This year's College of Optometrists' conference was held in Manchester and with lectures and workshops running concurrently, delegates could choose to gain CET points in the subjects and the learning styles that suited them best. David Cartwright reports
In the first lecture of the day Frank Munro and Trevor Warburton, both members of the Department of Health steering group that devised the Eye Care pathways, discussed the four model care pathways. These are: low vision, AMD, cataract, and glaucoma.
The speakers described the manpower and funding issues associated with each pathway and how the desired aim is to make best use of the available resource and reduce the number of steps that the patient has to go through before treatment.
Fundamental to this is to include optometry within the pathways and to do so, there should be adequate funding for the service provided. To illustrate the point, the use of optometrists within cataract pathways has reduced the number of patients attending secondary care prior to and post surgery, in turn reducing waiting lists. A fifth pathway relating to the treatment of anterior segment disease was also described, where it is hoped that optometrists with further training will be involved in defined levels of care depending on further training.
MYOPIA: A GLOBAL PERSPECTIVE
Professor Bernard Gilmartin discussed 'Myopia: a global perspective,' an area where the knowledge base is advancing at a rapid rate. This is partly due to the increasing incidence of myopia, in excess of 80 per cent in some Far Eastern countries, which has attracted interest from the World Health Organisation.
The obvious concern is the potential increase in pathology associated with the myopic eye and uncorrected visual impairment. The exact causes of myopia are still not clear, however there is evidence of association with factors such as cognitive demand and occupation, for example medical students. It also appears that some individuals have a high susceptibility to environmental factors, challenging the traditional nature versus nurture debate.
To further understand the myopic eye, new technology is being used that measures not only axial length but also transverse dimensions and so the volume of the eye. It is hoped that this will lead to advances in understanding the nature of myopic stretch and also the effect of off-axial stimuli in the mechanism of myopia. Wide-ranging studies in the US have shown that it is possible to reasonably predict the refractive status at 14 years of age, if the refraction at 5-6 years is known. Children above one dioptre of hypermetropia at age six are far less likely to become myopic at age 14.
The varied work in progress to investigate the treatment of myopia was covered, including minimising defocus with the use of positive lenses or bifocals. These seem to make no difference. However, the use of varifocals may have a statistically but not clinical significance. Professor Gilmartin highlighted the use of progressive lenses as an area of great research interest for the future.
GLAUCOMA
The third lecture on the Sunday was 'Glaucoma: Taking a closer look at the optic disc' - a subject all practitioners welcome as a refresher - by Dr Robert Harper.
This extremely informative and easy-to-follow lecture focused on the changing perspectives on glaucoma. He discussed the features of a 'normal' disc and demonstrated to some amusement, the variations subjective assessment of a cup/disc ratio produced among the audience.
He described the optic disc changes that should at least be regarded as suspicious, such as C/D ratio over 0.5, rim configuration to the 'ISNT' rule, and highlighted that a large C/D ratio is more suspicious in a small disc. Dr Harper also described briefly the various glaucoma imaging systems now available, but stressed that the combination of information taken from history, anterior segment, tonometry, and fields to disc evaluation continues to be important in assessment of glaucoma.
RED EYE
Dr Jeffrey Kwartz, consultant ophthalmic surgeon at Royal Bolton and Hope Hospital, Salford, delivered his lecture 'I've got red eye - Get me out of here!' and discussed anterior eye conditions that the colleges of ophthalmology and optometry feel we should have an interest in, if we are going to pursue therapeutics.
Kwartz advised us strongly not to panic when we are presented with a red eye but to use common sense and to be aware that 80 per cent of the diagnosis will come from a good history and symptoms. More serious conditions are unusual in optometric practice but all possibilities must be considered and every optometrist should be aware of the referral options available to them in their area.
College councillor and chairman of their academic committee, Professor John Lawrenson, covered 'Therapeutics in practice' in which he discussed new exemptions to the current Medicines Act that are due to become law in April 2005. These remove the 'emergency' caveat for the supply of pharmacy only (P) medicines (Level 1 exemptions) including ocular lubricants, antihistamines and topical mast-cell stabilisers, but most importantly allows the stock and supply of chloramphenicol and fusidic acid.
Further training in the future will allow Level 2 exemptions which are much more extensive. Supplementary prescribing for optometrists will also be introduced in mid 2005 with similar further training requirements. Independent prescribing will be discussed by the GOC and the Department of Health this year.
The conclusion to the first day was a presentation from Professor Gilmartin who described the history of the College Research Scholarship Scheme, and how this has provided much-needed funding to many research topics. Many past recipients were now well known and respected names in academic circles. To illustrate the diversity of projects that the funding supports, three current researchers presented their work: 'Effects of nutritional supplements on visual function in normal and low vision due to ARMD', by Hannah Bartlett;'Development of a test protocol for identifying childhood amblyopia and monitoring treatment efficacy', by Anneli Demberg; and 'Accommodative dysfunction in children with cerebral palsy'; by Julie McClelland.
Workshops running concurrently included Samantha Watson, who asked practitioners to think about planning their approach to their personal development in order to learn most effectively and to identify areas where they had skills gaps.
optician's clinical editor William Harvey dazzled his audience with his communication skills and many who thought he was not yet 40 were obviously in need of a good optician.
A large trade show with over 25 companies exhibiting ran throughout the two days, and gave delegates plenty of time to browse and investigate the latest available products and services. The whole event was generously sponsored by Topcon, Alcon, Johnson & Johnson Vision Care, Optos and Altomed.
A superb evening celebration was held on Sunday at the Imperial War Museum in Manchester where delegates enjoyed a meal and danced the night away to a live band, or sought a little quieter surroundings. This was an evening that helped to celebrate a very special year for the College - its Silver Jubilee.
LASER REFRACTIVE SURGERY
Delegates, who made it down to the ballroom again on Monday morning, were treated to the Jubilee Lecture. This informative and thought-provoking talk, 'What drives laser refractive surgery - worries, wavefronts or wallets?' was given by Professor John Marshall, Frost Professor of Ophthalmology at St Thomas' Hospital, London.
Marshall started by discussing patient worries that lead to both positive and negative feelings about these procedures. For example, the simple concern about not wanting to wear glasses, the problems sometimes associated with contact lens wear, and even the media giving the spectacle wearer a 'poor' image. These make patients feel positive about an alternative, but on the other side of the coin, patients have a fear of the unknown, which can be enhanced by 'horror' stories in the media. The optometric profession has its own worries about the control of standards and professional conduct associated with laser surgery.
He went on to discuss the huge changes that have taken place in refractive surgery over the last 20 years, with the transition from surface PRK to stromal Lasik to his preferred choice now, surface Lasek. Marshall explained his concerns over the Lasik procedure which interferes with the biodynamics of the cornea, thereby potentially allowing the flap to become unstable after two to three years. He is uneasy as to the effect this insult is having on the cornea, with particular reference to wound healing, which is something that can now be studied under laboratory conditions. PRK and Lasek, on the other hand, appear to be stable for up to 15 years as they are surface treatments.
He added that the future of laser surgery lies in monitoring and controlling the biodynamics of the cornea and regulating wound healing.
Welcoming the Private Members Bill in the Commons to regulate laser eye surgery, Marshall feels that although a lot of flaws have been ironed out, we have still not got it quite right yet, and we need to keep trying.
NUTRITION AND AMD
The second Monday lecture was from Frank Eperjesi from Aston University, on nutritional supplements, 'Does BBQ = AMD?'
This entertaining talk went through the known risk factors in AMD, in particular smoking, which is the principal preventative risk factor associated with any form of AMD, and which increases the risk factor of developing the condition by three to four times. He went on to discuss that other common vice - alcohol. It has been shown in a number of studies that AMD is significantly associated with heavy alcoholic consumption, particularly beer, white wine and spirits, but fortunately for many in the audience, red wine was associated with a lower risk of AMD.
Looking at fat consumption, there appears to be an associated risk of AMD with high cholesterol levels. Here, statins may provide some protection, however more research is required to provide conclusive evidence.
Eperjesi talked about the beneficial effects of high dietary intake of lutein and zeaxanthin and the unfortunate effect that the amount of leisure time spent outdoors and therefore increased sunlight exposure, is significantly associated with late AMD.
Peter Coe, GOC registrar, talked about 'Lessons to be learned from the 2004 Section 60 Order and the next steps'. He described changes for the profession which will tighten up registration procedures and the mandatory CET system and how to make it as practitioner-friendly as possible. Changes to fitness to practise systems will create a more streamlined and fairer system, but which is also seen to be in the public interest. In the future it is likely that discussions post-Shipman and the Hampton Report will have further significant effects on all healthcare professions in terms of registration, accreditation and validation.
Coe pointed out the challenge that the profession must have very clear ideas as to where we wish to go, or we could be driven into a mould created by the Shipman issues. Most importantly, there must be unanimity within the profession, and advice must have the support of the College, ABDO, the AOP and the GOC.
Finally, rounding up the conference, delegates were presented with a two-part talk on 'Contact lens complications in the 21st Century' by Professor Nathan Efron and Dr Clare O'Donnell, both from Manchester University. Dr O'Donnell described how presenting complications had changed in recent times due to access to new designs and lens materials. Today, problems such as SLK, oedema and vascularisation have relatively less importance, and mucin balls, CLPC, and conjunctival staining are relatively more important.
Professor Efron then talked about the potentially most devastating condition that can affect contact lens wearers - microbial keratitis. There is now a change in the method of classification of corneal infiltrate disease in that it is now classified in terms of its severity. He described the Manchester keratitis study carried out within hospital and the Department of Optometry in Manchester where every patient attending the acute referral centre at hospital was asked to complete a survey form if they wore contact lenses.
If, on clinical examination, they were found to have any corneal infiltrate disease, a second part of the form was completed, and the severity of 10 different signs and symptoms was documented. Out of 415 presenting contact lens wearers, 118 were found to have some degree of corneal infiltrates.
Professor Efron then discussed the question of whether silicone hydrogel lenses are safer for extended contact lens wear with particular reference to corneal infiltrate disease. It has been shown that there is no statistically significant difference between hydrogel and silicone hydrogel lenses in terms of actually getting corneal infiltrate problems. However, there is a greater number of cases of severe infiltrate problems in hydrogel wearers than silicone hydrogel wearers, indicating that silicone hydrogel material does not reduce the incidence of cases but does reduce the severity of them.
The conference was a great success for the College and it is hoped that the excellent programme will be even better next year.