather than the number of followers, is the most important metric. The best way to increase this is to interact with other users. A three or four-word thoughtful comment or genuine compliment will go a long way and is infinitely better than an emoji. A courteous user will return the favour. Network with peers and fellow alumni and follow other practices, lens manufacturers, vision
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charities and eyewear brands. If the practice stocks designer frames, follow that designer’s page and use royalty-free catwalk images to create an aspirational aesthetic.7 Link to other content from within the profession. This will demonstrate a willingness to share the best information with the consumer and will build relationships with fellow professionals and industry members.6 Invite people to view, share, like and leave a comment on posts. The Instagram and Facebook algorithms work such that the more engagement a post receives in its first hour, the more popular it is deemed. Consequently, it gets made visible to more followers, so increasing its reach. Facebook has a useful option to boost content. It targets users who have ‘liked’ similar optometry practice pages or content. It is then the decision of those users whether they follow. It is imperative that social media growth is organic. In contrast to the Facebook boost option, it is possible to ‘buy’ followers and ‘likes’ at the click of a button; this is inauthentic and has an adverse effect on engagement. ‘Bought’ followers are either bots or people paid to click a button. They are not invested or interested in the brand and are highly unlikely to visit again. Websites such as socialblade. com track user statistics and give a deeper insight into growth and trends and will reveal those with inorganic and fake followers.
Conclusion Social media is a useful tool to communicate with others in both our personal and professional lives. However, it is imperative that standards of professional communication should always be followed, such as avoiding potential confidentiality and defamation issues as well as ensuring any conflicts of interest are declared.
About the author n Elizabeth Yeowart is an optometrist, Optometry Today columnist and style blogger. She graduated from Aston University in 1996 and worked in practice for 15 years. She took a career break to raise her children, during which she began writing her blog What Lizzy Loves. This has led to global collaborations within the world of fashion and optics and features categories including style, food, life, and optometry which she balances with working in independent practice in North Yorkshire.
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Tear breakup time: are all methods created equal?
REPRO OP
Dr Louise Terry PhD, MCOptom, FHEA SUBS
Tear breakup time (TBUT) is a test commonly used to investigate and monitor dry eye. This article explores the various methods of assessing TBUT, along with their strengths and weaknesses.
ART
Introduction
PRODUCTION CLIENT
When we think of dry eye assessment, one of the first diagnostic tests that comes to mind is tear breakup time (TBUT). First introduced in the late 1960s,1 TBUT can be considered as a measure of tear film stability; assessing how long it takes, following a blink, for the tear film to destabilise and evaporate, creating areas of breakup. It can be used as part of a battery of tests to provide a clinical assessment of the tear film, particularly in patients with suspected dry eye. Thinning of the tear film following a blink is primarily due to evaporation, leading to a considerable increase in localised hyperosmolarity within the tear film.2,3 Once breakup of the tear film occurs, the ocular surface no longer has a smooth refracting and protective covering, and a blink is required to refresh this layer. If TBUT is reduced, either the blink rate is required to increase, or (more commonly) the ocular surface is left exposed for periods of time; this can result in symptoms of discomfort and visual disturbance, as well as potential damage to the ocular surface.
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Methods of assessing TBUT
Fluorescein breakup time (FBUT) A common method of assessing TBUT requires the use of fluorescein, a diagnostic stain commonly used for assessing ocular surface integrity – that is to say, corneal and conjunctival staining. Sodium fluorescein is instilled into the tear film, typically using an impregnated strip wetted with saline and is viewed using a slit lamp with a cobalt blue filter. Light of this wavelength excites the molecules, causing them to fluoresce. A Wratten 12 yellow barrier filter may be used for enhancing the contrast of the fluorescein in the tear film, giving it a green appearance. Fluorescein is distributed evenly across a stable tear film, but when the tear film becomes unstable and thins, the distribution of fluorescein becomes uneven and thin patches start to appear (see Figure 1). These areas appear dark, since less fluorescein is present. The time taken for these dark areas to appear following a blink is assessed and recorded as the fluorescein breakup time (FBUT). Although the FBUT diagnostic test is easy to perform and requires no specialist equipment, the instillation of fluorescein has been shown to destabilise the tear film10 and the results are highly dependent on the amount of fluorescein instilled.11 If a large quantity is instilled, the tear volume is effectively increased, prolonging the time taken for evaporation of the aqueous component. A reduced amount of fluorescein delivered by a modified
The delicate tear film
The tear film is a fragile structure, with an average central thickness of only 5µm (around 30 times smaller than the diameter of an average human hair).4 When assessing the tear film, this fragility should be considered. Altering the state of the tear film can easily affect the results obtained during the evaluation of TBUT. It is, therefore, crucial to consider the invasiveness of the test being undertaken and to perform the least invasive test available (or at least prior to conducting more invasive evaluations). Tear film stability is highly variable and is affected by many intrinsic and extrinsic factors; these include age, gender, race, contact lens wear and previous ocular surgery (in particular eyelid and refractive surgery).5 Environmental stimuli have also been shown to affect tear film stability, including temperature, humidity, air conditioning, air pollution, air currents, smoking, screen use and alcohol intake.6–9 Therefore, it is pertinent to consider these factors when measuring TBUT, particularly those likely to vary in a clinical setting, for
example, air conditioning and currents, which may influence repeatability between appointments.
Figure 1
Figure 1 Time series showing fluorescein break-up following a blink
Figure 2
fluorescein strip (1mm width compared to the standard 5mm width) has been shown to improve the repeatability of FBUT measurement;12 this approach has been termed the Dry Eye Test (DET) and is designed to deliver 1μl of fluorescein solution without the need for clinically unfeasible pipettes (as commonly used in dry eye research). Three consecutive measurements with the DET strip have been shown to be within three seconds for 96% of patients, compared to only 71% when using a standard fluorescein strip. Unfortunately, DET strips are not currently available in Europe. Another method of controlling the instilled volume is to modify a standard fluorescein strip by folding the end 1mm and using only this portion to deliver fluorescein to the eye.13 This modified strip has been shown to improve the repeatability of FBUT measurement over the use of an unmodified standard fluorescein strip by controlling the volume of solution instilled. The FBUT is highly correlated between the two methods but significantly shorter using the modified strip. This should be taken into consideration if using this modified method to assess FBUT, in terms of cut-off values for normal versus dry eye suspect – that is to say, a lower threshold should be used. Successive FBUT readings can yield substantially different values; this has been attributed to an initial destabilisation of the tear film following fluorescein instillation, lasting for typically 12–20 blinks.14 Given the variability in repeat measurements, it is pertinent to obtain multiple estimates of FBUT on each patient (typically three consecutive measurements) and use the median value to limit the effect of erroneous measurements. A cut-off of greater than 10 seconds is commonly used clinically to define ‘normal’ tear film stability, with values in the range of five to 10 seconds considered borderline and values less than five seconds to be strongly indicative of dry eye.15,16 Despite its frequent use in optometric practice, FBUT has been found to have a relatively low sensitivity and particularly low specificity to categorising dry eye symptoms.17,18 This low specificity suggests that FBUT, if taken in isolation, will likely result in a high rate of false positives in identifying symptomatic dry eye.
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Figure 2 Mires visible using a slit lampmounted Polaris NIBUT method: undistorted mires following a blink, showing a complete tear film (left); distorted mires following tear thinning (right)
Another quantitative measure which has been suggested for the diagnosis of dry eye is the ocular protection index (OPI). This index describes the interaction between blinking and tear film stability and can be determined using the FBUT. It is calculated as the FBUT divided by the inter-blink interval.19 Values greater than one describe a situation where the breakup time is longer than the inter-blink interval; the ocular surface is, therefore, protected by a complete tear film for the entire duration between blinks. A value of less than one is unfavourable, as there is a period between blinks during which the ocular surface is exposed. To obtain an accurate measure of OPI, inter-blink interval must be carefully assessed with influence from the practitioner minimised. For instance, blink rate is likely to be affected by artificial factors such as bright lights, air movement, and awareness of assessment (patients attentive to their blinking may alter their blinking habits). Non-invasive breakup time (NIBUT) To eliminate the effects of fluorescein instillation on tear film stability, non-invasive methods of assessing TBUT time are desirable. These methods involve projecting a regular grid onto the tear film then viewing the regularity and integrity of the reflected grid. When the tear film thins and becomes unstable, the regular grid becomes distorted. As with FBUT, the time taken for these areas of thinning to become apparent is measured and recorded as the TBUT, although should truly be considered as the tear thinning time (TTT). Although these methods negate the requirement for tear film additives, the ideal assessment of TBUT would introduce no sources of disruption for the tear film, including environmental influences. As mentioned earlier, temperature, humidity and air movement all affect tear film stability to some degree, as well as the evaporation rate. The tear film will be more prone to evaporation in a hot and dry environment, particularly with an increase in air movement around the ocular surface. Furthermore, patients should adopt their habitual head posture, aperture size and blinking
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Figure 3
Figure 4
REPRO OP SUBS
Figure 3 A Polaris instrument designed for tear film analysis (including lipid layer assessment and NIBUT) mounted on a slit lamp. Image courtesy of WOPEC ART PRODUCTION CLIENT
habits, to avoid influencing breakup time. For instance, a patient asked to stare wide will consciously widen their aperture, spreading the tear film thinner over the increased surface area, potentially causing it to thin more quickly than in a habitual scenario. One must also be aware of reflex tearing and the resulting increase in tear volume; this may be due to discomfort or mechanical stimulation – for example, with invasive tests such as Schirmer strips, or in the use of excessive light from a slit lamp or other instrument if directed into the pupil.20,21 The potential effect of each of these factors is dependent on the method used to assess TBUT, limiting the ability for direct comparison on measurements between techniques.22 Methods utilised to assess NIBUT include grid projection using a one-position (Bausch + Lombstyle) keratometer, or other devices such as the Keeler Tearscope, CSO Polaris or Mengher bowl.10,23,24 Each of these methods require specialist equipment, with the keratometer generally having the widest availability in clinical practice. Measurement is simple, whereby following a complete blink, the first observed distortion of the reflected mires is taken as the TTT (see Figure 2). However, this point occurs prior to complete tear breakup, and hence has been shown to be shorter than TBUT (with an average of 18 and 23 seconds, respectively).23 The other limitation of using keratometer mires to assess TTT is the area of cornea being assessed as the mires only cover approximately the central 3mm of cornea, while slit lamp-mounted techniques (see Figure 3) allow assessment of the entire cornea simultaneously. Different instruments for assessing NIBUT have been shown to yield different results (by as much nine seconds on average); therefore, the instrument used to assess TBUT should be recorded to allow future comparison of tear film stability on the same patient.25,26 The mean values for normal TTT are in the region of 15 to 20 seconds, while for dry eye this reduces to around seven seconds.23,27,28 It should be noted that these are longer than the accepted normative values for FBUT and this should be considered in the clinical assessment of dry eye, dependent on the method of TBUT assessment
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Figure 4 Objective non-invasive assessment of tear breakup, using the projected Placido disc of the Medmont E300. Areas of short break-up time are shown in warm colours. An objective NIBUT of 6.0s was determined by the software
being used. In fact, two studies comparing FBUT with NIBUT found the latter to be around four seconds longer on average.29,30 Therefore, a higher threshold value for dry eye diagnosis should be considered when assessing NIBUT compared to FBUT. Using a threshold of 10 seconds, the sensitivity and specificity of NIBUT were found to be considerably higher than the values quoted in the literature for FBUT.17,18,31 All methods described so far require a clinical observer to determine the point at which breakup occurs, introducing an element of subjectivity to the method. TBUT has high variability between measurements, which is exaggerated with multiple examiners (high inter-observer variability).30,32,33 With advances in high-speed imaging and computational capabilities, methods of objectively determining the endpoint have been developed. A series of images of a reflected grid of concentric rings are acquired over a time period following a blink and are analysed to compare the precise location of the projection between time points. Small differences in the location of areas of the reflected grid are identified and attributed to distortion caused by tear film thinning. This objective method is termed videokeratoscopy and removes both the inter- and intra-observer variability introduced by manual determination of the endpoint.34–36 This feature is becoming more common in practice, with instruments such as the Medmont E300 corneal topographer and Oculus keratograph facilitating objective NIBUT measurement (see Figure 4). The sensitivity and specificity of such techniques have been extensively reported as greater than that of FBUT and comparable with non-automated NIBUT (see Table 1).22 However, the differences in threshold used for diagnosing dry eye between studies should be noted
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Table 1 Summary of dry eye diagnostic performance for various methods of assessing TBUT. Adapted from the TFOS DEWS II tear film report22 Study
Method used
Sensitivity
Specificity
Threshold used (s)
Vitali et al, 1994
FBUT
0.78
0.39
10.0
Kim et al, 2015
‘Wet’ FBUT
0.79
0.55
4.48
‘Dry’ FBUT (dried sodium fluorescein)
0.73
0.69
3.5
Mengher et al, 1986
NIBUT (Mengher bowl)
0.82
0.86
10.0
Pult et al, 2011
NIBUT (Keeler Tearscope)
0.80
0.93
10.0
Hong et al, 2013
Videokeratoscopy (Oculus keratograph)
0.84
0.76
2.65
Downie, 2015
FBUT Videokeratoscopy (Medmont E300)
0.78
0.72
8.0
0.82
0.94
12.1
Gumus et al, 2011
Videokeratoscopy (Tomey RT7000)
0.82
0.88
3.0
Su et al, 2016
Thermography
0.80
0.89
4.0
and demonstrates the variability resulting from the methodology used. Ocular thermography has also been used as a noninvasive assessment of TBUT. This method is based on the principle that tear film thinning is associated with evaporation and, therefore, cooling in the areas of breakup, which are detected by a thermograph.37 This method has been demonstrated to have relatively high sensitivity and specificity for screening dry eye patients38 but requires specialised instrumentation not typically available in clinical practice.
Relationship with other dry eye tests
TBUT has moderate but significant correlation with other diagnostic tests for dry eye, including the Schirmer test, phenol red thread test, tear meniscus height, lid parallel conjunctival folds (LIPCOF), lid wiper epitheliopathy (LWE) and bulbar hyperaemia.39–41 Pult and colleagues investigated the relationship between clinical signs and symptoms of dry eye, comparing the results of several dry eye tests with the patients’ ocular surface disease index (OSDI) questionnaire score. The best predictive ability of dry eye symptoms was found to be a combination of NIBUT (measured with the Keeler Tearscope) and nasal LIPCOF, highlighting the importance of performing multiple dry eye tests on a suspect dry eye patient. This is also highlighted by the TFOS DEWS II Report, which outlines a workflow of several tests for diagnosing and classifying dry eye disease;42 this should always include a subjective assessment of symptoms, using a validated questionnaire such as the OSDI or the Dry Eye Questionnaire.43–45 The poor association demonstrated between clinical signs and symptoms emphasises the importance of basing dry eye diagnosis on a combination of clinical signs (from multiple objective diagnostic tests) and patient-reported symptoms.46
Conclusion As stated in the TFOS DEWS II diagnostic methodology report,42 NIBUT should be performed such that the entirety of the naturally exposed cornea is illuminated,
allowing observation of breakup over the whole surface following a blink. Objective methods are preferred, with the median of three consecutive measurements recorded. After reaching a final estimate, the lower value of the two eyes should be used in diagnosing dry eye. The threshold for a positive finding of dry eye should be up to 10 seconds for subjective measurement but can be as little as 2.7 seconds for automated algorithms. FBUT should only be considered when non-invasive techniques are not accessible and the minimum possible volume should be instilled (with the excess saline shaken off, or a reduced area fluorescein strip used). Again, a threshold for suspicion of dry eye is less than 10 seconds, although it should be noted that shorter times will often be observed, even in the absence of clinically significant dry eye. TBUT is a simple to perform and easy to interpret clinical measurement, often without the need for additional specialist equipment. It therefore remains the ‘gold standard’ in tear film stability assessment.5 However, the limitations of the technique should be considered during interpretation, including the ease of disrupting the fragile tear film stability from environmental factors and the use of tear additives. To minimise the effects of this, test protocols should be standardised to allow comparison between visits and to maximise diagnostic utility. The method used to assess TBUT should always be recorded for consistency and the interpretation of the results should depend on the method used. Finally, TBUT should always be used as part of a battery of tests, rather than in isolation, in the diagnosis of dry eye.
About the author 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.
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Using fixation disparity curves in clinical practice
REPRO OP
Dr Liat Gantz PhD SUBS
This article outlines the use of fixation disparity curves to assess binocular vision status and manage the patient accordingly.
ART
Introduction
PRODUCTION CLIENT
Consider a 16-year-old patient applying to the police force who presents to your clinic with an examination form. His uncorrected visual acuity (VA) is 6/6 and N5 at 35cm in each eye and his dissociated heterophoria at distance and near is orthophoria and 3Δ exophoria, respectively. His near point of convergence (NPC) with an accommodative target is 3cm break and 5cm recovery, and amplitude of accommodation measured using the push-up method is 11.5D. Although he recognises all the shapes in the random dot part of the Randot Stereotest, he does not correctly identify beyond target six (50″); this is unexpected given the normal binocular findings and his good, equal VA at near with both eyes. What would you do in this instance? Start with a careful refraction or examine for a possible pathology? If those are normal, what would you suspect then? A problem with fixation disparity (FD) perhaps? FD is measured using two principles. The first is that there are dissociated monocular targets presented simultaneously with associated binocular targets. The second, is that the monocular targets are printed with varying offsets with respect to each other. Patients are asked to specify the image in which the monocular targets appear to be aligned. A more comprehensive understanding of the patient’s visual system may be achieved by creating a full forced vergence FD curve (FDC).1,2 The curve is created by measuring the FD in arcminutes when varying amounts of prisms are placed in front of the patient.3 The x-axis of the curve depicts the amount of prism placed in front of the eye, with negative values corresponding to divergence, while positive values relate to convergence. The y-axis of the curve depicts the FD in arcminutes, with negative values corresponding to exo-FD and positive values corresponding to eso-FD. The major diagnostic components of the curve include: the type of curve; the xaxis intercept, which is the value of the associated phoria; the y-axis intercept, which is the value of the FD; the slope of the curve in its central portion; the centre of symmetry of the central portion of the curve; and the range of the curve. Each of these components will be considered.
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Fixation disparity curve types
FD curves can be classified into four different types which describe the visual system’s response to induced prisms.4 Type 1 curve Around 60% of patients are thought to exhibit a type 1 curve. The curve is sigmoid shaped, with a flatter central portion and a steeper peripheral portion in both base in and base out directions (see Figure 1).4 Type 2 curve In a type 2 curve, present in about 25% of cases,4 the patient only responds to base out prism and is not affected by increasing amounts of base in prism. It is often seen in symptomatic esophoric patients (see Figure 2).5 Type 3 curve In a type 3 curve, the patient responds to base in prism and is not affected by increasing amounts of base out prism. This curve is seen in approximately 10% of the population4 and is often seen in symptomatic exophoric patients (see Figure 3).5 Type 4 curve The type 4 FD curve is characterised by a steep slope in the central portion of the curve and no response to either base in or base out prism. It is only seen in about 5% of the population,4 typically in symptomatic patients (see Figure 4).5 X-intercept: associated phoria The x-intercept depicts the associated phoria – that is to say, the amount and direction of prism needed to reduce the FD to zero. If the curve crosses the x-axis on the right-hand side of the graph (positive values), base out prisms are necessary to reduce the FD. Conversely, the left side of the graph (negative values) represents the base in direction. Some report good results with this approach,6 whereas others suggest it is of little clinical value.7,8
CET
Figure 1 Fixation disparity 10 8 6 4 2 -12
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insensitive system. On the other hand, a patient with a slope that is higher than 1, responds in extreme measures for even little imposed stress. This type of patient is expected to have difficulties with even small changes to the spectacle prescription, or in the placement of optical centres. An ideal slope is equal to 1, in which the system is sensitive to change but does not respond in an extreme way.
-10 -12
Figure 1 Type 1 fixation disparity curve Figure 2
eso
Fixation disparity 10 8 6 4 2 -12
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Figure 2 Type 2 fixation disparity curve
Y-intercept: FD The y-intercept depicts the amount of FD measured in arcminutes. If the value crosses the y-axis in the upper part of the graph (positive values), this represents an esoFD. Conversely, if the value crosses the y-axis in the lower part of the graph (negative values), this represents an exoFD. The value of the FD is typically less than 6′ but can be as large as 30′.9 FDs that are large, beyond or at the limits of Panum’s fusional area, will result in fragile binocularity and even diplopia. Curve slope The slope of the FDC can provide information regarding the rate of response of the visual system to imposed stress. The two extreme scenarios are a slope of zero or a slope that is higher than 1. If the patient has a slope of zero, this means that the visual system does not respond at all to imposed changes and as such is a highly
12
Centre of symmetry The centre of symmetry of the curve is the flattest central region of the FD curve in which the visual system responds to changes induced by the placement of prisms. Ideally, the centre of symmetry of the curve should be close to the y-axis of the curve.
Range of the curve The ‘range’ of the curve refers to the range in which the visual system responds to the prisms. Typically, when creating the FD curve, prism of varying amounts and directions are placed in front of the patient’s eyes and the measured FD is recorded. If the induced prism causes diplopia, this point is not included in the curve. In other words, the curve only includes data points which depict the prismatic value and the measured FD. This, in practical terms, includes the range of prisms for which there is no diplopia, which is similar to fusional vergence ranges. If the range on a particular graph is very limited, the fusional vergence ranges are also expected to be very limited. In such cases, vision therapy can help to widen the fusional ranges.
Treating the patient using the FD curve
Based on the diagnostic criteria described earlier, the practitioner can decide about the optimal course of treatment for the patient. The practitioner can treat the
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Binocular vision
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the exo direction of the curve.12 Negative powered lenses stimulate accommodation, therefore, in this case, the coupling between accommodation and convergence causes an upward shift towards the eso direction of the curve.12
Figure 3 Fixation disparity SUBS
eso
10 8 6 4 2
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PRODUCTION
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Figure 3 Type 3 fixation disparity curve
The effect of vision therapy on the FD curve Vision therapy affects two parameters on the FD curve. It flattens the slope and widens the vergence ranges.12 This improvement is attributed to the visual system’s ability to adapt to prism-induced changes in vergence.13,14
Figure 4 Fixation disparity eso
CLIENT
10 8
Putting it all together
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exo
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Figure 4 Type 4 fixation disparity curve
patient either by modifying the refraction, prescribing prisms, providing vision therapy, or a combination of these options. In order to make a clinical decision, the effect of the various treatment types on the FD curve must be considered. The effect of optical lenses on the FD curve Positive powered lenses relax accommodative effort. Due to the synergistic relationship between accommodation and convergence,10,11 the relaxation of accommodation also reduces accommodative convergence and results in a downward shift towards
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-10
Convergence (base out)
-6
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The effect of prisms on the FD curve Base in prisms correct an exo deviation; however, if the amount of base in prism is larger than necessary, this shifts the location of the target outwards beyond the location of the visual axes. As such, the patient responds as if there is an eso FD. In other words, base in prism in an amount that is larger than the necessary correction induces an eso deviation and the curve shifts to the right. Base out prism corrects an eso deviation, but if the amount of prism is larger than necessary, an exo deviation is induced and the curve shifts to the left.
When considering a possible treatment for binocular visual impairments, one approach is to make a clinical decision based on the FD curve. The curve can be created by introducing prisms of varying directions and amounts in front of the patient’s eye and recording the induced change in FD. The measured FD value (the y- axis) is then plotted as a function of the prism amount and direction (the x- axis). FD instruments include the Wesson card, the Borish vectographic near point card II, Saladin near point balance card and the Sheedy disparometer, which have all been described in an earlier article (OT, June/July 2020). The plot is analysed by classifying the curve type, the xand y- intercepts, the range over which the curve extends, the slope and centre of symmetry. If the slope is steep, the clinician should consider that this patient will have a hard time adjusting to changes in the prescription although flattening of the slope is possible with vision therapy. If the range of x-values of the curve is narrow, this indicates limited fusional ranges and a possible vergence insufficiency that could benefit from vision therapy. Prisms in the amount corresponding to the x-intercept are indicated if they help to shift the centre of symmetry towards the origin of the graph. The centre of symmetry should be close to the y-intercept. Lenses or prisms are indicated if they can bring the centre of symmetry closer to the y-intercept.
Figure 5
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Figure 5 Type I curve with a steep slope, a limited range of fusional ranges spanning 4Δ base in to 6Δ base out and an eso-fixation disparity of 8’ Figure 6
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Fixation disparity 50 40 30 20 10 -15
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Figure 6 Type I curve with a steep slope and an eso-fixation disparity of 12’
Figure 5 demonstrates a type I curve with a steep
slope, a limited range of fusional ranges spanning 4Δ base in to 6Δ base out. The FD, indicated by the y-axis intercept, is approximately 8’ eso FD. The steep slope combined with limited vergence ranges and a relatively high FD indicates that the patient is likely to suffer from asthenopia and will not easily adapt to changes in the prescription. Prescribing a prismatic solution based on the x-axis intercept will be a very small amount and not in the appropriate direction (the associated phoria, or x-axis intercept for this curve is approximately 2Δ base in) and will not help the patient. Vision therapy will assist in flattening the slope and increasing the fusional
CET
vergence ranges which will likely reduce the FD. The 16-year-old patient described in the introduction has a FD curve indicated in Figure 6. This type I curve has a wide fusional vergence range, but a relatively steep slope. The patient’s FD, 12′ eso FD, explains the results of the Randot Stereotest, as stereopsis is reduced in the presence of FD.15 The patient’s associated phoria is 2Δ base out. Although the fusional ranges are wide, vision therapy is likely to flatten the slope, thereby reducing the FD. Another option for this patient is to provide a correction of 1Δ base out prescribed in each eye. However, prior to prescribing prisms, it is recommended that the patient’s adaptation to potential prism is examined as follows.16 First, the patient’s dissociated phoria is measured. Then, prisms are placed in the trial frame and the patient is asked to perform tasks at near such as reading for 10 to 15 minutes. Following this, the patient’s dissociated phoria is measured a second time. If the dissociated phoria value is similar before and after the trial, then the patient has demonstrated adaptation to the prism and it should not be prescribed.16 Therefore, visual therapy would be the preferred option for the patient to improve the stereopsis.
Conclusion
The use of FD curves in clinical practice allows the practitioner to carefully examine the binocular vision status of individual patients and determine the best course of action in each case.
About the author n Dr Liat Gantz is a senior lecturer and director of the MOptom programme at the Department of Optometry and Vision Science, Hadassah Academic College, Jerusalem, Israel.
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Binocular vision
VRICS VERSION REPRO OP
Features of diabetic retinopathy
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David Bundy BSc (Hons), MCOptom SUBS
This VRICS feature presents a series of diabetic retinopathy images for practitioners to interpret, using additional resources as required to answer the accompanying questions.
Image B
Image A ART PRODUCTION CLIENT
A 70-year-old female phakic patient presents for routine review in the diabetes clinic
A 66-year-old female patient with type 1 diabetes for 56 years presents with RVA 6/12-1
01 The optical coherence tomography (OCT) scan shows: a) Subretinal fluid b) Intraretinal fluid c) Exudates d) All of these options
04 Using the NHS diabetic eye screening guidelines for feature-based grading, what would the above image be graded as? a) R3SM1 b) R30M0 c) R3AM1 d) R3SM0
02 Which of following would not be considered as part of a management option? a) Intravitreal anti-vascular endothelial growth factor (anti-VEGF) b) Steroid implant injection c) Improving glycaemic control d) Macular grid laser 03 The patient could be considered for anti-VEGF treatment if: a) Central retinal thickness (CRT) is over 400μm b) Visual acuity (VA) is below 6/12 but above 6/96 c) They are noticing distortion d) Proliferative retinopathy is also present
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05 What is the most appropriate action for this patient? a) Monitor b) Arrange for further panretinal photocoagulation (PRP) laser c) Discharge to the diabetic eye screening service d) Arrange for anti-VEGF treatment 06 If the patient presented to primary care practice, what would be the course of action? a) Check they have a diabetic eye screening appointment and review in one year b) Refer to the hospital eye service (HES) routinely c) Refer to the HES as urgent d) Refer to the HES on the same day
Image C
Image D
A 68-year-old male presents with RVA 6/9.5. He has an eightyear history of type 2 diabetes
A 51-year-old male with a 20-year history of type 2 diabetes attends the diabetes clinic for review
07 Using the diabetic eye screening feature-based grading protocols, what is the diagnosis? a) No diabetic retinopathy b) None of these options c) Background retinopathy d) Wet age-related macular degeneration (AMD)
10 Which of the following is true about the fundus fluorescein angiography (FFA) result for this patient? a) It shows areas of capillary dropout and non-perfusion b) There are new vessels consistent with proliferative retinopathy c) There is a vitreous haemorrhage d) There is a choroidal neovascular membrane
08 Which of the following supplementary tests could help confirm the diagnosis? a) OCT b) Slit lamp binocular indirect ophthalmoscopy c) Widefield imaging d) All of these options 09 Which of the following information could alter the grading? a) If the patient had type 1 diabetes b) If the patient was female c) If the VA was 6/15 d) If the patient was a newly diagnosed diabetic
VRICS
11 What is the appropriate course of action for this patient? a) Referral to the macular service b) Referral to a vitreoretinal surgeon c) Referral for urgent PRP laser d) Close monitoring to watch for development of proliferative retinopathy 12 Contraindications for FFA include: a) HbA1c of 86mmol/mol or higher b) History of retinal vein occlusion c) Hypertension d) Kidney failure patient not on dialysis
About the author n David Bundy graduated from Bradford University and has worked in multiple practice and as a grader for the diabetic eye screening service before moving
into hospital optometry. He is a specialist optometrist at East Lancashire Hospitals NHS Trust in the diabetes, contact lens and paediatric refraction clinics.
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VRICS 1, 1
Systemic disease, OCT & retina
VRICS VERSION REPRO OP
Anterior eye abnormalities
1
CET
POINT
Stanley Keys FCOptom, Dip Glauc, Dip Tp (IP) SUBS
This feature presents a range of anterior eye abnormalities that may present in routine practice. Practitioners should use their clinical expertise and access additional resources where necessary to complete the questions.
ART
Image A
Image B
PRODUCTION CLIENT
A patient presents for routine examination with a longstanding history of chemical injury. 01 In relation to this case, which of the following is false? a) The limbus looks pale and underperfused b) There is significant corneal neovascularistion c) The cornea exhibits a degree of haze d) The conjunctival vessels appear normal 02 What is the most important step to take in the acute presentation of these cases? a) Measuring visual acuity b) Checking intraocular pressure c) Copiously irrigating with water or saline d) Checking pupillary reflexes 03 In cases of this type, which of the following statements is false? a) The extent of limbal blanching relates to the likelihood of long-term corneal damage b) Alkaline substances can cause aggressive and lasting damage to the ocular tissues c) Urgent ophthalmological review is required after the initial first-aid steps d) Examination of the fellow eye is unimportant
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04 Which of the following symptoms is the patient in this case least likely to have? a) Itching/burning b) Photophobia c) Ache/pain d) Redness 05 Which of these signs is least likely to be seen in a first presentation? a) Anterior chamber cells and flare b) Keratic precipitates c) Circumlimbal injection d) Posterior synechiae 06 In terms of management, which of the following is false? a) Topical antiviral medication is required b) Topical steroids are the first-line treatment c) Cycloplegic drops may be used to reduce pain d) Systemic investigation may be required
Image C
Image D
07 What condition is indicated in the image? a) Keratoconus b) Fibrinous anterior uveitis c) Band keratopathy d) Map dot fingerprint dystrophy
10 What is the best description of this image? a) Large corneal abrasion b) Microbial ulcer c) Recurrent erosion d) Dendritic ulcer
08 Patients with this condition are prone to developing: a) Recurrent corneal erosion syndrome b) Corneal hydrops c) Fuchs’ endothelial dystrophy d) Secondary glaucoma
11 What is the underlying cause of this lesion? a) Herpes simplex virus b) Fungal infection c) Acanthamoeba d) Mechanical abrasion
09 In relation to treatment of this condition, which of the following is false? a) Regular long-term ocular lubrication is important b) Topical steroids are used as first-line treatment c) Debridement of loose corneal epithelium can help this to heal d) Bandage contact lenses may help with symptoms and healing
VRICS
12 Which of the following is true in relation to this condition? a) Topical steroids are the drug of choice for this condition b) Corneal sensation will be increased in this eye c) Topical and oral antiviral medications are the treatment of choice d) The eye is unlikely to be painful/uncomfortable
About the author n Stanley Keys is an experienced hospital optometrist based in Raigmore Hospital Inverness. He has gained independent prescribing status and in 2012 became a fellow of the College of Optometrists. He is involved
in optometric education as a CET contributor to Optometry Today, giving lectures at a range of events and conferences and is the developer of the optometry-evolution website.
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VRICS 2, 1
Anterior segment & pathology
CET
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End notes and next edition
REPRO OP
Dr Liat Gantz OPTOMETRIST
CETs IN APRIL/MAY 2021
SUBS ART
n Primary care assessment and management of macular holes Guy Negretti n Specialist dispensing for children with complex needs Mitchell Reuben and Martyn Howlett n Communication essentials: health literacy in practice Linda Moore n Contact lens management of children with anisometropia Jo Mackenzie n Cases of gradual vision loss Prashant Shah n Instrumentation for anterior eye assessment Louise Terry and Neema Ghorbani Mojarrad
Dr Liat Gantz is full time associate professor at Hadassah Academic College. She is the director of the Masters of Optometry programme and teaches binocular vision in the undergraduate optometry programme.
PRODUCTION
What is your professional passion? Israel is quite different in terms of the scope of practice compared with UK optometry, and one way to advance the profession is by continuing education, which is why I am so proud to be involved with the MOptom programme at the College. I love the expression on my students’ faces when they finally understand an abstract concept such as why a patient with exophoria reports crossed perception. One can literally imagine a lightbulb turning on in their minds. What is the one thing you couldn’t live without? Coffee. I have so many things to accomplish that I do not sleep much – so I live on coffee.
CLIENT
How do you manage a work/life balance? I think the short answer is: who said I manage? The long answer is that when you want something done, you give it to a busy person. A busy person likes to tick items off the to-do list. A wise person once gave me great advice: “Done is perfect,” so I focus on doing. I have four kids ranging from six up to 18. Somehow, I always find myself on the parents’ association for the school, heading a volunteer committee and running projects in the community, aside from tending to my kids. Academia is very demanding. It is not simple to teach, check assignments and tests, update lectures, update teaching methods, update the MOptom programme, coordinate lectures, clinics and laboratories, while simultaneously running research experiments. I focus on being satisfied with my best efforts. What do you do to unwind? Zumba, at least four times a week. You have won the OT lottery. What are the first things you would do with the £1m jackpot? I would pay off my mortgage, take care of my kids’ future, and donate to charity. And I would totally treat myself to a daily house cleaner and personal chef.
LIAT’S 10-SECOND CHALLENGE Kindle or hardback? Hardback Cheese or chocolate? Chocolate Apple or Android? Android Takeaway or fine dining? Fine dining Trainers or heels/brogues? Heels Beach bum or culture vulture? Culture vulture Strictly or X Factor? X Factor. No idea what Strictly is…
LIVE CET n n n n n n n
OT has a range of CET videos and articles available online, including:
Light, sleep and biological time Visual fields in neuro-ophthalmic disease Measurement devices for dispensing Scleral lenses: dealing with a game-changer The visual challenges associated with driving 21st century low vision care: apps and accessibility Light for sight
The CET articles are available at www.optometry.co.uk/cet
Dr Ian Beasley
is the clinical editor for OT and head of education for the AOP, with responsibility for delivering education in the journal and at face-to-face events. He began his career as an optical technician and later went on to train as a dispensing optician ahead of qualifying as an optometrist in 1997. In 2013, Dr Beasley became the first person in the UK to graduate with a doctorate in optometry from Aston University and received a research excellence award from the College of Optometrists in the same year for his published work on susceptibility to pattern glare following stroke. He maintains strong links with academia as a visiting lecturer at Aston, and is continuing his research by exploring the effect of peripheral defocus on axial growth and modulation of refractive error in hyperopes.
Do you have an idea or request for a CET article? Email the clinical editor ianbeasley@optometry.co.uk
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CET Q&A, 1
www.optometry.co.uk
Jobs VERSION REPRO OP
Jobs
www.aop.org.uk/ot/jobs
SUBS
INTERVIEW SKILLS ART
COVER LETTERS
Director of CV Writers, Neville Rose, on what to include in your all-important cover letter
CLIENT
over letters, in addition to CVs, give the opportunity to further tell the recruiter or hiring manager exactly why you should be considered for interview. Not all job applications require a cover letter, but why miss out on a further chance to market your expertise and convince the employer that you have what it takes? Here’s how to do exactly that.
Your cover letter should complement your CV
Bespoke your cover letter for each application
Presentation and formatting
Some job seekers use the same cover letter for every application. Whilst you may have the core content, the more you can align the letter to the specific requirements of a post, the better the letter will resonate with the reader.
Keep your cover letter short Just as most recruiters will scan read a CV, the same is true for your cover letter. So, there is little point including lots of detail unless the instructions specifically ask for it. In most cases, you should keep your cover letter to three or four paragraphs. Introduce yourself, and summarise why you are applying.
BONUS TIP The job description and personal specification
Your CV and cover letter need to act both independently as well as together. Always include examples of achievements in your CV. However, you should pick your two or three most impressive achievements and cite these in the cover letter too.
The job description and person specification tell you exactly what the employer is looking for in experience and expertise. The more your cover letter can directly address these points, the better it is going to work for you. Mirror the key terms and phrases to show empathy with the organisation.
Ensure your cover letter contains three or four coherent paragraphs where there is a set theme for each paragraph. Address the respondent by name and include a heading at the top with the job title and reference number. It goes without saying that your cover letter should be proof-read carefully.
Shutterstock
PRODUCTION
C
Call to action
Sign off with a warm and positive message. Try something along the lines of ‘I believe I have all the attributes to succeed in this role and would warmly welcome being invited to interview.’
“The more you can align the letter to the specific requirements of a post, the better it will resonate with the reader” CV Writers offers a CV writing service as well as support with LinkedIn profiles, cover letters and career counselling. They provide a free CV review service via their website: www.cv-writers.org.uk
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Services and products for the practitioner
SUBS
THE PENTACAM Pachymetry measurements
ART
Emma Bolger, specialist optometrist at Birmingham and Midland Eye Centre, on why this stalwart piece of tech is still her most valued diagnostic tool
PRODUCTION CLIENT
the patient, such as helping us decide if they are suitable for treatment such as collagen cross-linking, or if contact lens fitting would be appropriate. Topography of the front and back corneal surface can also help us determine which surface is responsible for the change in corneal shape and the resulting effect I COULD on vision, so can assist NOT LIVE us in discussing visual OUT... symptoms. H IT W n my work as a hospital Whilst there is much optometrist, the piece of kit I more to analyse from a couldn’t live without is the Pentacam. Pentacam result, the topography maps This 20-year-old technology is still are an incredibly effective way of proving to be an essential diagnostic explaining corneal steepness and the tool, especially in the keratoconus clinic. resulting visual effects. Topography maps can also map out areas of Use in the keratoconus clinic corneal astigmatism and can help us The clinic helps to diagnose and manage those with keratoconus or other corneal ectasias. Confirming such “The topography maps corneal conditions requires a range of are an incredibly effective diagnostic tests including keratometry, way of explaining corneal pachymetry, visual acuities and slit steepness” lamp examination. Whilst there are pieces of equipment that support separate those patients that may have a all of these individually, some of changing astigmatic prescription due to these measurements can be obtained refractive error from those that have a simultaneously and more accurately changing prescription due to changing with the use of the Pentacam. corneal shape. The Pentacam also The topographical map of elevation provides keratometry measurements. of both the anterior and posterior surface of the cornea from the Pentacam For patients seen in the keratoconus provides us with a better understanding clinic with a view to being referred for complex contact lens fitting, these of the immediate anterior portion of readings provide us with steepest the eye. In relation to the work within and flattest K readings, which offer a the keratoconus clinic, this may help starting point for fitting. influence any further management of
I
The pachymetry results we record from the Pentacam are essential in the keratoconus clinic for diagnosing a thin cornea or one that is becoming thinner with time. Pachymetry measurements from the Pentacam are useful as they negate the need to use a handheld pachymeter and so reduce the need for patient contact and for using any topical anaesthesia. This is especially important in our new working environments. It is also a far more comfortable way to assess corneal thickness. For keratoconus suspect patients, they may often present with dry, itchy, gritty eyes or atopy that involves the lids/lashes and skin around the eyes, which can make sitting still much more challenging. Moreover, pachymetry readings from the Pentacam give us positions of thickest and thinnest loci as well as plotting a colour map of corneal thickness. This can be particularly insightful in the event that the topography map shows a normal cornea; an unusually thin cornea may reveal some early forme fruste keratoconus or a corneal ectasia that could potentially progress further down the line. This can help the practitioner in deciding how appropriate it is to follow up with the patient or how often. While there are numerous applications to the Pentacam across both the hospital setting and community practise, especially in its uses in the event a patient is considering refractive laser surgery, the primary application of the Pentacam in our hospital clinic is to identify those at risk of developing a progressing corneal ectasia and helping to manage them thereafter. For this purpose, the Pentacam is invaluable to me.
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MARKETPLACE CANT LIVE WITHOUT, 1
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Marketplace
VERSION
MY T SECRE ... S LI F E A
REPRO OP SUBS
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PRODUCTION CLIENT
Mark Cocksedge
ART
London designer and entrepreneur, Yair Neuman, on a collaboration with Cubitts that saw spectacle lenses transformed into works of art
“Once I started working with the material, it became fun and a little bit magical. I began to see all these colours and patterns showing up” 98 www.optometry.co.uk
he idea started as an emotional reaction to seeing the waste – that horrible feeling of taking this virgin plastic, an almost new material, and putting it in the bin. I discovered quickly that a lot of people within the eyewear industry feel like that. It made it relatively easy to connect with other opticians and collect lenses from them. Once I started working with the material it became fun and a little bit magical. I began to see all these colours and patterns showing up. That moment where the lenses transform is what made me very happy during the initial stages of making these pieces. It was probably the thing that made me continue. Lenses are made to manipulate light. The first pieces I created were responding to that – they were lamps. There was a lot of trial and error and experimentation. It took me around a year to see results. You can take lenses, shred them into small pieces and recycle them into something that does not look like a lens anymore. But for me it was important to keep the story within the objects I created. You needed to be able to recognise, at least in context, that these are lenses from many glasses.
My secret life
Do you have a hobby to share with readers? Get in touch with selinapowell@ optometry.co.uk
To be able to keep the general shape of the lenses but also turn them into a structure that is strong enough to support itself was quite a challenge. But with every problem, there was a solution. I ended the year with something to show. The project inspired me to go the extra mile and reinject the lenses back into the industry. Now I am working on a new collection that creates frames from lenses. Working on the Lens Light collection, I handled thousands of lenses. In one sculpture I might work with up to 2000 lenses. It is a big number but it is nothing in comparison with what goes to the landfill on a global scale. The idea is to communicate how many lenses are finding their way into the ground or into the atmosphere when they are burnt. Spectacles are an amazing thing that help a lot of people but they do come at a cost. Unfortunately, you are creating waste and you need to do something with it. People deserve to know the production chain of the things that they use. I think it will only make them appreciate it more.
February/March 2021
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LAST WORD SECRET LIFE, 1
LAST WORD
A GREAT PROGRAMME
REPRO OP
Combining Biofinity® toric and Biofinity multifocal optical designs for a reliable fit and exceptional vision.
SUBS
Optimised Toric Lens Geometry™
Balanced Progressive® Technology
for a stable and reliable fit
for exceptional vision at all distances
A GREAT LENS
ART
Two distinct optical designs Unique back surface curvature Reduces on-eye movement to support stable lens positioning.
D lens Distance vision
PRODUCTION
Spherical central zone
Intermediate vision Progressive zone
Large toric optic zone
Near vision
Helps provide good vision performance.
Spherical zone
CLIENT
N lens
Uniform horizontal ISO thickness
Near vision
Improves lens stability and reduces rotation for better visual acuity.
Spherical zone
Intermediate vision Progressive zone
SEE WHAT HAPPENS WITH PR ECISION1 ™ CONTACT LENSES
Distance vision Spherical central zone
Optimised ballast toric design
A GREAT PROGRAMME designed to reduce contact lens drop out by providing patients with a virtual experience, supporting them on both their pre- and post-fit contact lens journey.
Provides a stable comfortable fit.
A GREAT LENS to meet the needs of new and current wearers seeking precise vision,1 long-lasting comfort1 and ease of handling.1 PRECISION1TM contact lenses feature SMARTSURFACE® Technology, a permanent, microthin layer of moisture on the lens surface that exceeds 80% water.2 This is designed to provide longer-lasting lens surface moisture stability3-5* and a more stable tear film for precise vision and long-lasting comfort.2
In a recent clinical evaluation, Download the OptiExpert™ app today.
of lenses were within 10 degrees of the desired orientation position.1
Talk to your Business Development Manager today. coopervision.co.uk
The CooperVision OptiExpert™ app helps prescription accuracy and speeds up contact lens selection, for a fitting process that is efficient and effective for astigmatic presbyopic patients.
PRE-FIT SUPPORT Attract new wearers with a unique virtual PRECISION1TM experience, in practice material, social media content and more
DURING FIT Providing virtual contact lens application and removal support to maximise patient success during the first stages of handling lenses
POST FIT Supporting new PRECISION1TM wearers through their early lens wearing experience with 24/7 virtual support PRECISE VISION1
*Compared to 1-DAY ACUVUE^ MOIST, clariti^ 1 day, 1-Day ACUVUE^ TrueEye^, ACUVUE^ OASYS 1-DAY, Biotrue^ ONEday, and MyDay^ contact lenses. Based on in vitro studies wherein wettability was measured using the iDDrop System. ^Trademarks are the property of their respective owners.
LONG-LASTING COMFORT 1
EASE OF HANDLING1
Contact your Alcon® representative to find out more.
References: 1. Cummings S, Giedd B, Pearson C. Clinical performance of a new daily disposable spherical contact lens. Optom Vis Sci. 2019;96:E-abstract 195375. 2. PRECISION1 (DDT2) Lens with Smart Surface study; Alcon data on file, 2019. 3. Tucker B, Leveillee E, Bauman E, Subbaraman L. Characterization of the Surface Properties of a Novel Daily Disposable Silicone Hydrogel Contact Lens. Poster presented at the American Academy of Optometry Annual Conference, October 23-26; Orlando FL. 4. IDDrop Comparative Study DACP and BioTrue ONEday Report; Alcon data on file, 2019. 5. IDDrop Comparative Study Oasys 1 Day and TruEye; Alcon data on file, 2019. Please refer to relevant products IFU for complete list of indications, contraindications and warnings. Find at: ifu.alcon.com PRECISION1, Alcon and the Alcon logos are trademarks of Alcon Inc. 14602 © 2021 Alcon Inc. 01/21 UKIE-PR1-2100013
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Inner covers spread
VERSION
Also found in MyDay® toric and Avaira Vitality™ toric
REPRO OP ART
February/March 2021 / Volume 61:01
SUBS PRODUCTION CLIENT
Make a difference to the future of optics THE LENS TO START IN AND STAY IN
Regional representatives from our geographical constituencies 14 designated posts for optometrists working in core areas of practice and for optometrists working in Scotland, Wales and Northern Ireland.
“I urge every optometrist to take their professional development seriously”
THE FITNESS TO PRACTISE EDITION
We’re looking for members to join our Council
If you’re passionate about the profession and representing your peers, we’d like to hear from you. No previous experience required. Nominations open 10 February.
Find out more www.aop.org.uk/elections LONG-LASTING COMFORT 1
EASE OF HANDLING1
Page 27
£9.95
Biofinity® toric multifocal
www.optometry.co.uk
Prescribe freedom for your astigmatic patients with presbyopia.
/ www.optometry.co.uk
Mike George, AOP Council member
IN THEIR SHOES
“When I got the letter from the GOC, I thought: this is judgement day”
PRE- AND POST-FIT SUPPORT
Rise above the social media noise and help to shape the future of our profession with evidence, consideration and healthy debate on the AOP Council
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Hitlist Bio-acetate eyewear
February/March 2021 Volume 61:01
INTRODUCING
PRECISE VISION1
Outer covers spread
VERSION
Journal of the Association of Optometrists
What optometrists need to know about facing professional conduct proceedings and how they can strengthen their practice
“I didn't share what had happened with anyone when the complaint first came in, out of embarrassment and pride”
Reliable fit, exceptional vision. Optimised Toric Lens Geometry™ for a stable and reliable fit.
“I never thought I would find myself in the position that I did”
success rate on initial lens fitting.1
Balanced Progressive® Technology for exceptional vision at all distances. patients preferred their vision with Biofinity® toric multifocal over Proclear® multifocal toric contact lenses.1*
Powered by Aquaform® Technology for natural wettability, high breathability and proven comfort.1 Available in over 200,000 custom prescription options.2
CET How to talk to your patients about AMD
Perspectives COVID-19 and the impact on domiciliary optometry
In practice Teleoptometry and contact lens care
Page 68
Page 36
Page 43
1. CVI Data on file 2018. Non-dispensing, subject masked, randomized, bilateral, cross-over short-term clinical evaluation. 27 subjects at 2 sites (UK & US) fitted using CVI fit guide. *70% vs 15%; subjective vision assessed approximately 1 hour post-insertion. 2. CVI data on file 2019. Based on total number of prescription option combinations manufactured (for sphere, cylinder, axis, and add–including D & N combinations). Aquaform® Technology, Balanced Progressive® Technology, Biofinity®, Optimised Toric Lens Geometry™ and Proclear® are registered trademarks and trademarks of The Cooper Companies Inc. and its subsidiaries. © CooperVision 2020.
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