A key theme in modern optometry, and one very much represented at this year’s Optometry Tomorrow conference, is the increasing responsibility of primary care optometrists for the management of ocular disease within the community to support our ophthalmology colleagues. Better use of our skillset and availability of newer technologies, along with easier patient access to our services, has led to a major shift in the way our profession is viewed by colleagues in allied professions and secondary care. Indeed, optometrists are now to be viewed as the first port of call for anyone with concerns about adnexal, and anterior ocular disease, much of which is perfectly manageable in community practice.
This was clearly reflected in many of the clinical presentations during the two day event, as well as a topic for discussion in this year’s George Giles Memorial Lecture.
Dry Eye
Future trends in the diagnosis, classification and management of dry eye disease was the subject of a wide-ranging presentation by the ubiquitous Professor James Wolffsohn. Who better to cover such a broad topic than one of the key players in the production of the TFOS DEWS2 reports, the definitive evidence base for all matters to do with dry eye disease and ocular surface disorders? The scope of this wide-ranging publication was underlined when Wolffsohn told how a simple online search for “dry eye” had come up with 19,622 hits covering disciplines as various as ophthalmology, immunology and geriatrics. The need for an up-to-date synopsis of the assessment and management of such a broad topic could not be greater.
Figure 1: Pathways to specifying types of dry eye disease
What I particularly like about Wolffsohn’s approach to dry eye disease is his clear and logical stepwise approach to differentiating between the many ways dry disease can present, for example with or without symptoms and with a range of different signs. This allows a pathway approach to both classification (figure 1) and then management, allowing a clinician to tailor treatments rather than simply throwing ocular lubricants at every dry eye. Also useful, was a discussion of the many risk factors, many of them modifiable, for dry eye disease (table 1). Prevention is always better than cure.
Table 1: Modifiable and non-modifiable risk factors for dry eye disease
Angle Closure Glaucoma
In community practice, we can sometimes have such a focus on primary open angle glaucoma (POAG) as to neglect angle closure glaucoma (ACG), thinking of it only in terms of a rare and very painful medical emergency that simply needs to be directed towards the nearest eye hospital. So it was helpful to listen to an excellent presentation by Birmingham-based hospital optometrist Deepti Raina that encouraged the audience to have a fresh think about narrowing anterior angles.
The prevalence of ACG in the Europe runs at around 0.4% among the over 40s, accounting for a surprising one in 6 of glaucoma cases in the UK. Worldwide, studies suggest that primary ACG has caused bilateral visual impairment in 5.3 million people compared with 5.9 million people blinded globally by POAG. After explaining the various mechanisms for angle closure, Raina most usefully reminded delegates of the risk factors for closure, something essential for community practitioners to help predict problems and be able to intervene where necessary. Obviously, shallow anterior chambers and shorter axial lengths are the biggest risks, but there is also a 3 times greater risk in women, while Asian ethnicity also increases the chances of ACG. Regular monitoring of narrow angles is the key; I speak as someone with a 20% narrow angle who is more than happy to be monitored in the community, told of symptoms to look out for, while avoiding unnecessary hospital visits to be looked at. Any unexplainable asymmetry between the two chambers or narrowing over time are important indicators of potential problems. Also, symptoms may be more than just ‘pain and haloes’; Raina told of how one patient with intermittent closure and occludable angles had been initially managed as a migraine patient.
Half of patients with primary ACG demonstrate peripheral anterior synechia (PAS), with the extent of PAS correlated significantly with presenting IOP and narrower anterior chamber angles. The first line of management is YAG laser peripheral iridotomy, a technique which, as regular readers of this publication will know, is increasingly being undertaken by specialist optometrists.
Topography
The accurate assessment of the contour of the anterior eye by topography is still not as widespread a technique as one might expect, especially having heard Dr Shehzad Naroo skilfully demystify the sometimes confused process. After describing a brief history of topography, Naroo went on to show how the technique is helpful in disease detection and monitoring as well as contact lens practice. To illustrate this, he gave his top tips for spotting the cone of a keratoconic (figure 2; spot the cone of a keratoconic). These include noting a steep and displaced
apex, thinning on pachymetry with ectasia greater posteriorly, ad increases in higher order aberrations.
Eyelid Lumps
With such a wide range of eyelid lumps and bumps presenting in practice, it was useful to hear the advice of consultant oculoplastics, lacrimal and orbital surgeon, Miss Susan Sarangapani, explain which ones need referral to a specialist. Examples of benign lesions include haemangioma, cyst, xanthelasma, chalazion, granuloma, molluscum contagiosum, cutaneous horn, basal cell papilloma, squamous cell papilloma, milia, and dermatosis papulosa nigra (DPN). While rarely a cause of symptoms, benign lesions can become large and cause bleeding, pain and eyelid malposition. Indeed, on rare occasions, such lesions may transform to a malignant growth. Monitoring is essential. As is so often the case with ‘lumps and bumps’ lectures, delegates were treated to a horror show of various images. Fortunately, we were also treated to a picture of Morgan Freeman’s smiling face to illustrate the appearance of DPN, those black spots commonly seen on the skin of people with greater pigmentation (figure 3; dermatosis papulosa nigra).
Where malignancy is suspected, the maximum waiting time for suspected cancer is 2 weeks from the day your appointment is booked through the NHS e-Referral Service, or when the hospital or service receives your referral letter.
George Giles Memorial Lecture
This year’s memorial lecture was given by outgoing College of Optometrists president Colin Davison and Professor Bernie Chang, president of The Royal College of Ophthalmologists. Who better to show how closely allied the two professions are becoming and how a coordinated approach is evolving in each of the four countries of the UK. Davison confirmed that optometrists are at the heart of patient-centred eye care, making full use of their skills, being given opportunities to develop new skills, and playing a central role in leading and delivering new models of care to improve patient outcomes. It is reassuring to hear full support from ophthalmology in this vision for optometry as we move towards 2030.
During the conference, Colin Davison (left) handed over the reins of the College presidency to Professor Leon Davies (right), a familiar figure and leading researcher at Aston University. It has to be said that the outgoing president coped admirably over what must be the most turbulent years for optometry since the profession began.