There was more than one reason to remember the 5th of November this year. London optometrist Rod Whitereports from the last of this autumn's Replay conferences
Not only was it Bonfire Night, it was also the date of the fourth and final Replay Learning clinical conference of 2007. The venue, Charlton Athletic Football Club, was a somewhat unusual but entirely appropriate choice. Supporters of The Valley were still celebrating having beaten Manchester City the day before.
Anterior Eye
London optometrist Caroline Christie invited delegates into her imaginary consulting room to tell us some 'Tales from contact lens practice'.
The last five years have seen tremendous changes in the contact lens market, with the introduction of new daily disposables, silicone hydrogels, improved toric and bifocal lenses, and novel lens care products. But, as Christie explained, a significant number of patients still drop out of lens wear because their lenses are uncomfortable or do not meet their needs.
Dryness remains the most commonly reported symptom, and Christie pointed out that practitioners need to be aware of marginal dry eye signs and symptoms, in existing and potential lens wearers, so this can be managed and the associated complications minimised. Recent studies have shown that a high proportion of contact lens drop-outs are astigmats.
The latest generation of lens designs, materials and manufacturing techniques have resulted in lenses for astigmatism that allow practitioners to meet both the visual and all-day comfort demands of a wider group of patients. Similar advances in presbyopic lenses mean that long-term wearers no longer need to drop out of lens wear when they reach a certain age.
Accepting the status quo and adopting an 'if it ain't broke don't fix it' attitude no longer has clinical merit, said Christie. She encouraged practitioners to discuss new product developments with all patients if relevant to their particular needs, and to always search for something better than simply an 'acceptable' solution.
Allergic eye disease
Next up was a virtual lecture on allergic eye disease by James McGill, consultant ophthalmologist at Southampton University Hospital.
In one of the most informative lectures of the day, McGill's talking head explained that allergy was an increasing problem in Western society which affected 13 million people in the UK alone. This is thought to be due to environmental factors such as pollution, diet and hygiene - a fact that is further supported by the increased prevalence in urban rather than rural communities.
McGill went on to explain how allergens penetrate the epithelium, causing mast-cell degranulation, leading to hyperaemia, chemosis, lacrimation and itching. Mild allergy, such as seasonal allergic conjunctivitis, can be managed by optometrists using over the counter (P) medicines such as sodium cromoglycate (a mast cell stabiliser) and azelastine (an antihistamine). Allergen checking and allergen avoidance are also important parts of the treatment. More severe allergies, such as atopic kerato-conjunctivitis and vernal conjunctivitis, should be referred for specialist treatment with steroids. Vernal conjunctivitis is more common in atopic patients, is worse in spring and more severe in the Asian population. Atopic kerato-conjunctivitis can involve the lids and is characterised by failure to respond to basic treatments.
Presidential address
'The future of optical professions' by Kevin Lewis, president of the College of Optometrists, was the next lecture.
He outlined recent legislative changes that have affected the way optometrists practise. Changes at a primary care trust level have meant that practitioners must comply with local requirements to appear on ophthalmic lists. PCTs can prevent practitioners who are not correctly assigned to lists from undertaking NHS work.
It is clear that contractors rarely check with PCTs or the GOC to see if locums are actually registered and therefore able to practise prior to them working in a practice. The onus lies with the professional to ensure they are adequately registered to work within a PCT area.
Standards for better health is a document that underpins much of the NHS work that optometrists undertake, yet few optometrists know what this document is and what impact it may have on them. The standards apply in all areas where NHS services are carried out and therefore directly affect optometry. Optometrists conducting NHS work should be familiar with the requirements and their obligations under them. Smith explained that with increased interest in dispensing from optical and non-optical retailers, practitioners should not rely on profits from dispensing in the future. Practice-based commissioning and use of the wider core skills that optometry has to offer will be an important revenue stream in future years.
Binocular Vision
Professor Bruce Evans took us through a list of common conditions, tests and treatments in his presentation on 'Everyday orthoptics for the busy optometrist'. Refractive correction is the preferred treatment for many horizontal deviations.
Prismatic correction should be reserved for treatment of small or moderate vertical deviations, or for cases where horizontal deviations cannot be corrected by refractive treatment alone. Fusional reserve eye exercises can be used to treat small to moderate horizontal deviations in a co-operative, healthy patient. Exo-deviations improve best because it is easier to improve the ability to converge (positive or base-out fusional reserve) than to improve the ability to diverge (eso-deviations). When evaluating amblyopia for the prospect of treatment, Evans told us to consider the type of amblyopia, the age of the patient (now and at onset), the acuity and the co-operation or interest in treatment.
In anisometropic amblyopia where there is no strabismus it is important to look for pathology, including microtropia. The first line of treatment is always refractive correction alone. Occlusion should be reserved for cases where there is no improvement. Patients can improve at any age, although it is better to treat as young as possible, especially in the presence of a squint. Where there is a squint, patching should be avoided in patients over seven years of age as it may lead to intractable diplopia.
Cross-infection control in optometric practice was the subject of the next lecture by Professor Roger Buckley, consultant ophthalmologist at Moorfields Eye Hospital. A cross-infection is one acquired in a hospital or other healthcare facility. In the UK, about 9 per cent of patients acquire an infection while in hospital and 5,000 die each year from this cause. Cross-infection occurs in all clinical settings, including community optometric practices and includes cross-infection between patient and practitioner as well as between patients. The problem of cross-infection is inextricably linked with microbial drug resistance. Acquired resistance has escalated globally since the 1990s due to over-use of antibiotics in humans and in animals bred for human consumption. Ocular cross-infection is less likely to be encountered if disposable items, such as fluorets or disposable tonometer tips, are used.
Hand hygiene is of paramount importance, Buckley noted, and hand washing should be carried out both before and after patient contact, before handling an invasive device, such as a contact lens, after contact has been made with body fluids or mucous membranes and after contact with inanimate objects in the patient's vicinity. Compared with progress in some other clinical disciplines, ocular health care has scarcely begun to address the problems and potential problems posed by cross-infection.
Photopsia
Many patients present at optometric practices with symptoms of flashing lights and floaters. This was the subject of my final lecture of the day, which was given by Dr Trusit Dave, a visiting lecturer at Aston University.
Around 10 per cent of patients presenting with such symptoms may have some form of retinal break. Early detection is vital as visual loss is preventable if detected before the retina detaches over the macula. In order to examine all of the retina, one needs to be competent in indirect ophthalmoscopy combined with scleral indentation, or alternatively be able to use a three- or four-mirror contact lens. However, familiarity with these techniques is currently still not the standard expected of a reasonably competent optometrist. Dave recommended carrying out indirect ophthalmoscopy using an appropriate lens such as a +90D with slit lamp on all patients with symptoms and all patients at high risk. The presence of retinal pigment epithelial cells in the anterior vitreous has also been shown to be a good sign of a retinal break. Where there is an acute vitreous detachment and an associated retinal break, retinal pigment epithelial cells are shed into the vitreous. These cells can be observed within hours of the formation of a retinal break associated with an acute PVD. They can be seen using a fine, bright slit beam projected into the vitreous. The practitioner should look for brown coloured cells. In patients where a retinal break cannot be ruled out, emergency referral to a hospital eye department was recommended. Other patients should be told about the symptoms of retinal detachment and advised to act promptly if they notice those symptoms in future.