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).
The "Finding Your Niche" event was a success by all measures - a stellar line-up of speakers, truly engaging talks, genuine curiosity and quality CPD (12 pts, 2T!). It was humbling to listen to all the speakers share their journeys to how they practice the way they do today.
We had the magnificent Margaret Lam, who took us through the rollercoaster of life and the idea of work-life balance. Grant and Thao painted a picture of 'accidentally falling into a specialty' through true care for their patients, culminating in their interests in sports vision and advanced optics.
Gavin Boneham wowed us with his wealth of experience, built up over many years of hard work and dedication, Mark Kosek shared his journey into speaking roles and exploration of various specialities, asking all of us whether we were happy and satisfied with what we were doing.
Dr. William Trinh talked to us the power of education and critical thinking as medical clinicians, as well as the benefits of providing eyecare to communities less fortunate than our own. Finally, Chih-Chi Lee opened our eyes to accessing holistic care for our patients beyond just optometry and the excitement of behavioural optometry.
We thank our guest speakers for volunteering their time and sharing a piece of themselves to inspire all of us to find our niche. What a great event - we can't wait to hold it again. It isn't one to miss!
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!
This Young Unconventional Optometrist is both a practice owner AND a locum - talk about juggling roles!
Tell us a little bit about your journey into your field.
After I graduated uni I worked for corporate optometry to build up basic skills. A number of years later I ended up doing locum work and the odd BHVI clinic a few times a year to experience a different variety of practice. I was also limited in what I could do in corporate eyecare, and honestly I got bored do refraction day in and day out. I considered doing medicine at this stage but figured it was not worth the investment. I now own a small practice in partnership and continue to do locum and part time work in conjunction. I basically bought myself a job and didn’t do the numbers properly before I bought in (its nothing I regret though) I work for a behavioural optom once a week, which I never thought I would, and now has definitely changed the way I practice and see optometry as a whole, rather than just VA/refraction.
Tell us about your typical day at work (if 'typical' exists)
Typical optometry hours 9-5. General eye tests, mainly. (this is your bread and butter) Specialty contact lens fits (KC/ scarred cornea/ post graft) Lots of dry eye Myopia control for my kids on the weekend.
What are some benefits to working as both a locum and a practice owner?
Has allowed me to learn different niches of optometry and find what I like best.
What are some differences between what you do and a 'traditional' optometry job?
My job is pretty traditional. I just get more exposure to interesting cases due to the practice location. We have to deal with a lot of politics though including issues with referrals from the public to private sector.
What is the best thing about your job?
Freedom to do what I want for both myself and my patient. Everything you put into your practice eventually goes back to yourself (and your partners). Generally more rewarding, though the same can be said for a good independent or corporate practice. There’s also things that you hate doing, but you’re good at due to the numbers you see. So it’s good in a way for the practice still? Sometimes you’re just put into that positon and end up following that path.
What advice would you give to other optometrists who also wish to locum or own their own practice?
NETWORK, attend conferences , and always be eager to learn. Finding a good mentor who inspires you will help. Nothing beats actual experience, doing something yourself and getting your numbers up to improve your skill. A textbook or talk/seminar can only teach you so much. Its always different once you apply your knowledge in real practice.
What has been one of your most memorable patient encounters?
When your patient goes from 3/60 to 6/9 with an RGP and you change their life.
Is there anything you would like to change or improve about the way you practice?
Lots of things. But everything needs money/ enough budget to achieve. This isn’t always possible so you make do and remember there’s always plenty of time to learn it/or build it later.
We're excited to announce that Jane Kwon is joining us as a subcommittee member. She is a recent UNSW Optometry graduate and we're glad to have her on the team. Find out a bit more about her.
I was born in Paddington but grew up near the "Koreatowns" of Sydney (Yes, Strathfield for those of you who know ). I currently live in Port Macquarie which is a lovely city on the mid-north coast. I’ve fallen in love with the beautiful weather and beaches up here. My hobbies include vlogging and watching cute animal videos (I miss my cat).
I always wanted to be a healthcare professional because I love helping people and thought optometry would be a rewarding career. I now love that it also gives me the freedom to take up other hobbies.
Spending quality time with friends and family which has been quite difficult since moving up to Port Macquarie. I always keep in touch over skype and plan on visiting every month. I also love eating!
How do you spend your free time?
I love eating but hate cooking so now that I’m living away from home, I’m trying to figure it out one step at a time. Apart from that, I spend most of my free time filming and editing videos or watching dramas.
Hmm.. I’m usually good at erasing any embarrassing/stressful moments from my memory so I really can’t remember any.
YO has been with me during my optometry studies, I enjoyed going to their events and getting to know the team who were all very lovely and supportive. I wanted to be part of this amazing team who provide a great network and strong voice for young optometrists and soon-to-be optometry students.
I think all regional optoms/optoms working away from home will agree with me on this one - teleportation. While I love everything about working and living in Port Macquarie, it would be nice if I can go back to Sydney more often and skip the 4.5 hour drive/1 hour flight.
The journey of a thousand miles begins with one step.
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.
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.