The College of Optometrists

Just a few quick questions before my exams in a few days.

1. Had a px with myelinated nerve fibre at the OD of RE only. I did VF and it showed an enlarged BS. Is there any other tests I should have done and should I have referred px?

2. Can I advise patients to go to the pharmacy and get chloramphenicol 0.5% for uninfected mild CLPU or mild abrasion or do I have to refer px to GP for medication?? If not can I advise them to go to Pharmacist and get fusidic acid. Can chloramphenicl only be used for acute bact conj.

3. Is there anypoint in doing an Optic section if nothing is found on parallelpiped??

4. Finally I saw a px the other week who attended with signs of bacterial conj. He was under the NHS. Should I have given the px a full EE or was it fine to address the presenting symptoms as I did.

5. Are there any other cases apart from acute allergic conjunctivitis that we should advise our pxs to go to Pharmacist for Opticrom or antistine? When would you prescibe the otrivine over the opticrom??

Much appreciated.

Hi,

If you were sure all he had was myelinated fibres - then there would have been no point in referal. If the enlarged BS fitted in with your findings - and myelinated fibres can cause an enlarged BS. Then fine - well done on your presentation and findings.

2 You can only use Chloramphicol to treat bacterial conjunctivitis. And thats if you write a prescription (written order) for it. An odd drop of chloamphenicol is useless if all they have is a small, clean corneal scratch, so there really no point in advising that. It would be better to advise and prescribe an ocular comfort drop and pain killer if its bad. In your notes you would need to write a care plan which includes checking in a couple of days to see if its healed okay.

Fusidic acid is useful in treatment of bacterial blepharitis -. Thats why it comes in ointment form.

Off licence use of antibiotics is not allowed although you could argue that someone with blepharitis would also have some conjuctivitis.

So best to refer - and as I write in an earlier post - if they have a CLPU or marginal ulcer -best to send them to eye casualty for effective antibiotics -usually a quinolone such as ciprofloxacine. I can't stress this enough as it could be that the tiny scratchy CLPU is not a baby ulcer just forming.

Asking the px to get a bottle of chloramphenicol or something isnot good care. Best to write out a prescription and work out a care plan.

3) I agree with you here. Good thinking. You have to show the examiners that you can efficiently use the slit lamp and you maybe asked to demonstrate a particular way of using it.

4)There is a conflict here-

Under NHS terms of service - you MUST conduct a full eyetest on each patient irrespective of their initial complaint.

Under the new GOC rules you can concentrate on the problem, and you don't have to do a full eye test (as long as the patient was informed and given the oportunity to ask for one if they wanted).

5) You have to stick to what the drops are for - so if its seasonal alergic conjunctivitis - then thats what you can prescribe for. Again, it would be good practice to write out an Rx with patient instructions and doses. Opticrom is also useful in cases of contact lens related papilary conjunctivitis. However, that is best treated by removing the offending lens, letting the eye recover, and then refitting with something more compatable with the eye - such as a daily disposable lens; or even discontinuing cl wear.

So, in conclusion, you can see that the proper treatment of the px malady really consists of a care plan that covers side effects, unexpected problems (like your treatment does not work), patient non-compliance. It may include treatment - but this has to be a least and most gentle - leaving any medicated eye drops last.

hope it helps

steve

Hi Steve,

Just to clarify what to do when prescribing eg Chloramphenicol 0.5% etc. As we are now allowed to sell/supply all P medicines in the course of clinical practice, does this mean we can supply directly ourselves, or must we give a signed order to the px to obtain at a pharmacy?

If giving a signed order, silly question, but how do we go about it? do we write out on letterheaded paper or do we need GP style Rx pads?

What happens with pxs who have free prescriptions?

Thankyou for your help!

Yes you can supply directly yourself - but I can't imagine it would be economic to.

A signed order is exactly what the doctor gives you- it must include name, address,age of px. the medicament, dosage and duration. your details, name practice address and goc number.It may have the diagnosis as well - although I don't think this is a requirement.

Eg Re Mrs. A Blogs, 1 The Meadow, SheepDip, Northumberland, SH1 6HP age 34yrs.

Please supply one bottle Chloramphenicol 0.5% to use every hour for 2 days and then four times a day for at least seven days.

signed S Meynell, The Practice, High St, SheepDip GOC No: 01 00000 Dated 3/ 07 / 2007

I use preprinted forms some times and just write them out at other times. All our prescriptions would have to be paid for, if they want it free - they will have to go to the gp. steve

Just to clarify again, if you have a px presenting with baterial conjunctivits, then would the best action not be to send the patinet down to the pharmcy to but some 0.5% chloramphenicol instead of writing out a signed order? Is writing out a signed order a normal occurance for optometrists on the high street?

Yes a signed order is a common thing to do.