I’ve been an optometrist for over 12 years, and because my first job was in a group of practices with 10 branches along with the fact that I’ve spent the last year as a locum, I have worked in around 40 practices. And while on the whole, I think that as a profession we do a pretty good job of looking after the eyes of Australians, I think that there are some things that are getting overlooked.

Time and time again I see the same issues crop up. While I could almost write a book about it, I’ve decided to focus on the top 5.

Am I saying I’m perfect and always get it right? No. Of course not. I don’t perceive myself to be that deluded!!

I’m sure I miss things and stuff up too….. some of it I’m probably even blissfully unaware of…… but the following are things that we just can’t afford to overlook.

1.   Eyelash patients

It’s so easy to become familiar with the people who come in every few weeks for eyelash epilation. But please, stop and look at their record to see the last time the basics were done on these patients. I have found these patients to have some pretty nasty things lurking such as glaucoma and even a basal cell carcinoma on the very lid from which the lashes were being epilated (and I’m talking a classic nodular BCC complete with pearly edges and a central vascularized ulcer). Just last week I saw what I thought was possibly an OSSN in an “eyelash regular” and have sent that patient for an opinion on whether a biopsy looking for dysplastic changes is warranted.

Because these patients are often squeezed into a full book of patients, we don’t usually spend a lot of time with them. It’s not unusual for me to come across patients who have gone 3-5 years with only their lashes being epilated with no other testing being done.

There are a couple of approaches we can take here – let them know that it’s been a while since we undertook a full examination and book them in for that at their next visit, or do bits and pieces over successive visits. You might do IOPs at one visit, fundus microscopy at the next, and a refraction at the one after that.

Often time these people are so trusting of you that they are waiting for YOU to tell them that they are due for a full test because they think you will let them know what they need done. If you look at their glasses, they are often trashed because they’re really old and the patient is waiting for you to tell them that they need new ones.

Beware complacency with patients who are familiar to you.

2.   Retinoscopy

In my opinion we are negligent if we don’t perform retinoscopy on every patient under the age of 15. Personally, I perform it on every single patient I refract, regardless of their age. I almost had a meltdown about 2 weeks ago when my ret battery was going flat.

I cannot tell you the number of times I’ve had people who are +1.00 to +1.50 with an accommodative and convergence excess profile come in and been prescribed a pair of -0.50s for distance and wonder why they are getting eyestrain and pain around the eyes. While I understand that there are some cases where pseudomyopes do need some minus at distance, would it kill us to be aware that they’re actually hyperopic and consider whether we need to prescribe some form of multifocal? And please note that I will be ranting about phorias and binocular vision in point 3……

Now before you say that you don’t have time for retinoscopy, I will tell you that retinoscopy is the number one time saving weapon that I have in my arsenal. There are so many reasons why this is the case.

If we have someone who is presenting with presbyopic symptoms and you know how much plus there is in the distance (which they may or may not accept subjectively), keep in mind that we will most likely need to add that extra plus at near. So we might get a 41 year old who needs +1.50 at near, which when you first think about it sounds too strong, but if they are +0.75 at distance, is actually likely to be about right. This is a huge timesaver in doing a near add, and helps to reduce remakes too.

If we do have a young child who is say +1.00 or +2.00, we will figure this out a lot more quickly on retinoscopy than by doing a binocular blur back from +4.00 or +5.00. I’m not saying to forget our blur back, as this will give us an idea of how much plus they will accept at distance after we have figured out how much plus is actually there on ret. Time and time again I see patients from about age 8-12 present with headaches when reading who have previously been told all sorts of crazy things like they are shortsighted in one eye (I actually had that very scenario about 2 weeks ago and had to explain that sometimes the eyes were pretending to be myopic and explain the whole accommodation thing). Please consider that any patient’s life may be limited by their avoidance of reading, and we are doing them a disservice if we don’t rule out longsightedness as a possible cause of their lack of interest in near tasks.

If we see scissoring we know from the outset that it’s likely that they have keratoconus or another form of irregular corneal astigmatism such as that induced by a pterygium. It saves us from getting flustered during refraction as we know it’s going to be tricky from the outset and can be mentally prepared. And trust me, with one of my recent gigs being in a practice specializing in RGP / miniscleral lenses, I have seen that these patients often go from optometrist to optometrist with nobody figuring out why they can’t get the patient to 6/6. Finally when they’re at about 6/18 and struggling and it’s obvious as to what the diagnosis is these patients get referred to a contact lens specialist.

If we see the shadowy reflex coming back at me in someone who had cataract surgery months or years previously and comes in mentioning blur in that eye, then we can be pretty sure that we’re looking for posterior capsular opacification. In a similar fashion to the cataract itself, there will often be a myopic shift and some astigmatism in cases of PCO. We then get out the slit lamp, confirm that this is the case, and depending on the level of PCO, tell them about PCO and the fact that they may need to go back to their ophthalmologist for a minor laser procedure, and go and refract them to see what level of vision they can get. I let them know that at the end of the refraction, the decision we will need to make is whether or not they are happy with that level of vision (and obviously take into account the standards they need to meet if they drive). If that acuity isn’t what they’re after then it’s off to the ophthal…… I find this approach to be far more time effective than going into a refraction blind and fluffing around wondering why the acuity isn’t great, only to get your slit lamp out at the end and figure it out.

Beware the patient you haven’t performed retinoscopy on.

3.   Binocular vision testing 

When I was going through uni I had a supervising behavioural optometrist tell me that I should perform binocular vision testing on EVERY paediatric patient, whether after case history I thought that it was indicated or not. At the time I thought that it was a bit excessive, and I wondered how on earth I would ever fit it in as part of an initial consultation in 30 minutes.

Twelve and a half years later, after having performed binocular vision testing on every paediatric patient, I can say that I’m ALWAYS glad that I did. Here are some reasons why:

• I find that kids under 8-10 aren’t often aware that they are reading too close and that if they get used to over-accommodating, then they are headed down a path of headaches and usually intermittently blurred vision – these are the kids who might have a positive relative accommodation of -5.00D and often read at 15-20cm; why wouldn’t you want to let them and their parents know that in the long term it’s probably not going to be ideal to read so close, even if they have the ability to do it comfortably for now?
• I have had many, many kids over the years who either conk out or get aches around the eyes at a positive relative accommodation of around -1.00D to -1.50D, who had come in for a “routine check-up” reporting “normal vision and no problems” – and although their parents are usually initially horrified when I then ask the child if they get that “fuzziness” or “ache” in their everyday life and they say “yes, every day” – this is your opportunity to have further discussions and sort out what’s really happening…. and calm the parent down of course!! My usual line is “kids think that how they see is how everyone sees – so don’t feel guilty for a single second that they have told you everything is fine when you’ve asked.” Please note that while a lot of parents feel guilty, some will blame their child for not telling them they have been having problems with their vision, so be prepared to diffuse either situation!
• If they are genuinely normal and everything is going okay, you can feel confident in letting them know that this is the case

So can we please all agree to do some form of binocular vision including near testing on anyone under the age of 15, whether you think they need it or not?

And don’t get me started with the people in their 20s and 30s who spend long hours at the computer and have phoria and accommodative issues that aren’t being addressed because nobody bothers to do near testing on them…… we can’t think that indiscriminately giving anyone having issues at the computer a pair of +0.50s is going to sort them all out……

And while we’re at it, can we not assume that younger people who are myopic are okay at near in their minus powered specs or contact lenses. Have we thought about doing binocular vision testing over the top of those?!?!

Can we also take the time to discuss the ramifications of a strabismus with the child and parent in a way that they can understand? I had a 6 year old boy in recently with an esotropia in the range of 30 prism dioptres whose mum, on questioning with “does he bump into things and have lots of bruises on his knees?” almost started crying when she told me that he was always falling over and hurting himself, and it was to the point that he was so used to it that he didn’t complain any more even if she could see that he was really hurt. This sort of stuff breaks my heart. It’s obvious to us that if we sort out his eyes, we can help him out. But it’s not obvious to our patients!

And did I mention the other cases where children who have been passed off as clumsy (and supposedly “asymptomatic” during case history because nobody associates the eyes with clumsiness) might ret at +3.00 in one eye and +0.50 in the other, and instead of suppressing one eye unaided actually see 4 dots on the Worth 4 dot test with their prescription? Maybe I should go back and add that to the retinoscopy section….

Beware the child who has been passed off as clumsy or not interested in reading. Beware the child who is 6/6 at distance and supposedly asymptomatic.

4.   Dry eyes and allergy eyes

Statistically speaking, if we aren’t managing or at least having a conversation about dry eye symptoms with 57.5% of our patients aged 50 or over, then we aren’t doing enough for our patients. The Blue Mountains Eye Study found that 57.5% of patients in the 50+ age group experience at least 1 symptom of dry eye, with 16.6% reporting moderate to severe symptoms.

During the consultation there may be clues that someone has dry eyes. Apart from the obvious mention of eyes that feel dry, gritty or weepy, before you even get to the point of putting in a Schirmer strip or some fluorescein, does anyone else find that it’s the people whose eyes burn or water during subjective refraction who are often suffering the most with dry eye symptoms when they are out in the real world? And if their vision is better after a blink during refraction, there’s another clue too.

So if you’re like me and usually do refraction before slit lamp, be on the lookout for those dry eye symptoms as you go through this procedure because sometimes people forget that they experience symptoms even if they are asked point-blank during case history.

Now please also note that back when I was a student I was taught to pop in a lubricant if the patient is struggling with dry eye symptoms during refraction. Are you kidding me? That is the time to get out your slit lamp and fluorescein, check the Meibomian glands, think about if there’s anything else you need to check for and figure out what’s happening there. Then if you think you can get an accurate refraction on that day, proceed. If not, send them away with the appropriate dry eye treatment for 1-2 weeks and refract them again after that. I do the latter once every couple of months, and generally reserve this approach for people whose eyes are bone dry and as a result the refraction is just too variable.

The vast majority of people who suffer from allergies are fully aware that this is the case. However, have we thought to ask them things like:

• Do their allergies usually impact the nose, throat or sinuses, or are the eyes also involved?
• Have they discussed their allergies with their GP or pharmacist?
• Do they know what they are allergic to, and if so, how can their exposure be minimised?
• How often does the scenario arise where their eyes are itchy, and get redder and itchier when they rub them?
• Do they get white balls or strands in their eyes?
• If they take oral antihistamines, does this settle down the eyes as well?
• Are they aware that cold compresses can help?
• Are they aware that there is such a thing as antihistamine eye drops?
• Do they get symptoms of dry eye in the weeks or months in between the acute itchy allergy eye flare ups?
  On a recent 2 week locum trip, I was shocked to find the number of regular patients in the practice who had never had their allergy and dry eye symptoms addressed. I’m sure the local pharmacist must have thought I was getting a commission from every bottle of Zaditen sold!!

Beware the patient whose eyes burn, sting or water, or who blinks excessively during refraction.

5.   Peripheral retinal testing

If we are in a busy practice and aren’t finding a case of something in the peripheral retina AT LEAST once a week to once a fortnight, then in my opinion we cannot be doing our job properly. If we look beyond the optic nerve and macula, we should be routinely finding lattice degeneration, patches of chorio-retinal atrophy, naevi, benign peripheral degenerations in older folk, and perhaps a couple of times in your career a choroidal melanoma.

I recently locumed in a practice where one of the previous optometrists had often put “miotic pupils” in the internal examination section on the patient’s record. As if that is somehow a reason to not do a proper fundus examination. Heard of tropicamide?!?!

And please note that every retinal tear I have seen where I have been in a practice with an Optos wide-angle Optomap camera has been outside the range of the Optos image….. Yep, those pesky superior tears that get cut off in the image….. and I’m at 4 from 4 and counting…… so if you think everything is okay because the Optos comes up clear, think again and get out your fundus lens and/or BIO and get the patient to look in the 9 directions of gaze!!

Perhaps I should share with you the case in which I identified a choroidal melanoma……
The lady in her 60s had been booked in because she had a sore right eye for about 4-5 days. She wasn’t in too much pain, but was wanting to get it checked. Before I go any further, I would ask….. in your practice, would that person be given a full timeslot, or would they be squeezed in somewhere in your fully booked day?

Okay, so let’s move on……

I was fortunate enough to have been given a full time slot to examine this patient. So I took my time and went through a full case history, during which I found out that she’d had a melanoma removed from her thigh previously. She was also one of those “old school” patients who had always gone to an ophthalmologist for her check-ups. Her last consultation with him had been 18 months prior to her visit at the practice where I worked.

The right eye had a case of conjunctivitis (I can’t exactly remember – I think it was bacterial), and it wasn’t too bad, so I did a refraction and she came up nicely to 6/6. Fundus microscopy through and undilated pupil revealed a choroidal melanoma of approximately ¾ of a disc diameter in diameter temporally in the left eye. It wasn’t that peripheral. I would call it mid peripheral, but it definitely wasn’t visible with the patient in primary gaze.

To me this begs the questions:

• In how many practices would this patient have been squeezed in and only had her anterior segment examined due to “time restrictions”
• How many optometrists would not have considered doing a fundus check because it hadn’t been that long since she’d seen the ophthalmologist?
• If you did do a fundus check, would you have looked beyond the optic nerve and macula?

In my opinion there has to be a VERY GOOD REASON not to do a fundus check in every patient. Even at a 10916 or a 10918. Obviously here I have chosen to highlight the one case where there would have been severe ramifications for the patient (and maybe myself) if I’d missed this melanoma.

As well as having picked up cases of branch retinal vein occlusions, retinal tears and glaucoma at consultations that would have otherwise been a 10918 or similar, I could tell you about literally thousands of patients over the years who have had nothing wrong with their peripheral retina when I’ve gone looking. So while I obviously think we should all be routinely checking the posterior segment including the peripheral retina, the reality is that when we do so, the vast majority of the time there will be nothing to find. In my opinion this is not time wasted in a fruitless search, but time invested in our patient’s wellbeing. We don’t know unless we look!! And as an ophthalmologist mentioned in a lecture I recently attended, “more is missed by not seeing than not knowing.”

Beware the patient who has been examined by an ophthalmologist in the last 18 months, and has been booked in for a sore eye. They may have a choroidal melanoma in the asymptomatic eye.

Please don’t think for a second that I’m ophthalmologist or optometrist bashing!! I think we all owe it to our patients to have our wits about us. Because at the end of the day, we are all human and will all make mistakes, even despite our best intentions. It just seems to me that if we are always thinking about what the worst case scenario is for our patients, and then working towards ruling that in or out, then we can practice in our profession knowing that we are giving the best care we can in any scenario.

Please feel free to write your comments below as I would love to hear what other optometrists think we’re doing well and not so well as a profession on the whole.

Amanda Griffiths – founder My Health Career.

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