2024 Ryioptometry Pre-Reg Notes PDF

SCHEME FOR REGISTRATION COMPLETE PRE-REGISTRATION COMPETENCY BREAKDOWN @RYIOPTOMETRY  This booklet is a compilation of my own pre-registration notes that I revised from and solely used to pass my scheme for registration examinations. As it ha...

SCHEME FOR REGISTRATION COMPLETE PRE-REGISTRATION COMPETENCY BREAKDOWN @RYIOPTOMETRY  This booklet is a compilation of my own pre-registration notes that I revised from and solely used to pass my scheme for registration examinations. As it has been a few years since I qualified, I can’t quite remember exactly which bits of information I would have sourced from where - so I’d like to credit some incredible & very knowledgeable optometrists whose posts & courses would have helped me compile these notes together back in 2021: @theoptomacademy @osce_master @thecrazyoptom This booklet is split by visit, use the search function & key in the numerical codes listed in the contents for each competency to quickly jump to the information. Good luck! And feel free to drop me a message on @ryioptometry if you need help. J  CONTENTS Visit 1 1.2.3 Discusses with the patient the importance of systemic disease and its ocular impact, its treatment and the possible ocular side effects of medication. 2.1.2 Maintains confidentiality in all aspects of patient care. 2.2.2 Is able to work within a multi-disciplinary team. 2.2.3 Is able to work within the law and within the codes and guidelines set by the regulator and the profession. 3.1.1 Uses instruments to measure corneal curvature and assess its regularity. 4.1.2 Measures and verifies optical appliances taking into account relevant standards where applicable. 4.1.3 Matches the form, type and positioning of lenses to meet all the patient’s needs and requirements and provides appropriate advice. 5.1.2 Instructs the patient in soft lens handling and how to wear and care for them. 5.1.4 Instructs the patient in rigid contact lens handling and how to wear and care for them. 6.1.1. Understands the risk factors for common ocular conditions. 6.1.11. Understands the treatment of a range of common ocular conditions. 7.1.7. Understands the special examination needs of patients with severe visual field defects. Visit 2 1.1.1 Obtains relevant history and information relating to general health, medication, family history, work, lifestyle and personal requirements. 1.1.2 Elicits the detail and relevance of any significant symptoms. 1.2.4 Explains to the patient the implications of their pathological or physiological eye condition. 2.1.1 Adheres to health and safety policies in the practice including the ability to implement appropriate measures for infection control. 2.1.3 Shows respect for all patients. 3.1.2 Uses a slit lamp to examine the external eye and related structures. 3.1.3 Examines the fundi using both direct and indirect techniques. 3.1.7 Assesses the tear film. 3.1.9 Assesses pupil reactions. 3.1.11 Makes an assessment of the fundus in the presence of media opacities. 4.1.1 Identifies anomalies in a prescription and implements the appropriate course of action. 4.1.4 Advises on personal eye protection regulations and relevant standards, and appropriately advises patients on their occupational visual requirements. 4.1.5 Dispenses a range of lens forms to include complex lenses, multifocals and high corrections, and advises on their application to specific patients’ needs. 4.1.6 Prescribes and dispenses spectacles for vocational use. 5.1.1.Chooses, fits and orders soft lenses. 5.1.3 Chooses, fits and orders rigid lenses. 6.1.2. Interprets and investigates the presenting symptoms of the patient. 6.1.3. Develops a management plan for the investigation of the patient. 6.1.4. Identifies external pathology and offers appropriate advice to patients not requiring referral. 6.1.6. Manages patients presenting with cataract. 6.1.7 Manages patients presenting with red eye/s. 6.1.9 Manages patients presenting with macular degeneration. 6.1.12 Evaluates and manages patients presenting with symptoms of retinal detachment. 7.1.1. Refracts a range of patients with various optometric problems by appropriate objective and subjective means. 8.1.1. Assesses binocular status using objective and subjective means. 8.1.5 Manages children at risk of developing an anomaly of binocular vision. Visit 3 1.2.1 Understands the patient’s expectations and aspirations and manages situations where these cannot be met. 2.2.1 Is able to manage all patients including those who have additional clinical or social needs. 2.2.4 Creates and keeps full, clear, accurate and contemporaneous records. 2.2.6 Makes an appropriate judgement regarding referral and understands referral pathways. 3.1.4 Identifies abnormal colour vision and appreciates its significance. 3.1.5 Investigates the visual fields of patients with all standards of acuity and analyses and interprets the results. 3.1.6 Uses both a non- contact and contact tonometer to measure intraocular pressure and analyses and interprets the results. 3.1.8 Uses a slit lamp to assess anterior chamber signs of ocular inflammation. 3.1.10 Uses diagnostic drugs to aid ocular examination. 4.2.1 Advises on the use of and dispenses simple low vision aids including simple hand and stand magnifiers, typoscopes and handheld telescopes. 4.2.2 Understands the application of complex low vision aids. 5.2.1. Manages the aftercare of patients wearing soft lenses. 5.2.2. Manages the aftercare of patients wearing rigid gas permeable contact lenses. 5.3.1. Chooses and manages the fitting of toric contact lenses. 5.3.2. Chooses, fits and manages the correction of presbyopic patients. 6.1.5. Recognises common ocular abnormalities and refers when appropriate. 6.1.8. Evaluates glaucoma risk factors to detect glaucoma and refer accordingly. 6.1.10 Recognises, evaluates and manages diabetic eye disease and refers accordingly. 6.1.13 Recognises ocular manifestations of systemic disease. 7.1.2. Uses appropriate diagnostic drugs to aid refraction. 7.1.3. Assesses children’s visual function using appropriate techniques. 7.1.4 Understands the techniques of the assessment of infants. 7.1.5 Assesses patients with impaired visual function and understands the use of specialist charts for distance and near vision and the effects of lighting, contrast and glare. 7.1.6. Understands the special examination needs of patients with learning and other disabilities. 8.1.2. Understands the management of a patient with an anomaly of binocular vision. 8.1.3. Investigates and manages adult patients presenting with heterophoria. 8.1.6 Manages children presenting with an anomaly of binocular vision. 8.1.7 Manages patients presenting with an incomitant deviation. Visit 4 1.1.3 Identifies and responds appropriately to patients’ fears, anxieties and concerns about their visual welfare. 1.2.2 Communicates with patients who have poor or non-verbal communication skills, or those who are confused, reticent or who may mislead. 1.2.5 Communicates effectively with any other appropriate person involved in the care of the patient. 2.2.5. Interprets and responds to existing records. 4.1.7 Manages non- tolerance cases. 5.3.3. Understands the techniques used in the fitting of complex contact lenses and advises patients requiring complex correction. 6.1.14 Assesses signs and symptoms of neurological significance. 6.1.15 Recognises adverse ocular reactions to medication 8.1.4. Manages adult patients with heterotropia.  Visit 1 1.2.3 Discusses with the patient the importance of systemic disease and its ocular impact, its treatment and the possible ocular side effects of medication. 1.2.3 Discusses with the patient the APR Takes a thorough history from the Patient taking APR Achieved □ importance of systemic disease patient to include: medication, medication for systemic and its ocular impact, its control, disease and duration. disease Not Achieved □ treatment and the possible ocular Demonstrates a thorough e.g. cardiovascular side effects of medication. understanding of the disease process disease, diabetes. Not Assessed □ in cases such as diabetes, inflammatory disease, etc. Provides a layman’s explanation of the particular disease process. During History & Symptoms ask: “Do you take any medication for any conditions around the body?” “Which medication?” “What dose?” “What is the name of the condition being treated?” “How long have you been taking this medication for?” If relevant – “when was your last screening (e.g. diabetic eye screening, hydroxychloroquine screening) A good example for this will be a patient on metformin for Diabetes. Using Diabetes as the example, explain in layman’s terms to the patient the significance of Diabetes on the eye: “Diabetes that is left uncontrolled causes damage to the walls of vessels throughout the body. However, the vessels that supply blood and nutrients to the eye are very delicate and fragile, and so therefore are easily damaged by elevated blood sugar. This causes the vessels to leak fluid and blood into the eye which over time will cause permanent scarring and loss of vision.”  2.1.2 Maintains confidentiality in all aspects of patient care. 2.1.2 Maintains APR Demonstrates knowledge of the Data Protection Act (1998) and how All sampled anonymised APR _______ confidentiality in all this impacts on security, access and confidentiality of patient records. patient records aspects of patient care. Additional guidance The 1998 act has been replaced by the Data Protection Act (2018). Trainee also demonstrates knowledge of UK GDPR. Trainee must ask for and record verbal consent on all their records and be aware of what to do in the event that the patient refuses consent. Data Protection Act (1998) – controls how your personal information is used by an organisation, business or the government Information must be: Used fairly and lawfully Used for limited, specifically stated purposes Used in a way that is adequate, relevant and not excessive Accurate Kept for no longer than is necessary Handled according to people’s data protection rights Kept safe and secure Not transferred outside the EU without adequate protection As an optometrist this means you must: Obtain patient’s consent to keep a record Keep accurate patient data Use the data for specific purposes Amend inaccurate data & respond to objections from patients for how their data is used The data must not be kept longer than necessary: o Hospital records – 10 years o Children & young people – until patient’s 25th birthday or 8 years after their death o General – 8 years o Clinical trial records – 15 years Keep data confidential & secure Obtain consent before passing on their details to another practitioner Being sure the record is no longer needed before destroying it Disposing of the record securely  2.2.2 Is able to work within a multi-disciplinary team. 2.2.2 Is able to CS Respects the roles of other members of the practice team and how working together gives the patient work within a the highest possible level of care. In relation to shared care, is aware of: multi- local and national shared care schemes disciplinary the roles of practice staff within these schemes team. the local scheme protocols Additional guidance Is able to explain how they fit into the practice team in terms of role and responsibilities. Demonstrates respect for other members of the team. You will be presented a case study scenario where you must be able to demonstrate respect for practice guidelines & team members – just remember to be ethical, respectful and abide exactly by the guidelines set out by your practice & local schemes to pass this competency. 2.2.3 Is able to work within the law and within the codes and guidelines set by the regulator and the profession. 2.2.3 Is able to work within CS Demonstrates knowledge of the advice and guidance set by the the law and within the codes respective professional body and standards set by their local CCG. and guidelines set by the Demonstrates knowledge of the Standards of Practice set down by the regulator and the profession. General Optical Council. Demonstrates a knowledge of the relevant law relating to their role, e.g. Opticians Act, GOS benefits, fees and charges, Medicines Act. Understands the implications for patient care in relation to the Mental Capacity Act 2005. Additional guidance CCGs no longer exist. Trainee demonstrates knowledge of standards set by authority responsible for commissioning health in their area. Standards of Practice – the GOC standards of practice define the standards of behaviour and performance we expect of all registered optometrists General Optical Council – the GOC is the UK regulator for the optical professions with statutory responsibility for setting standards. Your Role as a Professional – as a healthcare professional you have a responsibility to ensure the care and safety of your patients and the public and to uphold professional standards. You are professionally accountable and personally responsible for your practice and for what you do and do not do, no matter what direction or guidance you are given by an employer or colleague. This means you must always be able to justify your decisions and actions. If someone raises concerns about your fitness to practise, we will refer to these standards when deciding if we need to take any action. The Standards – as an optometrist you must: Listen to patients and ensure that they are at the heart of the decisions made about their case Communicate effectively with your patients Obtain valid consent Show care and compassion for your patients Keep your knowledge and skills up to date Recognise, and work within, your limits of competence Conduct appropriate assessments, examinations, treatments and referrals Maintain adequate patient records Ensure that supervision is undertaken appropriately and complies with a law Work collaboratively with colleagues in the interest of patients Protect and safeguard patients, colleagues and others from harm Ensure a safe environment for your patients Show respect and fairness to others and do not discriminate Maintain confidentiality and respect your patients’ privacy Maintain appropriate boundaries with others Be honest and trustworthy Do not damage the reputation of your profession through your conduct Respond to complaint effectively Be candid when things have gone wrong The Opticians Act – Legislation compiled by parliament which gives the GOC the powers to make orders, rules and regulation in relevant areas. Sections of the Opticians Act: The General Optical Council Registration and Training of Opticians Fitness to Practice Proceedings and Appeals Restriction on testing of sight, fitting of contact lenses, sale and supply of optical appliances and use of titles and descriptions General Ophthalmic Surgery (GOS) – Covers NHS sight test entitlement, optical vouchers, voucher issued for repair or replacement NHS Sight Test Eligibility (GOS1) Aged 60 or over Children under 16 Under 19 in full time education Diagnosed with either diabetes or glaucoma Relatives aged 40 or over of glaucoma sufferer Registered blind or partially sighted  Eligible for complex lens voucher (>10D) Income Support Income-based jobseeker’s allowance Income related employment and support allowance Pension credit guaranteed credit Tax credits Universal credit Low income certificate holder (HC2 or HC3) Prisoner on leave NHS Optical Voucher Eligibility (GOS3) Children under 16 Under 19 in full time education Eligible for complex lens voucher (>10D) Income Support Income-based jobseeker’s allowance Income related employment and support allowance Pension credit guaranteed credit Tax credits Universal credit Low income certificate holder (HC2 or HC3) The Medicines Act – is an act of parliament. It governs the control of medicines for human use and for veterinary use, which includes the manufacture and supply of medicines. Key Points relating to Optometrists: You must act in accordance with the current legislation controlling the use and supply of drugs Drugs should normally be supplied by a pharmacist You should take particular care when using or supplying drugs to patients from at risk groups You should be aware of the indications, cautions, contraindications and side effects of any drug you instil or supply You should inform patients how to use the drug you supply and what to do in the event of an adverse incident following instillation or supply of drug You should instruct a patient to attend the local accident and emergency department if you are not available to deal with an emergency or adverse reaction following the instillation of a drug You may delegate the instillation of eye drops to another member of staff but you remain responsible for the patient You should not treat yourself or someone close to you or prescribe or prepare written orders for POM drugs for yourself or someone close to you, except in cases of minor ailments or emergencies You may supply or administer drugs under a patient group direction (PGD) You may supply drugs not in exemptions list under the authority of a PGD You should store all drugs according to the manufacturer’s instructions You should report adverse reactions to medicines or medical devices using the appropriate reporting scheme Drugs which can be used by all registered optometrists: Provided it is in the course of your professional practice, as a registered optometrist, you may sell or supply the following medicinal products to a patient: All medicinal products on a GSL All P medicines. Provided it is in the course of your professional practice and in an emergency you may sell or supply POMs that are eye drops and contain not more than 0.5% chloramphenicol or are eye ointments and contain not more than 1% chloramphenicol Contain the following substances: Cyclopentolate hydrochloride Fusidic acid Tropicamide The POMs to which this exemption applies may also be sold or supplied by a person lawfully conducting a retail pharmacy business on the presentation of an order signed by a registered optometrist. Mental Capacity Act – applies to every involved in the care, treatment and support of people aged 16 and over living in England who are unable to make all or some decision for themselves. The MCA is designed to protect and restore power to those vulnerable people who lack capacity Key Points for Optometrists are: You must respect the rights of patients to be fully involved in decisions about their care and obtain consent for those patients who have capacity before starting treatment. Patients over 16 assume to have capacity for consent you should involve such patient in discussion of treatment. Capacity for Consent from adults: No one can make a decision on behalf of an adult who has capacity You must work on the presumption that every adult patient (over the age of 18) has the capacity to make decisions about their care, and to decide whether to agree to, or refuse, an examination, investigation or treatment You must regard a patient as lacking capacity only once it is clear that, having been given all appropriate help and support, they cannot understand, retain, use or weigh up the information needed to make that decision, or communicate their wishes You must not assume that a patient lacks capacity to make a decision solely because of their age, disability, appearance, behaviour, medical condition (including mental illness), their beliefs, their apparent inability to communicate, or the fact that they make a decision with which you disagree If the patient in England and Wales does not have capacity, the Mental Capacity Act 2005 enables someone who is over 18 years of age and authorised to make decisions for them under a Lasting Power of Attorney (LPA). Alternatively, someone who has authority to make treatment decisions for that person as a court appointed deputy can give consent. Capacity for consent from children & young people: Where a child does not have the capacity to consent, you must get consent from someone with parental responsibility. Consent from one parent, providing that parent has the capacity to consent, is usually sufficient, but if parents cannot agree and disputes cannot be resolved informally you should seek legal advice about whether to apply to the court. GDPR Patients have the right: To be informed: Individuals have the right to be informed about the collection and use of their personal data. This is a key transparency requirement under the UK GDPR Of access: individuals have the right to access and receive a copy of their personal data, and other supplementary information. to rectification: The UK GDPR includes a right for individuals to have inaccurate personal data rectified or completed if it is incomplete. to erasure: The UK GDPR introduces a right for individuals to have personal data erased. to restrict processing: Individuals have the right to request the restriction or suppression of their personal data.  To data portability: The right to data portability allows individuals to obtain and reuse their personal data for their own purposes across different services. to object: The UK GDPR gives individuals the right to object to the processing of their personal data in certain circumstances. to automated decision making including profiling: to have the option to intervene/opt- out of such services. 3.1.1 Uses instruments to measure corneal curvature and assess its regularity. 3.1.1 Uses instruments to measure WT Uses instruments to accurately measure, assess and WT corneal curvature and assess its record the corneal curvature and regularity. regularity. Correctly interprets the information gathered. Additional guidance Choice of instrumentation could include: manual or automated keratometer topographer Accurate results to within +/-0.10mm radius. A typical corneal radius measures from 7.4mm to 8.8mm. The cornea is aspheric in shape. Keratometry The two meridians are measured at 90 degrees from each other and take a measurement of the central 3mm of the cornea. Bausch & Lomb Manual Keratometer  The B&L measures both meridians of the cornea in one position. To get an accurate measurement you must use the dials to align the + & - signs Follow this link to watch a full tutorial on this keratometer: https://www.youtube.com/watch?v=ig82EVvfuYo Javal-Schiotz Keratometer The J-S measurements must be angled at both meridians of the cornea, 90 degrees away from eachother, to take the readings. To get an accurate measurement you must use the dials to align the middle line of the green arrow with the middle line of the orange arrow, as seen in the image above. Causes of Error/Inaccurate Readings on a Keratometer Poor alignment Poor orientation of mires on the cornea Poor focusing Inaccurate fixation of patient Corneal distortion Uses of a Manual Keratometer Measurement of corneal steepness/flatness Measuring the degree of corneal astigmatism Þ The difference in K readings between the two meridians can be used to work out the degree of corneal astigmatism (every difference of 0.05mm between the two meridians = 0.25D of corneal astigmatism) Non-invasive TBUT  4.1.2 Measures and verifies optical appliances taking into account relevant standards where applicable. 4.1.2 Measures and verifies optical WT Measures and verifies that lenses have been WT appliances taking into account produced to a given prescription within BS relevant standards where applicable. tolerances. Verifies that all aspects of the frame or mount have been correctly supplied. Measures and verifies that the lenses are correctly positioned in the spectacle frame/mount within BS tolerances. Additional guidance Choice of instrumentation could include: manual or semi-automated focimeter (Fully automated focimeter e.g. Eye refract VX40 is not acceptable) Accurate results to within: ± 0.25DS/DC for dioptric measurements Axis appropriate to cylinder power o ≤ 0.50DC ± 9° o > 0.50DC ≤ 0.75DC ± 6 ° o > 0.75DC ≤ 1.50DC ± 4 ° o > 1.50DC ± 3 ° Centres – 1mm tolerance. Must demonstrate a knowledge of actual tolerances.BS EN ISO 21987:2017. When measuring the spectacle power, the lens may not be exact to the refracted prescription. Depending on the prescription, accepted tolerances are noted below: (Essilor Product Information Guide, 2019)  4.1.3 Matches the form, type and positioning of lenses to meet all the patient’s needs and requirements and provides appropriate advice. 4.1.3 Matches the form, type and APR Provides all the necessary information for a pair of Patient dispensed where APR positioning of lenses to meet all the CS spectacles to be duplicated, to include: information from the old _______ patient’s needs and requirements and prescription spectacles was required provides appropriate advice. lens type and form centration and fitting positions frame details lens surface treatments. A reglaze order where all the above noted elements are noted will be enough for your APR. 5.1.2 Instructs the patient in soft lens handling and how to wear and care for them. 5.1.2 Instructs the patient in soft lens RA Instructs a patient in the techniques of soft lens Insertion and removal RA_______ handling and how to wear and care insertion, removal and other relevant handling training to at least one soft lens patient. for them. instructions. Instructs a patient on the principles of soft lens wear and care including use of soft lens care products. Additional guidance This must include: sufficient detailed knowledge of own lens banks and solutions to advise appropriately and safely. sufficient general knowledge of materials and care regimes to resolve problems. Insertion Regime 1. Wash hands 2. Check the CL is the correct way up (Bowl test/taco test) 3. Place CL on the tip of the finger 4. Ask the patient to look toward to side, and place the contact lens on the sclera 5. The patient should then look toward the contact lens, up, down and then blink. 6. The lens should now be centred. Removal Regime 1. Wash hands 2. Ask the patient to look to the side and slide the contact lens away from the cornea and onto the sclera 3. The patient should now carefully pinch the CL from the sclera 4. If it is a monthly lens, replace the solution in the pot & use the multipurpose solution to perform rub & rinse. Contact Lenses Lens Materials Hydrogel Hydrophillic polymer (Main material used is Poly-HEMA). The oxygen permeability depends on the water content, the higher the water content the more oxygen that can pass through the lens. Advantages of Hydrogel: Thinner lenses Better initial comfort Disadvantages of Hydrogel: Low oxygen permeability Higher risk of eye infections and hypoxia-related issues Not ideal for overnight wear Silicone Hydrogel Allows 5x times more oxygen to pass through than hydrogels. The oxygen permeability depends on the amount of silicone used, not the water content Advantages of Silicone Hydrogel: High oxygen permeability Extended wear and longer wear times available  Easier to handle as generally thickness aids sturdiness and enhances durability Disadvantages of Silicone Hydrogel: Tend to be more expensive Lens Bank Dk: Oxygen permeability of the material T: Thickness of the material Water Content: Higher water content allows for more of the natural hydration of the eye, the tear film, to absorb into the lens, ultimately drying out the eyes. Daily Spheres Water Dk/t UV Back Curve/Diameter Material Content (%) Clariti 1-day 47 86 Yes 8.6 / 14.1 SiHy Acuvue Moist 1-day 58 33 Yes 8.5 or 9.0 / 14.2 Hydrogel Aqua Comfort Plus 69 26 No 8.7 / 14.0 Hydrogel Focus All Day 69 26 No 8.6 / 13.8 Hydrogel Comfort MyDay 54 100 Yes 8.4 / 14.2 SiHy Acuvue Oasys 1-day 38 121 Yes 8.5 or 9.0 / 14.2 SiHy  Daily Toric Water Dk/t UV Back Material Content (%) Curve/Diameter Acuvue Moist for 58 23 Yes 8.5 / 14.5 Hydrogel Astigmatism (1-day) Acuvue Oasys for 38 129 Yes 8.5 / 14.3 SiHy Astigmatism (1-day) Daily Multifocal Water Dk/t UV Back Curve/ Material Content (%) Diameter Acuvue Moist 1- 58 25 Yes 8.4 / 14.3 Hydrogel day Multifocal Dailies Total 33 156 No 8.5 / 14.1 SiHy Multifocal 1-day Daily lenses are more suitable to patients who have allergies as it does not allow for the build-up of allergens or deposits overtime, which can trigger a reaction when reinserted into the eye. Monthly Spheres Water Dk/t UV Modality Diameter/Back Material Content Curve (%) Clariti Elite 56 86 Yes Monthly 8.6 / 14.2 SiHy Biofinity 48 160 No Monthly/Extended 8.6 / 14.0 SiHy Wear Air Optix N&D 24 175 No Monthly/Extended 8.4 or 8.6 / 13.8 SiHy Wear Acuvue Oasys 38 147 Yes Two - Weekly 8.4 or 8.8 / 14.0 SiHy Avaira Vitality 55 110 No Monthly 8.4 / 14.2 SiHy AirOptix Aqua 35 138 No Monthly 8.6 / 14.2 SiHy Monthly Torics Water Dk/t UV Modality Diameter/Back Material Content Curve (%) Avaria 55 90 Yes Monthly 14.5 / 8.5 SiHy Vitality Toric Clariti Toric 56 57 Yes Monthly 14.4 / 8.7 SiHy Air Optix for 33 110 No Monthly 14.5 / 8.7 SiHy Astig Biofinity 48 116 No Monthly/Extended 14.5/ 8.7 SiHy Toric Wear Acuvue 38 129 Yes Two - Weekly 14.5 / 8.6 SiHy Oasys for Astigmatism Clariti Toric 56 86 Yes Monthly 8.7 / 14.4 SiHy Monthly Multifocals Water Dk/t UV Modality Diameter/Back Curve Material Content (%) Clariti 56 86 Yes Monthly 14.2 / 8.7 SiHy Multifocal AirOptix 33 138 No Monthly 14.2 / 8.6 SiHy Multifocal Biofinity 48 142 No Monthly / 14.0 / 8.6 SiHy Extended Wear  Soft Lens Solutions Typical Multipurpose CL Solution Ingredients Ingredients: Polyhexanide - Disinfectant and Preservative Sodium Hyaluronate - stores and absorbs moisture, lubricates and filters inflammatory molecules Sodium Chloride - Maintains similar tonicity to the tearfilm to avoid discomfort and conjunctival hyperaemia Sodium Phosphate - Balances pH for natural lens wear Poloxamer - Surfactant and cleaning agent EDTA Water Rub and Rinse for 15-20 seconds, leave the CLs to soak for at least 4 hours to be sufficiently disinfected or overnight. Saline Solution Never to be used for disinfection, but can be used for rinsing debris from SCLs. Easyvision Peroxide Solution Preservative Free Ingredients: 3% Hydrogen Peroxide Sodium Chloride - Maintains similar tonicity to the tearfilm to avoid discomfort and conjunctival hyperaemia Sodium Phosphates - Balances pH for natural lens wear One-step and doesn’t require neutralisation (has a built in neutraliser in the barrel that converts the peroxide to oxygen and water). Removes bacteria and protein deposits. Let them soak for at least 6 hours for the lenses to be properly sanitised.  Comfort Drops Hycosan Extra o Sodium Hyaluronate 0.2%. – stores and absorbs moisture, lubricates and filters inflammatory molecules o Preservative Free Hycosan Plus o Sodium Hyaluronate 0.1% - stores and absorbs moisture, lubricates and filters inflammatory molecules o Dexpanthenol 2% - Lens moisturiser, creates a barrier inhibiting moisture evaporation and therefore prevents lens dehydration o Preservative Free Hycosan Dual o Sodium Hyaluronate 0.1% - stores and absorbs moisture, lubricates and filters inflammatory molecules o Ectoin – Flushes allergens from the eye and protects allergens from entering the tear film o Preservative Free Hyloforte o Hyaluronic Acid 0.2% - Aids in epithelial healing, can retain water making it a valuable wetting agent for dry eyes. o Preservative Free Antimicrobial Flat Case or Barrel Case: Contains Silver Ions on the inner walls of the case, making it more resistant to bacteria. Protein Remover Tablets: Enzymatic Cleaner that removes Protein build up in reusable lenses. Tablets are placed in multipurpose sol with the CLs and left overnight.  5.1.4 Instructs the patient in rigid contact lens handling and how to wear and care for them. 5.1.4 Instructs the patient in rigid RP Instructs the patient in the techniques of RGP lens contact lens handling and how to wear insertion, removal and other relevant handling and care for them. instructions. Instructs a patient on the principles of RGP lens wear and care including the use of RGP lens care products. Additional guidance This must include: sufficient detailed knowledge of own lenses and solutions to advise appropriately and safely. sufficient general knowledge of materials and care regimes to resolve problems. Insertion 1. Wash hands 2. Place lens on the tip of the finger and add a drop of the comfort solution 3. Secure the upper and lower lid out and away 4. Place the contact lens directly onto the centre of the cornea 5. Release the contact lens & blink, it should now be centred. Removal 1. Wash hands 2. The patient should look straight on 3. Using the upper and lower lid, press onto the edges of the contact lens to gently pop the lens out of the eye 4. Rinse the lens with the appropriate chosen solution, replace the solution in the lens case & place the RGPs inside  RGP LENS MATERIALS Material Dk/t Characteristics UV Boston Hyper Dk Good wettability, stability, comfort. No XO2 Fluorosilicone Excellent deposit resistance Acrylate Boston XO Super Dk Stability is poor – equals that of lower Dk materials No Fluorosilicone Acrylate Quantum 2 Super Dk High Oxygen Delivery No (ML210) Fluorosilicone Good Protein Resistance Acrylate Boston EO Super Dk Excellent Wetting + deposit resistance No Fluorosilicone Acrylate Boston High Dk Fluorinated Polymer leading to Improved Oxygen delivery Yes Equalens Fluorosilicone Acrylate Quantum 1 Mid Dk Medium Oxygen delivery No (ML92) Fluorosilicone Good Protein Resistance Acrylate Boston ES Low-mid Dk Exceptional durability and modulus No Fluorosilicone Exceptional wetting and deposit resistance Acrylate Fitting Choices Characteristics UV Maxim / Flattest K Constant Dk/t and centration No Maxim throughout power range due to Toric same mean thickness across all lenses High first fit success rate Quantum Flattest K Quantum 1 – Dk 33 Spheric/Aspheric design: No – 0.1 due Quantum 2 – Dk 97 Accurate Corneal Alignment to the Quantum 141 – Dk 141 Clear Vision in all light levels aspheric Increased fitting choices geometry  Gas Permeable Lens Solutions Typical RGP Multiaction Solution Ingredients Ingredients: Poloxamine – Removes lipids and environmental debris Hydroxyalkyl phosphonate – Removes protein deposits Boric Acid – eliminates bacteria and fungi Sodium Borate – anti-fungal and Balances pH for natural lens wear, to match the tearfilm: 6.6 – 7.8. Sodium Chloride - Maintains similar tonicity to the tearfilm to avoid discomfort and conjunctival hyperaemia Hydroxypropylmethyl cellulose – Conditions and lubricates the lens surface Chlorhexidine Gluconate - Disinfectant Polyaminopropyl biguanide – Disinfectant and preservative 1. Soak lenses in solution for 4 hours or overnight in an empty lens case 2. Wash your hands 3. After soaking, rub both sides of the lens with 4 drops of the cleaner solution in the palm of your hand for 20 seconds. 4. Rinse using the solution for approximately 5 seconds to remove loosened surface deposits 5. Insert lenses 6. Discard solution 90 days after opening Boston 2 Step Cleaning and Conditioning System Ingredients: Boston Advance Cleaner (Step 1) Alkyl ether sulfate – Surfactant to remove contaminants from the lens surface Ethoxylated alkyl phenol – Alcohol to remove bacteria from the lens surface Quaternary phosopholipids, Titanium Dioxide and silica gel – aids to physically scrub off proteins and deposits when rubbing Boston Advance Conditioning Solution (Step 2) wetting and cushioning agents: cellulosic viscosifier polyvinyl alcohol polyethylene glycol preserved with: chlorhexidine gluconate polyaminopropyl biguanide edetate disodium  How to use: 1. Wash your hands 2. Rub both sides of the lenses carefully with 4 drops of cleaner (Step 1) in the palm of your hand for 20 seconds 3. Rinse both sides of the lens with a saline solution 4. Soak your lenses for 4 hours with the conditioning solution (step 2) 5. Add a drop of conditioner to the lens for extra cushioning and insert into your eye. 6. Rinse your lens case with a sterile disinfecting solution and then wipe dry with a clean tissue. Avoid air-drying. 6.1.1. Understands the risk factors for common ocular conditions. 6.1.1. Understands the risk factors for TCD Understands the risk factors for developing common Patient with a risk factor TCD______ common ocular conditions. ocular conditions including: for an ocular condition Glaucoma, cataract, diabetic retinopathy and AMD. Glaucoma Risks Primary Open Angle Glaucoma o Older Age o Afro/Caribbean Race o Thin Cornea o Myopia of >4.00D o FHG Acute Angle Closure Glaucoma o FHG o Age of >40 o Women o Chinese Race o Short axial length o Hyperopia Cataract Risks Nuclear Sclerotic o Poor diet o Age o Smoking o UVB Cortical o UVB o Older Age o Diabetes o Smoking  o Female o Non-caucasian Posterior Sub-Capsular o Diabetes o High Myopia o Steroids o Older age o Male o Thyroid Hormone Use Diabetic Retinopathy Risks Longer Duration of Diabetes Poor glycaemic control Pregnancy Smoking High Blood Pressure High Blood Sugar High Cholesterol Black, Native American or Hispanic Ancestry AMD Drusen at the macula Smoking UV exposure Older age Poor diet lacking vitamins, minerals & antioxidants 6.1.11. Understands the treatment of a range of common ocular conditions. 6.1.11. Understands the treatment of CS Demonstrates a basic understanding of the a range of common ocular Q treatment regimes of cataract, AMD, glaucoma, conditions. diabetic eye disease and minor anterior eye problems. Can discuss the treatment options for two of the above conditions. Cataract Day case procedure 1. Local anaesthetic drops and possibly intra-cameral (into AC) injection 2. Small incisions made in the outer edges of the cornea (1-3mm in size) 3. Viscoelastic substance injected to maintain shape and pressure in eye 4. Capsulorrhexis – round incision made in the anterior capsular bag to gain access to the cataract  5. Hydrodissection – fluid is injected between the capsule and cataract to separate them 6. Phacoemulsification - high frequency ultrasound device which breaks the cataract up into 2-4 small pieces which are then suctioned out 7. A folded artificial intraocular lens (IOL) is then inserted (via the small incision) and placed into the capsular bag 8. Stitches are rarely required due to it being keyhole surgery Posterior capsular opacification (PCO) Common complication (in 20% of people) Usually 2-5 years after the cataract operation 1. The posterior part of the lens capsule (the bag which holds the lens in place) becomes hazy due to residual cataract cells growing onto it 2. Younger patients have an increased likelihood of developing PCO 3. Routine referral 4. Treatment is via YAG laser to get rid of the residual cells in the central area to allow clear vision AMD Dry AMD Smoking cessation Lutein, Zeaxanthin can help slow the progression of it AREDS/AREDS 2 studies have shown that supplements have the best prognosis if used in the following patients: o Extensive medium sized drusen o Multiple large drusen o Non central geographic atrophy in one eye or both o Advanced AMD or reduced VA due to AMD in 1 eye Aka. Supplements are best for Intermediate or Advanced AMD suffers. There are contraindications for advising supplements in the following patients: o Smoking & Beta carotene – More likely to trigger lung failure o Genitourinary problems & Zinc - May cause kidney stones or UTI o Heart failure & Vitamin E – Increased risk of heart failure Ensure the patient speaks to a doctor/pharmacist about the supplements BEFORE they are taken  Wet AMD Fast track referral to macular clinic (2 weeks) OCT Disruption of the RPE Serous PED: o Vascularised: Due to exudation from a choroidal neovascular membrane o Non-Vascularised: Bruch’s membrane degeneration Drusenoid PED: o Soft Drusen accumulates and separates the RPE from Bruch’s membrane (differential: Choroidal Neovascularisation: neovascular membrane grows from choriocapillaries through bruch’s membrane into sub-RPE space, and then can grow through RPE and into Sub-Retinal Space). Fundus autofluorescence & fluorescein angiography Sodium Fluorescein Dye is injected: o Maximum vessel fluorescence is at 25s, this gives best visualisation of capillary network. Hypofluorescence o (vascular perfusion or blood/exudate is blocking the passage of light) Hyperfluorescence o Increased transmission of light due to an abnormal amount of fluorescence at a certain time period. o Loss or thinning of the RPE o Leakage of fluorescein from hyperpermeable vessels (e.g. CMO, CSCR, Choroidal Neovascularisation) Anti-Vascular Endothelial Growth Factors (VEGF) injections (Lucentis, Avastin, Eyelea) Loading dose: 3 sets of monthly injections Following this, if more are needed (maintenance dose): Lucentis (Ranibizumab) is given every 4 weeks: 6/12 – 6/96 Eylea (Aflibercept) is given every 8 weeks: 6/12 – 6/96 Up to date refraction as recommended by consultant Support services (RNIB/macula society) Sight impairment registration: Min VA 6/60 Diabetic Retinopathy Good control of blood sugar, blood pressure and cholesterol levels. Regular diabetic eye screening: Microaneurysms, Haemorrhages (flame/NFL, Dot/blot Intra-retinal), Exudates, Venous Beading due to ischaemia, NVD (1DD of ONH) or NVE. Scattered Pan-Retinal Photocoagulation laser – Removes Neovascularisation and stops the progression of the growth of these vessels. Vitrectomy for vitreous haemorrhage - clears visual axis, reduces VEGF, reducing neovascularisation especially when combined with anti-VEGF. For Retinal Detachment: o Cryotherapy: Retinal tear is frozen creating an adhesive scar to seal the tear back together o Laser Photocoagulation Treatment: Laser creates a scar to weld the tear back together o Pneumatic Retinopexy: A bubble of gas is injected to push the area of the retina containing the hole, closing the space created behind the retina. This stops the flow of fluid into the space behind the retina causing a Rhegmatogenous RD (Separates Neurosensory Retina from the RPE). o Scleral Buckle: Silicone is sutured onto the sclera above the affected area to relieve some of the force caused by vitreous traction. Lucentis anti-VEGF injections – VEGF causes neovascularisation and the break down of blood-retinal barrier at the RPE (which regulates the movement of fluid into the sub-retinal space) which causes fluid leakage resulting in Macula Oedema. Dexamethasone or iLuven (Fluocinolone) (steroid) injections for Diabetic Macula Oedema: Steroids reduce the inflammation of vessels which causes the breakdown of capillaries and pericyte loss. Glaucoma Surgeries Peripheral Iridotomy A hole created to allow drainage of aqueous humour through a different channel, allowing for the push back of the iris that may otherwise lead to iris bombe/anterior synechiae and ultimately pupil block in ACG. Normally used for ACG or those with narrow angles. Selective Laser trabeculoplasty (SLT) Laser triggers the regeneration of cells in the trabecular meshwork to increase and improve the outflow of aqueous humour in patients with OAG. Lowers IOP by approx. 30%. Procedure can be repeated as it wears off over time. Trabeculectomy A bleb is created, usually at the superior part of the sclera to allow fluid to drain out into the sub-conjunctival space. From here it either filters into the tearfilm, gets absorbed by vascular or perivascular conjunctival tissue or through lymphatic vessels to be drained through aqueous veins.  Filtration tubes/aqueous shunt In cases where other treatment methods have not worked. The tube creates a new channel for aqueous humour to drain out underneath the conjunctiva. A bleb is also created Cataract extraction If the cataract is phacomorphic, it pushes forward and compresses the anterior chamber angle. Drops The first call of treatment for glaucoma is IOP lowering drops -> the first line drop used is Latanoprost. Alpha-antagonists Brimonidine Apraclonidine Beta-Blockers Timolol Betaxolol Cartelol Carbonic Anhydrase Inhibitors Brinzolamide Dorzolamide Prostaglandin Analogues Latanoprost Travaprost Bimatoprost Miotics Pilocarpine Dry Eye Treatment Lubricants - Used to replace tears in tear deficiency patients Blinking exercises: o Close both eyes normally, pause 2 seconds, and open. o Close the eyes normally again, pause 2 seconds and then aggressively squeeze the lids together (as if you are trying to crack a walnut with your lids) for 2 seconds. o Open both eyes. Repeat every 20 minutes, 20 X a day. Air humidifier: Cool mist to use in dry climates Blepharitis (anterior or posterior) Warm compresses – loosens the collarettes and makes them easier to wipe away and melts the oil in blocked glands, making them easier to express. Lid wipes or gel – lid wipes often contain tea-tree oil which is known to kill off and remove demodex Lubricants - Used to replace tears in tear deficiency patients Meibomian Gland Dysfunction Biggest cause of dry eyes Heated eye mask and lid massage: to melt oils and push them out of glands Lubricants: Used to replace tears in tear deficiency patients Lid hygiene: Warm flannel over the eyes for 3 mins, massage the lids in a rolling motion to express the oils, wipe away excess oils Tear Film Assessment Evaporative Dry Eye Aqueous Deficiency Dry Eye Pre-disposing Wind Medications (Oral, Factors Air Con antihistamines, Beta- Visually attentive tasks where blockers, antipsychotics, blink rate is reduced: reading, antidepressants) VDU Causes Lid Disease: Blepharitis, MGD Inflammation of lacrimal Thyroid eye disease glands Allergic eye disease Sjogren’s Syndrome Age Treatment Modify local environment Lubricants Lid hygiene Omega 3 Omega 3 Punctal Plugs Lubricants Appearance Streaky Pattern on Tearfilm Circular Pattern on Tear Film  7.1.7. Understands the special examination needs of patients with severe visual field defects. 7.1.7. Understands the special CS Understands the different types of severe visual examination needs of patients with field defects and how to adapt examination severe visual field defects. technique to take them into account, in particular: consideration of patient’s mobility adaptation of routine. Types of Visual Field Defects Paracentral Scotoma: A loss of nerve fibres in the central 10-20o of fixation, respects the horizontal midline Nasal Step: A step-like defect along the horizontal midline due to asymmetric loss of the nerve fibre bundles in the superior and inferior hemifields. Arcuate Scotoma: Coalescence of arcuate scotoma and nasal step, follows the arcuate pattern of the NFL Ring Scotoma: If the arcuate scotoma involves the upper and lower quadrants. It can be macula sparing as the papillomacular bundle is the last to be affected LE monocular defect: Lesion at Optic Nerve Bitemporal Hemianopia: Chiasm lesion Central Vision loss: AMD, Stargardts or Best Vitelliform à macula disorder Right Homonymous Hemianopia: Lesion in Left LGN or Left Visual Cortex Right inferior Quadranopia: Left Optic Radiation Cecocentral Scotoma: Optic Neurits Peripheral Vision Loss: Glaucoma or Retinitis Pigmentosa Approximately 50% of nerve fibres in a region have been lost by the time a visual field defect is observed. A Visual Field Defect Should be: Reproducible Consistent with Optic Disc Appearance/Relevant structures Reliable: 0.3mm o G2: 0.2 mm o G3: 0.75DC: As the rx given is a best vision sphere, you won’t know if vision is poor because of the lack of cyl or they’re struggling with multifocal lenses. After Fitting o For 20 Min px goes for a walk around to have a look. o Subjectively score D and N out of 10 o If rx needs to be changed, use Binocular Flippers only to help over-refract: § Dominant Eye: If the change helps in the distance, make sure it’s not negatively impacting their vision at near § Non-Dominant Eye: If the change helps at near, make sure it’s not negatively impacting their vision at distance. However, remember if the patient has a CL poor fit & the power profile isn’t in the pupil centre, the px will not access the appropriate rx correction in the lens and VA will be poor.  Multifocal Soft Contact Lenses Water Dk/t UV Modality Diameter/Back Sphere Powers Add Material Conten Curve t (%) J&J Acuvue 58 25.5 Yes, Daily 14.3 / 8.4 -9.00 - +6.00 High, Med, Low Hydrogel Moist Handling Multifocal tint Eyexpert 56 86 Yes, Daily 14.1 / 8.6 -10.00 to +8.00 High, Low SiHy Finess Handling Multifocal tint (Clariti 1- day) Eyexpert 54 100 Yes, Daily 14.2/8.4 -12.00 to +8.00 High, Med, Low SiHy Pure Handling Multifocal tint (MyDay Multifocal) CV Proclear 62 17 No, Monthly 14.4/8.7 Sph: -8.00 to +6.00 +1.00 to +2.50 Hydrogel Multifocal Has Cyl: -0.75 to -5.75 (0.50) Handling (0.50) Tint Air Optix 33 138 No, Monthly 14.2 / 8.6 -10.00 to +6.00 High, Med, Low SiHy Multifocal Has Handling Tint Eyexpert 48 142 No, Monthly/ 14/ 8.6 -10.00 - +6.00 High, Med, Low SiHy Silk Has Extended Multifocal Handling Wear (CV Tint Biofinity) B & L Ultra 46 114 No, Monthly 14.5/8.6 Sph: -5.00 to +3.00 High, Low SiHy Multifocal Has Cyl: 0.75 or -1.25 for Handling Astigmatis Tint m Multifocal GP Contact Lenses Work by steepening the RGP to create a positive tear lens at near, allowing the patient to see up close and at distance. All available in radii 7.00 – 9.00 in 0.05mm steps Contraindications for RGP Fit: High Riding Lens: doesn’t create positive tear lens >2.00DC or Keratoconus: unstable platform: variable vision/unreliable reading add due to compromised fit RGP Lens How it works Other Notes Power Add To Fit Dk/ Material Range t Quasar Optics of lens is -10.00 0.75 60 DK60 Plus steepened to to to + DK90 create a +12.00 2.50D 90 positive tear lens at near, allowing the patient to see up close and at distance Icon Centre for -25.00 0.50 FIT: 200 Boston XO Ideal Fit: Multifoca Distance, to to Flattest K: 3.00DC gets add. blink Back Surface Lens must be central or Lens slightly low in primary position Quasar Centre for Lens should sit central or -25.00 0.75 – Choice of lens FS Distance, slightly low on the patient’s to 3.00 materials Peripheral lens cornea, to allow correct +25.00 from is more alignment of the distance manufacturer positive. As px prescription and allow looks down, optimum near vision with peripheral lens some translation on down comes into gaze. view and px gets add. Determining Ocular Dominance Motor (Hand Triangle)– the dominant eye is the one which less readily relinquishes binocular fixation or foveal vision when BV is stressed. Not repeatable, can be affected by position, head posture, etc.  o Use the fixation disparity test: the bar which slips is the less dominant eye. Sensory – Test of sensory of ocular dominance assess which image is selected as predominant by the visual cortex. 1. Put px’s distance rx in trial frame 2. +1.00 blur one eye 3. Ask the patient ‘looking around the room, how comfortable does your vision feel? Score out of 10’ 4. Repeat on other eye 5. The eye that feels the least comfortable when blurred, that’s the dominant eye. 6.1.5. Recognises common ocular abnormalities and refers when appropriate. 6.1.5. Recognises PR Recognises using appropriate technique/s all Patient where OCT is PR - Achieved □ common ocular of the following: indicated. Not Achieved □ abnormalities and I cataract Not Assessed □ refers when glaucoma or glaucoma suspects (OCT does not have appropriate. anterior eye disorders, e.g. blepharitis, dry to be carried out) eye, meibomian gland dysfunction, lid lesions AMD and macular abnormalities. Manages appropriately. Cataract Cataract – Caused by denaturation of protein fibrils within the lens due to oxidative stress, increasing age and metabolic disturbance Symptoms of a Cataract; Reduced VA Reduced CS Increased Glare Nuclear Sclerotic light scattering associated with Brunescence. Poorer Diet Low socio-economic status Age Smoking Larger Lens Higher Ambient Temperature Signs: Yellowish hue Myopic Shift Cortical – Appearance of spokes Sunlight (UVB) Lens size Age Diabetes Smoking Female Non-Caucasian Signs: Increased astigmatism Monocular Diplopia Posterior Sub-capsular – abnormal epithelial cells and granular material at posterior pole due to swelling and breakdown of lens fibres Diabetes High Myopia Steroids Age Male Thyroid Hormone Use Signs: Rapidly progressing loss of visual acuity. Referral Criteria – no clear cut off, when sufficient cataract present to limit: The quality of life (mobility, glare) ability to work ability to drive willingness to have surgery College Management Guidelines – ROUTINE Referral Glaucoma Normal Tension Glaucoma VHG4 IOPs below 24mmHg Visual fields show glaucomatous changes Optic Nerve head shows glaucomatous changes C:D ratio asymmetry of >0.2 bilaterally Loss of ISNT rule Notching of the RNFL Baring, Bayonetting and Overpassing of the vessels around the optic nerve head Primary Open Angle Glaucoma VHG4 IOPs above 24mmHg Visual fields show glaucomatous changes Optic Nerve head shows glaucomatous changes C:D ratio asymmetry of >0.2 bilaterally Loss of ISNT rule Notching of the RNFL Baring, Bayonetting and Overpassing of the vessels around the optic nerve head Ocular Hypertension VHG4 IOPs above 24mmHg Visual fields show NO glaucomatous changes Optic Nerve head shows NO glaucomatous changes Lids and Lashes Blepharitis Consider DD to reduce chances of infection Grade 3 or 4: Cease lens wear until resolved as risk factor for corneal infection due to pathological microbes close to ocular surface. Lid Hygiene: Warm compress Tea tree oil wipes Ocular lubricants MGD Lens wear can be continued if this is tolerated by the px, as more likely to experience discomfort due to dryer eyes Artificial tears Low water content lens: prevents CL from acting like a sponge and absorbing the tear film Dry Eye Evaporative Dry Eye Aqueous Deficiency Dry Eye Pre-disposing Wind Medications (Oral, Factors Air Con antihistamines, Beta- Visually attentive tasks where blockers, antipsychotics, blink rate is reduced: reading, antidepressants) VDU Causes Lid Disease: Blepharitis, MGD Inflammation of lacrimal Thyroid eye disease glands Allergic eye disease Sjogren’s Syndrome Age Treatment Modify local environment Lubricants Lid hygiene Omega 3 Omega 3 Punctal Plugs Lubricants Appearance Streaky Pattern on Tearfilm Circular Pattern on Tear Film Dry AMD A natural dysregulation of biological retinal processes with time causes a build-up of waste product generated by the photoreceptors. This product sits between the RPE and Bruch’s membrane and is called Drusen. Signs: Dry AMD Multiple small drusen Few intermediate drusen RPE pigmentary changes Intermediate AMD Extensive intermediate drusen (63-124 ym) At least 1 large drusen (>125ym)  Geographic atrophy not involving the fovea At this stage, the AMD may progress into either Late DRY AMD, or WET AMD Late AMD Geographic Atrophy involving fovea WET AMD VEGF release causes angiogenesis, triggering neovascular vessels to grow within the choriocapillaris and through into bruch’s membrane. These vessels are extremely fragile, causing breakage and subsequent fluid leak of fluid & blood beneath the macula. Signs at the macula: Drusen Hard exudates Haemorrhages Sub-retinal fluid Sub-RPE fluid Hyper & Hypopigmentation 6.1.8. Evaluates glaucoma risk factors to detect glaucoma and refer accordingly. 6.1.8. Evaluates PR Discusses the key risk factors. Patient requiring glaucoma risk factors to Identifies findings suggestive of open and closed angle management for potential PR_________ glaucoma from clinical examination. detect glaucoma and suspect glaucoma (not Uses the above information to determine if referral is refer accordingly. appropriate. solely ocular hypertension). Decides on urgency and pathway of referral. Normal Tension Glaucoma – Routine Referral VHG4 IOPs below 24mmHg Visual fields show glaucomatous changes Optic Nerve head shows glaucomatous changes C:D ratio asymmetry of >0.2 bilaterally Loss of ISNT rule Notching of the RNFL Baring, Bayonetting and Overpassing of the vessels around the optic nerve head Primary Open Angle Glaucoma – Routine Referral VHG4 IOPs above 24mmHg Visual fields show glaucomatous changes Optic Nerve head shows glaucomatous changes  C:D ratio asymmetry of >0.2 bilaterally Loss of ISNT rule Notching of the RNFL Baring, Bayonetting and Overpassing of the vessels around the optic nerve head Ocular Hypertension – Routine Referral VHG4 IOPs above 24mmHg Visual fields show NO glaucomatous changes Optic Nerve head shows NO glaucomatous changes Acute Angle Closure Glaucoma – Emergency Referral VHG1/closed IOPs above 40mmHg Painful red eye Corneal Oedema Haloes around lights Nausea Vision severely blurred Glaucoma Risks Primary Open Angle Glaucoma o Older Age o Afro/Caribbean Race o Thin Cornea o Myopia of >4.00D o FHG Acute Angle Closure Glaucoma o FHG o Age of >40 o Women o Chinese Race o Short axial length o Hyperopia Glaucoma Treatments Surgeries Peripheral Iridotomy A hole created to allow drainage of aqueous humour through a different channel, allowing for the push back of the iris that may lead to iris bombe/anterior synechiae and ultimately pupil block in ACG. Normally used for ACG or those with narrow angles. Selective Laser trabeculoplasty (SLT)  Laser triggers the regeneration of cells in the trabecular meshwork to increase and improve the outflow of aqueous humour in patients with OAG. Lowers IOP by approx. 30%. Procedure can be repeated as it wears off over time. Trabeculectomy A bleb is created, usually at the superior part of the sclera to allow fluid to drain out into the sub-conjunctival space. After reaching this part, it either filters into the tearfilm, get absorbed by vascular or perivascular conjunctival tissue or through lymphatic vessels to be drained through aqueous veins. Filtration tubes/aqueous shunt In cases where other treatment methods have not worked. The tube creates a new channel for aqueous humour to drain out underneath the conjunctiva. A bleb is also created Cataract extraction If the cataract is phacomorphic, it pushes forward and reduces the anterior chamber angle Drops The first call of treatment for glaucoma is IOP lowering drops -> first line drop used is Latanoprost. Alpha-antagonists Brimonidine Apraclonidine Beta-Blockers Timolol Betaxolol Cartelol Carbonic Anhydrase Inhibitors Brinzolamide Dorzolamide Prostaglandin Analogues Latanoprost Travaprost Bimatoprost Miotics Pilocarpine  6.1.10 Recognises, evaluates and manages diabetic eye disease and refers accordingly 6.1.10 Recognises, PR Recognises and names correctly the stage of Patient with diabetic PR - Achieved □ evaluates and diabetic eye disease. Gives local referral route eye disease. Not manages diabetic I and the appropriate timescales for referral Achieved □ eye disease and following diabetic retinopathies: Not refers accordingly. background/maculopathy/pre- Assessed □ proliferative/proliferative. Diabetic Retinopathy Dysfunction of the retinal vasculature caused by chronic hyperglycaemia resulting in structural damage to the neural retina. Pathogenesis 1. Damage to the endothelium 2. Loss of pericytes) 3. Breakdown of blood-retinal barrier 4. Thickening of capillary basement membrane 5. VEGF release Key signs of Diabetic Retinopathy: o Flame Haemorrhages o Dot-blot o Exudates o CWS o Microaneurysms o Venous Beading o NVD o IRMA Flame Haemorrhages: originate from pre-capillary arterioles in the nerve fibre layer. Dot-blot Haemorrhages: arise from the venous end of capillaries (aka. Intra-retinal haemorrhage) in the Inner Plexiform and Inner nuclear layer. Exudates: Lipid laden neuronal breakdown products that have left leaky vessels with the blood plasma and accumulate in the outer plexiform layer Cotton Wool Spots: accumulations of neuronal debris within the nerve fibre layer as a result of interruption of normal axoplasmic flow. This debris accumulates in the ganglion cell nerve axons. microaneurysms: Weakening of the capillary walls due to a loss of pericytes resulting in an outpouching (typically in the INL) Venous Beading: vessel change associated with ischaemia NVD: NV within 1DD of the disc, NVE: NV of the retina and elsewhere IRMA: A-V shunt (abnormal connection between an artery and a vein) that bypasses the capillary bed in the retina Drusen: Abnormal deposits of lipid material generated by the photoreceptors that accumulate between the RPE and Bruch’s. Clinically significant macula oedema: 1. Retinal thickening within 500 micrometres of the centre of the macula 2. Exudates within 500 micrometres of the macula and associated retinal thickening anywhere else 3. Retinal thickening 1 disc area (1500micrometres) or larger, any part of which is 1 DD of the centre of the macula Classification of Diabetic Retinopathy Risk Factors Longer Duration of Diabetes Poor glycaemic control Pregnancy Smoking High Blood Pressure High Blood Sugar High Cholesterol Black, Native American or Hispanic Ancestry 1. Background DR Microaneurysms Dot/Blot haemorrhages Exudates 2. Diabetic Maculopathy: Leakage of fluid due to hyperpermeable vessels causing macula oedema. M1: DMO, Haems, Exudates  3. Pre-proliferative DR Indicates retinal ischaemia with a high risk of progression to retinal neovascularisation. Cotton Wool Spots Venous Changes: beading and looping IRMA Deep retinal haemorrhages 4. Proliferative DR NVD or NVE 5. Advanced Diabetic Eye Disease Tractional Retinal Detachment Persistent Vitreous Haemorrhages Neovascular glaucoma Treatments Good control of blood sugar, blood pressure and cholesterol levels. Regular diabetic eye screening: Microaneurysms, Haemorrhages (flame/NFL, Dot/blot Intra-retinal), Exudates, Venous Beading due to ischaemia, NVD (1DD of ONH) or NVE. Scattered Pan-Retinal Photocoagulation laser – Removes Neovascularisation and stops the progression of the growth of these vessels. Vitrectomy for vitreous haemorrhage - clears visual axis, reduces VEGF reducing neovascularisation especially when combined with anti-VEGF. For Retinal Detachment: o Cryotherapy: Retinal Tear area is frozen creating an adhesive scar to seal the tear back together o Laser Photocoagulation Treatment: Laser creates an scar to weld the tear back together o Pneumatic Retinopexy: A bubble of gas is injected to push the area of the retina containing the hole onto the space behind the retina. This stops the flow of fluid into the space behind the retina causing a Rhegmatogenous RD (Separates Neurosensory Retina from the RPE). o Scleral Buckle: Silicone is sutured onto the sclera above the affected area, to help relieve some of the force caused by vitreous traction. Lucentis anti-VEGF injections – VEGF causes neovascularisation and the break down of blood-retinal barrier at the RPE (which regulates the movement of fluid into the sub-retinal space) allowing for the fluid leakage à Macula Oedema.  Dexamethasone or iLuven (Fluocinolone) (steroid) injections for Diabetic Macula Oedema: Steroids reduce the inflammation of vessels which causes the breakdown of capillaries and pericyte loss 6.1.13 Recognises ocular manifestations of systemic disease. 6.1.13 APR Provides evidence of examining patients and Patient with ocular APR - Achieved □ Recognises recognising ocular manifestations of systemic manifestation of Not Achieved □ ocular I disease in hypertension and diabetes. systemic disease Not Assessed □ manifestations Answers questions and recognises a range of other than diabetes. of systemic ocular disease. conditions from images provided by the assessor and relates these to systemic disease. Hypertensive Retinopathy Ocular manifestation of systemic hypertension. Blood Pressure Normal - 160mmHg/>100 mmHg Stage 3 hypertension- >180mmHg/>110mmHg Features Tortuous Vessels Venous compression at A/V crossing Focal arteriolar narrowing Arteriosclerotic changes Nerve fibre haemorrhages (Flame-Shaped) Accelerated hypertension: Cotton wool spots, Disc Oedema, Macular star of exudates Severe Hypertensive Retinopathy Features Swollen Disc Macular Star  Cotton wool spots Dilated retinal veins Tortuous vessels Macular oedema Classifications Keith Wagener-Barker Grade 1– Mild arteriolar attenuation (narrowing) Grade 2 o Focal arteriorlar attenuation o venous compression at arterio-venous crossings (Nipping) Grade 3 (>110mmHg DBP) o Haemorrhages o Cotton Wool Spots o Exudates Grade 4 (>200mmHg/>130mmHg. Malignant Hypertension) o All of above plus Disc Oedema and Macular Star formation (accumulation of exudate in NFL)  § Headaches, Diplopia, Decreased Vision, Scotomas, Photopsia Arteriosclerotic Changes Grade 1 o Broadening of Arteriolar light reflex Grade 2 o Deflection of the veins when crossing the arteries (Salus’ sign) Grade 3 o Copper Wiring of the retinal arterioles o Banking of veins distal to the crossings (Bonnet’s sign) o Tapering of veins on either sides of crossings (Gunn’s sign) o Right angled deflection of veins Grade 4 o Silver wiring of retinal arterioles Pathogenesis of Hypertensive Retinopathy 1. Vasoconstriction of Retinal Arterioles (Grade 1) 2. Acceleration of atherosclerotic changes in retinal vessels (Grade 2) 3. Retinal Vessel alterations impede blood flow, through retinal arterioles and capillaries – retinal perfusion is reduced as a result 4. Ischaemia and hypoxia lead to damage of the blood vessel walls Blood Retinal barrier is disrupted There’s increased vascular permeability 5. Blood and plasma leak out of blood vessels and into the surrounding retina (G3 and 4) Hypertensive Retinopathy vs Diabetic Retinopathy Diabetic Retinopathy Hypertensive Retinopathy  Dot & blot Haemorrhages Flame Haemorrhages Extensive oedema & exudates Rarely oedema & exudates IRMA Arteriovenous crossing changes Fewer CWS Multiple CWS Venous beading & Looping Visibly abnormal retinal arteries Reversible Irreversible Management for Hypertensive Retinopathy Grade 1/2 - Non-urgent referral – inform GP Grade 3 – Urgent Referral Grade 4–Emergency Referral Central Retinal Vein Occlusion (CRVO/BRVO) Ocular Blood Supply 1. Common Carotid Artery 2. Internal Carotid Artery 3. Ophthalmic Artery 4. A. Central Retinal Artery Inner Retinal Layers (NFL – INL) B. Posterior Cillary Arteries Outer Retinal Layers (OPL – RPE Via choriocapillaris) Optic Nerve Signs of Retinal Vessel Leakage Haemorrhages: Dot/blot, Flame, Microaneurysms Oedema Hard Exudates Signs of Retinal Vessel Occlusion Occlusion causes ischaemia, leading to: CWS Neovascularisation CRVO Occlusion of the central retinal vein at the level of the lamina cribosa due to thrombosis. Risk Factors Hypertension Hyperlipidaemia Diabetes Hyper-viscosity of blood Smoking Contraceptives Raised IOP (>30mmHg) Pathogenesis 1. Occlusion of CRV 2. Hypoxia 3. Leakage 4. Capillary Occlusion 5. Retinal ischaemia Appearance  Tortuous dilated veins in all 4 quadrants of the retina Round/Blot and flame haemorrhages CWS Possible macula and disc oedema Non-Ischaemic CRVO Where the outer retinal layers are still perfused as choroidal circulation remains intact 30% will progress onto ischaemic Sx Sudden onset, unilateral blurred vision (6/36-6/60). Main concern: conversion to ischaemic Signs Tortuous dilated veins in all 4 quadrants of the retina Round/Blot and flame haemorrhages Occasional CWS Mild Possible macula and disc oedema Mild/absent RAPD Ischaemic CRVO Complete retinal ischaemia Sx Sudden onset, unilateral, severe vision loss (6/60 - HM). Main concern: development of neovascularisation. Signs Tortuous dilated veins in all 4 quadrants of the retina Extensive Round/Blot and flame haemorrhages Multiple CWS Macula Oedema and disc oedema Marked RAPD Complications Macular Oedema NVD (New vessels disc) & NVE (New vessels elsewhere) could possibly cause vitreous haemorrhage Rubeosis Iridis Neovascular glaucoma (Very High IOP) Both signs will resolve over the course of 12 months. Residual Signs of both: Disc collaterals Epiretinal Gliosis Pigmentary changes at the macula Referrals If IOP is normal and signs/sx suggest non-ischaemic: Routine to Ophthalmology and GP OR urgent if macula involved If IOP is elevated and signs and sx suggest ischaemia: urgent to GP and Ophthalmology Investigation – Investigate underlying cause and blood work up. Assess whether ischaemic or non-ischaemic. Treatment – Laser PRP for neovascularisation, Intravitreal Anti-VEGF and steroids for neovascularisation and macula oedema Central / Branch Retinal Artery Occlusion (CRAO / BRAO) Obstruction of artery due to atherosclerosis, a thrombus or embolus (Carotid Embolism) (usually BRVO If embolus) blocking the artery or inflammation of the artery. CRAO BRAO History & Symptoms Aged 70-80yrs Carotid artery occlusive disease systemic hypertension high cholesterol smoking diabetes history of stroke or TIA Amaurosis Fugax attack (sudden blanking of vision lasting a few seconds) Symptoms – Sudden, painless loss of vision, sometimes preceded by Amaurosis Fugax attacks Signs CRAO VA – No LP (although LP and HM may be preserved in some parts of vision) Marked RAPD Central vision may be preserved if the patient has a cilioretinal artery supplying the macula (6D do not emmetropise Under 2-3 years old: monitor Rx overtime Over 2-3 years old: prescribe significant Rx Prescribe: o Myopia of -0.75D or greater o Astigmatism of 2.50D or greater o Hyperopia of +3.00 as its likely to be amblyogenic Amblyopia: a lack of visual stimuli to one or both eyes during the critical period resulting in structural and functional damage in the LGN and V1 in the form of atrophy of connections, lack of cross-linking between connections, a loss of laterality of connections. This leaves the child with permanently reduced VA. VA Charts For a Child Kay Pictures: o Tested at 3m. o Tests VAs at 6/4.8 – 6/36. o Rows of 5 pictures for the child to identify. o Can say out loud what they see or point to the same shape on the near card. o Flipperbook Sheridan Gardner: o Tested at 6m o 7 different letters are shown o VAs range from 6/4.8 – 6/60 o Flipperbook Not the best as it is uncrowded. Crowding is important in detecting amblyopia, as amblyopic px’s perform worse on crowded than uncrowded acuity tests. Lea Symbols o Tested at 3m. o 3 symbols used: house, apple and square o VAs range from 6/4.8 to 6/24 o Can say outloud what they see or point to the same shape on the near card o Flipperbook  7.1.4 Understands the techniques of the assessment of infants. 7.1.4 HES Describes the use of vision testing Child patient Achieved Understand certific equipment for an infant under two, under two □ s the ate/ for example, preferential looking, years (23/12 or Not techniques WT optokinetic nystagmus. less) seen in Achieved of the practice or HES. □ assessment Can be an Not of infants. observed Assessed episode. □ Visual Acuity and Development Resolution (minimum resolvable) – smallest angular separation between adjacent targets that can be resolved(spatial frequency grating). Limited by optical limitation of the eye and retinal photoreceptors spacing. Preferential Looking and VEPs: can estimate acuity in infants. Recognition (minimum recognisable) – type of acuity measured with Snellen chart. Ability to identify a form (letter/picture matching/recognition) or its orientation. Used from 2.5yrs. More sensitive to pathological and physiological degradation. Optokinetic Nystagmus (OKN) – Combination of a saccade and smooth pursuit eye movement which develops around 6 months. Crude assessment to show that the visual system is intact. Using an optokinetic drum, spin it in front of the Px and watch their eye movements. Preferential Looking (Keeler/Teller cards) way of estimating VA in infants and non-verbal Px. Child is shown two circles. Principle is that the child will look towards the patterned circle instead of the blank stimulus. Pattern is a square wave grating (alternate black and white lines of equal thickness). Present the grating and record the looking response highest SF that gives correct looking response used to estimate VA. Cardiff Acuity Cards An image with a white band bordered by two black bands on neutral grey background is shown. Preferential looking’s only method of assessing VA. Picture Naming and Matching Kay’s pictures, LH symbols, Landolt C, Tumbling E Kay Picture Test For young children who are unfamiliar with letters (age 2 – 3), Consists of shapes which are considered easily recognisable to age group, 6m testing distance (no mirror) Versions: Snellen notation Crowded Uncrowded LH symbols Four diff