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.
Tell us a little about yourself?
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).
How did you end up in optometry as a career?
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.
What are you most passionate about outside of optometry?
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.
Most embarrassing moment?
Hmm.. I’m usually good at erasing any embarrassing/stressful moments from my memory so I really can’t remember any.
What inspired you to join YO as a subcommittee member?
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.
If you had one superpower, what would it be?
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.
What is your current favourite phrase?
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.
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.
http://www.optometry.org.au/nsw/become-a-member/membership-application/
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.
https://www.acbo.org.au/members/signup/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.
http://www.aco.org.au/membership/join-the-aco
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.
https://www.cclsa.org.au/
OA
Recent graduate fees for optometrists, who have worked for 6 months, are discounted to $1746 (incl. GST)
http://www.optometry.org.au/nsw/become-a-member/
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).
http://www.oso.net.au/join
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.
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