In Contact - September 2010

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As You Do

As so often happens, the first patient I saw on return from Snowvision was the sort of case we discussed in our CPD sessions in Queenstown. Considering the après ski revelry I was impressed that I absorbed it and didn't fall asleep.

I'd had an early morning cancellation on returning to work that Monday which was promptly filled with two red eye patients.

The first, new to our practice, was a thirty-five year old female legal executive, who'd developed a red eye five days prior. A pharmacist had provided Brolene eye drops for 'conjunctivitis' with no improvement. Over the weekend her eye had become painful and photophobic. The eye was watery with no mucous discharge. She had severe redness and conjunctival chemosis. The cornea was clear with no conjunctival staining. The pupil on the affected eye was constricted and there were trace cells in the anterior chamber with trace pigment on the lens. I diagnosed suspected iritis and referred her to an ophthalmologist. Two days later a report arrived confirming possible iritis with Rx Maxitrol. Based on opinions espoused by some lecturers, Maxitrol was arguably not the 'best' drop for such a case. With the conjunctiva looking as it did it was probably prescribed as a 'cover', albeit not the 'ideal' antibiotic. Some would say that maybe Maxidex or Pred Forte combined with a more targeted separate antibiotic eye drop would have been ideal. A swab and culture could help target the bugs if any were present, although potentially delay treatment.

The next 'red eye' was a thirteen year old schoolgirl who'd been fitted by a colleague with overnight Ortho-K a year ago. Her concerned parents had brought her in two weeks prior with a mild red eye, that seemed more related to meibomian gland dysfunction. I'd noted mild blepharitic 'scaling' of her distichiatic lashes and advised SteriLid for lid hygiene coupled with lid- massage. They requested the second visit as there was now mild discharge in the morning. They'd attended Greenlane Clinical Centre on the Sunday prior. The registrar suggested it might be a 'mild virus' and suggested no CLs for two weeks, although she'd already been off CLs for almost that time.

Discussion revealed she also had mild itching and had been sneezing of late.

She could be one of the rare people with SteriLid sensitivity so we suggested stopping that for a few days with a diagnostic trial of Livostin as the tarsal conjunctiva also showed some mild changes.

A review by my colleague two days later confirmed that things had settled and the Livostin had worked well. The only sign now was of a resolving tarsal conjunctiva and she will resume her OK lens wear. They took the opportunity to obtain an up to date backup pair of spectacles as they were off to Europe for a family holiday and wanted peace of mind while away.

Self Selection

So that was my welcome back to work after the conference. The rest of that day and week was chokka with the usual mix of cones, presbyopes and challenging cases. A long term presbyopic PRK patient wanted monovision as she'd developed some myopic 'progression'. It worked a treat.

Another patient had self prescribed a +2.75 1 Day Acuvue Moist (that her friend had provided in the UK) but wanted professional fitting and management. I upgraded her into TruEye and she was immediately a great success. By pure chance her friend's Rx was spot on!

Practising in the Auckland CBD for well over the past decade I have watched with interest the shift in demographics and change in our typical, traditional patient. There has been a significant shift in our practice and in those shopping and walking around the city. We now, on an almost daily basis, have patients coming in from the Middle East and a variety of Asian countries almost demanding we sell them coloured lenses or the risk-laden 'big eye' circle lenses that Lady Gaga made famous. There are also all manner of requests for instant supply of Rx lenses from a variety of travellers from all over the world. They stay in the local backpackers and often just ask for 'minus four' or 'four hundred degrees' but have no idea of the brand or base curve. They don't have prescriptions and if we do sight a foil pack it is often a rebranded lens making things even more difficult. They also want the lenses now as their bus is leaving for Rotorua later that day. Their cavalier attitude toward eye health and lens wear is both frightening and astounding. Their lack of preparedness also leaves us scratching our heads. They decline an eye exam and tell us they want lenses over the counter 'just like they get in their home country'.

Sorry but we just don't do it that way!

We do our best to help them out and would rather they have clean fresh lenses than wear a three month old, two-week disposable that they spit on to clean.

We are sitting on a time bomb of MK and other complications when one considers the increasing numbers of self prescribed lenses and modalities. Non-compliance rates as high as 80% and more are reported.

I have even seen a few people that had purchased extended wear silicone hydrogels online, having never been fitted with them, or been prescribed such lenses or modality. They simply buy them off the Net and start sleeping in them.

I hope that one day when the wheels fall off or their eyes fall out that they sue the hell out of the online suppliers who supply them without verifying the Rx. The manufacturers should not supply websites that provide lenses without Rx verification. The cynical among us would say they don't care so long as they sell lenses, however the truth is that practitioners are going to prescribe less lenses if they see too many problems, so overall prescribing rates will drop. The low penetration of lenses is already a concern so maybe the manufacturers will wake up to these issues sometime?

In some cases it seems that patients have even been recommended such things by online suppliers. There appears to be some patient initiated switching of lens brands, with 'generic recommendations' of lenses and lens care solutions also suggested by the supplying websites.

If things do go wrong then this excellent freely downloadable Corneal Atlas from Review of Optometry is a must have. Excellent images with diagnostic and therapeutic management tips from renowned experts.

Nice.

Straight Facts?

I also note one of the retail optical chains is offering a 'free 30 day supply of daily disposable silicon (sic) hydrogels' with a spectacle package.

Is it a silly con or do they just not know the difference between silicon and silicone? Even Wikipedia clearly states that silicon should not be confused with the synthetic polymer silicone.

I hope they know the difference between the cornea and retina.

Don't they check terminology and proof read the advertising?

One doesn't know if these lenses are even fitted or trialed and whether their suitability is investigated prior to handing out the free supply of lenses, to 'the same prescription' as their glasses. One wonders if they even bother to vertex correct the Rx which in a -9.00D myope could make quite a difference. (At a vertex distance of 13mm this would equate to -8.00D at the corneal plane). A forty year old would not be too happy being over-corrected by a dioptre! I have also been told that the deal is dependent on signing up for ongoing supplies but people who've tried to obtain specific details have been left waiting for answers.

I wonder in how many cases less than optimal results will occur and in fact I wouldn't be surprised if we see a few serious complications. We've already had some clients requesting less expensive lenses than the rebranded version they offer. The original lens is no longer independently available in our market as a result of a deal that alienated many ANZ practitioners.

It seems that their monopoly on these lenses is not exactly leading to the 'best price' either.

Funny that.

Some consumers are fortunately getting savvy and waking up to the fact that the big marketing machine is just that.

I cannot believe that the registered practitioners in such operations allow the marketeers to run roughshod over their professional ethics in such a way. Don't the ECPs have the balls to stand up and tell them it's not the way to do things? They should because at the end of the day it's the optometrists' butt on the line when things go wrong. They are the ones likely to be hammered and have their board registration cancelled and their livelihood terminated. If one reads the latest proposals by the Board to alter CPD and include things like ethical competence and so on then it is clear that practitioners need to stand their ground on such things. Not that it ever was any different as far as ethics are concerned. (See article on intended CPD changes elsewhere in this edition of NZ Optics and remember to submit your views on time!)

Optometry sure has been dumbed down and commercialised.

It's just not the same is it?

More is the pity.

Conversely

At the same time I have also been surprised by the number of new patients I am seeing while retaining the bulk of my long term patients. We are also happy to have those that strayed return to us as they realise that you get what you pay for. This satisfactory patient load is especially positive when one considers we are probably lingering around at the bottom of a recession, as opposed to those who thought we were out of it and in recovery phase. One only needs to look at the numbers of liquidations and mortgagee sales, with shops closing all over the place, empty stores and sales of 30-70% almost everywhere you go.

Who would have guessed, a few years ago, that our largest optical wholesaler would be in receivership?

NZ Rulez

I noted with interest that NZ is now the largest per capita prescriber of si-hy lenses for daily wear and we beat Aussie, the home of si-hy lenses, by a good 10%. Check out some interesting results in the latest 2010 prescribing trends from Morgan et al. Here's a link to a good summary.

If we could become the top single use prescribers on the planet I'd be way impressed.

NZ Rulez, Reprise

The ABs deservedly took the Tri Nations in front of a record 95,000 people at the Calabash in SOWETO.

I'll leave it to Buck Shelford to sum it up.

I couldn't have said it better.

Epic