Optrafair London gave delegates the opportunity to debate with leading experts on a variety of optical topics. Here Optician reports on sessions by Specsavers store director Rakesh Kapoor and ABDO president Peter Black that focused on clinical and legal matters while Chris Hemmerdinger offered advice on when to refer
Optrafair London gave delegates the opportunity to debate with leading experts on a variety of optical topics. Here Optician reports on sessions by Specsavers store director Rakesh Kapoor and ABDO president Peter Black that focused on clinical and legal matters. In the panel below Chris Hemmerdinger offered advice on when to refer
With optical professionals being urged to increase their scope of practice, keeping a firm grasp of the regulations has become evermore important.
One of these opportunities, the possibility of independent prescribing, was explored by Rakesh Kapoor, store director of Specsavers, Wembley and Broadwalk, who works as an optometrist with special interest.
He said prescribing work enabled practices to offer something different and distinguish themselves.
‘The main reason I got involved with IP was to build practice referrals,’ he said. ‘It’s not just about testing eyes now, it really is talking about healthcare overall, being able to refer to doctors and talk to other healthcare professionals in the way they talk.
‘That really does build links with the healthcare community and it is very important we do that.’
However, he said the most important reason to do any type of IP was to offer patients better accessibility and give them the convenience they needed. ‘If you remember we are practitioners for a reason – we are there to serve our customers and should be in a position to offer everything to them,’ he added.
Kapoor explained how the origins of prescribing in the profession could be traced back to 2000 when it was recommended to the government that it made sense for certain healthcare providers, including nurses and pharmacists, to be able to prescribe.
How to get involved
Fourteen years later it is still early stages for the profession, but ways to get involved in therapeutics were as an optometrist with special interest, additional supply optometrist, and through independent prescribing status. ‘In essence this is how independent prescribing and therapeutics have moved on in practice,’ Kapoor added.
Indeed, training in additional supply in an emergency was available at City University, London and Glasgow Caledonian University, while courses in independent prescribing have been set up at City, Glasgow Caledonian and Aston University.
Accreditation by the General Optical Council could lead to managing a range of common non sight-threatening disorders such as infective conjunctivitis, allergic conjunctivitis, blepharitis, dry eye and superficial injury. Indeed, Kapoor said the College of Optometrists had identified 60 conditions where treatment could be feasibly prescribed by an IP practitioner.
Furthermore, with local enhanced services high on the NHS agenda some areas were creating specific pathways for IP optometrists, although this too was still evolving. For this reason reimbursements for accredited ECPs varied across the country.
‘There are some up and down the country that do that but as a general rule it is very much in its infancy,’ said Kapoor.
He added that private practices offering dry eye management and nutritional advice were more commonplace but again in their infancy. Therefore, the lack of structured schemes in the area of prescribing was deemed as one of the reasons holding back the take-up of independent prescribing but the question remained what came first?
‘Should we be waiting for the big NHS contract or should we be a force out there that has got this qualification and say “here you go think of us, let us prescribe”,’ Kapoor added. ‘On that basis the pharmacists have managed to do it, there’s no reason why us optometrists can’t.’
Law of supply
[CaptionComponent="258"]Meanwhile, the first day of Ask the Expert also featured Peter Black with his debate on when supplying glasses and contact lenses becomes illegal, addressing some of the pitfalls in everyday supply and how optical laws were being policed.
However, the sale of spectacles, contact lenses and low vision aids turned out to be illegal in more instances than expected when ABDO set out to find evidence a few years ago – and the findings were not mainly from the internet but from the high street.
Black said: ‘That left ABDO in a difficult position because we didn’t want to wage war on independent optometrists. So we had to quietly park our evidence on illegal supply and take it a different way.
‘We took a different tack, especially regarding illegal supply of spectacles to children which remains a regulated function. We decided to educate registered people, dispensing opticians and optometrists in regulated function and particularly paediatric dispensing.’
He said the examples reported by ABDO members typically involved practices that did not employ dispensing opticians. In its study were complaints of spectacles being handed to children by receptionists when it was the optometrist’s day off, and unregistered glasses shops selling to children without any registrant on the premises.
‘The rule on supervision has been clarified. The registrant must be on the premises and must be in a position to intervene. There is still a little bit of debate about exactly what that means, but they can’t be out in Costa Coffee down the road and they can’t be on their lunch,’ Black said.
‘I do fear for optometrists in particular who don’t work with DOs, who are in a darkened room every day and don’t actually know what’s happening on the shop floor,’ added Black. ‘A lot of children’s prescriptions come in from the hospital so the person in the consulting room doesn’t necessarily know that child’s been in.’
He said a number of registrants and companies had failed to take the rules on regulated supply seriously since partial deregulation of dispensing. ‘There’s been a raft of fitness to practise cases against some of the largest companies in the business centred around the supervision of a regulated function. That has resulted in large training initiatives and a whole raft of standard operating procedures across many of these companies. I believe it’s had great effect.’
Although the ABDO study resulted in fewer alerts about the internet than expected, the online supply of optical goods still posed a number of legal questions.
Black said: ‘The internet is a vexed issue to our profession. We are all aware of a whole host of online suppliers – many of them are offshore – who will supply contact lenses without valid specification, spectacles to children and inappropriate low vision aids for the certified visually impaired. Many of these operators see themselves as providing a better service than what is available in practices on the high street. People will always be creative and innovative in coming up with ideas to make money.’
Information gap
Black believed there was a lack of information about professional standards available to online start-ups. GOC-enforced legislation including The Opticians Act, together with Trading Standards provided some guidelines but lacked clarity, according to Black. He said: ‘It’s all a bit daft in my opinion and the whole thing needs re-writing so that it’s very clear to all of us, whether we’re registered or otherwise, what is and what isn’t legal.’
ABDO had also collated extracts of British Standards relating to optics that were now available to optical professionals. Black added: ‘I believe it is illegal to dispense spectacles online that are not single vision, that are over plus or minus five, unless they’re for sports for some reason. I also think it’s illegal to sell low vision aids and contact lenses without a valid specification.
‘However, nowhere in the Act does it say contact lenses need to be to the specification, so as long as someone’s got a valid specification you could sell them any contact lens.’
Within practice, ECPs were told there were certain instances whereby acting in the best interests of a patient would be a key consideration.
Black said: ‘If a bride-to-be comes in the day before her wedding and has done everything; she’s got the dress, the car and the flowers and it’s all been arranged but she’s forgotten her contact lenses, but you can’t fit her in for a check-up, so what do you do? Well in my opinion it’s in the patient’s best interests psychologically to help them enjoy their wedding day.’
Ready-reader spectacles were also on the agenda, with Black arguing they should say by law on the packet you should have an eye test every two years. Black, who is also retail development director at Conlons Opticians, said: ‘We had a guy in one of our practices recently who came in after his 60th birthday, full of the joy of spring. He’d had his bus pass, free dentist appointment and came in to get his free eye examination – he hadn’t had an eye test ever and had relied on ready-readers all his life.’
ABDO guidance on ready-readers stated if an ECP intervened to recommend them they should make a record card out in the same way as prescription glasses. ‘In my opinion we should be advising people to have a proper eye test and buy proper glasses,’ added Black.
Given its title, one of the most widely anticipated Ask the Expert sessions was ‘What ophthalmologists hate about optometrists’ by ophthalmologist and former optometrist Chris Hemmerdinger who opened by saying any frustration went both ways.
[CaptionComponent="259"]‘The title could easily have been “Why do optometrists get frustrated with ophthalmologists”. Personally I don’t have any issues with optometrists, firstly because of my background and my wife.’
Optometrist Scott Mackie pointed out the issue of lack of referral feedback, that led to an incomplete learning loop. ‘In 30 years I’ve had five letters back,’ he said.
Hemmerdinger agreed on the need for feedback. ‘In Warrington we have very good feedback. It’s about communication. A lot of the time junior doctors don’t realise optometrists want feedback. The other issue is to do with finances. The Trust want me to do as few letters as possible as it’s work for my secretary and postage.’
This contrasted with referrals in the private sector. ‘There’s no such thing as a bad referral privately. Who doesn’t want to see dry eye privately?’
If you had something that needed an opinion it was reasonable to refer it, he said, adding that the only way to move forward was negotiations with LOCs.
An issue was that often both junior ophthalmologists and some senior ophthalmologists did not know how high street optometry was funded. ‘They don’t know you don’t get paid for dilation or extra field checks. Are you going to do that for the love of the general public?’
When asked about the NICE glaucoma guidelines, Hemmerdinger said they could be the subject for a whole talk in themselves, such were the issues. ‘In Warrington I was lucky, with good levels of referrals that increased our numbers a little, not massively.’
Corneal thickness
Optometrist David Cartwright, who described feedback as absolutely essential, asked whether measuring corneal thickness was now outdated.
There was an issue with corneal thickness, replied Hemmerdinger. ‘It’s important and the reason it got so much attention is the development of a £2,000 gadget to measure it. Is it as important as corneal hysteresis or flexibility? If you look at the graphs, hysteresis is far more important, but can you measure it? Pascal is not the easiest kit to use. Many glaucoma specialists do not use correction factors, they just think of thick or thin corneas. You have a thick or thin cornea and that stratifies your risk. If you have a thin cornea you are more likely to develop glaucoma.’
He pointed out that corneal thickness could change throughout the day with jumps on different readings. ‘I suspect the corneal thickness being updated comment relates to this.’
Most people could be managed happily in optometric practice, said Hemmerdinger. ‘My job is to find the 30 per cent of glaucoma patients who, if you do nothing about it, are going to go blind. Those safe pressures can be quite easily managed in practice.’
After discussing gonioscopy, then flashes and floaters, he was asked by a contact lens optician how to avoid over-referring.
‘I see as many problems from my junior doctors in managing these things as from optometrists,’ he said.
With contact lens red eye, practitioners had to consider: Is it a microbial keratitis? Can you see an infiltrate? Is it painful? Are there cells? Is the eyelid swollen? When did they take the CL out? Is it getting better or worse? ‘If it’s an infiltrate it’s either MK or a CL-induced acute red eye episode.’
The patient should take the lenses out and come back in a day. A recent cautionary tale was a soft CL wearer went to A&E instead of her optometrist, and complained of pain. ‘They said conjunctivitis, gave her chloramphenical and it got worse. She then visited our A&E for a second opinion. She has Pseudomonas keratitis and will be left with a scar.’
He had also been asked to represent another similar case. ‘The worst thing you can give is chloramphenical as it’s ineffective against Pseudomonas. They get really bad.’
He advised referral and the proof of the pudding was if the patients were getting treatment.
On whether he would refer a long-term rigid gas permeable (RGP) wearer who had red eye, he said: ‘I love RGPs and tell everyone they should be wearing them. Fitting them is a lost art. The skill has kind of gone out of fitting soft CLs apart from soft torics. Fitting a RGP takes a bit more chair time, you’ve got to coach the patient through, but they don’t give anything like the problems. I can’t even remember a RGP patient being treated for MK. If they come in and have pain and you can’t find an answer for that then it’s not unreasonable to refer.
‘The big thing at the moment and it has happened in Bristol as well, is that in the last year we’ve had four cases of Acanthamoeba keratitis which is far more than you would expect to see.’
All had the same thing, presenting in agony and photophobic, yet the eye did not have a large white infiltrate and did not look that bad, he said. All that was present was a tiny linear-type lesion.
‘If they’re a soft contact lens wearer and even if you can’t see why they are in a lot of pain you have to be very worried. The British Ophthalmic Surveillance Unit are going back to look at Acanthamoeba because of an increased note. I’m sure it’s on the rise.’
Urging practitioners to be cautious, he said: ‘You have a low threshold with contact lens wearers. They’re high demand patients. If you mess them up they’re young and quite a litigious group and will sue. If they’ve lost vision you could argue they’ve been mismanaged.’ ?