As with much to do with Europe at present, there is a lot of activity in the optometry world. The professions concerning optometry and optics are developing in most member countries and addressing the various challenges in each to ensure both clinical excellence and improving patient care. In this article I aim to summarise some of the key points from a selection of the various presentations during the conference. Look out for further features addressing the political and organisational evolution of European optometry.
Extended service role
Renowned authority in glaucoma detection and management, Dr Robert Harper (Manchester) opened proceedings with a review of the role of optometrists in community screening and referral of suspect glaucoma and ocular hypertension. He showed how enhanced services in the community had helped to significantly reduce false positive referral rates (10% reduction was cited) and how extended roles in hospital optometry were helping to ensure best use of resources in effective management. He later presented a paper supporting this last statement which showed how surveyed UK hospital optometrists (n=70) were now undertaking roles offering extended services in glaucoma (86% of respondents), macula (66%) and retina/diabetes (51%) along with other procedures including some laser treatments.
Ocular surface
Dr Stefan Bandlitz (Cologne) usefully reviewed the use of staining agents in assessing ocular surfaces. Of note was his description of the (not yet available in Europe) dry eye test (DET) strip. The fluorescein impregnated substrate portion of the DET test strip is substantially slimmer than the traditional fluorescein test strips. This unique design modification allows delivery of 1µl of fluorescein dye to the ocular surface, without compromising the tear film. The traditional fluorescein test strips typically deliver up to 17µl of dye fluid into the fragile tear film’s 3 to 7µl tear volume. This large dye volume overwhelms the tear film structure and leads to inaccurate and unreliable TBUT results. The DET test strips provide a concise and reliable TBUT measurement. He also pointed out that contact lenses with a more knife-shaped edge (he gave Acuvue designs as an example) are more comfortable but may show more staining.
Professor Christine Purslow (Keele) offered the following notable points:
- The eyelids travel 80km a year
- Blepharitis is found in 40% of patients
- Baby shampoo remedies are a ‘no no’ as saponification destroys meibum and inflames gland openings
- Use of bicarbonate stems from a letter published in the 1940s – it is the wrong pH and inappropriate for lid treatment
- Myopia
Professor Mark Bullimore (Houston) offered an overview of current trends in myopia interventions and stated how he had now changed his opinion and felt that this was an important area of future clinical significance. Key points he stated included:
- Under-correction of myopia makes matters worse
- Multifocal spectacle correction has a modest benefit and are ‘a lot of expense for minimum clinical effect’
- Executive bifocals show most benefit out of spectacle options (three times the impact of multifocals)
- Beta blockers are ineffective
- Atropine shows the most effect upon myopic progression, even with low concentrations1, and appears to act upon muscarinic receptors in the retina
- A drug selective to M1 receptors in the retina (pirenzepine) would be better tolerated
- Soft contact lenses have no effect and RGPs ‘no real effect’
- Orthokeratology (OK) is proving to be a ‘game changer’ with meta-analysis showing around 43% improvement
- Multifocal contact lenses have similar properties to specialist lenses (like the ‘mysight’) which offer a peripheral shell defocus and a 30% benefit with contact lens intervention was cited
- Practitioners wanting to enter this field can be reassured that microbial keratitis rates with OK seem no different than with other wear modalities and, where cases have arisen, tap water is usually to blame.
Of the various environmental influences upon myopic progression, there was little evidence of near work as a trigger but outdoor light exposure does lower the risk of myopia development. Also, in response to a question from the floor, Bullimore explained that a rebound effect upon ceasing use of atropine is significant but less so with the lower concentrations of the drug.
Refractive correction
Jennifer Brower (Abdo, UK) explained how, globally, uncorrected refractive error was a major concern, with an estimated 4.5 billion of the global population of 7.2 billion requiring vision correction and about 2.5 billion still not having this correction for a variety of reasons.
Professor Bruce Evans (UK) explained how non-tolerance to a particular refractive prescription was most common in the 50 to 59-year-old patient age group, with 88 per cent in one study being presbyopic. No gender bias had been found and all cases had been managed with adjustments of 1.00DS or less. His work had suggested that intolerance due to the prescription accounted for just over 60% of cases, with dispensing problems causing 22%, disease 8.5%, data entry errors 6.8% and anomalies of binocular vision just 1.7%. In conclusion, Evans suggested we might view the ‘non-tol as an opportunity.’
Ocular health
Dr Jeffrey Weaver (Missouri) showed how the increasing recommendation of vitamin supplements by eye care professionals needs to be considered against the back drop of some significant points about their usefulness. For example, the potential toxicity of vitamin A means that its widespread use needs to be viewed with caution. Further understanding of possible adverse responses, either when supplements are used alongside prescribed medications or where, for example in the case of vitamin D and skin cancer risk, there may be comorbidity issues.
Bill Harvey (UK) emphasised that approaches to eye health need to focus as much upon early detection and prevention as on low vision strategies. He gave examples of crystalline lens autofluorescence screening for diabetes and dark adaptation assessment methods for early maculopathy as areas ripe for clinical development in the primary care community.
Paediatrics
Dr Dorothy Thomson (Great Ormond Street) explained how some newly introduced methods of electrophysiological assessment of children may make early disease detection more realisable in the community practice. Instruments such as the RETeval unit are worth looking at.
Bruce Evans (again) discussed dyslexia and vision. He stated that many possible visual correlates exist, but emphasised that these are not definitely causative, but rather coincident. These include binocular instability, accommodative deficit and saccadic movement dysfunction. The evidence for a magnocellular deficit as causative, however, far outweighs opinion of it being coincidental (see Optician 29.1.16). Also pattern glare (visual stress related to certain pattern images) should also be considered as a separate entity to dyslexia (look out for a forthcoming paper in Optician on this).
Commenting on the evidence base, Evans stated how sometimes we have to use the best evidence available and incorporate that into mode of practice – even if the ideal of randomised control study evidence is not forthcoming.
Lens anomalies in children can sometimes be effectively screened for by the ‘just look’ retinoscopy approach recommended by US optometrist Glenn Steele, explained Dr Marie Bodack (Memphis). Differences in the reflex of brightness, colour, motion or quality are useful indicators of a problem in even the youngest patients. This can even be done during activities like feeding when co-operation might otherwise be lacking.
Ten common complaints
Dr Frank Eperjesi (Aston) emphasised the importance of careful questioning when dealing with the sorts of aches and pains that commonly present in practice but are all too often either dismissed or inadequately managed.
Professor James Wolffsohn and Dr Frank Eperjesi
The cases he cited were very familiar such as a patient complaining of sudden sharp stabbing pains. These typically presented in the female post-menopausal patient and often resolve well with lubricants. Feelings of ‘pressure in the eye’ are rarely to do with intraocular pressure, and most often related to conjunctival inflammation, sometimes mild corneal epithelial disruption. This may be a conversion reaction linked to life challenges?
Jumpy or twitchy eyes, more formally known as blepharomyokymia, are very common. In 98% of cases, the symptom is unilateral and related to a number of underlying factors such as fatigue, stress, caffeine and other stimulants, CNS depressants and decongestants.
Though apparently minor, patients often are very concerned by the ‘twitching’ and identification of the cause alongside reassurance is very important to help the patient.
He finished by discussing problems of ‘poor night driving vision’ and helpfully stated how, though sometimes linked with the need for spherical adjustment, often is best sorted out by careful cleaning of the inside of the windscreen, known to be a major factor in causing glare from oncoming headlights.
Presbyopia
In one of the keynote lectures, Professor James Wolffsohn (Aston) showed the latest results of the success or otherwise of a wide range of corrections for presbyopia, from spectacle and contact lens multifocal options through to the very latest in intraocular lens technology. It is essential practitioners keep up to date so they can advise their patients of the options available.
Next year, this conference will take place in Barcelona – look out for previews in Optician along with further features looking at the state of European eye care education and practice.