Professional Documents
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4430 - Oip Volume 10 Issue 1 Pgs 1-32 47104
4430 - Oip Volume 10 Issue 1 Pgs 1-32 47104
A peer-reviewed journal
published quarterly
CET Information
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Optometry in Practice
Editor-in-chief
Stephen Parrish BSc PhD FCOptom MIET FHEA
Visiting Professor, Anglia Ruskin University, Cambridge and City University, London, College of Optometrists
Examiner and Assessor
Editorial Board
Dr Maria Dengler-Harles
Paul Carroll
Dr Russell Watkins
Prof. Jonathon Jackson
BSc FCOptom
Dr Clare ODonnell
Editorial
Professor ST Parrish BSc PhD FCOptom MIET FHEA
Visiting Professor, Anglia Ruskin University, Cambridge and City University, London, College of Optometrists
Examiner and Assessor
Welcome to the first issue of Optometry in Practice for 2009, the last year in the current CET cycle; this issue provides
opportunity for a further 6 CET points.
In the wake of meticillin-resistant Staphylococcus aureus (MRSA) and other infectious diseases, there is an increasing
awareness of the need for infection control within the healthcare arena. This concern goes beyond the confines of
hospitals and health institutions and extends into all areas where patient safety is an issue. Clearly, optometry is not
excluded from these considerations and whilst many may have thought that our lack of involvement with invasive
procedures might exempt us from such matters, it will be clear from the article on infection control by Blakeney that this
is certainly not the case. Infection control now forms part of our contract to provide NHS services and the profession will
need to embrace this topic in the modern world.
Whilst infection control may be a new concept for many of us, the patient presenting with headaches will be all too
familiar. In his review of migraine, Larner discusses the various presentations of both migraine and other headaches,
together with their associated pathophysiology and causes. I am sure that this will be of interest and value to all of us
who are presented with such patients; for many of us this will be on almost a daily basis.
Although recent changes in infection control have been influenced largely by the spread of MRSA and Clostridium difficile,
changes in healthcare regulations have undoubtedly been influenced by cases such as the Shipman inquiry and others.
In the first part of his series on legal cases, Kapoor sets out recent legislative changes and illustrates difficult situations
that can occur in practice. This should serve to remind us all of the need to be aware of current guidance and to
implement it wisely when required.
I hope you will find the articles both enjoyable and helpful in practice as well as an opportunity for obtaining CET points.
ii
2009 The College of Optometrists
Introduction
Risk Management
A risk management strategy relating to infection control
would include firstly identifying the hazards posed to both
practitioner and patient from optometric (and dispensing)
activities. The risk to the patient would include acquiring
infection from the practitioner and from other patients via
the practitioner or equipment/drugs/solutions used. The
risk to the practitioner would include acquiring infection
from the patient (and possibly other members of staff!).
The degree of risk of each activity (eg dispensing, the
routine eye examination it may be helpful to break this
into parts, eg contact versus non-contact tonometry and
contact lens fitting/aftercare) should be quantified. For
further information on how to quantify risks, see the
College of Optometrists module on risk management
(College of Optometrists 2004).
Address for correspondence: Dr S Blakeney, The College of Optometrists, 42 Craven Street, London WC2N 5NG, UK.
1
2009 The College of Optometrists
S Blakeney
Types of Microbes
Microbes are found almost everywhere and are able to
survive in almost every conceivable environment.
Bacteria
Fungi
Protozoa
Protozoa are organisms, many of which have complex life
cycles. They can move in at least one of their life cycle
stages and some form thick-walled, dormant cysts. One
example that can affect the eye is Acanthamoeba, which is
present in almost every environment, including soil, dust
and water. It can also be found in the nose and throat of
healthy people. Acanthamoeba keratitis, although rare,
can be blinding. Around 85% of cases are associated with
contact lens use. Acanthamoeba cysts can be difficult to
kill and so it is important for practitioners to check that
disinfectants such as contact lens solutions are effective
against them and that patients immerse their lenses in the
disinfectant for the amount of time required for adequate
disinfection to occur. The risk factors for Acanthamoeba
infection in contact lens wearers are: the use of tap water
during lens care; wearing lenses without goggles whilst
swimming, showering or in hot tubs; the use of ineffective
lens care solutions and failure to follow lens
care instructions (for further information see
http://www.bcla.org.uk/acanthamoeba.asp).
Viruses
Routes of Transmission
The human body is densely populated by a wide variety of
microorganisms which use it as their habitat. These are
called commensals and they live on the host without
causing any harm. Different organisms are present in
different areas of the body and in many cases both the
organism and the human benefit from the relationship.
The key benefit to the host is that the presence of the
normal flora prevents other harmful microorganisms from
colonising the habitat. According to Noble (1975) humans
disseminate more than 107 particles of skin every day,
although bathing or showering will remove many of these
mechanically. Natural walking movements have been found
to release about 104 skin flakes (squames) per minute.
Approximately
10%
of
squames
carry
viable
microorganisms. This means that 106 skin squames
(flakes) containing viable microorganisms (such as S.
aureus) are shed daily from normal skin (Noble 1975). The
larger particles of dust settle within a few minutes on to
exposed horizontal surfaces, but small particles may
remain airborne for several hours and microbes carried on
them may be inhaled into the respiratory tract or settle
into wounds (Wilson 2006 p. 40). Patient gowns, bed linen
and bedside furniture as well as other objects in the
patients immediate vicinity can therefore easily become
contaminated with patient flora. In skin disease, such as
eczema and psoriasis, the skin may be densely colonised by
S. aureus. These organisms are then dispersed on skin
scales and such persons may contaminate their
environment with these pathogens. The hair can carry S.
aureus but opinion is divided as to the role of the hair in
dispersal (Noble 1975).
S Blakeney
Hand hygiene
SP1: Hands must be decontaminated immediately
before each and every episode of direct patient contact
or care and after any activity or contact that could
potentially result in hands becoming contaminated.
SP2: Hands that are visibly soiled, or potentially grossly
contaminated with dirt or organic material, must be
washed with liquid soap and water.
SP3: Hands must be decontaminated, preferably with an
alcohol-based handrub unless hands are visibly soiled,
between caring for different patients or between
different care activities for the same patient.
SP4: Before regular hand decontamination begins, all
wrist and ideally hand jewellery should be removed.
Cuts and abrasions must be covered with waterproof
dressings. Fingernails should be kept short, clean and
free from nail polish.
SP5: An effective hand-washing technique involves three
states: preparation, washing and rinsing, and drying.
Preparation requires wetting hands under tepid running
water before applying liquid soap or an antimicrobial
preparation. The handwash solution must come into
contact with all of the surfaces of the hand. The hands
must be rubbed together vigorously for a minimum of
1015 seconds, paying particular attention to the tips
of the fingers, the thumbs and the areas between the
fingers. Hands should be rinsed thoroughly before
drying with good-quality paper towels.
S Blakeney
Airborne particles
Disinfection
Disinfection reduces the number of microorganisms to a
level at which they are not harmful, although spores are
not usually destroyed. Methods of disinfection include the
use of heat or chemicals and is appropriate for items that
have contact with mucous membranes or which may be
contaminated by microorganisms that are easily
transmitted to others, although sterilisation is preferable
(Wilson 2006 p. 262).
In addition:
People should avoid touching their mouth, eyes and/or
nose unless hand hygiene has been performed.
Sterilisation
Sterilisation is the removal or destruction of all
microorganisms, including spores. This method of
decontamination should be used if the skin is penetrated
or sterile body areas are entered or there is contact with
broken mucous membranes. This is unlikely to occur in
routine community optometric practice.
S Blakeney
Summary
All optometrists and practice staff have a responsibility to
themselves, their patients and colleagues to control
infection as much as is practicable. Such procedures need
not be onerous and need to be embedded into practice
protocols. It is recommended that optometrists contact
their local primary care organisation to see what help they
can offer with this.
Further information
Further information can be found in the College of
Optometrists Guidance on Infection Control (2009a).
Acknowledgement
College of Optometrists (2009b) Advice on the Disposal of
Waste from Optometric Practice. London: College of
Optometrists (in press)
References
Ali Y, Dolan MJ, Fendler EJ et al. (2000) Alcohols. In: Block
SS (ed.) Disinfection, Sterilization and Preservation.
Philadelphia: Lippincott Williams & Wilkins, Chapter 12
S Blakeney
6.
(a)
(b)
(c)
(d)
8.
(a)
(b)
(c)
(d)
10
11
S Blakeney
12
Introduction
The rest of this paper explores legal issues that are relevant
to everyday practice and helps the reader understand the
implications by giving fictitious examples. Please note that
the examples are not real cases and so do not create a
precedent, in the way that case law is derived.
The scenario
Mrs Wallace attended for an eye examination. She had not
visited for some time so was very nervous about the visit.
On arrival the receptionist took her details and then
escorted her to a pretest area. At this point Mrs Wallace
was not told anything about the tests which were being
undertaken.
Address for correspondence: R Kapoor, Specsavers Opticians, 476 High Road, Wembley, Middlesex HA9 7BH, UK.
13
2009 The College of Optometrists
R Kapoor
At this point the test ended. Mrs Wallace was worried that
the pretest might have damaged her eye, and left the
practice immediately. She subsequently noticed the eye
that was tested started to feel dry so she wrote a letter of
complaint.
The manager of the practice passed the letter to the
optometrist who dismissed her complaint: We do this test
on everybody over 40. Ive never known anybody having dry
eye after such a test, and so did nothing about it.
The issues
In this case several issues need to be looked at. Firstly, was
consent granted to perform the pretest? This is a commonlaw issue and, if trespass is proven, ie Mrs Wallace did not
give or imply consent, then there is a case to answer.
When such questions are asked case law needs to be
examined. Chatterton v. Gerson (1981) can be used to
test if consent was given. In this case a doctor failed to
disclose the risks associated with a procedure. The judge
ruled: In my judgement once the patient is informed in
broad terms of the nature of the procedure which is
intended, and gives her consent, that consent is real, and
the cause of the action on which to base a claim for failure
to go into risks and implications is negligence, not
trespass. So, was Mrs Wallace given in broad terms the
nature of the procedure? If so, she would then need to
prove negligence.
The issues
Each of these must be proven on balance of probabilities.
A well-known case law, Bolam v. Friern Hospital
Management Committee, is used since in this case the
judge devised a test to prove negligence.
14
The issues
The College of Optometrists in its professional conduct
ethics and guidance also mentions the patientpractitioner
relationship with minors. It refers to the Gillick v. West
Norfolk and Wisbech Area Health Authority case in making
such judgements.
In this case, the patient has made it clear she does not wish
her family to know about her eye condition. In law, since
the patient is under 16 and therefore a minor, does she
have this right? Katie has not given her optometrist
consent to discuss her case with her parents, but she is
only 14 years old.
Communication skills
Like other clinicians, all opticians have a responsibility to
explain to patients the testing process and to inform them
of the results obtained. In this case, the optometrist
assumed from the patients appearance that he had
learning difficulties and therefore a problem in
comprehension. Core competency 1.9 relates to:
The scenario
Stephen, a 29-year-old man with Downs syndrome, attends
for an eye examination. Mr Patel, the optometrist, calls
Stephen in and notices his disability. He invites Stephens
companion, John, into the consulting room with him. John
is a friend of Stephens mother and has given Stephen a lift
to the practice.
15
R Kapoor
Guidance
The College of Optometrists' guidance on examining
patients with learning difficulties recommends few
measures but relies on the optometrists judgement of
what may be required. The guidance can be summarised
as follows:
16
References
Bolam v. Friern Hospital Management Committee [1957]
1 WLR 583
Chatterton v. Gerson [1981] 1 ALL ER 257
College of Optometrists (2008) Section 26: Examining
Children and Vulnerable Adults guideline. In: College of
Optometrists Members' Handbook. London: College of
Optometrists
College of Optometrists (2008) Scheme for Registration
Trainee Handbook. Annex C. London: College of
Optometrists
College of Optometrists (2008) Code of Ethics and
Guidelines for Professional Conduct. London: College of
Optometrists
Gillick v. West Norfolk & Wisbech HA (1986) AC112
Hall v. Brooklands Auto-Racing Club (1933) 1 KB 205
Lord Nicholls of Birkenhead re H (minors) (Sexual Abuse:
Standard of Proof) (1996) AC 563, 586
17
R Kapoor
1.
(a)
(b)
(c)
(d)
2.
(d)
3.
(a)
(b)
(c)
(d)
A Gillick-competent child:
Is nearly 16 years
Asks lots of questions
Understands issues of treatment and management
Will have no legal guardian
(a)
(b)
(c)
6.
(a)
(b)
(c)
18
Migraine
Andrew Larner
BMBCh MRCP
Introduction
Jane Austen
Hildegard of Bingen
Charlotte Bront
Sigmund Freud
Caleb Hillier Parry
Clinical Features
Thomas Jefferson
Immanuel Kant
Address for correspondence: Dr AJ Larner, Walton Centre for Neurology and Neurosurgery, Lower Lane, Fazakerley, Liverpool L9 7LJ.
19
2009 The College of Optometrists
A Larner
20
Migraine
Basilar-type migraine
(International
Headache
Society
Classification
Subcommittee 2004), in part because of changing
perceptions about its pathophysiology. In such cases MRI
may show focal swelling of the oculomotor nerve (observed
pathologically in the 19th century), with enhancement in
the acute phase, suggesting that this may be a focal
demyelinating neuropathy; response to steroids would also be
consistent with this interpretation (Doran & Larner 2004).
Retinal migraine
The characteristic feature of this rare condition is
monocular visual phenomena, such as aura, altitudinal
field defect, scotomata or even blindness, followed by or
concurrent with migraine headache. Care must be
exercised in accepting a history of monocular visual
phenomena at face value, since patients may have difficulty
in distinguishing unilateral and bilateral symptoms. As
with typical aura without headache, there are important
differential diagnoses for these visual phenomena,
including ocular TIA, structural disorders of the eye such
as retinal detachment and optic neuropathy.
Ophthalmoplegic migraine
Diplopia with an external ophthalmoplegia, typically an
oculomotor (third) or abducens (sixth) nerve palsy
accompanied by migraine-type headache, has been termed
ophthalmoplegic migraine. However, the headache is
atypical since it may last a week or more. Clearly, a
structural lesion, such as a posterior communicating
artery aneurysm causing an oculomotor nerve palsy, needs
to be excluded with this presentation. Cases of
ophthalmoplegic migraine are in fact extremely rare: a
French retrospective epidemiological study identified only
9 possible cases in more than 52000 headache
presentations (Giraud et al. 2007). Moreover, this disorder
has now been reclassified as a cranial neuralgia
21
A Larner
Cluster headache
Pituitary tumour
It is well recognised that pituitary tumours may be
complicated by episodic migraine, as well as other
headache types (Levy et al. 2005), with improvement in
some cases following hypophysectomy. In the absence of
systemic features suggestive of pituitary disease,
examination for bitemporal field defects may be the most
reliable way to exclude local effects of pituitary gland
enlargement.
Treatment of Migraine
Although treatment of migraine may be deemed to lie
outwith the remit of optometry practice, nonetheless
some awareness of management is appropriate if only to
avoid misleading advice, such as the need to see a
neurologist (urgently or otherwise), have a brain scan or
even to attend hospital immediately. Referral to the
general practitioner and/or self-directed treatment will
suffice in the majority of cases once a definite diagnosis of
migraine has been made.
Arterial dissection
Spontaneous, atraumatic dissection of the carotid
(Silverman & Wityk 1998) or vertebral (Young &
Humphrey 1995) artery has been reported to mimic
22
Migraine
Mayo Clinic:
www.mayoclinic.com/health/migraine-headache/DS00120
Migraine Action Association (MAA):
www.migraine.org.uk
Migraine in Primary Care Advisors (MIPCA):
www.mipca.org
Migraine Trust:
www.migrainetrust.org
References
Aird H (1870) On a distinct form of transient hemiopsia.
Phil Trans R Soc Lond 160, 24764
Bickerstaff ER (1961) Basilar artery migraine. Lancet 1,
1517
British Association for the Study of Headache (2007)
Guidelines for all Healthcare Professionals in the Diagnosis
and Management of Migraine, Tension-type, Cluster and
Medication-overuse Headache. London: British Association
for the Study of Headache
Conclusion
Diener HC, Kper M, Kurth T (2008) Migraine-associated
risks and comorbidity. J Neurol 255, 1290301
23
A Larner
International
Headache
Society
Classification
Subcommittee (2004) The international classification of
headache disorders, second edition. Cephalalgia 24,
1160
24
Migraine
1.
(a)
(b)
(c)
(d)
2.
(a)
(b)
(c)
(d)
3.
(a)
(b)
(c)
(d)
4.
(a)
(b)
(c)
(d)
5.
(a)
(b)
(c)
(d)
25
A Larner
26
BSc(Hons) MCOptom
Background
Case Record
First visit: 08/04/2008
Patient BW, a 43-year-old architect, presented for an eye
examination and contact lens check. He had worn a soft
contact lens in his right eye only for over 10 years, on a 30day continuous-wear basis for roughly the last 6 years. He
was generally satisfied with both the vision and comfort
with his current lens, reporting only occasional episodes of
mild discomfort, and he seldom wore his spectacles. He
was in good health, taking no medication and suffering
from no allergies. He had never attended the Hospital Eye
Service for any treatment and there was no family history
of eye disease. His working day is split fairly equally
between computer work and client visits; his free time is
mostly spent with his young family.
Address for correspondence: Mr Nigel Best, 6 The Oval, Wynyard, Cleveland TS22 5SQ.
27
2009 The College of Optometrists
N Best
Slit-lamp examination
The lens showed 0.5mm movement on blinking and
recentred briskly following digital displacement. The
centration of the lens was excellent, both in the primary
position and on versional movements. The quality of the
lens surface was good with minimal deposition; no drying
of the lens surface between blinking was apparent.
Slit-lamp examination
VA and lens fit remained unchanged. The current lens was
1 week old and no significant surface deposition was
observed. BW felt that the new lens was more comfortable
than his previous one.
28
Discussion
SEALs are not commonly seen in hydrogel lens wearers;
however the increasing trend amongst practitioners to fit
silicone hydrogel lenses for both daily and continuous wear
(Efron & Morgan 2008a, 2008b) has led to increasing
reports of SEALs (Dumbleton 2002, 2003, Holden et al.
2001, OHare et al. 2001, Stapleton et al. 2006). With
continuous wear of the first-generation silicone hydrogel
lenses, one study found that up to 4.5% of patients per year
would present with the condition (Dumbleton 2003).
The aetiology of SEALs is multifactorial, although
increasing lens modulus and excessive lens mobility appear
to be the most significant contributing factors. It is
believed that the following factors may all also predispose
to its occurrence: peripheral corneal topography, uppereyelid pressure and lens surface characteristics
(Dumbleton 2002, 2003, Holden et al. 2001, OHare et al.
2001, Young & Mirejovsky 1993).
Material modulus
Lotrafilcon A (All Day All Night Air Optix)
Lotrafilcon B (Air Optix)
Comfilcon A (Biofinity)
Galyfilcon A (Acuvue Advance)
Senofilcon A (Acuvue Oasys)
Balafilcon A (Purevision) 1.1
Etafilcon A (Acuvue 2)
MPa
1.5
1.0
0.75
0.4
0.7
1.1
0.29
Data from French & Jones (2008): Etafilcon A data from manufacturer
29
N Best
References
Conclusion
30
31
Nigel Best
1.
(a)
(b)
(c)
(d)
6.
(a)
(b)
(c)
2.
(a)
(b)
(c)
(d)
3.
(a)
(b)
(c)
(d)
4.
(a)
(b)
(c)
(d)
5.
(a)
(b)
(c)
(d)
(d)
32
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1
D
1. Infection Control in
Optometric Practice
Question 1
Question 2
Question 3
Question 4
Question 5
Question 6
Question 7
Question 8
Question 9
Question 10
Question 11
Question 12
Question 13
Question 14
Question 15
b c
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
b c
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
4. The Alleviation
of SEALs
3. Migraine
Question 1
Question 2
Question 3
Question 4
Question 5
Question 6
b c
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
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0
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Question 1
Question 2
Question 3
Question 4
Question 5
Question 6
b c
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Interest [ ]
Relevance to your work [ ]
Interest [ ]
Relevance to your work [ ]
Interest [ ]
Relevance to your work [ ]
Optometry in Practice
Volume 10 Issue 1 pages 1 32
ST Parrish
ii
Editorial
Susan Blakeney
1 12
Rakesh Kapoor
13 18
Andrew Larner
19 26
Migraine
Nigel Best
The Alleviation of SEALs
27 32
ISSN 1467-9051
Optometry in Practice