Raising the stakes

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The past year has been a crucial time for the College of Optometrists as it defined its role among the professional and representative bodies, and further extended its reach into research and the public arena.

In education and practice, it developed the new OSCE (Objective Structures Clinical Examination) scheme for registration, incorporating work-based assessment, and brought in continuing professional development with CPD Online. It also published evidence-based Clinical Management Guidelines for optometrist prescribing and ran the first exams for independent prescribers.

In research, the College helped launch the new European Academy of Optometry and Optics, introduced a research symposium to its own annual conference, and provided funding through research fellowships and support for practice-based studies.

And in the public arena, it increasingly became the voice of the profession in the lay media with more than 400 items of coverage and a new consumer website, lookafteryoureyes.org.

Little wonder that this year's annual conference and AGM was an opportunity for the College to celebrate its achievements not just over the 30 years since its foundation but over the past year in particular. The programme reflected many of these areas of interest over the two-day meeting at York Racecourse.

It was an impressive event. Six parallel tracks of lectures, workshops and seminars ran concurrently, providing delegates with a choice of format and diversity of topics. Posters were included for the first time in the exhibition area, where 36 companies and organisations had stands.

Workshops proved popular and reflected several of the clinical techniques prominent on the lecture programme, such as contact tonometry, pachymetry and OCT.

Small-group CPD seminars covered business issues such as leadership and management and improving customer retention, along with a useful session on 'How to articulate your case to commissioners' using evidence-based eye-care schemes.

Translational research

In fact evidence-based practice was the key theme of the conference, supported by some interesting presentations in the research stream. Keynote speaker Professor Peng Tee Khaw, director of the National Institute for Health Research at Moorfields Eye Hospital and the UCL Institute of Ophthalmology, made the case most eloquently for 'translational research' through which laboratory discoveries could be translated into practical applications.

There was still a huge demand and unmet need for better treatments, which could have the potential to transform lives. Recent breakthroughs in stem cell treatment, tissue regeneration and gene therapy placed ophthalmology at the very highest level of priority nationally and collaboration was key. 'The opportunity and funding is there for optometrists to be involved in research at any stage in their careers,' he said.

Other lectures on the research programme had useful clinical information to apply in the consulting room, such as on diabetic eye disease and 'flashes and floaters'. Director of research for the College, Michael Bowen, explained that the aim was to provide a forum for a range of research, whether university, community or practice-based, that would form an integral part of the conference.

'If optometry and other optical sectors outside ophthalmology want to develop public and policymakers' appreciation of the importance of their role, they need to be able to contribute and process evidence, or even just take the time to be interested,' he argued. 'We have to prepare ourselves today for 5-10 years hence.'

CMGs: for all optometrists

Therapeutics was also a strong theme, with two presentations on the Clinical Management Guidelines (CMGs)developed by ophthalmologists and optometrists under the direction of Professor Roger Buckley and now available on the College website. The guidelines are intended to provide a reliable source of evidence-based information on the diagnosis and management of 60 conditions that present in primary care.

Dorset-based John Tickner, one of the first optometrists to become independent prescribers, explained the hierarchy of evidence behind the CMGs, 45 of which are now published. Although the guidelines had been developed specifically for those on the specialist register, he stressed that all optometrists needed to be familiar with them. 'If things go wrong you may need to defend your practice against them,' he warned.

Two-thirds of the CMGs completed were appropriate to anyone on the register and only 12 related specifically to independent prescribing.

The NICE effect

One of the most useful sessions on the main programme discussed the optometrist's role in the diagnosis and management of glaucoma and ocular hypertension, one year on from the publication of the NICE guideline.

Chris Steele, head of optometry at Sunderland Eye Infirmary, outlined the rationale behind the guideline which he described as 'an important step forward in raising standards of care'. He argued that evidence-based treatment and timely monitoring through integrated care pathways offered many opportunities for optometrists.

Incoming College president Dr Cindy Tromans, consultant optometrist at Manchester Royal Eye Hospital, described the College's response to the guideline. A joint working group with the Royal College of Ophthalmologists which she chaired issued supplementary guidance in December. The guidance recommended Goldmann applanation tonometry, clarified the procedure for non-contact tonometry and specified circumstances in which non-referral was acceptable.

Next year, the College would be launching a more advanced higher qualification than currently available that would offer a 'flexible and achievable' means of specialising in glaucoma, she said.

Professor Stephen Vernon of the University Hospital Nottingham, who represented the Royal College of Ophthalmologists on the joint working group, presented his personal perspective on NICE. There had been misunderstanding among both professions as to the purpose of the guideline. A 'massive increase' in new referrals had caused a major problem for ophthalmologists who were already struggling with increased workload.

New treatments for wet AMD were overwhelming hospital eye departments and had not been properly funded. This was having a knock-on effect on all other services, especially in glaucoma and diabetic eye disease. One positive outcome was that glaucoma was now 'very firmly on PCTs' radar', he said.

His own department had seen a doubling of referrals, half of them based on raised IOP alone, and a huge number of false-positive referrals. Under-65s with pressures 22-25Hgmm and central corneal thickness less than 555 microns were the problem group, and most consultants did not agree with the NICE guideline for these patients.

For Professor Vernon, the way forward in primary care was locally tailored referral refinement and shared care schemes. Every patient should have Goldmann tonometry before referral and pachymetry should be more widely used. In secondary care, more services should move into the community, with virtual clinics and, again, shared care among the options put forward.

Relationships between the two professions had suffered since the NICE guideline was published. 'There's been a great deal of loss of goodwill between optometrists and ophthalmologists since April 22 last year,' he warned.

Yet many delegates at this conference reported good cooperation at a local level. Many were already involved in co-management and referral refinement schemes, and not just in glaucoma, that had led to better inter-professional relationships. Neither was it necessary for optometrists in existing shared care schemes to have a higher qualification in glaucoma in order to take part, said Professor Vernon, provided the scheme was organised by a consultant.

Role in AMD management

Elsewhere on the programme there were interesting presentations from ophthalmologists on the role of the optometrist in recognising skin lesions and ways the profession might be involved in anti-VEGF treatments for wet AMD.

Retinal specialist Martin McKibbin of St James's University Hospital in Leeds said that hospitals were already looking at using non-medical staff to assess AMD referrals in order to cope with demand for treatment with Lucentis and Macugen. If optometrists wanted to get involved now was the time to do so. 'If we can't cope now, we won't be able to cope in future when these drugs are indicated for other conditions too,' he argued.

Fast-track referrals of AMD cases, supervised assessment and treatment, and moving treatment out into the community to increase capacity were just some of the options for an expanded role for optometrists.

No doubt many in the audience of experienced, mainly independent practitioners relish the prospect of such a role, although a large number of delegates had opted to attend a lecture in the safer waters of managing allergic eye disease at the time. How the wider profession might perceive some of the more ambitious ideas discussed remains unclear.

There are some who believe that the College is taking the profession too far down the therapeutic route. Even within the College itself there are those who feel there is still plenty of mileage in the optometrist's traditional role in assessing and correcting vision.

These topics were less prominent on the College's conference programme as it examined the opportunities that lay ahead for the profession and looked forward to its role over the next 30 years, making the theme of Optometry Tomorrow particularly apt. ?

? The College of Optometrists' Clinical Management Guidelines can be found at its website www.college-optometrists.org