Eyecare2000, Reviews - Optician Magazine

Conference review
OPTICIAN MAGAZINE, February 12 1999

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This year's Eyecare 2000 conference offered an extensive and varied programme from topical ocular agents to orbital and ocular tumours. Sandip Doshi gives details of the highlights:

Whether continuing education and training should become compulsory remains a contentious issue in UK optometry. The ongoing arguments were further fuelled by the recent extension of the College of Optometrists' voluntary CET scheme to the whole optometric profession. This move has been suggested by some as the first step towards compulsion. With very little middle ground, optometry still remains divided into those willing to accept CET and those who stand firmly against it.

These issues aside, few would dispute the fact that over the past decade the role of the optometrist has changed. Optometrists, in all respects, have become the gatekeepers of the nation's eye care, and with many becoming involved in co-management schemes, it is apparent that the optometrists' role as a primary healthcare practitioner is now firmly established. With these developments comes the need to keep abreast of new ideas and changes in technology. This demand has seen a rise in the popularity of conferences and courses. Indeed, the growth in the number of courses in the UK has mirrored the widening of the profession's role.

Among the many workshops, assessment of children's vision by Dr Roisin Mackie was the most popular

Course organisers must be sensitive to the changes affecting the profession, but they must also supply material which continues to reinforce the knowledge already possessed by their audience. Through careful planning and forecasting, the organisers of Eyecare 2000 were able to formulate a programme that addressed both areas.

Over its brief history, the biennial event has grown to become one of the UK's largest CET conferences. This year around 400 delegates attended the two-day conference in Glasgow, held from January 17-18.

Delegates were able to select from two parallel lecture programmes as well as attending practical, 'hands-on workshops'. The programme was packed with a variety of topics ranging from eye disease to the safety of laser pens, dispensing and behavioural optometry to the ocular effects of systemic drugs. Many areas of debate currently affecting the profession were addressed.

Professor Wallace Foulds, University of Glasgow, opened the proceedings with a lecture on ocular and orbital tumours. In a succinct and informative lecture, Professor Foulds emphasised that optometrists possessed skills that allowed them to detect tumours at an early stage and this was vital if there was to be a good prognosis.

Tumours were swellings, but by common usage the term tended to be restricted to benign or malignant neoplasms, explained Professor Foulds. Ocular tumours (benign or malignant) could arise anywhere in the eye (Figure 1). But the lens was unique in that it was the only ocular structure that never developed a malignancy. Tumours were most common in adults but some malignancies were specific to children.

Professor Foulds explained that tumours arose from excessive cell proliferation or a failure of apoptosis - the process of programmed cell death. A common reason for failure of apoptosis was damage to DNA, such as that caused by ultraviolet light. This resulted in damage to the protein P53 which played an important role in programmed cell death. Tumours were highly vascular and they stimulated growth of new vessels which 'fed' the growth. One treatment was to kill-off this blood supply. Other options included radiotherapy, chemotherapy and surgery, or a combination of these procedures.

Professor Foulds explained that there were many types of tumours but the simplest way of classifying these was by their location:

tumours affecting the periorbital skin or the surface of the eye;
tumours affecting the orbit;
tumours affecting intraocular structures; and
secondary tumours from elsewhere in the body that metastasised to the eye.

Choroidal melanomas are the most common intraocular tumours

Each subdivision was explained, illustrating the kind of neoplasm the optometrist might encounter, and the treatment protocols for each kind of tumour were discussed. he urged the audience to remember the importance of visual field testing in cases of unexplained visual symptomatology as this may lead to a diagnosis of a previously unrecognised intracranial tumour.

Eye disease was strongly represented at this conference. Consultant Ophthalmologist Pat McGettrick, from Ayr Hospital, discussed the pathogenesis, clinical signs and management of inflammatory eye disease and its associated complications. She explained that inflammation in the eye was usually restricted to the uvea and said that it could be classified in many ways. The most common was to describe the inflammation by its anatomical location, hence the terms: iritis; anterior scleritis; choroiditis etc. However, it could also be classified by:

the type of cellular inflammation, which gave rise to the adjectives granulomatous and non-granulomatous;
the source of inflammation, with the terms exogenous, endogenous, infective;
infective or non-infective; or
age group (childhood, adulthood or elderly).

The speaker explained that the clinical signs of inflammation were dependant to its location and the duration it was present. Unusually uveitis was associated with pain and photophobia but sometimes it could be painless. However, there was usually a loss or disturbance of vision, and inflammation affecting the posterior pole often gave rise to floaters.

It was important to investigate the patient's personal history when examining for or attempting to exclude uveitis. Careful questioning could elucidate information that might aid a firm diagnosis. It was also important to ask questions about family history of disease extending to non-immediate family, explained Mrs McGettrick. Age and race were important factors but at a time when HIV and AIDS were common among drug users who shared needles, the practitioner should be aware of social factors.

Mrs McGettrick catalogued a series of inflammatory eye conditions and explained how the optometrist could be involved in their detection. Treatment options were elaborated upon and included clinical data from various new treatments.

Anterior segment eye disease and ocular therapeutics are topics that generate much interest in the UK. This was evident by the large attendance at a lecture by Professor Michael Doughty (Glasgow Caledonian University) on glaucoma medicine for shared care in the UK. However, as the profession moves into these areas it is easy to lose sight of the fact that optometrists encounter adverse reactions to topical and systemic drugs on a daily basis. In a definitive and concise lecture, David Edgar, City University, London, discussed such reactions. He explained that not all adverse drugs reactions were negative, but most caused undesirable effects either to the eye or elsewhere in the body.

With the increased use of mydriatics in optometric practice, some practitioners were still concerned about including an attack of acute closed-angle glaucoma. however, the advantages of pupillary dilatation far outweighed the risks. For example, the ability to grade diabetic retinopathy was 40 per cent lower through an undilated pupil. The College of Optometrists' guidelines on instillation of eye drops in optometric practice recommended assessment of the depth of the anterior chamber prior to dilation, added Mr Edgar.

With increased use of topical agents in everyday practice, the practitioner should be aware of the potential for ocular adverse drug reactions with these and synthetic drugs

A recent study reported that 48 per cent of subjects found mydriasis affected their ability to drive or prevent them from driving. The most common cause of problems was glare. The College guidelines advise that 'the patient should avoid driving after dilation' and on the information sheet provided for patients undergoing dilation it was recommended that driving should be avoided for at least six hours afterwards.

Mr Edgar continued with a succinct review of the benefits and disadvantages of commonly used topical ocular agents. Turning his attention to systemic drugs, he explained that although a number of drugs caused ocular adverse reactions it might be necessary to 'put-up' with these as the drug might be being used to treat a severe disease. Patients with ocular adverse drug reactions (OADRs) were unlikely to consult their general practitioner initially. It was therefore important that the optometrists was aware of drugs that could cause such reactions. Mr Edgar explained that there were many factors involved in OADRs, these included:

dosage, duration and frequency of the drug therapy;
the patient's age and their general health; and
individual idiosyncrasies and other substances being consumed.

There were many sources of information about OADRs. These included publications such as: MIMS; the British National Formulary; a compendium of data sheets; the drug information services and various books. In the past, optometrists had reported suspect OADRs to the College of Optometrists via a green card system. However, recent changes in legislation now allowed optometrists to report directly to the Medicines Control Agency (MCA) via the yellow reporting card system, the same as that used by GPs and dentists. He advised the audience that yellow reporting cards were available directly from the MCA.

Mr Edgar suggested that the audience should have their own 'hit-list' of drugs which were known to cause ocular adverse reactions. For a patient taking a drug on this list, an OADR should be suspected when a finding was obtained on examination with no other obvious explanation, or if the patient described symptoms or signs that coincided with the duration of taking medication. Mr Edgar suggested that the audience might include the following drugs on their hit-list: amiodarone; prednisolone; beta-blockers; benzodiazepines; amitriptyline; carbamazepine; tamoxifen; indomethacin; thiazide diuretics; and conjugated oestrogens. These 10 drugs were the most common cause of OADRs, he commented.

In concluding his presentation, Mr Edgar cautioned the audience never to alarm the patient if they suspected an OADR, as this might cause the patient to cease life-preserving medication. Since it was important that the optometrist did nothing to upset the patient-GP relationship, comments should be kept general. But most of all it was important to report suspect OADRs to the patients' GPs and the MCA.

In its short history, Eyecare 2000 has become one of the largest and most informative CET course in the UK. Each year the conference has served to refresh the knowledge of 'grass-roots' practitioners as well as educate them in advances in the field. On the strength of this latest conference, Eyecare 2000 looks set to continue to grow in popularity.

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