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?
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 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.
Alison A.: My year as a new graduate has been quite a unique experience. I decided to head across the pond to learn from some of New York’s best ophthalmologists. It has been a steep learning curve, but the experience I have gained in just a year will surely shape my optometric practice for the better once I return home.
Patricia L.: I’ve found my first year out to be a steep learning curve but very worthwhile. It has allowed me to strengthen my clinical skills and helped me work out my areas of interest.
Anonymous: One of best/worst moments was when my patients chief complaint was that his eyes hurt too much when playing on the pokies. On a more serious note, it's also amazing how good the optos is at picking up retinal tears/detachments even with undilated pupils. One of my patients with previous retinal tears had a full blown asymptomatic RD and came in to get her RMS form. She was lucky she had an optos taken that day.
Anonymous: It’s been quite diverse (at least more than I expected in a metro area) in terms of patients, ocular disease and aspect of optometry like ortho-k/myopia control, cl, paediatrics.
Marriette K.: I would describe first year as incredible because of the many ways I have seen the applications of optometry improve people's vision and lives. All the challenges of time management and troubleshooting has helped me become more confident and competent practitioner and I am enjoying growing and becoming better and better everyday.
Piranaa A.: Moving out of home to a new town to start a new job was challenging at first but the community feel of working in a regional town where everyone is so welcoming and appreciative makes it so much easier! I have enjoyed my first year out of university and would definitely recommend my colleagues to work in regional towns where all your skills will be utilised everyday and your service will be always valued.
Michelle C.: Working in a regional location has been very rewarding. Patients are very grateful for everything we do whether it’s changing the add or detecting a retinal tear. The five minute drive to work is also great.
Howard L. : This year has been a large learning curve, with the most eye opening experience as you come across so many types of people in different walks of life.
Charles W.: I've had a great year so far, really enjoying what I do because I get along well with the staff. I stuck to the same practice that I was working as a dispenser during uni, so the friendships and bonds that was formed during that time carried over when I became an optom. It's really been rewarding for me.
Anonymous: One of best/worst moments was when my patients chief complaint was that his eyes hurt too much when playing on the pokies. On a more serious note, it's also amazing how good the optos is at picking up retinal tears/detachments even with undilated pupils. One of my patients with previous retinal tears had a full-blown asymptomatic RD and came in to get her RMS form. She was lucky she had an Optos taken that day.
Jessica C: “I think this year has been a big confidence booster. Working in a busy practice is tough but worth it because you learn lots so quickly.”
Vincent L: Sudden loss of vision . Fuck. RAPD. Fuck.
Lyn P.: My first year out since graduating has been filled with interesting and challenging patients and I've learnt a lot along the way. But being out in the real world has also allowed me to realise that there is so much more to learn and work on, both clinically and personally. I've also come to realise that becoming strong and confident as a person is something that needs time and focus too.
Rachel K.: As I look back on the past year, it's quite amusing to think how scared and nervous I was in the first few months I started out as a graduate optometrist, constantly worrying over whether I have made the right diagnosis, didnt miss anything, given proper management etc.. now after almost a year out, it has become less of that and more about providing best patient care and really utilising the support network around me. I have learnt so much through my peers and mentor, and undoubtedly my mistakes. Also, moving to a regional location definitely had it's advantages in terms of patient volume and variety, and I would recommend it to all the grads just starting out. All in all, if there is one thing that I have learnt from this past year as I transitioned from a nervous fresh grad to a somewhat more competent optometrist, is to not become complacent in testing and think that everyday/ every test is repetitive, because it's not.
Anonymous: Trust yourself by don't let it get to your head
Sylvia C.: The first year out has been both challenging and rewarding. My experiences have varied from simple script updates, to an emergency BRVO with macula oedema, to a young lady diagnosed with a brain aneurysm. Despite the occasional angry patient or screaming child, I'm looking forward to the surprises next year has to offer.
Emily P.: My first year out was daunting at first but it turned out to be the most rewarding so far. I was fortunate to be in a nurturing workplace with supportive front of house staff and optometrists. I also had opportunities to attend conferences where I realised my special interests in myopia control, orthok fitting and specialty cl fitting. Refraction is your bread and butter, explore and you'll find theres more to optometry."
Lisa F: The most rewarding and unexpected experience this year is definitely the connections I made with my patients. A red eye patient whom I was reviewing was getting weekly update of my training progress for city2surf and a patient's dad went out of his way to call and thank me for doing a thorough eye exam. Maybe I'm just really lucky to have had so many kind patients this year.
Anonymous: Still don't know what I'm doing half the time :)
Tyson X: A fantastic year of personal and professional growth. Highlights include seeing my first retinal detachment, initiating therapeutics for contact lens related microbial keratitis, removing metallic foreign bodies, dealing with a CRAO, comanaging an acute angle closure attack and teaching a 9-year old who had been bullied about his glasses how to insert/remove contact lenses. What makes these moments extra special is that on a personal note, they’re signs that I’ve overcome some of my greatest fears as a graduate optometrist; Missing disease, handling emergencies and dealing with kids
Jennifer B.: In my first year as a graduate optometrist, I feel that I have learnt so much more about optometry - not just in developing clinical skills but understanding how to deal with different characters and personalities of our patients. Some of the most rewarding moments of my year include convincing a patient with a macula-on retinal detachment to go straight to the closest hospital eye clinic rather than to his work meeting, finding papilloedema in an asymptomatic mentally impaired young girl, prescribing contact lenses for countless patients who just want to be specs-free on their wedding day, and prescribing specs for a 50 year old mentally impaired woman who just wants to read again.
Anonymous: Looking back, I have grown a lot as an Optometrist in the past year. Every mistake I've made along the way had been a great learning experience, and I was extremely lucky to have the help of really supportive mentors!'
Congratulations to Carina for receiving the inaugural YO Placement Scholarship. She has and is always involved with all things Optometry. Read more about this influential lady:
Name: Carina Trinh
Practice: Dresden (MLC Centre, Martin Place, Sydney)
What do you plan to do with the scholarship?
Originally, I wanted to visit a contact lens practice in Victoria that fits numerous babies, along with a whole variety of interesting patients with all sorts of lenses. However, I'm also curious to visit some orthokeratology gurus in New Zealand, so I will do some further research and approach the practices to find out what suits best - then will keep you posted!
How do you think the scholarship will help you?
I'm hoping that it will provide me a really good understanding of how their style of contact lens practice works, and also harness my interest into advancing my skills, so that I can better service patients in my area. I look forward to witnessing on-the-spot calculations and measurements from the experts, and also learning the nuances in communication, education, and counselling patients while balancing their contact lens needs with their other ocular health needs.
If you could choose one superpower what would it be?
Time travel - I've always had a curiosity to meet my ancestors to learn about the upbringing of my parents, my grandparents, and far beyond. It seems like a really humbling experience to better appreciate all the people who've made it possible for me to be here in existence today on this planet, typing away right now on my laptop. I suppose I'm really interested in what contributes to the making of a person be who they are and behave the way that they do, and this would allow me to use my parents as case studies! Although, time travel would also allow me to explore other galaxies, and also maybe experience life as a bacterium - sounds sort of zen.
Please join us in congratulating the Tier 3 Scholarship winner for 2018, Vivian Ho! Read more about her upcoming plans to make the most of her prize.
Name: Vivian Ho
Practice: OPSM North Sydney
What do you plan to do with the scholarship?: I hope to use it towards the Masters of Clinical Optometry program that I'm currently doing. Or the OEP course for Behavioural Optometry which I've completed 2 parts of.
How do you think the scholarship will help you?
It will help me gain more of an in-depth knowledge of what I already know, and extend that to other specialty areas. It will be very relevant and applicable to all areas of Optometry and better equip me when I come across more challenging situations.
If you could choose one superpower what would it be?
I would like to travel through time and space, would be interesting to see things from different perspectives.
YO in conjunction with the Centre For Eye Health (CFEH) held its first ever trivia night on the 18th of August 2018 at the Pyrmont Bridge Hotel. Dr Michael Yapp from CFEH was a phenomenal host, both writing and presenting the questions. It was a raucous night where Dr Yapp kept the crowd entertained with optometry but also non-optometry related questions. We learnt about common but also rare conditions that even the most experienced of us had not heard of before. All through this we dined on seafood or vegetarian platters. Thankyou to Dr Yapp and to those who attended, making it a fun and memorable night.
Congratulations to the prize winners and thankyou to CooperVision and CFEH for supplying the prizes:
1st place: Team OPTOMism (Prize $20 Apple/Android gift card and CooperVision power banks)
2nd place: Team EYE DEER (Prize Guide Dog plush and CooperVision power banks)
Last place: Vitreous is sweet (Free access to CFEH's webinar)
Name: Celine Zhang
Practice: Eyecare Plus Bankstown & Eyecare Plus Kareela
What do you plan to do with the scholarship? I will be attending the 13th Congress of the Orthokeratology Society of Oceania (OSO), held at the sunny Gold Coast this year. Ortho-K is such an exciting field and I can’t wait to equip myself with the latest information to implement into practice.
How do you think the scholarship will help you? Childrens’ vision and myopia control are two of my greatest passions. Myopia control is a strong need in the population of children I am seeing. Currently, I’m drawing upon therapeutic, spectacle lens and soft lens options to slow myopic progression and referring to my capable colleagues to fit ortho-K lenses. I’m very fortunate to work in practices that have topographers and fitting kits right at my fingertips – I would love to have the autonomy to prescribe ortho-K lenses and be involved in every aspect of myopia control for my patients. Being able to learn from the best in the field and attend the Beginner’s Bootcamp at OSO will be invaluable.
If you could choose one superpower, what would it be? The ability to understand and communicate with anyone in the world, regardless of language. It would also be useful to get into the thoughts of babies … what are you seeing through your new glasses?