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Mr Gavin Orr (consultant ophthalmologist at Nottingham University, Queens Medical Centre) opened the lecture programme with a presentation on the current management of diabetic eye disease. He stated that diabetes is still the leading cause of blindness in the UK working population with macular oedema being the most common reason. He described a new macular oedema treatment called intravitreal triamcinolone which is now available in larger ophthalmic departments. This involves injecting a steroid into the vitreous cavity and when successful can give dramatic improvement in vision (for example, 6/36 to 6/12 in four weeks). However, he said the technique is not without risks: following treatment, 20 per cent of patients have a significant increase of IOP, secondary cataracts can occur and there is a risk of endophalmitis. It may also need to be repeated as the effect can diminish with time.
Professor Bruce Evans presented a lecture on 'Migraine and the optometrist' and told us how when diagnosing headaches, the most sensitive instrument we have as optometrists is our ears, since the diagnosis is based mainly on history and symptoms. Essentially, for differential diagnosis we should know the typical and refer the atypical, paying great attention to the 'first or worst' rule - namely, if a patient reports a new type of headache or the worst they have ever experienced, these are the ones which may potentially have the most serious causes.
He described how to distinguish between different headache types. Migraines, which are the most common cause of headache, classically give a moderate or severe pulsating unilateral pain which builds up, lasts for 4-72 hours and becomes worse with physical activity. Headaches caused by brain tumours are usually a tension type, which worsen with time, also increase with physical activity and cause field loss in 50 per cent of cases. In contrast, subarachnoid haemorrhages cause a very severe bilateral (thunderclap) headache and are usually accompanied by vomiting and photophobia.
Malcolm McPherson (optometrist in Aberdeen), assisted by Sarah Farrant, ran a 'Removal of foreign objects' workshop. Delegates were given the unique opportunity to remove embedded iron filings from mounted sheep's eyes using a slit lamp and a sterile needle. Top tips were to have the needle in place and in the slit beam before looking through the slit lamp, keep the needle angled towards you with the hole of the needle visible, and lift the foreign body off with a scoop or flick, always ensuring movement away from the visual axis. It was suggested afterwards for those who may prefer not to use needles in practice, PVA spears or the pointed corner of an unused minim are possible alternative tools.
Daniel Ehrlich (head of optometry at Moorfields Eye Hospital) gave a fascinating insight on the developing role of optometrists in secondary care, describing how optometrists are taking on extended roles within the hospital setting. This includes diagnosing and managing conditions in ophthalmic A&E clinics, performing post-op retinal detachment assessments in vitreoretinal clinics and undertaking YAG laser capsulotomies and peripheral laser iridotomies. For any extended role he stressed the need for rigorous clinical governance, clear clinical guidelines and protocols, appropriate training for individuals and thorough auditing set up from the start.
Amanda Harding (principle optometrist at Manchester Eye Hospital), assisted by Dr Kamlesh Chauhan, ran a gonioscopy workshop where after watching a live video slit-lamp demonstration, delegates were allowed to attempt the technique on a group of willing patients. A large choice of gonioscopy lenses was available to try including those with one, two and four mirrors and ones which required coupling fluid. With assistance, everyone appeared to get an image with the various lenses and it was interesting to compare the ease of use and images obtained between the different types. We left feeling that this was a technique within our capability to learn but certainly one that would require a lot of practice to confidently carry out and interpret the findings correctly.
Lynne Weddell of City University gave a lecture on 'examining children' full of practical tips and descriptions of useful techniques. A procedure she believes is currently under-utilised in paediatric examinations is the 20-dioptre base-out prism test. She described how when a 20-dioptre base-out prism is held in front of each eye in turn, if normal binocular single vision is present, the eye without the prism will first diverge (due to Hering's law) then converge. If no movement or a vergence movement is seen this would indicate suppression or a manifest deviation. She said this simple test is invaluable to determine the presence of binocular single vision, especially in unco-operative children.
Charter Lecture
The Charter Lecture entitled 'The practice of the future' was presented by Ian Davies (vice president of the Vision Care Institute). He predicted that today's optometric possibilities would be commonplace in 20 years' time due to transformational technology. He envisaged a future where prior to an eye examination, electronically entered symptoms would be obtained and linked with external databases to provide full patient information including genetic risk factors. Ocular coherence tomography would provide an objective assessment of the eye using digital analysis against age-related norms and manual refraction would be replaced by automated subjective and objective refractors which incorporate binocular balancing. He urged us all to embrace the opportunities that this technology revolution would bring.
Tina Romany and Priya Dabasia of City University ran a slit lamp BIO workshop and expertly instructed us on how get the best out of the technique. To obtain an optimum image they recommended to accurately adjust the eyepiece focus and separation beforehand, use low magnification, zero angle of illumination, a slit with a 2mm width and height just larger than the pupil and the BIO lens held approximately 10mm from the cornea. We were shown with a live video slit-lamp demonstration, how the field of view and image quality can be improved by altering the patient's position of gaze and adjusting the lens angle for example, to look at the superior peripheral retina, instruct the patient to look up, realign the slit beam and tilt the top of the lens towards you. Delegates could try the technique on dilated subjects using a wide array of BIO lenses, from +60D to +125D.
Retinal imaging
Mr Paulo Stanga (consultant ophthalmologist and vitreoretinal surgeon at the Royal Eye Hospital Manchester) gave a presentation on advances in retinal imaging, focusing on the use of OCT (optical coherence tomography) and the application of OCT imaging in macular disease. In the past 10 years, OCT has moved from being a research tool to essential equipment in a retinal clinic for both diagnosis and monitoring of treatment.
He told us how, within seconds, the new equipment using Fourier domain technology can scan an entire macula and produce a computer generated image of the retinal layers which can be viewed in 2D, 3D, rotated, cropped and accurately analysed. Delegates were transfixed as Stanga showed OCT images of his patients with a wide variety of macular disease including looking at a macular hole from different angles, 2D and 3D images of cystoid macular oedema and a macula following RPE translocation. The depth and extent of the lesions could be viewed in amazing detail and the different layers of the retina affected were easily visualised.
Delegates obtained hands-on OCT experience in a workshop run by Donald Cameron (optometrist in Edinburgh) who shared his knowledge and expertise of the technique acquired from private practice and through running an acute macular referral clinic at the Princess Alexandra Eye Pavilion. Two Topcon 3D OCT-1000s were available to use and we discovered that operating the instrument was very similar to using a fundus camera. It creates an OCT image alongside a fundus photograph and within seconds gives a high quality image, even through undilated pupils. The optometrists found it fascinating to view 2D and 3D images of the layers of our own retinae and optic discs.
After a full weekend of lectures and workshops and a gala dinner at London's Guildhall where royalty and state visitors have been entertained down the centuries, delegates left feeling inspired and eager to apply the knowledge learned. Feedback forms rated the conference overall as 90 per cent and 100 per cent of delegates stated they would like to attend another Optometry Tomorrow event.
The next Optometry Tomorrow conference will take place in Birmingham in spring 2009. Full details will be released in the optical press and at www.college-optometrists.org
Mary Ware is an optometrist and College of Optometrists councillor
