In Contact - April 2005
Dust in Yer Eye, Mate
Now that the fact the cornea really needs adequate levels of oxygen is becoming widely accepted - and that HEMA is being relegated to the great big optical scrap yard in the sky - we can move on to other issues.
As many of you may recall, I have generally bucked the trend for big, ?flat? fitting lenses. Generally I like to fit just a little ?steeper than K?. How much steeper of course depends on a number of factors, including overall and optic zone diameter, HVID, PAH, lid anatomy, the amount of astigmatism and of course corneal topography.
For typical corneas, my initial trial lens and often the final, Rx?ed lens, will be around 0.05 to 0.08mm steeper than flattest K. This usually provides a mild NaFl ?pool? of fluorescence within the optic zone. A target range of 10 to 30m of ?tear thickness? is my goal. There are good reasons for this, some of which will become clear in the following case report.
This style of fitting has proven itself for over fifty years, since the pioneering days of hard lenses. On a daily basis I see patients fitted in this manner, by a number of my skilled predecessors. By far the majority of these wearers are still going strong with successful wear of twenty, thirty and forty years, or more, duration. Not only are they successful wearers but their Rx and K readings are often within 0.25D of prefit measurements. Confirming yet again that lenses thus fitted have very little effect on corneal topography. Where it does, corneas usually ?bounce back? to prefit levels within a few days or weeks.
Provided of course they have been refitted in RGPs along the way, ideally in the 30 to 100 Dk unit range.
Oops, sorry, there I go harping on about oxygen, again?
Unfortunately some of these patients have, over the years, had no change to the lens Rx they were supplied a decade ago. This can occur for various reasons.
In some cases, particularly progressive cones, this means that a lens base curve of a decade ago, is often fitting way too flat. Many of these patients eventually return and in these cases we often have to refit lenses that are 0.3mm to as much as a full millimetre steeper than the ten year old design they are wearing.
One particular case, recently seen provides a classic example. This pleasant gentleman, with form fruste keratoconus [FFKC], first consulted me in 2003. He had last been seen in 1993 as he had broken a lens. It was replaced at that point. His main reason for coming in, after a ten year absence, was that he was noting a reduction in distance vision that was interfering with his deer hunting. He was however still happily and comfortably wearing his ten year old pair of custom-tricurve XL40s, fifteen hours a day.
They measured;
R 7.63/-4.75 6/18 and with over-refraction of -1.00D obtained 6/7.5p [This lens had steepened 0.07mm]
L 7.69/-4.00 6/12 and with over-refraction of -0.75 obtained 6/7.5 [This lens was only 0.01mm steeper than original manufacture!]
I duly refitted him in lenses that were around 0.33mm and 0.2mm steeper, respectively, as follows;
R 7.30w(7.2)8.20(7.7)9.20(8.1)11.00 8.6? F= -7.75D ct=0.14mm Fluoroperm 30 gReen
L 7.50(7.3)8.30(7.8)9.30(8.1)11.00 8.7? F= -5.75 ct=0.13mm
Fluoroperm 30 bLue
I specified DAC back surface blending of 0.5 with front CN bevel and well tapered, fine edges.
You may well ask ?Why didn't he use his favourite Boston XO??
As this gentleman likes to get long life out of his lenses and does not rush back for aftercare, I wanted a tried and tested material [like XL40] that would last and at the same time could more than double the Dk. As his corneas were in good condition and with a good tear pump, FP30 was a great compromise. On delivery he was very happy with binocular 6/7.5, even though I had left him 0.25D under corrected as I didn't want to hammer this imminent presbyope with too much accommodation, that he had not fully utilised for some years.
At aftercare in late 2003, and again recently he positively remarked that he could tell I had steepened his lenses and that these were now ?clearing his cones?, as he hardly ever had problems with dust anymore.
That was one of my points about the 10-30m tear reservoir. The average piece of dust is apparently around 10m in size, so if a lens is clearing the corneal apex by at least this figure, it is less likely to ?crash? into the epithelium ? with resultant abrasion and discomfort.
I had explained and demonstrated this with a Burton Lamp and mirror at refit.
Coupled with better acuity, and less dust-problems in the bush, he's happy.
So am I.
Win-win, which is more than one can say for the current Optometry regulations?
A Day in the Life?
Here?s a snapshot of a day in March.
I saw a Px wearing 9.35base curve/+32.00D RGP lenses on ?cornea plana?, with bilateral microcornea and aphakia, following bilateral congenital cataracts, with shallow AC. She is also a glaucoma suspect and has been under the care of a specialist ophthalmologist and a respected optometric contact lens specialist.
The last thing this lady wanted was for me to dilate her, for the umpteenth time.
As she was from out of town and now living in Auckland I referred her to a specialist in glaucoma ? exactly what she needed ? and the best place to ensure ?public safety?.
That very same day started with a -19.00D severe myope in whom I had correctly diagnosed myopia-related retinal pathology, some time ago. He too is under expert care with a leading Auckland VR specialist. He had also been dilated a few times in the past year and also didn't want or need dilation, on the day. He was there to see me for my skills in contact lenses and has been quite happy with the care I have provided these past seven years. that's not to say I don't check retinal heath - with whatever tools and techniques are indicated - among dozens of other things.
In between these two extreme cases - with a range of 51.00D between their extremes of Rx ? I also saw a nice simple -3.50D, twenty year old myope [no worries mate], who has however needed good management of her lackadaisical approach to compliance, a penchant for ?cosmetic? lenses and heaps of make up issues over time.
Thereafter I had to waste a few hours responding to Board related issues. No benefit to public safety and a reduction in patient contact time.
Next I saw a fourteen year old Form Fruste Cone, also in lenses and son of a local GP, who is also an RGP patient of mine. She couldn?t believe the nature of the APC debacle. She joined dozens of other patients and colleagues who have offered countless testimonials and affidavits.
My last patient of the day was a moderate myope, [and glaucoma suspect] who, over the past few years, following my referral, has seen two Auckland Glaucoma specialists who have done every test in the book, including HRT, numerous fields, gonio, fundoscopy, pressure series and so on. Their diagnosis? Well, um, none of us is quite sure about this rather complex and interesting case.
It's a matter of careful monitoring and regular aftercare.
The point I am making is that skill and experience, not just three trendy techniques, are what we need. We need a multitude of skills and techniques and we should, like every other ?medical? professional, have the right and power to choose what is indicated and when. Not be dictated to or told that ?five times a week is okay?.
Most of us do slit lamp fundoscopy many times a day, and some use a BIO regularly but I am yet to find significant numbers who admit to ?routine? gonioscopy. In fact many don't even own one, DPA and TPA alike. Some that do think they might use it a ?few times? a year ? where indicated. Some people see geriatrics all day with pinpoint pupils and may need to dilate most. Others see mostly school kids and young adults whose pupils, undilated may be as big as a dilated geriatric.
We have to get some common sense in action here..
One cannot make a 100% definitive diagnosis is some cases. Some of the tricky ones I deal with are things like this. Is it glaucoma? Myopia related field defects from PPA? Was that a PIC, MEWDS, SC or APMPPE? CSR or CME? Is it papilloedema? Hydrocephalus?
You get my drift?
So I put it to you all, have I acted in anyway incompetently, in these cases, which represent a typical, routine day for me?
Was dilation indicated? Was gonioscopy?
No!
It's often been done, many times and recently.
So if I have a book full of these patients, day after day, do I have to be forced to satisfy some doctrine when they have no clear idea of what I actually do, what is necessary, on the day, nor what my training really involved?
I challenge, and extend an open invitation, to the Minister?s of Health and Immigration, Chairman of the ODO Board and President of the NZAO to come and spend a day at our practice and see what we do, how we do it, how our patients are cared for and how they feel about our standard of care. This way they can see our massive investment, how much we actually do, what sort of speciality work we do, all in our own environment geared to efficiently and thoroughly provide a level of care that I am confident would stand up to the test, anywhere.
This seems a whole lot more reasonable than judging us via an incomplete assessment and missing information,? with zero evidence to even remotely suggest any incompetence, whatsoever.
In my submission to the board last year - regarding the poorly subscribed ?discussion document? the Board correspondence keeps referring to - I very pointedly mentioned the fact that if they want to play with our futures then at the very least they would have to create a scope of practice for ?tertiary care practise?. By definition we've been referred these complex cases, already under expert care. These patients are in no need of repeated, potentially risky, uncomfortable dilations.
don't get me wrong. BIO, gonio, 90D, 132D, 60D, 20D, 2.2, direct, indirect, and one hundred other tests, tools and techniques are great things. The more people that can and do use them the better.
We don't however understand why just three of many techniques have been made such a fuss of. Why not also ?force? everyone fitting contact lenses to buy a Radiuscope, or others to buy/use a perimeter?
Ad infinitum.
When I suggested to a patient I recently saw, that we dilate him, he refused saying he was regularly dilated when living in the USA. He added that he found it most invasive and uncomfortable and couldn?t function for the rest of the day and found driving dangerous or impossible thereafter. In addition he added that he avoided going back for years knowing that they would dilate him. He is happy to supply an affidavit on this issue.
We hear this type of comment from many patients.
Is a patient ?lost to follow up? in the interest of ?public safety? or is it better to at least see them annually and attend to possible problems as the need arises?
C?est La Vie
Thanks for all the correspondence on the state of our profession. It appears to me that a significant number are not impressed.
That we plan to put to the test.
Some are extremely angry. Some are looking at greener pastures.
One thing I learned, growing up under the apartheid regime, is that solidarity creates an unstoppable power that all the force in the world would be hard pressed to destroy.
We need to stand together as colleagues and decide what future we want for our profession.
Contrary to the ?Get with the Program? message from the NZAO, we feel It's more a case of ?stand up and be counted?.
It has also been pointed out, by a Queensland resident, that a letter to NZ Optics stated; ?New Zealand is not alone. The Queensland Optometrists Board has made having a qualification in DPA?s (sic) compulsory for continued registration with that Board from 2006?
NZ is apparently, alone on this anti-MCOptom stance, as Queensland regards ??criteria to get DPA endorsement here (Queensland) is registration in the UK after 1965" The same applies in NSW, as their Optometry Board specifically gives DPA equality to GOC registerable qualifications [ e.g. MCOptom] and NZ equivalents!
This is but one point that many optometrists, in NZ and elsewhere, have been making [See NZ OPTICS letters pages, the past few months]. It seems these facts are being ignored or overlooked.
Selective perception?
I guess we have to take the NZ Herald?s advice in the following article.
Laughter may really be the best medicine.
Other very recent Herald articles also caught my eye.
One titled Skilled migrants welcome, is a joke. As was another.
The most disconcerting article appeared in the weekend Herald 12th March 2005 entitled Quarter of NZ's brightest are gone
There are alarming stats in there and facts and figures from the OECD that should make most of us wake up and take notice. there's a bit in there that some should take cognisance of, as regards the educational quality of immigrants?.
Some real Kiwi?s express their reasons here.
So don't take it from some disgruntled immigrant Jaapie.
that's what real Kiwi?s have to say?
I have pointed much of this out to the Immigration Minister. It seems NZ was happy to accept my qualifications for registration, these past twelve years and regard me as competent while I and my fellows have pumped tens of millions into the NZ economy. I don't have any problem being fully able to practise in Oz, Europe or most of Africa and plenty of other places I haven?t even considered.
We are not Dr Fang the ?Dentist?
You can buy ?coloured contacts? at Rock Concerts and Tattoo shops. People go blind.
It is time for the many great New Zealanders [and others] that I have met and in many cases befriended, to stand united.
If you have any comment on the current situation or performance of the ODO Board, NZAO, OCANZ or any other optometric issue please let me know, as I have been challenged to provide evidence of this as some regard my comments regarding ?significant dissatisfaction? as innuendo.
Send those emails NOW, to incontact@optom.co.nz
Rest assured your privacy will be ensured, should you so request, as we use BCC email that renders all recipients of email 100% hidden. Our systems and mail servers are behind secure firewalls, encryption and other security measures ? designed to comply with the Privacy Act and the security of our patients and data.
I think that somewhere, sometime, something will eventually be ?worked out?, but we do need to show ?significant numbers? in order to get the attention of some parties.
It's up to you.
I already have 100s of emails and megabytes of documents on the subject but the more support, the better
The majority of our colleagues are respected, multi-skilled professionals, with broad based knowledge. Many are highly-creative individuals, with a passion for life, learning and their profession of choice. The Optometrists of NZ are on the whole great people, as are the majority of people. It was like that in South Africa too. It's like that in most places. Unfortunately you only need five or ten percent hell-bent on blindly following a dogmatic path and things can be rather unpleasant for the rest. Especially if they are part of the silent majority?
Where do we start?
Treating one?s colleagues with respect would be good. Offering, sharing and enjoying learning processes, in a co-operative, nurturing and caring way would do so much more for standards of care, quality and compliance. Public safety would win.
The profession would stand proud.
Even the politicians would look good.
Last word
We hope to see you at the NZSCLP Napier conference in a few days, where we hope our actions will meet the aforementioned criteria and a sharing of knowledge leading to improvements in skill, care, standards and public safety.
We have some great presenters.
C ya.
For more information or any comments email Alan at incontact@optom.co.nz.