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Clinical track
Donald Cameron (private practice), chair of the GOC Investigation Committee, advised delegates how to reduce the likelihood of ever finding themselves standing in front of a fitness to practise committee (FTP).
He suggested ways to minimise risk when investigating symptoms of 'flashes and floaters', when you should discuss the presence of cataracts with a patient (essentially as soon as possible) and always to advise patients to expect some distortion with varifocals.
The common denominator in almost all cases was poor communication. He then summarised the procedures the GOC follows after receiving a complaint from a patient and the censures available to the FTP. The majority of cases heard relate to 'incorrect prescriptions', often small changes which seem to provide little or no improvement in vision. Low level complaints often start in the Optical Consumer Complaints Service (OCCS) but can rise to GOC level if the patient feels particularly aggrieved.
Cameron advised delegates to swallow professional pride, apologise to the patient if appropriate and consider refunding even if the patient's complaint seems unreasonable - it's better than standing in front of a FTP committee.
Dr Simon Barnard (private practice) gave a lecture discussing current trends in retinal and optic nerve diagnosis in optometric practice. This initially focused on glaucoma and the difficulty optometrists face when trying to detect it in its early stages. He reminded delegates that 20-30 per cent of glaucomatous patients have 'normal' IOPs, and that upwards of 25 per cent of retinal nerve fibres have to be lost prior to a visual field defect being detected. He suggested that slit-lamp microscopy was better than direct ophthalmoscopy for assessing cup/disc ratio, the latter tending to underestimate the reading. Disc size evaluation should be considered an essential part of optic disc assessment.
He then went on to describe some of the newer technologies available for optic nerve assessment including scanning laser tomography (HRT II), optical coherence tomography (OCT) and scanning laser polarimetry (GdxVcc). He then turned his attention to raised optic nerve heads and the difficulty in distinguishing between physiological and pathological. The presence of spontaneous venous pulsation is reassuring, any associated haemorrhages suspicious. Papillitis tends to result in visual loss in its early stages, whereas in papilloedema, vision can remain normal until the condition is advanced.
Dr Frank Eperjesi (director of undergraduate studies, Aston) delivered a lecture entitled 'Can't see or won't see? Dealing with non-organic visual loss'. While many of us will have seen the term 'malingerer' written on record cards, true malingerers mimic visual loss consciously, whereas non organic visual loss is often a subconscious process.
Typically, patients present between the ages of 10 and 14 with symptoms of reduced vision accompanied by myriad signs including visual field defects, colour vision anomalies and pain in the eyes. The role of the optometrist is to rule out the presence of underlying pathology by proving the vision is better than the patient would have you believe.
Dr Eperjesi discussed a number of techniques which could be used to achieve this, including neutralising lenses and suggestion, the demonstration plate on Ishihara and stereopsis testing. Co-existing social conflict was common and may be a contributory factor. Once the presence of non-organic visual loss has been confirmed, careful explanation and reassurance should follow with parents alone and again with the child present.
Mission Impossible meets Masterchef meets PAC Conference. only one man can bring these disparate themes together - the irrepressible Brian Tomkins (private practice). He peppered his lecture with images he had taken himself, mainly of anterior segment conditions which he felt could be managed in optometric practice and finished his lecture by preparing a dessert on stage and inviting Paul Carroll, director of professional services for Specsavers Optical Group to join him on stage for a glass of champagne.
Jeffrey Kwartz (Royal Bolton and Hope Hospital) delivered a lecture on cataract surgery. An optometrist must distinguish between patients with visually significant lens opacities and others who can be monitored in the primary care sector. One hundred per cent contrast acuity will not detect symptomatic contrast reduction so ophthalmologists will only use visual acuity as a guide. Apart from reduced visual acuity, other symptoms of cataracts include glare, colour shift and diplopia. Sight-threatening complications now occur in less than 2 per cent of all procedures.
Ian Marsh, (Liverpool) specialises mainly in adult strabismus surgery and began his lecture by discussing the prescribing of prisms for the relief of decompensated phoria or diplopia. He discouraged the use of prisms in phoria treatment, with the exception of older patients who are less responsive to orthoptic treatment, as the prism may worsen a patient's fusional ability.
He explained that the HES mainly uses therapeutic prism for recently acquired muscle weaknesses once the underlying cause has been identified. Diagnostic prism is used frequently in the HES to help predict surgical outcomes. Surgical correction of adult deviation can be associated with an improvement in the patient's social functioning. Marsh then stressed the importance of cycloplegic refraction in strabismus management. Strabismus surgery techniques have progressed over the years, but a myectomy procedure is still commonly used, muscles being strengthened by resection and weakened by recession. Repeated botulinum toxin injections can be used to treat patients in whom multiple surgeries have been unsuccessful.
Dispensing track
Professor Bruce Evans (private practice and City University) defined dyslexia as 'an unexpected problem in learning to read and spell in people otherwise capable and intelligent'.
He discussed the role of the eye-care practitioner, not in the treatment of dyslexia but the management of patients with reading difficulties who manifest some type of visual dysfunction.
It was explained how important it is to first look for conventional visual factors, namely patient's prescription and binocular and accommodative function. The dispensing optician's role being to provide spectacles where alternative treatment, such as exercises, is not suitable. These spectacles may include prisms, multifocals for decompensated esophoria at near or negative adds for an emmetrope to elicit accommodative convergence. The goal being to reduce the add over time.
Lyndon Taylor provided a thought-provoking talk on 'The rules and regulations you thought you knew'
As well as the GOC rules, there are the GOS guidelines, including sight test intervals, which as Taylor pointed out are very ambiguous - with enforcement varying greatly from PCT to PCT. What became obvious by Taylor's talk was that professionals need to be more aware of the rules and regulations, especially in a 'blame culture' society. It is important to remember ignorance is not a defence in the eyes of the law. Thanks to the internet, the information is out there - one just needs to make the time to sieve through it.
Geraint Griffiths (private practice) outlined some areas of visual assessment for sports players, such as assessing ocular dominance. He noted that cross-dominance, where eye and hand dominance differ, varies greatly among sports and no obvious patterns have emerged.
Philip Gilbert (Carl Zeiss Vision UK) claimed free-form technology can virtually close the gap between lens design technology and the actual wearer needs.
'New delivery and production models now allow us to customise the basic lens design as much as desired for the individual wearer on demand.' He went on to explain in some detail the manufacturing process and how, in future, free-form technology may incorporate higher-order aberration correction to improve visual quality yet further.
Contact Lens track
Dr Vicki Evans (Institute for Eye Research, Australia) delivered a presentation on getting the best out of contact lens solution combinations in practice, sharing the very latest findings from the IER.
The presentation concentrated on the interaction between daily wear silicone hydrogel lens materials, which are capturing an ever-increasing share of the contact lens market, and a number of lens care solutions. Dr Evans explained that, structurally, silicone hydrogels are much more complex than conventional hydrogels due to the incorporation of various hydrophobic, highly oxygen-permeable components such as silicone, plus the various treatments to aid surface wettability. As a result of the extra complexity in the lens materials, it is likely that their interaction with lens care products will be different to that with conventional hydrogels.
The IER study aims to gain an understanding of how the different contact lens solutions interact with all of the different silicone hydrogel materials, so that practitioners receive scientifically valid guidance on which combinations are most efficacious and benign. There were references to the recently published Andrasko Staining Grid, which is based on soaking a lens overnight in a particular solution and then measuring the average percentage of corneal staining after two hours' wear.
The IER study follows 40 patients for three months with clinicians seeing the patients at baseline, two weeks, one month, and three months. The extent of corneal staining was graded (by per cent) in the study, in each of the five zones of the cornea. In addition, clinicians indicated the presence of solution induced corneal staining (SICS). The early results, presented in a matrix format, indicate that hydrogen peroxide caused far less corneal staining than any of the multipurpose solutions in the trial.
In 'Immunology - what the practitioner needs to know', Jonathan Walker (private practice) guided practitioners through how to deal with that difficult decision - the differential diagnosis of red eye. Vague symptoms and a mild red eye can be very difficult for a practitioner to make a clear, accurate diagnosis. Having an understanding of the underlying disease process - part of which is an appreciation of the immune system - can help make the appropriate management decision.
The presentation covered the two arms of the immune system - the innate and the adaptive. Innate immunity is present from birth and gives first line defences against invading organisms, an example being lysozyme. Acquired immunity is gained as part of our development - an example being lymphocytes, which can recognise and destroy the vast majority of invaders that threaten our health.
Dr Rachel Peterson (Waterloo, Canada) covered 'Grading scales and diagnostic dyes in everyday contact lens practice'. In the first part of the presentation Dr Peterson discussed how to optimise the use of grading scales, thus allowing practitioners to assess the eye with greater consistency and sensitivity. Accurate and reliable monitoring of changes in ocular surface conditions is vital in practice and the grading scale is a tool which has evolved to help provide a degree of objectivity to clinical assessments. While the scales are becoming more widely used, it has been recognised that the accuracy is only as reliable as the practitioner using it. It was suggested and demonstrated during the presentation that the accuracy of scales could be improved by using up to one decimal place rather than simply a 1-4 scale.
The presentation then moved on to cover the various diagnostic dyes commonly, or less commonly, used in everyday practice for evaluation of the eye, concentrating mainly on sodium fluorescein and lissamine green. In summary, fluorescein is an important part of the assessment of the anterior eye and is the only true way to reveal corneal staining. It should be used routinely along with a barrier filter to help improve the view further.
'Contact lens care systems today and into the future', by Howard Griffiths (Sauflon) took delegates through the development of hydrogen peroxide as a method for disinfection. Despite being first introduced in the 1970s, it is still considered to be the most effective disinfecting agent available in contact lens practice today. The key considerations for contact lens care products are that they are sterile, safe and efficacious. Recent product withdrawal issues, specifically those relating to outbreaks of fungal keratitis and Acanthamoeba keratitis, were also discussed.
In summary, lens care systems have evolved dramatically with advances in convenience, safety and efficacy and the importance of contact lens hygiene cannot be over-emphasised.
Next year's PAC conference will be held on Sunday, October 12, 2008 at the ICC Birmingham. ?