Causes of diplopia or double vision can be a challenge for eye care practitioners to diagnose as they can be benign but also can be life and sight threatening. Is the cause of your patient’s diplopia merely uncorrected astigmatism or could it be a sign of a possible brain tumour?
We first need to determine whether the diplopia is monocular or binocular. Generally, if the diplopia goes away when one eye is closed, this means that the patient is experiencing binocular diplopia, whereas if the diplopia persists, this indicates that the patient is experiencing monocular diplopia. In most cases, monocular diplopia does not warrant a neurological evaluation and treatment involves addressing the underlying cause.
Some examples of causes of monocular diplopia include:
There are many different presentations and causes of binocular diplopia and in the worse case scenario, a life or sight threatening cause may be underlying.
Knowing the direction (vertical vs horizontal), onset (sudden vs long standing), and committance (comitant vs non comitant) of the diplopia can guide our clinical diagnosis.
We need to evaluate the motility of the eyes individually and together. Ocular alignment should be evaluated in all gazes and at both distance and near.
Some examples of causes of binocular diplopia include:
Red flags for urgent referral in association with bilateral diplopia include:
The main treatment objective in patients with binocular diplopia is to create the largest, most central area of single binocular vision, however this may not be achievable in all fields of gaze. Patients may adopt an abnormal head position in order to overcome their diplopia.
Conservative approaches to managing binocular diplopia include occlusion of the vision in one eye, vision therapy and refractive correction including the use of prisms. Less conservative options include surgery, in cases where the strabismus is stable.
As millennials, we are exposed to unprecedented quantities of information through the advent of social media and the internet. The internet is full of traps: rich Nigerian princes, being the millionth visitor to a website, hexed downloads, pyramid schemes and the like. The ability to distinguish between true information and misinformation is vital due to the sheer volume of content we are consuming. “Fake news” has become a common term in our vernacular.
Critical thinking is the skillful analysis and evaluation of an issue to form a judgement. It something we use daily in our clinical decision-making – we relate scientific concepts to clinical application. When we are presented with new information, we have been taught to evaluate its relevance to evidence-based optometric practice.
Critical thinking should also occur outside the safety of our consultation room. Whether it’s navigating a job contract or evaluating a new lens design, diagnostic equipment or clinical procedure, we should always have our critical thinking caps on.
Consider the following...
Be skeptical: Approach what you see and hear rationally and critically. Does the proposal make sense (a distortion-free multifocal anti-scratch, uber thin, unbreakable, feather light lens, anyone?)? Why are they posing this to me? Is it trying to persuade me of a certain viewpoint? Who else are they offering this to?
Is the offer too good to be true?: A salary of $200k a year with full benefits should ring some alarm bells (after the initial “wow!”). Is this a sign that the job is having difficulty retaining applicants due to job conditions? Or do they really value you as an optometrist?
Verbal commitment to actual commitments: You should never walk away from a verbal commitment without solidifying it as a written one. It can be as simple as a quick email saying, “It was great meeting you, thank you for your generous offer of 60% off this product”. It is easy to renege on a verbal agreement as there is no physical evidence to follow through on. ‘Let’s shake on it”, they say. In a week’s time it can become forgotten promises.
Pick your sources: If it seems improbable, do some research. Consider the credibility of the source of the information – is the company/person who is presenting the information have suitable expertise and reputation? Is there more information available to you?
The ability to think critically is the ability to weigh the merits of contrasting arguments.
When you hear something, don’t just take the information at face value. Stop and wonder whether what is posed to you seems correct. Take the time to consider both sides of the story and think critically.
Tis the season for dry hands! Heaters are a crackling, our dry hands are a cracking. The winter chill brings lower humidity in the air and room heaters aren’t helping this.
With the non-stop handwashing, alcohol swab and hand sanitizer use, our hands are taking a beating this winter. The constant wetting and drying removes protective substances from the skin making it less pliable and more prone to cracks and fissures. When soap/cleansing agents are added, these agents act as secondary irritants, resulting in a change in the pH of the skin and removal of protective lipids from the skin.
Here are some tips to keeping your hands healthy:
Thoroughly rinse off your (gentle) soap
Use a gentle hand soap to wash your hands. Gentle cleansers that contain moisturisers can help retain the moisture on your skin. A foaming soap base is easier to rinse off. The skin on the palm side of your hands is thicker than that on the back of your hands. Unless you’ve been in contact with germs with the back of your hand, try to avoid lathering this thinner skin. Rinsing is another important step. Soap that stays on your skin will pull out the natural oils from your skin. Pay attention to the space between your fingers where soap residue can accumulate.
Best time to moisturise is right after you wash your hands
The best time to moisturise your skin is straight after you dry off your hands from washing or a hot shower. It is the best time to trap moisture into the skin. As optometrists, we want something that is safe and non-greasy for contact lens handling. The most effective non-greasy hydrating ingredients are glycerin and lanolin
Apply moisturisers overnight for severely chapped skin
One of the best remedies for dry hands is to soak them in warm water for 5 mins to start the hydration process, then slather then at bedtime with a thick moisturiser, then cover your hands with soft gloves. Trapping the moisturiser will help it absorb more into your skin
If your hands are extremely irritated, you may have to consider wearing non-latex gloves as a protective barrier. The use of gloves does not allow one to avoid washing their hands completely. Gloves provide an imperfect barrier to infectious material. Once gloves are removed, hand washing is imperative.
Is it more than just dry hands?
If you have scaly and inflamed skin, deep and painful cracks and thick scaly skin, it may be more than just ‘dry hands’. You may have a form of hand eczema. There are many things that can cause hand eczema - latex gloves, chemicals, water, the list goes on! Please seek the professional advice of a dermatologist to get to the root of the issue.
We want to get the most out of every slit-lamp examination. You can’t diagnose or treat a problem with your therapeutic skills if you can’t identify it!
Filters, filters, filters!
We use filters in our social media lives to highlight detail and make things really ‘pop’.
The neutral density filter is a drastically underused part of the slit lamp. Without its use, finer detail can be missed. The neutral density filter (symbol is usually circle with hashed lines) modifies all wavelengths of light and avoids under and overexposure. In image A, the blood vessels of the conjunctiva cannot be seen due to overexposure; in image B, the addition of a neutral density filter enables the conjunctival blood vessels to be visualised.
We all know the benefit of the red free (green) filter for posterior eye examination - it allows us to visualise RNFL defects and pigmented lesions of the retina. The red-free filter obscures anything red so blood vessels and haemmorhages appear black. In the anterior eye, it can be used to highlight the path and pattern of inflamed blood vessels. It is also great for highlighting the presence of a Fleischer ring.
The Wratten filter bolsters contrast when used with the cobalt blue filter. Most slit-lamps have a Wratten filter built in so remember to flip it on when you use the cobalt blue filter. It make examination with fluorescein much simpler.
2. The Basics: Alignment and PD
There is a human on the other side of the slit-lamp. Make sure the patient is aligned well with the canthus mark with their forehead resting on the plastic band and chair at a comfortable height. Make sure you’re also comfortable with your alignment with the oculars and the PD adjusted accordingly to ensure a stereoscopic view. Never duck or tilt your head - remember your personal ergonomics also. Rest your elbow on your lens case or foam discs for comfort when you’re using your diagnostic lenses.
3. Turn up the rheostat!
The anterior chamber and the anterior vitreous is very tricky to visualise without adjusting the brightness. Turn up the light when examining these structures. A stray cell or anterior vitreous detachment is easily missed if the brightness of the slit-lamp is too low. While amping up the intensity of the light may improve your ability to see, it will be uncomfortable for the patient. If you must increase the intensity of the light, let your patient know and keep it as brief as possible. The general rule of thumb is to lower the beam width and/or height as you increase the brightness of the slit lamp.
Our 'Unconventional Optometrist' column is where we chat to optometrists who are a bit out of the ordinary! Do you know anyone who we should feature? Let us know!
Mimi Nguyen Ly is a young optometrist who has made the leap to full-time journalism. She is truly a unique soul and a joy to interview, with an interesting journey from full-time optometry to journalism. Mimi strives to provide a voice to issues for the public good above all else.
Tell us a little bit about yourself
I came from Vietnam to Australia when I was 7. I’m an only child but grew up with my aunt and uncle, and two cousins who I consider sisters. My parents eventually permanently moved to Australia later. I completed UNSW Optometry in early 2015. I chose optometry because I was raised in a family that valued healthcare. My cousins are doctors and dentists and I’m the only optometrist in the family.
How did you get into the world of journalism? How long have you been at it for?
I joined the Epoch Times because I was inspired by the paper’s mission—to report true, uncensored news. At the time, only news filtered by state run media were being reported out of China. I care about China because I saw there were a lot of human rights issues that were not being reported about. Epoch Times, on the other hand, was the first to report on things like the SARS outbreak when it was initially censored by state-run media. The paper later won an award for its thorough investigative reporting on organ harvesting in China’s state-run hospitals, at a time when the regime thoroughly denied the practice and when no other medias were covering the story.
I joined as a volunteer contributor in 2011 (second year university) because I wanted to be able to help in some way. The general news I was writing helped to support the work of other investigative journalists on the front line. Over time I saw that the paper was also reporting on other issues in other parts of the world that were being avoided or overlooked by other medias. We could report on these things because we are independent and not guided by profit or other interests. Our mission as a media has since evolved to “Truth and tradition.” I believe that people have a right to be informed, especially about the world’s most critical issues.Responsible journalism benefits society by empowering people with knowledge so they can make the best decisions for themselves and their communities. I came to realised that, even today, there is a void and a need for more news outlets to take on this role. I wanted to help fill that void.
I started to do journalism full time since April last year, but I’m still keeping up with optometry, in a locum role.
Tell us about your typical day at work
I’m currently on the web news team, which means we cover breaking news and trending news. While getting ready for and driving to work, I’m listening to the radio to get updated from what I missed out while asleep. At work I browse for news topics and help assign topics to writers. I’m also writing news pieces for the day; basically, my role is to constantly update the world on what’s happening. Sometimes I will call potential sources to ask questions or to ask for a short face to face interview with them. Generally for now, I’m working on the web news.
How do you keep up with the optometry world?
I am doing locum optometry. On my free days, or in the evenings, I may be attending CPD evens. I’m keeping updated with the news in the optometry world generally through browsing insight and mivision magazines, and other outlets via social media.
Do you have any goals for your optometry career?
Children’s vision has always interested me. My current goal is to learn more about children’s vision and related issues such as vision training. In the long term, I aim to continue to practice as an optometrist in any capacity I can.
It's easy to get stuck in the bubble of Optometry. What's something that you wish people knew about journalism?
Anyone, including you, can be a journalist. You don’t have to be working for a media company to be one. If you care enough about an issue you can report on it. What will make it a journalistic work is the intent and how you gather your information. Being a journalist means that you place the public good above all else (instead of your own assumptions or self interests) and that you are adhering to journalistic standards when you gather and report information (eg seeking out multiple witnesses/voices, telling as much as possible about your sources, and asking different sides for comment are some such standards). It’s what differentiates it from propaganda, advertising, fiction or entertainment—in the current media landscape the lines can blur between these. I’ve come to realise that some media companies, even some major ones, don’t serve people in this way anymore. So when we consume the news, we should all be vigilant and discerning.
What's some advice you would impart on a Young Optometrist seeking a career change?
There is so much you can do to help others with optometry, from solving their vision issue to simply bringing a smile to others every day through your sincerity and care, and that’s special, never forget that. If you can see how special this is you may even consider staying with optometry. Every job will have the fun aspects, but also will have the challenges and the mundane—are you mentally prepared to endure what’s to come? Don’t think the grass is always greener on the other side. Reflect deeply on what truly inspires you to leave to seek another path—if it still drives you, and you’re very clear and solid, go do it. If you really want to do it you will figure out a way, others will see your sincere passion, and doors will naturally open.
Otherwise, stay in optometry and do the best you can to benefit the world with your already acquired knowledge.
Where can we follow your work?
You can follow me on Twitter @miminguyenly
Cycloplegic drops have two main benefits in optometric practice. Firstly, cycloplegic is a useful tool in assessment of refractive error. Cycloplegia inhibits the accommodative power of the eye by blocking the action of the ciliary muscle, allowing the static or objective refractive error of the eye to be measured. Two main cycloplegia drugs are used in practice: atropine and Cyclopentolate. These drugs are called anticholinergic because they block the muscarinic action of acetylcholine. This action inhibits cholinergic stimulation of the iris sphincter and ciliary muscle, which results in mydriasis and cycloplegia. Secondly, as it dilates the pupil it allows for ophthalmoscope examination.
Cycloplegic retinoscopy and refraction helps determine full hyperopia in patients with accommodative esotropia and prevents overcorrection in myopic patients, making it a great tool, especially when testing children. It is also useful in prescribing correction in patients with limited cooperation during subjective refraction and amblyopic patients.
In practice, cyclopentolate hydrochloride 1% is the cycloplegic agent of choice. It has a faster onset of effect and reaches peak effect after 30-45minutes, its effect also washes out after 4-8 hours. Contradictions for cycloplegic drops is in patients with: closed-angle glaucoma, Down’s Syndrome, seizures, in pregnancy or breast feeding patients its effect is still unknown. Hypersensitivity to atropine is also not uncommon.
Here are some of our top tips for instilling eye drops in children:
If the situation allows, let the parents and child know that the eye drops cause a stinging sensation: doing so is important as it builds trust.
Show the child what the container of eye drops/ointment looks like. Put some on the back of the child's hand so he or she knows what it feels like.
Work as quickly and calmly as you can - this minimises the child's distress.
Recline the patient backwards or leaning into the chair comfortable, have them look up to the ceiling (have a picture or object for them to look at to distract them) and instill into nasal canthus. Or they can keep their eyes closed as you attempt to pull down their lower eyelid and instil it into their conjunctival sac.
Blinking exposes the eye to air and causes an increased stinging sensation. After the drop is in, ask child to keep their eyes closed and count to the highest number they know. Make it a silly competition. “1, 2, 3,...685,...ten billion”.
Praise, praise, praise! Let the child know they’ve done a great job. A little reward such as a sticker or jellybean goes a long way.
If your patient is nervous or afraid, often demonstrating on yourself or their parent (with a substituted lubricant) can help relax and calm them as they can see what would happen. If they are still nervous you can have them practice at home with lubricants before returning for their cycloplegic examination.
You’re running late, the printer has stopped working, you’ve got a backlog of clinical records to finish and then...they enter. The ‘difficult' patient.
“It’s an emergency!”
“My old optometrist never charged me.”
“I always sleep in my lenses, I don’t have any problems.”
“Why are you asking me for my medications, you’re not a doctor.”
“Why is this taking so long?”
You’d be hard-pressed to find a definition of a ‘difficult’ patient, yet all of you have encountered at least one during our career. Patients are diverse and like all human beings, have good and bad days. Some of our patients have complex medical issues which affect the way they interact with us and some are just having a bad day. They can push you to the limit. Work would be a very unpleasant place if most patient interactions weren’t positive. Luckily, ‘difficult’ patients are few and far in between. Here are some tips to help you smooth out the bumps in patient interaction.
There are a few factors that can make a patient interaction challenging.
It can be the patients themselves: perhaps they are hostile, have unrealistic expectations and are uncooperative.
It could also be us as optometrists: personal factors such as personality clashes, if we're tired, angry or late can also contribute to a poor patient interaction. It is important to reflect on our own mood and stress levels.
It may also be the types of resources available to us at the time: are there enough support staff, adequate space and equipment and reasonable time expectations?
Identify you’re in the midst of a challenging interaction by being authentic and transparent
Identifying you’re in the midst of a challenging interaction is the first and most crucial step. Our reactions guides the tone and direction of the consultation. Our subconscious changes in body language can lead to a downward spiral. Rolling your eyes or shaking your head may feel justified, but remain calm and professional (even when you think you’re in the right). Early on, verbalise the difficulty that you’re having and avoid casting blame. For example, you can say “We both have different views about how we should address these concerns and it's causing some difficulty between us, do you agree?” Being honest, transparent and raising awareness of the 'difficult' situation can help build trust and open doors in working on an agreeable solution together.
Acknowledge their emotions and remain calm
Remaining calm will allow you to keep control and address the patient in a way that will defuse the situation. Upset patients may try to pull you into an argument. While you are completely entitled to voice your opinion, it’s important to do so respectfully. Acknowledge a patient’s emotional state. Have a willingness to understand the situation from their point of view and let them be heard. Reflective statements, such as “I can see this is upsetting to you,” and “I can understand why this made you upset” can identify the observed emotions of patients. Open communication is key in defusing difficult situations. These statements show the patient that it’s okay to talk about their concerns and fears and demonstrate that you care about them and they are important to you.
Have boundaries and be assertive
When it comes to difficult patients who make seemingly unreasonable demands, a useful approach is to set limits. This can be through company policy, for example, to enforce a policy for showing up late for appointments. Be firm in adhering to your clinical knowledge and professional management plan. Explain the consequences if compliance is an issue. Keep accurate records of the consultations and complaints they make to protect yourself.
You may also create a boundary by inviting the patient back into your consult room. This is a great way of separating your patient of interest with practice staff and bystander patients. This allows the patient to express their concerns privately and can allow you to contain and defuse the situation.
If the patient begins to become abusive, whether physically or emotionally, it is time to step back. Let them know their behaviour is unacceptable, discharge them from the situation and alert the other staff in your practice.
Breathe, debrief and self-reflect
After an unpleasant interaction with a difficult patient, it’s normal to feel upset, frustrated or angry. You may even feel a sense of relief knowing that the difficult situation has been dealt with. Regardless, take a moment to have a breather, so your whole day isn’t ruined. Take a deep, cleansing breath and as you exhale, let out all the stress and anger. You may find some relief if you debrief with colleagues after a difficult consultation, whether it's a phone call, text message or in person. Not all days in Optometry are easy, but you have the strength and skill to handle whatever difficulties come your way. Acknowledge that you have experienced a difficult situation. It's important to digest the experience and reflect on how the situation occurred, how things could have been prevented or could have been managed better and how things can be changed so that difficult situations like the one you experienced do not occur again.
Reward yourself after handling a difficult situation
No one likes dealing with 'difficult' situation, but someone has to. And it's important that you give yourself a pat on the back and reward yourself for taking that courageous step forward and defusing the situation. Sometimes having a little treat from your secret little stash of chocolates, sweets or cookies may even empower you to take on more difficult situations ;).
And if you ever get stuck, have a chat with one of your friendly YO team members and we'll gladly help point you in the right direction.
April is Fabry Awareness Month. Fabry disease is a rare genetic disorder. It results from the buildup of a particular type of fat, called globotriaosylceramide, in the body's cells. The enzyme that breaks down globotriaosylceramide is absent or does not function properly. The fat accumulates in the walls of the blood vessels, decreasing blood flow to the kidneys, heart, skin and nervous system.
Beginning in childhood, this buildup causes signs and symptoms that affect many parts of the body. Characteristic features of Fabry disease include; episodes of pain, particularly in the hands and feet (acroparesthesias); clusters of small, dark red spots on the skin called angiokeratomas; a decreased ability to sweat (hypohidrosis); problems with the gastrointestinal system; ringing in the ears (tinnitus); and hearing loss.
Fabry disease also involves potentially life-threatening complications such as progressive kidney damage, heart attack, and stroke. Some affected individuals have milder forms of the disorder that appear later in life and affect only the heart or kidneys.
As optometrists, we are on the frontline to diagnose this often overlooked disease and allow our patients to seek critical treatment. All you need is a slit-lamp. There are some tell-tale ocular signs including:
Cornea verticillata: Cornea verticillata consist of bilateral whorl-like opacities located in the superficial corneal layers, most commonly in the inferior corneal area. These opacities are typically cream coloured, ranging from whitish to golden-brown. This manifest as early as in childhood. These corneal whorls are sometimes attributed to systemic drugs such as amiodarone. Amiodarone is an antiarrhythmic cardiac medication, commonly used in older patients. Keep in mind some patients may be on amiodarone due to Fabry disease affecting their heart. You should keep this in mind for younger patients - perhaps they are on amiodarone for complications secondary to Fabry?
Lenticular opacities: Anterior capsular or subcapsular cataract and a radial posterior subcapsular cataract (Fabry cataracts) have been reported in patients with Fabry disease. These are best seen with retro-illumination.
Vascular abnormalities: Conjunctival, retinal and choroidal vessels tend to show increased vessel tortuosity. Conjunctival abnormalities are commonly located in the inferior bulbar conjunctiva. In the retina, you may see tortuous “corkscrew’ vessels with segmental venous dilation, arteriolar narrowing and arterio-venous nicking.
Optometrists can make a huge difference in our patients’ lives, if we just look and act upon the signs we find. There is no cure for the Fabry disease, but patients often benefit from enzyme replacement therapy. If you suspect Fabry disease, you should refer the patient to their GP to commence genetic testing.
We're excited to announce that Austin Tang is joining us as a subcommittee member. He is a recent UNSW Optometry graduate and we're glad to have him on the team. He brings with him the perspective of a new graduate in rural NSW. Find out a bit more about him!
Tell us a little about yourself?
I’m Austin and I’m currently in my first role on the other side of NSW, Broken Hill! I like travelling because it opens me up to new experiences, ways of thinking and cultures. I also like things that take us away from the normal rhythm of our daily lives, whether it would be chatting to someone we haven’t spoken to in a long time, or spontaneous sunset trip.
How did you end up in optometry as a career?
I was interested in science and health and couldn’t imagine myself being a doctor, so this is where I ended up.
What are you most passionate about outside of optometry?
One of my passions is tennis but deep down, I think it’s making a positive difference to those around me.
How would you spend your free time?
I like continuously learning through reading as well as investing in my hobbies. I also like keeping in contact with family and friends.
Most embarrassing moment?
It would have to be waving when I thought someone was waving at me, or saying something when I thought someone was talking to me.
What inspired you to join YO as a subcommittee member?
I found YO pretty helpful for me; some of the posts as well as the events, and I thought it’d be cool to be a part of it. I would like to use any of my knowledge and experiences to help those who are upcoming optometrists!
If you had one superpower, what would it be?
What is your current favourite phrase?
I’ve been picking up a lot of Aussie slang in Broken Hill, I can’t pick out a favourite one.
Refraction is the bread and butter of most optometrists’ days. We have the privilege of seeing our patients year after year, usually not expecting more than a 0.25-0.5D change in their prescriptions. Significant or unexpected refractive changes can be a sign of something more complex. In such cases, differential diagnoses can be arrived through logically working through the structures of the eye from the front to the back. Perhaps it is corneal pathology, lenticular changes, retinal change or a mass originating from the orbit.
Here are some things that should be running through your head when you encounter someone with an unexpected change in prescription.
Drug-induced refractive changes: Cholinergic drugs can cause accommodative spasm responsible for myopia. Sulfonamides and diuretics can also lead to myopia without accommodative spasm. Some proposed mechanisms of drug-induced refractive error change include changes in hydration of various ocular tissues and contraction and oedema of the ciliary body. Although unpredictable, drug-induced refractive disorders often resolve after treatment cessation. Potential clues: New medications in patient history, correlation of the intake of the drug with noticed visual changes.
Binocular vision issues: Poor accommodative flexibility, facility and control may mean the measured refractive error isn’t necessarily a reflection of their true refraction. It is important to perform a cycloplegic refraction or a careful refraction that ‘pushes plus’. Ensure the underlying binocular vision issues are addressed e.g. through spectacles, vision therapy. Potential clues: Patients are symptomatic of fluctuating vision, Rx changes depending on time of refraction, changing reflex on retinoscopy.
Corneal Ectasias: Corneal ectasias is one of the major conditions that should come to mind when seeing a patient with frequent refractive change. Progressive thinning or distortion of the cornea leads to visual changes. Signs of keratoconus include asymmetric refractive error with high or progressive astigmatism, scissoring reflex on retinoscopy, and reduced spectacle BCVA. Early detection is key. Potential clues: Age of the patient, history of atopy or allergy, eye rubbing, ethnicity and/or family history, frequent changes in spectacle prescription.
Diabetes-related changes: Diabetes mellitus can affect lens clarity, as well as the refractive index and accommodative amplitude of the lens. The glucose content in the aqueous humour rises as one’s blood glucose level increases. The glucose metabolises and causes subsequent changes in osmotic pressure. This may cause an influx of water, which leads to swelling of the lens fibers. The state of lenticular hydration can affect the refractive power of the lens. Patients with uncontrolled diabetes may show transient refractive changes owing to large changes in their blood glucose level. Acute myopic shifts may indicate undiagnosed or poorly controlled diabetes. People with diabetes have a decreased amplitude of accommodation compared to age-matched controls, and presbyopia may present at a younger age in patients with diabetes than in those without.
Join our discussion here at the Young Optometrists NSW/ACT Forum. (please note - you must be a FullYO to access the forum).