In Contact - April 2007

EBM

there's a great article in Time Magazine, February 26th 2007; Are Doctors Just Playing Hunches?
It deals fairly and effectively with the issues surrounding evidence based medicine [EBM], while giving a brief account of the history and some good explanations and examples. Clear points are made surrounding the problems relating to the over zealous switch to EBM style education in medical schools in the US and elsewhere. The article quotes Mark Tonelli; "I'm worried about training a generation of physicians who don't have the other skills they need for the optimal practice of medicine,"
that's precisely what I've been trying to get across for some time: Balance!
While it lauds the benefits of EBM, quotes such as this show we need to avoid extremism and focus on expanding the professions - rather than simply redirecting them. EBM was coincidentally discussed in a paper presented by Doug Coster at the recent CCLS conference in Queenstown
The article ends with a quote from a pioneer of EBM and indeed the man who coined the phrase, Gordon Guyatt, who says "You have to be able to take a good history and do a physical examination ?.and you have to have an understanding of patients' values and preferences."
As much as some might wish it otherwise, there is still as much art to medicine as there is science. A similar comment was made in the contact lens fitting DVD that accompanies Krachmer, Mannis and Holland?s massive text, Cornea, as reviewed in NZ Optics, October 2006.
Hear hear.
I hope the powers-that-be take note, as I detect a wobble in the steering and sense our profession is out of balance?
So is the Ministry of Police - now run by the former Minister of Health.
We know where that got us.
We see the drama the Police have now.
Is it coincidence?
It seems that there is no longer much discipline in NZ.
Police are ineffective. [Except at revenue-gathering speed traps.]
Parents may be prevented from ?smacking? children. [Although some MPs might enjoy being spanked?]
In my failed effort to open CCLS membership to all registered optometrists in NZ, I was told that apparently the ODO Board and HDC are potentially ineffectual in disciplinary matters of a ?minor? nature and unlikely to act. Only matters of a serious nature - like raping or killing a patient ? will get prompt attention. [Although the system may not take that seriously and lets off rapists and bails murderers].
It seems that the NZAO will manage ?lesser? discipline.
It all seems rather counter intuitive to me.
Thus if the ?bad guys? resign from the NZAO they are left potentially unaccountable. [Except for serious misdemeanours.]
Some of these opinions and doubts about the Board and HDC?s effectivity in matters relating to professional discipline came from former ODO Board and NZAO chairpersons and councillors.
Strange but true.
I heard it with my own ears and saw it with my own eyes. As have many others.
Of course we are still way better off in NZ than South Africa, Zimbabwe, and many other places, but why dumb it down so we get on the same slippery path?
Maybe Mugabe will get exile in NZ and a cabinet position? Down with Robert.
Why is he so crazy? [My sources concur].
Viva Tsvangirai

Pop goes the RGP

An interesting recent case: Annual aftercare of a keratoconic wearing an RGP on the left eye and a spectacle corrected PKP right, around eighteen months post op.
The majority of my graft cases are usually performed by one of my ?favourite? surgeons who, in the main, achieve excellent results. In most cases these patients achieve 6/9 to 6/7.5 vision with sphero-cyl spectacle lenses. Toricity typically ranges between a low of around 2.00DC and a max of 5.00DC. In most keratoconics one eye is usually much more advanced than the other. When the wheels fall off, as they often do in severe cases, with RGP intolerance, apical scarring and hydrops, we typically have the ?bad? eye grafted. In my experience it may never be necessary to graft the less severe eye.
I encourage these unilateral graft patients to obtain a pair of spectacles so that they get great spectacle vision in the grafted eye when glasses are worn. They can also often function quite well with just an RGP in the other eye. This allows them to go without the RGP around the house, or visa versa.
Should they suffer an apical abrasion, foreign body discomfort, a rare infection or even reduced tolerance due to allergies and so on, they can wear spectacles and keep functioning this way. As many of them are presbyopic by this stage of their lives, I often Rx the specs in the form of progressives. This way we cover all bases.
Of course we can sometimes fit a high Dk disposable toric, RGP or piggyback the grafted eye. They?ve often suffered some long term wearing and comfort issues pre-graft so mostly they take my advice and avoid CL wear. The benefits are reduced physical and physiological stress on the graft and thus less likelihood of rejection or infection.
Win, win.
At this particular exam I noted, on occluding the grafted eye, that the RGP wearing left eye had reduced, cloudy vision. The patient was even more surprised as he hadn?t noted it. His 6/9 spec wearing eye had been ?carrying him?. On examining the fit with the Burton lamp and NaFl, I noted a rather unusual, very steep central pool over two to three millimetres and an annular donut-shaped band of rather firm bearing.
Something was amiss with either his lens or cornea.
On examining the lens, as we always do, I noted a distorted nipple-like irregularity over the central three or so millimetres. The Radiuscope revealed a very steep, distorted reading. Optics on the vertometer were ?hazy? and well out from the last analysis a year prior and significantly different from the verified specifications at manufacture. On checking the centre thickness I was amazed to find that it was only 0.03mm: A quarter of its original 0.12mm manufactured thickness.
I've seen thin lenses before but this had to be a record. I was surprised it hadn?t cracked or perforated.
It had however ?popped? forward with a nipple-like central protrusion.
These induced ultra-thin lenses usually develop from a combination of repetitive repowering/polishing over many years, as well as overzealous cleaning with ?abrasive? cleaners - like original formula Boston. [Until recently available in NZ as B&L concentrated cleaner].
In the late ?80s I wrote, in my original South African Optometrist Journal-based ?In Contact?, what was probably the first reported case of 'self repowering? from user-induced excessive cleaning. [In combination with rough skin.]
I often say to my patients ?Good news! It was the lens not the eye?. Occasionally I get a confused look and go on to explain that lenses can be replaced a lot easier and for a lot less hassle and cost than corneas or eyes.
They usually appreciate that point.
I duly ordered a replacement; it arrived in under three days and was dispensed the same week. Immediately on insertion he reported improved comfort and his vision was back to his habitual 6/7.5.
His right post-graft refraction was so similar to that prescribed a year previously, [within the manufacturing tolerance of the spectacle lens], it needed no change.
He left a happy chappy, after a quick chat about our common interest, motor sport.

CCLS 50th

The 50th anniversary CCLS conference in Queenstown, as reported elsewhere in this issue was, by all accounts a resounding success. The programme was good and the annual dinner party a raging success.
After nearly thirty years on student, conference, contact lens society, optometric association committees and councils, I am at last and for the first time in decades a free agent. Serving on such bodies is invariably an ?honorary role? and takes up significant time and resources
On the whole I've enjoyed my time on councils - particularly the collegial relationships with some fine people ? but I'd got to the point where I needed a break. No more minutes. No more meetings. No more conference planning and hopefully some quality time for my long suffering family. Thanks to them for putting up with it all. I may well find they?ll be encouraging me to get back on council after they tire of the novelty of my time and attention?
I'd also like to thank all those I've worked with over the years as well as to those who mentored, encouraged, nominated and voted for me: Des Fonn originally got me involved in conferences, way back in the late ?70s and taught me a lot along the way.
Thanks Des.
In those days most communication was by post or expensive toll calls. Slides were made from typewritten text that was photographed by large format cameras onto 16x20 inch lithographic sheet film. Each image was cut out by hand to fit a 35mm slide mount and projected as white text on a black background. Occasionally we would hand-colour lines of text with red felt-tip pens to get some colour into a presentation. Putting a lecture together could take months. The planning was done by a small committee and took a long time.
It still takes a lot or organising by committed people but today we have PowerPoint, USB memory sticks, laptops, cordless mikes and data projectors. Some presenters modify their presentations minutes before they step up to the podium. Most communication and registration is done online. Conference organisers do a lot of the hard work, for a fee.
We owe a huge debt of gratitude to the manufacturers and suppliers for their support, then and now.
In the decade I've served on CCLS and NZSCLP councils and conference committees, I'm proud to have been part of getting the society online and onto the information superhighway. This was achieved initially with email communication between councillors and the society?s first website [now in its third evolutionary stage]. Email has largely replaced post with significant cost savings. we've arranged a number of highly rated conferences and educational opportunities.
Greg Nel, our new President initiated the excellent email based KERATOsite which adds to Trevor Duncan?s legendary, politically incorrect newsletter.
Greg is the third ?South African? President in a row, following my two terms as the first and Trevor Gray?s recent sterling effort of four terms. Congratulations Greg.
Trevor maintained the evolution with some excellent efforts during his terms such as the new look website, conference organisation, workshops, road-shows and registrar training. He also fronted the recent TV and press coverage of the cosmetic lens ?lost eye?, MK and risk. It gained an excellent response and action from government officials.
Many thanks to all those I've served with on council for their support, collegiality, putting up with my emails, the great working relationship we've had and of course, the fun times.
I wish the society all the best for the future.
I know It's in excellent hands with a top class and capable council and welcome newly elected Nisha Jeyaseelan on board. She has already proven her worth on the 50th Anniversary conference committee and as a presenter.
I hope that in time progressive thinkers will see the folly of limiting CCLS membership to optometrists that are NZAO members. My view is that at fifty years the CCLS is a mature body that no longer needs to hang onto the apron strings of its ?parent? association. It seems some members are concerned that the ODO Board?s near identical ethics and disciplinary processes are ?ineffectual?. My attempt to change the rules to allow all NZ registered optometrists the option to apply for membership was thus rejected.
I've now passed the ball to others who may wish to take up the challenge.
Democracy won on the day.
that's why we're stuck with a labour government too.
I guess I'm just not main stream.
We did eventually achieve our name change - less than ten years after I first mooted it at an AGM - when it suited recent changes in Optometry. I'd figured the membership change would also fit the HPCA Act, but it seems it may take a few more years.
You can?t win every battle but I'm looking forward to the Super14, the RWC and F1 GP and all my new found free time.
I guess it must be winter.
Not that we had a summer.

 

For more information or any comments email Alan at incontact@optom.co.nz.