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!
Here's this month's Unconventional Optometrist. Megan Tu is an optometrist who works in primary and high schools in South-West Sydney. Read ahead to find out more - what an interesting optometrist she is!
Tell us a little bit about yourself and how you got into being a School Optometrist.
I graduated from UNSW School of Optometry and Vision Science at the end of 2011. Upon graduating I worked at a full-scope independent practice in regional NSW, which allowed me to freely explore different avenues of Optometry, such as behavioural optometry, contact lenses, sports vision and advanced optical dispensing. This was a fantastic experience to help me develop clinically and professionally, and helped shape my passion for Optometry.
Tell us about your typical day at work. Is it a full-time or part-time position?
On Monday to Fridays, I work in primary and high schools in South West Sydney, providing comprehensive eye examinations to students. In the evenings and on the weekends, my partner and I have recently opened an after-hours optometry clinic. I also work a couple hours a week at the UNSW Optometry clinic as a clinical supervisor for the paediatric clinic. Finally, I was a founding member and current Secretary for Young Optometrists NSW/ACT.
What are some benefits to working in your unique situation?
My work puts me into very different environments and allows me the opportunity to develop a good mix of clinical, teaching, networking and business administration and management skills. It keeps me on my toes and it means that I am never bored! Being a part of YO keeps me aware of our professional environment outside of the consultation room, and allows me the opportunity to actively contribute to shaping the future of Optometry.
What are some differences between what you do and a 'traditional' optometry job?
I am generally not in your typical consulting room, as the bulk of my consultations are in a mobile working environment. My own practice operates after-hours, which again is different from the usual 9-5 job, and can involve home visits as well. With a particular interest in behavioural optometry, the bulk of my patients are children and I am fortunate to be able to offer and develop my skills in areas such as vision therapy.
How did you get into this unique area of optometry?
I was passionate about paediatrics and behavioural optometry since my undergraduate degree, where (unlike most of my peers) paediatrics clinic was my favourite clinic! I did the Behavioural Optometry units of the UNSW Masters course and I have practiced in full-scope behavioural practices since graduating. I am a member of ACBO and continue to develop my interest by attending CPD conferences.
What advice would you give to other optometrists who also wish to pursue this type of optometry?
Keep an open mind, critically think about information that you’re given and keep on learning and improving yourself. Don’t just accept the status quo. Find your passion and pursue it.
Change isn't easy, but forming new habits could be the start! We all have a morning routine when we get up (bathroom, brush teeth, eat breakfast, run for the train....) but these habits are triggered automatically in response to contextual cues (e.g. the action of washing our hands comes from the contextual cue of finishing our business)?
If you've got a spare hour, check out this fantastic article, but if not here's the gist:
Habit forming is never easy, and realistically of everyone who reads this only 5% will enforce any of the above. Most of the time we'll revert back to our old ways, because they're familiar. But don't give up, give it a go - whether it be checking less social media, walking the dog daily or even writing in a gratitude journal daily. Best of luck!
Deciding which professional organisations to join can be quite daunting as an optometrist, especially as a newer graduate. There are many questions that may be lingering on your mind. How will I meet the right people in optometry? How can I find my niche? What organisations are “worth it”? How much will it cost? Do you really want to be spending your first paycheck on member fees?
Joining professional organisations can connect you with valuable professional networking opportunities and access to a wealth of relevant information. Most organsisations have 'members only' access to exclusive forums, CPD events, netowrking activities and educational resources. Networking can create lasting ties through common ground and support you in times of need. In optometry, continuing education is a key part of our career. The more varied and rich CPD events we undertake, the more likely we are to implement positive changes to our optometric practice.
Most importantly, organisations depend on the power of people and numbers. Optometry is a small profession and we have our strength when we join together in numbers. The 'collective voice' is a powerful tool. Large organisations are able to advocate for optometry in the wider sense, whether it be in politics, the healthcare system or otherwise. Their influence is governed by your membership - with fewer numbers, their influence dimishes.
If you find a passion in certain aspects of optometry, we highly encourage you to join the organisations that align with your personal and career goals. By joining an organisation, you are providing yourself with a competitive advantage as an active, informed member of the industry.
We've selected some key organisations we reccommend you join. Keep reading because we’ve tried to narrow it down for you! Remember all membership fees are tax deductible.
Young Optometrists (YO) NSW/ACT
YO is run by young optometrists, for young optometrists. Young Optometrists (YO)’s mission is to support optometrists and students by providing a dynamic and progressive environment to advance the profession. We provide a collective voice to support optometry students and optometrists in their first 10 years of practice (within NSW/ACT). We know and listen to what you want and strive to represent young optometrists in this ever-changing world of optometry.
As part of our YO Community, you get a huge range of benefits. Our focus is not only continuing education through tailored CPD events and workshops, but also networking, social outings and your overall well-being.
As a member you also get access to CCLSA member discounts for your first 12 months. This is a great way to trial out CCLSA events before joining up as a full member.
For the price of a big night out, you have access to our myriad of benefits as a Full YO Member (incl. access to >30CPD points). If you don't want to miss out, sign up ASAP to become a part of a dynamic YO NSW/ACT community.
Let us welcome you into the YO NSW/ACT community today - https://www.yoptoms.com/Membership/
Free Membership for New Graduates
Optometry Australia (OA)
OA is a not-for-profit body which represents about 90 percent of Australian optometrists. They are an influential voice who aim to provide clinical and professional advice, professional development opportunities, networking and career-advancing opportunities for optometrists by optometrists. Optometry is a small profession and historically membership rates have always been high, with the majority of optometrists choosing the join OA. The only way OA will remain influential is if you choose to be a member. Membership is free for the first 6 months for new graduates.
Australasian College of Behavioural Optometry (ACBO)
ACBO is an association for optometrists with an interest in functional vision care, neurodevelopmental optometry and vision therapy. ACBO kindly extend a free 12 month membership to all final year students.
Australian College of Optometry (ACO)
ACO is an independent, non-for-profit institution in science, education and optometric practice dedicated to preserving sight and preventing blindness. First year graduates can enjoy free membership for 12 months.
Discounted First Year Membership
Cornea and Contact Lens Society of Australia (CCLSA)
CCLSA’s mission is to support research and innovation and promote professional development and education amongst members in the field of cornea and contact lenses. First year graduates receive a 50% discount off their annual membership.
Recent graduate fees for optometrists, who have worked for 6 months, are discounted to $1746 (incl. GST)
Other Memberships to consider
Orthokeratology Society of Oceania
OSO is dedicated to improving the lives of people now and in the future through Ortho-K and Myopia control. OSO members will be recognized as a member of the International Academy of Orthokeratology (IAO) as well. Joining fee is $275 (incl. GST).
These are not just memberships but communities where you can network and learn from each other. So what are you waiting for? Get signed up!
Note: This post does not represent all the optometry organizations and societies in Australia.
*Prices are for optometrists practicing in Australia or New Zealand (as of Feb 2019).
Ptosis is an abnormally low position of the upper eyelid. It can be congenital or acquired, but is more common in elderly patients due to a gradual loss of muscle function. It typically impacts vision as it reduces the amount of light entering the eye.
However we can’t blame everything on “age” or “you were just born this way” … there are other sinister causes of ptosis and it is important to rule them out or identify them in order to manage your patient appropriately.
PEARL 1: IDENTIFY THE PTYPE OF PTOSIS
Ptosis can be classified broadly based on their cause.
PEARL 2: RULE OUT OR REFER
Ensure you have a mental check list of ruling out all sinister causes of a ptosis and refer appropriately if necessary.
PEARL 3: PTYPES OF PTESTS
PEARL 4: PROPER RECORDING IS KEY
Ensure you record in detail the responses to the questions you have asked (both yes and no), results of tests you have conducted (positive and negative), and state that you have explained to the patient the situation, reason for referral (if necessary), and the importance of further testing/imaging.
Our 'Clinical Pearl of the Month' column is where we present a clinical pearl to provoke thought and discussion.
The Demodex mite is an eight-legged ectoparasite that resides in our hair follicles and sebaceious glands, including our eyelashes. Every adult will have some demodex mites, but presence of blepharitis indicates they simply have too many. Demodex infestations increase with age, affecting 84% of the population at age 60, and 100% of those older than 70 years old.
It is contracted and spread by either direct contact or dust containing eggs. Two species are found on humans:
- the shorter Demodex brevis (0.2mm long) which tends to live inside the lashes' sebaceous glands and meibomian glands, and is suggested to be associated with posterior blepharitis
- and the slender, tapered Demodex folliculorum (0.4mm long), which bury themselves face down in the lash root, associated with anterior blepharitis
There are multiple types of blepharitis, each with their own path to effective treatment.
How do I diagnose Demodex Blepharitis?
Patients suffering from a demodex infestation may complain of crusted or matted eyelashes, tearing, burning, madarosis, and foreign body sensation on the base of their eyelashes. It is important to rule out other sources of anterior surface inflammation as there are many crossover symptoms to a myriad of conditions. N.B. Demodex mites are found in both symptomatic and asymptomatic individuals, and there is poor correlation between Demodex infestation and symptoms, as paralleled in other anterior segment conditions such as blepharitis.
A definitive diagnosis can be made through lash sampling. Select an eyelash with cylindrical dandruff as it is more likely to yield results. Mount the lash onto a coverslip with a droplet of oil.
However, this is not always practical in a clinical setting. Some signs which may be noted on routine clinical examination include cylindrical dandruff, eyelash disorders such as madarosis, and lid margin thickening and erythema. Inflammation of the lid margin can spillover and result in blepharoconjunctivitis and corneal inflammation.
What is that classic cylindrical dandruff?
This fine waxy, dry debris is considered pathognomonic of Demodex. The clear cylindrical dandruff classic of Demodex blepharitis is through to be a product of the mites' claws scraping around the eyelash follicle. Demodex infestation can cause increased keratinisation near the base of the eyelashes. As the keratinisation is mixed with lipids, it produces the classic clear cylindrical dandruff.
What is the lifecycle of Demodex?
Understanding the lifecycle is important to how we tackle demodex. A demodex mite lives around 2-3 weeks. A female will lay 15-20 eggs inside the hair follicle. These eggs turn into larvae and subsequently develop into an adult mite. They are fast little creatures, walking around 10 millimeters/hour.
Ok, I've heard enough, how do I treat my patients of these mites?
Long-term lid hygiene is required as Demodex is a chronic condition requiring chronic therapy. Prior to initiating therapy, there are several effective in-office demonstrations that have proven to increase compliance among patients with Demodex, as many lid therapies targeted specifically for Demodex cause ocular discomfort contributing to therapy dropout.
The most effective and commonly used agent for demodex is tea tree oil. Tea Tree Oil (TTO) is currently the most effective in-office and at home treatment option. The TTO stimulates the mite to exit the hair follicle and migrate to the skin before mating. Studies have shown that concentrations of TTO as low as 5% (applied 2x/day) and as high as 50% (applied in office once a week) to the base of the eyelashes and lids, is effective in reducing Demodex infestation.
There is no one single treatment method that fully eradicates the Demodex after 4 weeks of therapy. It is a chronic condition that requires long-term treatment. Here are some common treatments you can implement in practice.
- Commercial eyelid cleansers (foam or wipes) used 2x/day: Patients are instructed to clean the lids and lashes, as well as smear the lid cleanser onto the eyelash roots of the lid margins. They can also be instructed to use the wipes on their eyebrows, forehead and cheeks as well as demodex live in those regions. The foam/scrubs are meant to be left on the skin to dry. Examples of lid cleansers include: Blephadex, Cliradex, Oust Demodex, Ocusoft Lid Scrub Plus
- In-office high concentration TTO: A weekly office lid scrub with 50% TTO solution is to stimulate the migration of mites out of the lash follicle. Anaesthetic is instilled in both eyes and then the eyelashes are thoroughly debrided with a cotton bud soaked in 20-50% tea tree oil. 100% tea tree oil solution causes intense patient discomfort and toxicity to the ocular surface. A 50% TTO mixture can be prepared by diluting the tea tree oil in macadamia oil. Caution must be taken in those patients with nut allergies and allergy to tea tree oil. This is then followed by daily home therapy with eyelid cleansers 1-2x/day.
- Microblepharoexfolation: This involves a high-speed rotary sponge (BlephEx) soaked in a lid cleanser. It removes the biofilim on the surface of the lids and lashes, removes the cylindrical dandruff and helps to remove the mite eggs at the base of the eyelash follicle. This is a powerful tool to kickstart treatment and may need to be repeated at 3-6month intervals for those with severe blepharitis.
- Other hygiene measures: All makeup should be discarded, hot water should be used to wash clothers and linens dried on the high-dryer setting.
- Aiding compliance: Compliance tends to be simple once the patients can see photos of their mites. This can be taken through the slit-lamp or in free space if the infestation is severe enough. A digital microscope can also be used to take photographs and video of an extracted eyelash.
The standard of clinical record keeping is extremely variable. It is easy to get stuck into poor habits of record keeping. Accurate record keeping is important for the provision of quality eyecare, especially in a multi-practitioner setting, to protect the optometrist in the event of an accusation of negligence and for use in My Health Record to be accessed by other practitioners. Not surprisingly, there is a strong link between poor record keeping and successful claims against practitioners for clinical negligence.
Optometrists tend to under-report, that is, perform and examine more than is recorded on their record cards.
The Optometry Board of Australia Guidelines dictate that optometrists must: "Keep accurate, up-to-date and legible records that report relevant details of clinical history, clinical findings, investigations, information given to patients, medication and other management in a form that can be interpreted by another optometrist."
Here are some reminders and tips to refresh your clinical record keeping skills:
- Detail your case history: This should have a clear indication of the patient's concerns and complaints that led them to seek a consultation. Questions asked during history taking (negative or positive answers aside) must be recorded. Their ocular and health history, medications and allergies and adverse reactions must also be recorded.
- Examination findings: The results of every test and procedure performed should be recorded, whether it is normal or negative. It should be recorded in a way that it is easy to interpret. Recording such as WNL (within normal limits) or NAD (no abnormality detected) should be preceded by the tissue or structure examined. e.g. Cornea WNL.
- Therapeutic prescriptions: When a therapeutic medication is prescribed, supplied or administered by the optometrist (including diagnostic eyedrops), the date and details of the medication should be recorded alongside the instructions given to the patient.
- Be smart with your smartphone: Increasingly, clinical images may be captured on private hand-held smartphones. A good example is taking an anterior eye photo with a phone camera through a slit-lamp. Clinical images and videos on your mobile device are considered part of the patient's clinical record, and should be treated as such. Patient consent is essential when capturing images or videos using your smartphone or tablet. Patients when giving consent should understand the purposes of the clinical image, how the image will be used, who will have access to the image, whether it will be de-identified, and how the image will be stored. Once consent is obtained, document this on the patient’s clinical file and delete the file from your device after the image has been transferred to your computer
Picture: Vincent enjoying his 'birthday cake' at work - who said work can't be fun?
Here's our first Unconventional Optometrist. Vincent Ling is an optometrist who works full-time in a rural Queensland ophthalmology practice.
Q: Tell us a little bit about yourself and how you got into what you are doing
Hi, So basically I was a new graduate who started my career with OPSM in Wagga Wagga. I spent about 5 months with OPSM before I decided I wanted a change. I did enjoy my time at OPSM and gained a lot of my skills there. I did a placement at Omni Eye services and I really enjoyed how optometry was practiced in the US. There was a strong relationship between optometrists and ophthalmologists which isn’t quite as apparent here. When an opportunity came up and to work on a coastal area, it was too hard to pass up.
Q. What is a typical day at work like? Is it a full-time or part-time position?
Full time. So I work 4 days a week and it is very hard to describe a typical day of work. This is what makes my job so fun. A wide variety comes in through my door since often my boss will have a full book and she will not have time to take any more patients. I do many of her follow-ups such as cataracts, glaucoma, uveitis, red eyes. She gives me full control to change medications or management plans as I see fit. Other stuff that comes in through my door include emergency referrals from the hospitals, often I will see the patient first and if I don’t feel comfortable managing whatever is through my door, my boss takes over. Sometimes if a patient cannot afford to see an ophthalmologist, they will see me and she will ‘duck’ in too have a look. All my consultations are bulk billed besides any scans that I may need to do. I really enjoy my job and I look forward to waking up everyday and going to work.
Q: What are some benefits to working in your unique situation?
My boss said to me during the interview was that I would be “under her protection.” It certainly does feel good being able to call the shots and when in doubt, she is always next door. There will be days where I do not need her help, but there will be days where I would be calling her every 10 minutes. I have a walking Kanski next to me so I feel comforted by that, however, there will be days where she is in theatre, charity work, conferences and I am left alone and I am responsible for the patients. It is certainly tough having to be the one that breaks the bad news. It never is easy to tell a patient they will lose their vision permanently or they will be requiring injections for life. I realise how complicated the art of surgery is, whether it be lids or cataracts. I am also responsible for calculating the lens implants that goes into people’s eyes, ordering them and making sure they are ready for my boss on time. This is probably the most stressful part of my job, as unlike glasses, changing a lens is much more difficult. My boss does double check my work. I am surprised how the IOL industry is evolving, we rarely implant monofocal lenses , most of the time we deal with multifocals or extended depth focus lenses which gives patients functional vision for both distance and near. However these patients are selected very carefully. Given the many happy patients outcomes I have seen, getting an IOL done when I undergo presbyopia is certainly something I would consider. Hopefully the IOLs will have come close to a normal human lens. I realise there is so much I am ignorant about when it comes to the eye and this unique situation allows me to realise this.
Q: How did you get into this unique area of optometry?
I found this job online, I think ophthalmologists are starting to see the worth in having an optometrist within their clinic. I cover about half my wage on consults but I believe I bring much more than monetary value to this clinic and I think my boss shares this belief. Especially where I am in rural Australia, ophthalmologists are often very busy and so having an optometrist with therapeutics can really lessen the load.
Q: What advice would you give to other optometrists who also wish to pursue this type of optometry?
If you take a keen interest in pathology, it is absolutely worth it. Although I cannot speak for what your responsibilities are at other ophthalmology clinics, I certainly couldn’t really think of anything, that I would change about my current job.
Q: What was your most memorable patient encounter?
I have plenty of memorable patient encounters that I can’t really single out one. I do build very strong connections with patients because I get to follow them up regularly and make the choices that impact their ocular health. I suppose the ones that are most memorable primarily revolve around delivering bad news to the patients.
Our 'Clinical Pearl of the Month' column is where we present a clinical pearl to provoke thought and discussion.
Optical dispenser: "Hey Optometrist, Mrs. Smith is having issues with his new glasses"
Optometrist: *knots begin to form in their stomach and they feel a sense of impending doom*
We all know the feeling.
Remakes are costly to a business and inconveniences the patient. Taking care of our patients is our top priority and we want to get it right each and every time. It isn't possible to eliminate remakes, but there are steps we can take to help reduce them.
1. What does the patient want to use the glasses for?
Show how much you care about your patients by listening to them and trying to understand what they want to use the spectacles for. A prescription is not just a jumble of numbers - it is also your recommendations. A prescription means nothing without recommendations. Does the patient need reading glasses, multifocals, split-seg bifocals with prism, extended focus lenses or a special set for their fine jewellery work? Clearly state your lens recommendations. Set aside some time to discuss realistic expectations in the consultation room.
2. Trial frame
Trial frame the prescription. Trial framing can tell you a lot about how the patient likes the prescription. After what I think are stellar refractions, I've been met with a humbling "oh my gosh that is way too strong!" or I feel nauseous" from my patients. Trial framing can save you a world of pain.
2. Make sure you correctly neutralise their current/favourite glasses (including heights, PD and check for prism)
Watch out for prism (of any orientation, up, down, in, out, yoked) or accidentally induced prism by the way the frame is sitting on their face. Lopsided glasses never did anyone any good... Check their cyl axis and don't make huge changes to their prescription without explaining adaptation.
3. Check their tear film
An unstable tear film is one of the biggest contributors to inconsistent refractions. If you suspect your patient has dry eyes affecting their refraction, instill a lubricating eyedrop before commencing. Long-term management of the dry eye issue is the goal.
4. Communicate with your optical dispensing team
The optical dispensing team is your greatest asset. Trust in your team and communicate regularly to ensure you are all on the same page. Ensure you clearly communicate what you would like dispensed for the patient. Has there been a prescription change?. E.g. Mrs. Wood has a +7.00DS prescription for reading. "Hi Dispenser, Mrs. Wood has quite a high script so it'd be great for her to have a smaller frame and custom (grind) high-index lenses to keep them nice and light for her."
Remember to communicate to the dispenser as to what vision the patient should be expecting with their new glasses. If the patient only reads N10, the dispenser will know not to ask them to read the N4 line when they pickup their new reading glasses (hopefully).
5. Remember, YOU are the expert
There will be times where the patient will need time to adapt to their new spectacles. It may be due to a new frame, material or change in prescription. Reassure them and give them time. However, some remakes may be due to unrealistic patient expectations. Pass on your expert advice without forcing your opinion on their decision.