More than 200 hospital optometrists from across the UK were treated to a diverse and challenging range of lectures, workshops and presentations at this year's Hospital Optometrists Conference in Chester.
Following the opening address, Dr Michael Crossland, of Moorfields Eye Hospital, gave a presentation on the use of the Nidek MP-1 microperimeter. This is a new, commercially available system that allows simultaneous imaging of the retina and projection of stimuli to perform automated perimetry, even in cases of eccentric viewing or poor fixation stability.
This technique has been shown to be useful in cases such as age-related macular disease, diabetic retinopathy and posterior uveitis, as highly specific areas of the retina can be targeted for testing.
Low Vision
Next, Clare Flynn, research optometrist at Royal Victoria Hospital in Belfast, gave an account of the international history of guide dog provision and the use of guide dogs in Europe.
Established in 1989, the International Federation of Guide Dog Schools for the Blind now has 68 member schools across 23 countries. Of all the European countries with guide dog schools, the UK has the highest proportion of guide dog users, with 3 per cent of the 157,000 people registered blind or severely sight-impaired in the UK using a guide dog, compared to just 0.4 per cent of the 2.7 million blind people in Europe. However, unlike in some European countries, the provision of guide dogs within the UK falls totally within the voluntary sector, with no government funding.
Mary Bairstow, low vision implementation officer at the Royal National Institute of the Blind, discussed the barriers faced by visually impaired people in the workplace and in seeking employment.
There are several organisations and schemes, both local and national, that can assist visually impaired people in finding work. The RNIB has its own employment advisers, while the Job Centre employs disability employment advisers. Bairstow encouraged hospital optometrists working in low vision clinics to be aware of the help that is available, in order to advise their patients accordingly.
Health and Happiness
Professor Jonathan Jackson, also from the Royal Victoria Hospital, entertained his audience with an amusing, yet serious talk, titled 'Health and happiness: Do we really make a difference?'
He posed the question that in today's climate of evidence-based practice, do practitioners really know whether low vision interventions help to improve patients' quality of life? He suggested the development of generic, vision specific and low vision-specific quality of life questionnaires used in the clinical setting would allow us to qualitatively assess the patient's perception of how they function visually, both before and after low vision rehabilitation.
The afternoon session comprised of a varied selection of workshops and manufacturer's presentations, covering hand-made frames for children, treatment options for CNV, an optometrist's guide to flashes and floaters and scleral contact lenses, to name but a few.
Binocular vision and development
The Sunday session began with 'An investigation of the genetic basis of human strabismus', presented by Aine Rice, from St James University Hospital in Leeds. Large Caucasian families from Leeds and Kent, where at least two people in the family had non-syndrome esotropia, were studied clinically and genetically, in order to characterise the genetic contribution to the condition. The findings showed a link between esotropia and a susceptibility locus at 7p, termed STRMS 1. Further results are anticipated, following a genome trawl of DNA from an expanded cohort of families to look at the nature of the genetic basis of strabismus and hypermetropia.
This was followed by a presentation by Richard Allen from Great Ormond Street, London, looking at the long-term outcomes of the management of unilateral aphakia. Unilateral congenital cataract is frequently dealt with by cataract extraction in the first few weeks of life, followed by contact lens correction of the resulting aphakia, along with intensive patching of the fellow eye.
The aim of this retrospective study was to look at whether useful visual acuity is a realistic goal of treatment. It was found that only 32 per cent of eyes had a final VA of 0.60 logMAR (6/24) or better, and this was generally correlated with earlier surgery, at an average age of 5.0±4.1 weeks, whereas 68 per cent of eyes had an acuity less than 0.6, with an average age for surgery of 9.7±6.5 weeks. Twenty-seven per cent had a final VA of hand movements or worse.
Complications included glaucoma (19 per cent) and strabismus (84 per cent), and occlusion therapy was abandoned in 30 per cent of cases before age four due to significant distress to the child and the parents. Overall, it was concluded that the treatment of unilateral aphakia had a poor success rate.
Jane Farbrother, Oxford Eye Hospital, presented some preliminary results of a survey carried out at the beginning of the conference, looking at the prescribing decisions of the delegates with regard to refractive errors in young children. The results were compared to survey data, research trial results and published recommendations for preferred practice, for example the Royal College of Ophthalmologists Guidelines.
Overall, it was found that the majority of surveyed hospital optometrists were more cautious with their prescribing decisions, and so were more likely to recommend glasses at a lower refractive error. More analysis is needed to look at such factors as regional variation.
Clinical negligence
In today's increasingly litigious society, more and more optometrists are facing charges of clinical negligence, by either the civil courts or by the disciplinary committee of the GOC.
Geoff Woodward, emeritus professor at City University, gave a revealing analysis of 50 cases where he had provided an expert witness report. As may perhaps be expected, the most frequent complaints were failing to detect glaucoma (15 cases), and retinal detachment (13 cases). These were followed by failure to detect papilloedema in six cases of young adults or children, all of whom suffered migrainous symptoms, and five cases of missed ocular neoplasms.
Negligence on the part of the optometrist would be failure to carry out a particular test where indicated, rather than simply making a mistake, and so it is important that optometrists practise 'defensive optometry' at all times. Of course, one of the most important factors in good clinical practice is to keep clear, concise and full records of each patient episode.
Corneal surgery
James Ball from Leeds Teaching Hospitals NHS Trust provided an update on current techniques in corneal surgery, for both the correction of refractive error and the treatment of a range of corneal disorders. With the development of intricate operating tools - such as the excimer laser, mechanical microkeratomes and the femtosecond laser - more surgical options are available, allowing surgical procedures to be better tailored to patient needs. For example, due to the risk of endothelial rejection of corneal grafts, more surgeons are now performing deep anterior lamellar keratoplasty in conditions such as keratoconus. This leaves the healthy host endothelium in place, reducing the risk of rejection episodes, wound dehiscence or rupture. Conversely, in endothelial disease such as Fuch's dystrophy, it is now possible to perform deep lamellar endothelial keratoplasty where only the endothelium is removed and replaced.
This move towards corneal 'component' surgery, where only the diseased part of the cornea is replaced, rather than replacing the whole cornea as with penetrating keratoplasty, will hopefully lead to a decrease in postoperative problems and better use of available donor tissue.
Poster presentation
Delegates also had the opportunity to read posters on a variety of topics, produced by different eye hospitals. These included 'Eye care in Madagascar', 'Management options for raised nebula scars in keratoconus', 'Contact lens fitting on blind and partially sighted patients' and 'The importance of central corneal thickness measurements in glaucoma clinics'.
The poster competition was won by Vicky O'Connor, Christine Purslow and Martin Rubinstein from Nottingham University Hospital. Their poster detailed the results of a pilot study on thermal imaging in ophthalmology. Ocular temperature is related to ocular blood flow, particularly to the anterior eye, but absolute temperature values may be of limited value due to many confounding factors. Instead, thermal asymmetry between eyes has been shown to be a more useful indicator of inflammation of the ocular surface and adnexa. For example, chalazia, corneal abrasions, iris, scleral or conjunctival inflammation can all increase the temperature of the affected eye relative to the other eye, whereas acute corneal ulceration will decrease the temperature.
? Emma Sharples is a specialist optometrist at Manchester Royal Eye Hospital