This year, Super Sunday kicked a few clinical gears into play, showing the interrelation necessary between clinical pearls, new research and technology, and the importance of looking at the patient as an individual in terms of their needs, capacity, and expectations.
Optometry New South Wales’ annual Super Sunday conference in May elevated professional education to a new level, drawing attention to our role as optometrists in patient mental health. Here are some highlights of the day:
Neuro-ophthalmic Grand Rounds: Disorders of the Elderly
Dr. Clare Fraser reinforced clinical guidelines for the investigative process of the sight-threatening giant cell arteritis, reviewing visual symptoms such as transient visual obscuration (due to affected choroidal circulation), diplopia, and systemic symptoms such as jaw claudication/scalp tenderness.
Clinical pearls communicated were to watch out for mimicking conditions (e.g. Lupus) in patients younger than 50 years of age; and to look for indirect clues to manifesting symptoms – for example, noticing scalp tenderness via complaints at the hairdresser, or jaw claudication via a recent change in diet (e.g. a patient who has moved to a more soup-based diet for no reason).
As optometrists, our role in recognising warning signs is becoming more relevant, particularly because of the changing attitude to mental illness
Other points of focus were Parkinson’s disease and its ocular disease profile (for example, dry eye that accompanies the drastically reduced blink rate of those with Parkinson’s), blepharospasm, decreased contrast sensitivity, altered colour vision, and convergence insufficiency.
One last clinical pearl was to judge driving ability, not just based on legal requirements, but also on the patient’s safety (e.g. spatial perception/visual memory/motion abilities), and also to facilitate your patient’s confidence with divulging cognitive issues or experiences of visual hallucination (relevant e.g. in Charles Bonnet Syndrome which can occur in patients with low vision as a result of age-related macular degeneration). The point being that optometrists play a role in patients’ emotional and social support.
Mental Illness in Optometric Practice
Psychologist Rachel Clements spoke about the increasing presence of depression and anxiety in our society. As optometrists, our role in recognising warning signs is becoming more relevant, particularly because of the changing attitude to mental illness (more people are willing to disclose, or at least indirectly, reach out for help).
The Four Rs
Ms. Clements summarised her recommended approach to managing a person with a mental issue with the Four R’s:
Recognise the warning signs – as detailed above, as well as signs of a vulnerable personality /behaviour.
Respond – not just to overt statements, but also to emotional hooks e.g. ‘I can’t go on’.
Refer – not just to phone services e.g. Lifeline, but even to a GP, considering Medicare’s eligible 10 counselling sessions can outweigh the stigma of seeing a family doctor.
Review – you may not be the counsellor but you do have a role in showing your patient that you ‘care’; a follow up call in a few weeks can be impactful.
Take home messages
Recognise early warning signs: Typical physical warning signs, which may have an overlooked mental root, include sleep difficulties, muscle pains/headaches, skin changes, and change in appetite. There are also mood changes, such as feeling discontent, being reactive, lacking in confidence, and feeling frustrated. These are actually warning signs that many of us have become numbed to noticing. One other relevant major sign is presenteeism which is when one shows up to work but has decreased productivity; many people use excessive work hours as a mask for routine, or it can come about as a manifestation of insecurity about one’s job.
Have a Conversation: Having a caring start, e.g. begin with an observational statement (“ you’ve been looking a little run down, are you ok?”) will help elicit a genuine response from your patient/colleague, as opposed to receiving a reflexive ‘I’m fine’.
Listen without judgement
Encourage action: Refer on and encourage personal action e.g. starting a mood diary; writing a list of positive affirmations, and understanding the benefits of regular exercise.
A Closer Look at Cataract
This session provided solid reinforcement of a major part of our clinical role as optometrists in collaborative care: knowing when to refer for cataract surgery. Dr. Shish Lal reviewed classification of cataract by aetiology and anatomical location and highlighted that even mild cataracts (e.g cortical or posterior subcapsular (PSC) opacities) can cause significant visual symptoms (e.g. glare) depending on location and that we must consider visual impact on lifestyle (visual disability) and keep in mind that symptoms may not correlate with visual acuity. Other indications for referral for cataract surgery include coexisting ocular pathology (e.g. age-related macular degeneration and mild nuclear sclerosis in a patient who wants to restore vision suitable for driving legally), patients with hyperopic scripts and narrow angles, those with ongoing myopic shift (making Rx difficult to obtain), high refractive error, and ocular conditions which can potentiate problems with time (such as PXF and zonular weakness, or Fuch’s endothelial dystrophy and increasing risk of corneal decompensation).
Another take home message was the importance of awareness of Tamsulosin use for patients undergoing cataract surgery, to allow planning of surgical techniques to decrease interoperative risks of IFIS (such as iris trauma, vitreous loss, and posterior caspular rupture). This was one of the five ‘Choosing Wisely’ messages selected by members of the Royal Australian New Zealand College of Ophthalmologists. Besides that, an interesting review of the use of femtosecond laser assisted cataract, and discussion about managing patient’s expectations with choosing what type of IOL to use took place.
Glaucoma Treatment: Thinking Beyond the Prostaglandins
Dr. Jay Yohendran highlighted the big issue of assessing the patient’s profile in relation to predicting compliance e.g. a 40-year old male patient on no other medications might not be as compliant to glaucoma drops as a 70-year old female already adjusted (physically and mentally) to taking five medications daily. To try to minimise effects of compliance, alternatives to medication were discussed, including selective laser trabeculoplasty, cataract extraction, intraocular lens surgery (particularly for hyperopes with narrow angles) and more.
Besides that, compliance related issues such as irritated eyes from too many drops, were discussed. Toxic epitheliopathy is particularly relevant to patients on several medications containing BAK, and it is important to be conscious of BAK free options as well as preservative free medications, because keratopathy can influence compliance.
Other clinical pearls included the reinforcement of the importance of the 10-2 visual field for detection of early glaucomatous field defects if the patient has suspicious ONH/IOP/OCT findings.
A useful suggestions was to have a poster on hand with images of all the available glaucoma eye drops (since patients tend to forget what drops they are taking) to help gauge compliance or trouble shoot side effect symptoms. The importance of collaborative care was discussed and lastly, we heard about the introduction of new minimally invasive glaucoma procedures being developed such as canaloplasty, CyPass, and Hydrus Microstent. Although more data is required for conclusive recommendations to be made, they are interesting considerations for the future.
Layal Naji graduated as an optometrist from UNSW (2014) with her honours research project focusing on Asylum Seekers’ access to eyecare in NSW. She currently divides her time between two private practices and is a visiting clinical supervisor at UNSW. Ms. Naji is most passionate about optometry’s role in public health, and ocular manifestations of chronic lifestyle related disease.
