College of Optometrists

A cold December evening saw both hospital and high street optometrists, spanning three generations fill the room for the College’s North West regional event at Haydock. Immediate Past-President, Dr Cindy Tromans, who as many of you will know has put in such an immense amount of work over recent years to raise the profile of the College , gave us an overview of the College’s recent work and updated website, which has become an excellent resource for professional development, guidance and information. Cindy described its latest additions; the new children’s  eye health leaflet developed for the recent campaign, which saw College members give interactive presentations at local schools and the new Peer Review section, with its detailed information and downloads to guide us through this new process. The new “Look for the Letters” campaign  encourages the public to look for the letters MCOptom and FCOptom as a mark of membership of the College, which promotes the highest professional standards.

With research high on the College agenda, £1/3 million has been spent on studies and projects, including one collating evidence of how optometrists can develop their role in health care so that we might gain recognition from Clinical Commissioning Groups. Support is available from the College at all stages for those practitioners wishing to become involved in research projects, from preparation of proposals, to applying for grants, through to writing up results and conclusions by contacting the iPRO team.

Cindy announced that Professor Mark Bullimore, a world renowned expert on myopia, is to be the keynote speaker at the next College conference in Nottingham in March, where “Fresh Eyes”, a unique event to support newly-qualified optometrists, will run alongside the main  conference for the first time.

It was then time to introduce the first guest speaker, Professor David Thomson to deliver “Children’s Eye Care – Can we do better?” He began his entertaining talk by asking whether optometrists had a role in children’s eye care. He took us through the different stages of assessing a growing child’s vision, how and why it changes, the consequences of poor vision, its detection and management, before finally asking the question, can technology help?

The trick to detecting the development of vision in the neonate lay in harnessing the reflexes present, for example, the rotation of an infant to evoke OKN and by fix and follow, where jerky saccades give way to smooth pursuit movements at  two months of age. In research, electro-diagnostic tests, such as VEP can also be used to determine acuity and the “visual cliff experiment” can be used to observe awareness of depth cues to indicate developing stereopsis. Toddlers were said to be the most challenging group to assess: they would co-operate if they wished to and were no longer reflex-driven. Cardiff Acuity Cards, Lea Symbols (LogMAR) and Kay Picture Testing were thought to be the most useful measures of acuity here.

A neonate may have an acuity of approx 6/180, but, as the quality of vision is far less developed, this is probably functionally much worse than the 6/180 we as adults could relate to. Contrast Sensitivity Function data shows high, intermediate and low spatial frequencies all being reduced in infancy, giving a more washed out appearance to the world. Red-Green colour vision is well developed at birth, but Blue takes longer to develop and infantile accommodation may be very active, but is very poorly controlled due to the poor acuity. By the age of  seven, visual maturity is usually achieved, with structural changes in the retina and cortex occurring to bring about the dramatic acuity and eye movement changes in addition to the well documented axial length growth and emmetropisation of the eye.

At birth, there is incomplete migration of ganglion cells and bipolar cells out of the foveal region, such that the foveal pit is not fully differentiated at birth; the outer segments of the cones are also shorter at birth and continue to grow; the density of cones increases over the first few years of life; the visual cortex undergoes a massive remodelling of synaptic connections to give a “cortical awakening” from the very immature neural network at birth, which cannot make sense of visual images. Visual stimulation is also important and the consequences of stimulus deprivation were demonstrated by a reminder of the animal experiments of the 1960s where meridional amblyopia occurred when monkeys were only exposed to one orientation of stimuli and kittens that were only exposed to stroboscopic lighting did not develop the ability to detect movement.

In looking at how early detection of visual problems could be achieved, the fundamentals of screening and its justification were explained. Analysing each aspect of vision to see if it did indeed fit the model for screening, Professor Thomson surmised that refractive error rather than amblyopia is the important factor which fits the screening model. He discussed which professions might be best suited to vision screening in terms of their availability, cost and having access to the target population:orthoptists gave good sensitivity and specificity, but had low capacity and were not cost effective unlike the school nurses, who were cost effective and had capacity, but lacked the skills required without further training. Professor Thomson favoured the use of an accredited group of optometrists, signed up to a protocol, using an auditable pathway to screen vision.

In answering his final question, whether technology could help in the assessment of children’s vision, Professor Thomson described his own computer based Vision Screener, which can end transcription errors and give uniformity to testing, taking out the variables of luminance and contrast arising from testing in different ambient lighting levels. Automated scoring allows accuracy of reporting and progression through the tests without the operator understanding the tests, with on-screen language translations to give instructions to non-English speaking children. A friendly cartoon character presents the tests and a +2.50D check test shows if significant hypermetropia is present. Letters to parents are automatically generated and real time audit data presented. A similar model has been adapted for hearing tests.

In summing up, Professor Thomson concluded that the first few years of life are critical to the normal development of vision and obstacles which led to amblyopia need to be detected early for effective treatment. Given how much is spent on educating children, he felt it was surely worth investing in a good vision screening programme to avoid the pitfalls of special needs provisions when a child cannot see.

After breaking for refreshments and a chance to network with friends old and new, local College Council member Shane Canning, introduced the final speaker of the evening, Mr Leon Au, Consultant Ophthalmologist from Manchester Royal Eye Hospital, who specialises in cornea and glaucoma and presented on “New Advances in Glaucoma Medication, Surgery and Service Delivery”.

In 1996, Prostaglandins revolutionised glaucoma treatment, initially decreasing surgery rates dramatically, but these have increased again recently with advancing age of the population and longevity of the disease. Combination drops then followed and greater understanding of the effects of preservatives on the ocular surface allowed the useful development of preservative-free drops. With the advent of drug-delivering ocular implants, such as Ozurdex, Mr Au said he felt it was only a matter of time before glaucoma medication was delivered in the same way. To improve adherence to medical treatment, MREH now use a text reminder service, “Florence”, to prompt medication use and remind about repeat prescription requests. Side effects of the drug used are also sent by text and if the patient replies “YES” to indicate they are experiencing one or more of the effects, a glaucoma nurse practitioner telephones them to discuss it.

Moving on to surgical developments for open angle glaucomas, Mr Au described the ideal pathway as being low risk, effective (long lasting), repeatable (between patients) surgery and told the audience that we are now getting close to achieving this. Available surgical interventions were now: the modern trabeculectomy, Selective Laser Trabeculectomy (SLT), Trabecular Bypass (iStent), Supra-choroidal Stent, Endoscopic Cyclophotocaogulation (ECP) and High Intensity Focussed Ultrasound (HIFU). He described the effectiveness and pros and cons of each of these. In ECP and HIFU, aqueous production is shut down is by delivering laser or focussed ultrasound through an endoscope to the ciliary body in a technique borrowed from prostrate cancer treatment.

Finally, Mr Au reported on service delivery changes and described the changes made possible by the development and popularity of higher qualifications for optometrists. To clear a backlog of appointments, virtual clinics have been set up, for glaucoma suspects, stable ocular hypertensives and stable glaucoma patients. On arrival, vision is recorded by an HCA before a trained technician performs SITA standard visual fields and Goldmann IOP. After dilatation, posterior segment OCT is taken for optic nerve fibre analysis at the optic disc. Average patient time in clinic is half an hour with 20 patients per clinic, twice a week. A letter is sent to the patient to inform them of the results by the Consultant, who reviews all 40 patients in one 3 ½ hour session; a quarter of the time which that number of patients would normally be seen in, saving both time and money. In summary, Mr Au said there had been limited advances in glaucoma medical therapy, but a fast expanding armoury of minimally invasive glaucoma surgery techniques were developing and there is now increased reliance on optometrists in glaucoma service delivery.

Mrs Jo Mackenzie BSc MCOptom, DipTp(AS), DipTp(SP), DipTp(IP)