The management of systemic hypertension in optometric practice

AIM: Systemic hypertension is a silent killer that may have very few warning signs. This study examines detection and management of patients with cardiovascular disease (CVD) by optometrists in the UK. METHOD: A survey was sent out to 1402 optometrists who practice in the UK to investigate the nature and knowledge of detection of systemic hypertension. RESULTS: The survey response rate was 37%. Optometrists were neutral to slightly positive towards the use of blood pressure (BP) monitors, but not on a routine basis. The most frequently asked question during history and symptoms concerned the patient's prescribed medication for systemic hypertension, and the least was that of specifying the last BP measurement. The additional test most widely used in the examination of the systemic hypertensive patient was direct ophthalmoscopy with red-free filter. Over one-tenth of optometric practices had a BP monitor, with automated devices being the most popular. Patients most likely to have their BP measured were suspect systemic hypertensives. Retinal haemorrhages are the most important finding in influencing an optometrist's referral criteria for suspected systemic hypertension. CONCLUSION: Although optometrists monitor the retina for signs of damage from systemic hypertension, further education in this important condition is warranted.     

Signs of ocular disease: A prevalence study in optometric practice

Data on the prevalence of all ocular conditions seen in 1500 consecutive optometric patients were obtained during an investigation into the effectiveness of routine visual field screening. In many instances, these are the first prevalence figures for optometric patient populations. Some of the estimates of prevalence are compared with other optometric and general population surveys. Many disorders were observed, the most frequent being slight to moderate increases in retinal arterial reflex and attenuation, optic cup/disc ratio of 0.4, shallow anterior chambers and family history of glaucoma. The occurrence of some conditions was sporadic, resulting from the relatively small sample. However, this survey may serve as an audit of ocular disease detection for other practitioners.     

Patterns of Practice in Australian Optometry Part II — Patient age influences the procedures used in optometric examination

ABSTRACT: In a questionnaire survey, 106 Australian optometrists indicated the percentage of their patients, in five age groups, on whom they performed 24 procedures. Results were analysed using Friedman two-way analyses of variance. Procedures carried out significantly more frequently on older patients were measurements of visual fields, biomicroscopy, tonometry and mydriatic examination. Procedures carried out more frequently on younger patients were examination of pupil reflexes and versions, measurement of hetero-phorias, ductions, fixation disparity, stereopsis, amplitudes of accommodation and convergence; cover test, cycloplegic examination and colour vision testing. Procedures whose use was curvilinearly related to patient age were contact lens wear, keratometry, length of history taking and consultation time. No significant differences were found in use of direct or indirect ophthalmoscopy, automated refractometry, and anterior eye or fundus photography. The appropriateness of these clinical decisions is discussed in terms of knowledge of epidemiology, visual development, prescribing of ophthalmic prosthetics and recommendations regarding minimum eye-care examination.     

Clinical characteristics of unilateral myopic anisometropia in a juvenile optometric practice population

PURPOSE: A retrospective study of longitudinal case histories, undertaken to establish the clinical and statistical characteristics of unilateral myopic anisometropia (UMA) amongst the juvenile and adolescent population at an optometric practice, is reported. UMA was defined as that specific refractive state where an unequivocally myopic eye is paired with a 'plano' [spherical equivalent refraction, (SER) = +/-0.25 Dioptres (D)] companion eye. METHODS: The clinical records of all patients aged <19 years on file at an established independent optometric practice were categorised as 'myopic' (SER < or =-0.50 D), 'hypermetropic' (> or =+0.75 D) or 'emmetropic' (> or =-0.37< or =+0.62 D). Subsequently all juvenile patients matching the UMA criterion, together with a case-matched group of bilaterally myopic individuals, were selected as the comparative study populations. RESULTS: A total of 14.4% (n = 21 of 146) of the juvenile myopic case histories were identified as cases of UMA. More than half of these UMA cases emerged between the ages of 11.5 and 13.5 years. There was a marked female gender bias. The linear gradient of the age-related mean refractive trend in the myopic eye of the UMA population was not statistically significantly different (p > 0.1) to that fitted to the ametropic progression recorded in either eye of the case-matched population of young bilateral myopes; uniquely the slope associated with the companion eye of UMA cases was statistically significantly (p < 0.025) less steep. Compared with bilateral myopes fewer cases of UMA required a refractive correction to relieve visual or asthenopic symptoms, and this initial correction was dispensed on average 1 year later (at age 12.7 years) in UMA patients. CONCLUSIONS: Individuals identified as demonstrating clinically-defined UMA can be considered as distinct but functionally normal cases on the continuum of human refractive error. However, any unilaterally-acting determining factor(s) underlying the genesis of the condition remain obscure.     

Gender differences in the utilisation of optometric services in Victoria

Medicare and population data demonstrate clear gender differences in utilisation of health services. There are three broad hypotheses that may explain different utilisation rates of health services by gender: differences in access, differences in incidence and differences in attitudes in seeking health care between the genders. Men are 28 per cent less likely than women to see an optometrist in Victoria. Both women's and men's utilisation of optometric services in Victoria increase with age but there are clear gender differences apparent at every stage of life after childhood. These utilisation rates between genders are tested against incidence rates between genders for eye conditions. There are few noted gender differences apparent in the incidence or prevalence of ocular conditions. The data on the incidence of health conditions often has limitations, either in measurement tools or in differences in incidence between genders. These limitations are not as evident in eye care incidence data. Access and incidence differences do not adequately explain the differences in optometric service utilisation rates. This promotes the hypothesis that attitudinal differences in seeking health care between men and women are significant.     

Continuing optometric education

Approximately one-third of the total number of optometrists practising in New Zealand participated in an hour-long session during which their views of continuing education were solicited using a questionnaire. These optometrists felt that continuing education was a necessary part of professional life from the time of entry into practice until (and even beyond) retirement. The majority felt that pressure should be brought to bear on optometrists to participate in continuing education but that compulsory continuing education in any form was not desirable. The most effective continuing education was said to be that gained from interactions with colleagues. The least effective method was said to be lectures which reported the results of research that could not be applied directly to clinical practice. The most commonly reported new general skills learned since graduation were management skills and ‘people’ (communication) skills. The most commonly reported new optometric skills learned since graduation were contact lens related and were learned in optometric practice and from interaction with colleagues. Significant differences were found between groups of practitioners with regard to the perceived importance of continuing education. Continuing education was held in higher regard by optometrists with more years in practice, female optometrists, optometrists working more hours per week, and practitioners located outside cities or suburbs. The optometrists participating in the survey were prepared to spend about two hours a week on continuing education during normal work hours and about two weekends or one week away from the practice each year pursuing continuing education. The implications of these findings for planners of continuing optometric education are discussed.     

The prevalence and symptoms of migraine in a consecutive series of patients attending an optometric practice.

The purpose of the investigation was to determine the prevalence of migraine in optometric practice and to document the variety of presentation. One thousand consecutively presenting patients of a suburban optometric practice were asked questions to establish whether they experience migraine or have experienced it in the past. Those with a history of migraine were asked further questions to establish the type of migraine and to document the variety of the symptoms they experienced. Eleven percent of male and 23% of female patients currently had migraine or had experienced it in the past. When corrected for the age distribution of the population of the state from which the sample was drawn, it is estimated that the general population prevalence of migraine is 9.5% for men and 19.7% for women. Half of the sample of migraineurs had not experienced a migraine within the last 12 months. A third had a known family history of migraine. Nearly half had not had a formal medical diagnosis of their migraine but only 7 had attended for optometric examination because of their migraine symptoms. Four of these patients had single migraine-like episodes and three had migraine equivalents (acephalic migraine, experiencing the visual aura without headache). Optometrists must be thoroughly familiar with migraine and its varied presentation because of its high prevalence, the explanatory value in offering a formal diagnosis of migraine, and the risk that headache or visual aura may be wrongly ascribed to migraine when there is some more sinister cause of the symptoms.     

Non-compliance in optometric practice

The purpose of this paper is to explore how some of the recent and future changes relating to the optometric profession could affect non-compliant behaviour among patients. Non-compliance has been widely documented and discussed in numerous health care fields and is understood to be the responsibility of both the practitioner and patient working in a health care partnership. At least one third of patients have been reported to be non-compliant with health care recommendations which can result in the poor outcome of a treatment, secondary medical problems, dissatisfaction, frustration and the wasting of health resources. In recent years contact lens complications have been linked with non-compliant behaviour with contact lens care and maintenance regimens which has led to several media scares over contact lens related hygiene risks and has heightened interest in the issue of non-compliance in the field of optometry. Shared care schemes have already been adopted in some areas of the United Kingdom and if therapeutic pharmaceutical agents are introduced to the list of drugs permitted for use by optometrists in the future the issue of non-compliance will become even more poignant. Every optometrist needs to be aware of the high probability of non-compliant behaviour among patients, the consequences of this non-compliance and the steps that can be taken to enhance compliance in different areas of eye-care.     

Fundus photography in optometric practice

Fundus photography, an established facet of institutional clinic and hospital ocular care, is emerging as a valuable tool for the private practitioner. Ocular photography permits improved patient care with the additional benefit of providing a means for continuing education for the practitioner. The initial investment depends on the type of fundus camera selected and the number of accessories included in the purchase. The type of camera and accessories selected by a practitioner will vary with the mode and scrope of his/her practice. Numerous types of film are available, but Kodachrome 25 (ASA 25) is recommended. The experienced fundus photographer develops a routine of camera preparation and photographic techniques that provides a consistently successful photographic session.     

Improvements in performance following optometric vision therapy in a child with dyspraxia

SS, an 8-year-old boy with dyspraxia, presented for behavioural optometry assessment. He had been diagnosed with a subtle form of dyspraxia by his paediatric occupational therapist, based on poor proprioception, delayed bilateral integration and poor visual perception. A full visual assessment was carried out. SS was given a programme of reflex inhibition exercises for 3 months. Then, a programme of optometric vision therapy (OVT) exercises was prescribed at home and in practice for a period of 8 months. SS was assessed using a battery of occupational therapy Sensory Integration and Praxis Tests (SIPT) before optometric intervention, and after OVT. There were significant improvements in fusional reserves, accommodative facility and oculomotor control of pursuit and saccadic eye movements. His reading level had changed by 4 years in 11 months. The SIPT results showed improvements in the visual and motor/visual perception subtests, confirming the significant changes in visual perceptual performance. Consideration is given to treatment modalities for dyspraxia, and the studies confirming their effectivity of approach. This case study provides evidence supporting the use of OVT eye exercises in dyspraxia, ocular motility, accommodative dysfunction, learning difficulties and sports performance. The need for further research and inter-professional working is discussed.     

The Pulfrich effect in optometric practice

The Pulfrich effect can occur spontaneously, giving severe symptoms of changed visual perception in a variety of conditions in which an interocular latency difference has occurred. The symptoms principally involve misjudgements on the location of objects, especially when driving. Interocular latency differences can inadvertently be created in patients in practice and this study has investigated the Pulfrich effect in anisocoria, uniocular mydriasis, and with uniocular tint (X-chrom lens). In all cases a Pulfrich effect was consistently evident and compared to the size of the effect provoked by neutral density filters. The results show that with anisocoria, uniocular mydriasis and the X-chrom lens, the provoked Pulfrich effect is similar to that found reported previously in cases of trauma. These cases had severe visual symptoms so that care should be exercised in practice, where procedures likely to provoke the Pulfrich effect are contemplated. Specifically, patients who have received uniocular mydriasis in practice should be cautioned about the possible visual effects and advised not to drive until the effect of the mydriatic has finished and equal pupil sizes have been restored.     

Computerizing management in an optometric practice

Successful computer automated management of an optometric practice requires software products which are suitably engineered and designed to accomplish all required tasks cost and time effectively without intimidating the user. The design of the software's "human interface" which determines the ease of use and acceptance is discussed. The prioritization of management problem areas and the software requirements for their solution are evaluated.