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JUNE 2009 EDITION
Free Monitor
with 1 year Spectrum
subscription* Pg24
CPD PROGRAMME
CASE STUDY
– CONVERGENCE
INSUFFICIENCY
LASIK - BOOSTS EYE
SURGERY SAFETY
AND EFFICACY
ESSENTIAL CONTACT
LENS PRACTICE
– PART 1
IMPORTANCE OF
LENS MEASURE &
LENS FORM
FRONT COVER IMAGE
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contents
- June 2009 SPOTLIGHT & FEATURES
24
http://www.eyesite.co.za/magazine
16 HEADLINE NEWS
THE HPCSA PROVIDE THE GUIDELINES FOR VISION
SCREENING, ITINERANT PRACTICES AND MOBILE CLINICS.
30LASIK - BOOSTS EYE SURGERY SAFETY AND EFFICACY
READ ABOUT THE LATEST IN EYE SURGERY USING WAVEFRONT
3-D MAPPING TECHNOLOGY.
32 ESSENTIAL CONTACT LENS PRACTICE – PART 1
THIS FIRST PART OF THE ARTICLE GIVES A DETAILED
EXPLANATION OF THE INITIAL PATIENT ASSESSMENT.
40DRUG USE AND ITS EFFECTS ON THE EYE AND VISUAL SYSTEM
– PART 2
LEONI JOUBERT CONTINUES TO LOOK AT THE NEGATIVE
EFFECTS CAUSED BY DRUGS SUCH AS BARBITURATES, LSD,
INHALANTS, ECSTASY AND METHAMPHETAMINES.
48
44 CASE STUDY – CONVERGENCE INSUFFICIENCY
A LOOK AT HOW VISION TRAINING CAN BE USED IN
TREATING CONVERGENCE INSUFFICIENCY.
48IMPORTANCE OF LENS MEASURE & LENS FORM
A LENS MEASURE IS A VALUABLE TOOL WHICH CAN PROVIDE
IMPORTANT INFORMATION FOR A CLINIC OR PRACTITIONER
AND THE SIGNIFICANCE OF LENS FORM FOR INSERTS WHEN
FITTING PRESCRIPTION WRAP SUNGLASSES, IS DISCUSSED.
REGULARS
4 Editor’s Comment
6 News & Events
14
Headline News
56
CAREY’S CORNER
40
30
66
38
COLUMNS
38
RECOVERY OF FUNCTION
AFTER HEAD INJURY/ BRAIN
DAMAGE
66 A GLIMPSE INTO SOUTH
AFRICAN OPTOMETRIC
HISTORY PART FOUR
59 EYESITE.co.za CPD SEPTEMBER
2008 Programme
62
EYESITE.co.za Directory
JUNE 2009
EYESITE.co.za
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Telephone: +27 11 728-3307
Fax: +27 11 728-0450
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Web-Site: www.eyesite.co.za
editors
Editor: Simon Goldblatt
[email protected]
Technology Editor: Clinton Dicks
[email protected]
- comment -
Columnists: Leoni Joubert; Anthony Carlson,
John Carey, Hazel Sacharowitz,
Michelé Hlava
The Product Launches
In the last couple of months there have been a couple of new contact
lens products launched through a series of road shows. Johnson & Johnson
Vision Care launched The ACUVUE® OASYSTM for ASTIGMATISM on page 10
and Bausch & Lomb launched the new SOFLENS DAILY DISPOSABLE
TORIC FOR ASTIGMATISM together with their REVITALEYES CAMPAIGN
on page 14.
Contributors: Harry Rosen, Nishanee Rampersad,
Richard Pearson & Andrew
Hobday (Transitions Optical);
Fabrizia Degli Esposti (Liquidlingo
Communications), Aarti Singh
(Bausch & Lomb), Arifa Charafaray &
Belinda Gibson (Johnson & Johnson
Vision Care), Dr Mark Deist, Natalie
Jackson (Jenni Newman Public
Relations (Pty) Ltd), Russel Meyer &
Graham Chrich(Digital Optometry),
Gullan & Gullan Advertising.
On the software side, Digital Optometry has gone all out in their
launch of the latest version of the award winning software programme
– Spectrum. On page 24 you can read about testimonials from various
optometrists who have worked with the new Spectrum software
program.
Finally Optifin Finance on page 28 has been launched as a smart
financial solution that enables optometrists to enhance their service to
clients, while increasing their own turnover.
Accreditation: University of Johannesburg
Design & Layout: Wrayhaus Studios
[email protected]
Headline News
On page 16 you can read how the HPCSA has identified a need to
try and protect the public from the negligent effects of certain
practices and as a result of this has developed specific guidelines for
Vision Screening, Itinerant Practices and Mobile Clinics.
Photography: Simon Goldblatt, Clinton Dicks
& Warren Carlson
The Latest in Surgery Technology
Advertising: Simon Goldblatt
iLASIKTM is the world’s only bladeless vision correction technology. It is
the result of a decade’s worth of technical refinement and the first and
only method approved by NASA to improve the vision of U.S. astronauts. It is
also the only LASIK procedure which combines the IntraLaseTM
FS Laser System with WaveScanTM wavefront 3-D mapping technology,
a groundbreaking innovation which captures the unique imperfections
in each individual’s eye.
Reproduction: Burlington-Dataprint
Printing: Burlington-Dataprint
Distribution: Prestige Bulk Mailers
& Mercury Couriers
Dr Mark Deist is one of the first ophthalmologists in South Africa that is
certified to use the blade-free iLASIKTM procedure. You can read about
this breakthrough in vision technology on page 30.
EyeSite is a wholly owned
subsidiary of Domino Publishing
Essential Contact Lens Practice
Copyright 2009
Despite the significant advances internationally in contact lens technology,
materials and design which allows more patients to comfortably wear
contact lenses there is a lack of proactive recommendation by eye care
practitioners and high number of contact lens drop outs. This article on
page 32 describes how correct patient selection and pre-screening is a
key element in addressing both these issues.
The Golden Age of Optometry in South Africa
In the 4th part of A GLIMPSE INTO SOUTH AFRICAN OPTOMETRIC
HISTORY on page 52, John Carey describes how Optometry had only
“relatively recently received statutory recognition and to establish a
“professional image” to enhance status in the eyes of the public as
well as the medical profession.”
Copyright 2009 EYESITE.co.za. All rights reserved. No part of thispublication may
be reproduced or distributed in any form or by anymeans, or stored in a database
or retrieval system, without the prior written permission of the publisher.
©
Whilst every effort has been made to ensure the accuracy of it’s contents, neither
EYESITE.co.za, nor the editors can be held responsible for any omissions or errors;
or for any misfortune, injury or damages which may arise there from. The views
expressed in this publication are not necessarily those of EYESITE.co.za.
NEWS & EVENTS
CliC Magnetic Eyewear is the culmination of chic styling and clever design.
CliC is the only genuine product of
its kind that has a patented magnetic
closure on the bridge, polycarbonate
frames and continuous arms that
form a wrap-around neck band. The
end result is a secure and durable
pair of fashion glasses that is always
at the ready and can’t be sat on,
dropped or misplaced.
For further information and Exclusivity Options please contact
Claudio at 076 810 1314 or [email protected]
EYESITE.CO.ZA LAUNCHES
NEW INSTRUMENTS WEBSITE
Looking for a comprehensive range
of products including auto-ref
keratometer, phoroptors,
ophthalmoscopes,
tonometers, slit lamps?
Visit the new EYESITE.co.za
INSTRUMENTS website at
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ray-ban.com
NEWS & EVENTS NEWS & EVENTS
Silmo
- jumps into action Ever since its inception, the Mondial de
l’Optique has adopted a long-term perspective
with a stance that evolves through each
new season without departing from its fundamental values: a comprehensive product
range, an open minded approach, market
awareness and an ability to anticipate new
trends…
As a platform to do business and explore the latest products
on the market, SILMO remains a valued point of contact
recognised by the entire optics and eyewear sector. Much
more than just a trade fair, the Mondial de l’Optique casts
a prospective eye over the profession, remains committed
year on year to get the sector moving, understand the
expectations and needs of both visitors and exhibitors, and
keep a step ahead of the market in order to integrate new
avant-garde ideas and adopt proactive concepts.
A commitment to highlight professional achievement by
means of the Silmo d’Or Awards which celebrate innovation,
aesthetic appeal and creativity from the top companies
and brands across the globe along with trend forums, workshops and the Cahiers du Silmo guide.
A commitment to stimulate creativity with the founding of
the Village, a unique exhibition area showcasing creative
brands and new companies in the sector – a feature which
last season launched an evening of entertainment, the After
Village, bringing together clients and exhibitors to party…
at the same time as doing business.
A commitment to develop all market opportunities with a
stand dedicated to Low Vision (the only one of all professional
trade fairs in the sector!) giving opticians the chance to better
understand visual deficiencies via a multi-sensory pathway.
A commitment to meet the major challenges of today not
only by dedicating a special Silmo d’Or award to sustainable
development, but also by integrating ethical and ecological
norms into the organisation and planning of the event (waste
sorting, energy efficient lighting, etc.)
A range of commitments all demonstrating the difference
that SILMO has successfully created in order to attract
professionals from all over the world.
SILMO 2009 COMPETITION
Rendez-vous in Paris from 17 to 20 September 2009
Paris – Porte de Versailles
You can win one of 3 prizes if you enter this competition
1st prize:
One return ticket to SILMO and 3 night’s accommodation
2nd and 3rd prize:
Moet & Chandon bottle of champagne
You need to answer the following questions:
When SILMO will be held this year?
Where does SILMO take place
What is the name of the Silmo Award Competition?
To enter the competition,
each participant will be exclusive to optical industry
You will need to either e-mail
PROMOSALONS SOUTHERN AFRICA, exclusive agent for SILMO
at the following: [email protected] or
enter online: www.promosalons.co.za/silmo
Ref: Silmo 09
Entries closed by: 30th June 2009
Draw 14th July 2009 at Promosalons office
Get ahead of the market
Paris
Porte de Versailles
France
www.silmoparis.com
PRESS RELEASE
Acuvue
- launch -
Johnson & Johnson Vision Care recently
launched their latest innovation in the
Acuvue® Brand Contact Lens range, the
ACUVUE® OASYS™ for ASTIGMATISM.
Colin Atkinson, Business Manager of Johnson & Johnson Vision
Care South Africa stated the following: “We are committed
to innovation and developing products to meet the needs of
patients and understand that patient satisfaction is of utmost
importance to Eye Care Professional’s. He mentioned that
only 33% of toric lens wearers are very satisfied with their current lenses1 and as a result, Johnson & Johnson Vision Care
saw the need to offer eye care professionals an astigmatic
soft lens which is as easy to fit as a spherical soft contact lens,
is stable on the eye and would offer patients improved performance in terms of clear stable vision as well as comfort and
health.” Furthermore, he added: “We listened to the needs
of our customers and many eye care practitioners who have
requested this unique product as a result of the success
of ACUVUE® OASYS™ with HYDRACLEAR® Plus in the South
African market.”
ACUVUE® OASYS™ for ASTIGMATISM combines the unique
Accelerated Stabilisation Design technology, and the material benefits of Senofilcon A with HYDRACLEAR® Plus, which
has a higher oxygen flux compared to hydrogel lenses, it
is more smooth and flexible, and offers the highest UV
protection in any contact lens which is Class 1. The Accelerated
Stabilisation Design has shown a number of advantages over
traditional designs in reducing variable vision and blur 2-5
and was developed after much research to understand
what happens during blinking as well as the interaction
between the lids and the lens. With the Accelerated
Stabilisation Design, there is minimal destabilising interaction
with the lids when the lens is in the correct position. Only when
the lens is misaligned, does lid interaction have maximum
effect by utilising the upper and lower lid forces to orient and
stabilise the lens to return it to its correct position.
The ACUVUE® OASYS™ for ASTIGMATISM is available in the
South African market from 01 April 2009 in an extensive launch
parameter range which covers 90% of astigmatic prescriptions.
The lens can be prescribed for extended wear one week or
for two weeks on daily wear basis. Additionally, the improved
design aids for ease of insertion and handling.
If your astigmatic patients would like the benefits of more
stable vision, greater comfort, health or the option of
sleeping in their lenses, we would recommend offering
ACUVUE® OASYS™ for ASTIGMATISM.
10
1. Data on file 2005, Johnson & Johnson Vision Care inc.
2. Hickson-Curran S and Rocher I. A new daily wear silicone hydrogel lens for astigmatism. Optician, 2006;232:6067 21-25.
3. Zikos GA, Kang SS, Ciuffreda KJ et al. Rotational stability of toric soft contact lenses
during natural viewing conditions. Optom Vis Sci, 2007;84:11 1039-45.
4. Chamberlain P, Morgan P, Maldonado-Codina C and Moody K. A vision chart to
quantify disturbances in acuity during wear of toric contact lenses. Optom Vis Sci,
2008; E-abstract 85079.
5. Young G and McIlraith R. Toric soft contact lens visual acuity with abnormal gaze and
posture. Optom Vis Sci, 2008; E-abstract 85051.
Discover the toric lens that moves less
so your patients can move more.
The difference is in our unique Accelerated Stabilisation Design.
Unlike traditional ballast designs, ASD harnesses the natural pressures of both lids during blinking to balance the
lens in place and quickly realign it if it rotates out of position. Also ASD is less influenced by gravity so your patients
can experience clear, stable vision1 - no matter how active their lifestyle may be.
As well as ASD, ACUVUE® OASYS™ for ASTIGMATISM
with class 1 UV Blocking combines the proven senofilcon A
material and HYDRACLEAR® Plus Technology that helps
keep eyes feeling fresh and moist all day long.
Traditional ballast design
Our unique ASD technology
159/1
No other toric lens combines all these benefits - so let your
patients experience it today!
1. Johnson & Johnson Vision Care Data on file, 2006. ACUVUE® and ACUVUE® OASYS™ with HYDRACLEAR® are registered trademarks of Johnson & Johnson Vision Care. © JJVC 2009, a division of Johnson & Johnson Medical (Pty) Ltd.
NEWS & EVENTS
World
Glaucoma
day 2009
For the second consecutive year, World
Glaucoma Day was commemorated in
March in an effort to raise awareness about
the silent “thief of sight” – Glaucoma. The
particular focus this year in South Africa
was to urge people with a family history of
glaucoma to have their eyes examined.
Dr Ellen Ancker examines glaucoma patient Nigel Curling at her
private practice in Cape Town prior to World Glaucoma Day
Locally, leading eye care company, Alcon Laboratories, in
association with the South African Glaucoma Society, embarked
on a countrywide communication initiative to increase awareness
about this devastating disease, and in particular, to reinforce the
message that family members of glaucoma sufferers are at a
much higher risk of developing this disease and need to have
regular eye tests.
Prof Grant McLaren examines celebrity and business woman Gerry
Rantseli-Elsdon for glaucoma at St John’s Eye Clinic at Chris Hani
Baragwanath Hospital in Soweto
A joint initiative between the Department of Ophthalmology at
the Steve Biko Academic Hospital in Pretoria and the National
Council for the Blind, supported by Alcon Laboratories, saw free
glaucoma screening take place at Mamelodi Hospital in Pretoria
on World Glaucoma Day, 12 March 2009. Of the 267 patients
screened on the day, twenty newly diagnosed cases of glaucoma
were found (7.4% of those tested). This number is slightly higher but
confirms estimates which state that glaucoma affects around 5
to 7% of the black population, and 3 to 5 % of the white population
in South Africa.
In the Western Cape, free screenings and awareness campaigns
took place in various regions, driven by local opthalmologist Dr
Ellen Ancker. Dr Ancker also arranged former Cape Town Mayor,
Helen Zille to release a proclamation about World Glaucoma
Tim Borland from Alcon, 72 year old Amos Mziza, Maireen Kemp
and Prof Polla Roux from the South African Glaucoma Society
pictured during the free testing held in Mamelodi on World
Glaucoma Day. Amos Mziza was the second patient diagnosed
with glaucoma during the free testing held that day.
Day which led to a significantly heightened awareness about
glaucoma in the region.
At the St John’s Eye Clinic at Chris Hani Baragwanath Hospital
in Soweto, patients over the age of 40 were invited to free
screenings on World Glaucoma Day. The first 40 patients were
screened with the remaining persons being booked for
screenings on subsequent Thursdays. St John’s Eye Clinic, under
the auspices of Dr Grant McLaren, runs free glaucoma screening
on every Thursday throughout the year.
Other screenings also took place at Tshwane District Hospital,
Pretoria West Hospital and Pretoria Eye Institute in Gauteng as well
as the National Hospital and Pasteur Eye Centre in Bloemfontein
and Vincent Mall and Mdantsane Mall in East London.
12
Maireen Kemp tests the pressure in Mamelodi resident Gladys
Mothong’s eyes to assess whether she may have glaucoma
NEWS & EVENTS
Pna Shows it’s Heart
for eyes -‘Give The Gift
Of Sight’ Campaign
PNA, one of South Africa’s leading stationery,
book and art material retail groups in close
collaboration with supplier partners, HP,
Jetstream, Pritt, Fiskars, GBC, Rexel and
Bantex, launched a groundbreaking in
store campaign on Saturday 30 May 2009,
at Greenstone Shopping Mall.
R1 of every flagged product sold
within the 47 PNA stores, will be
donated to The Vision in Sight Trust
(The fundraising leg of The South
African Optometric Association).
The trust provides eye care to
indigent communities throughout
South Africa. All the proceeds
from the PNA campaign, which
runs until the end of December,
will be dedicated exclusively to
children’s eye care.
The launch event at Greenstone Shopping mall had a strong
celebrity contingent with the likes of Cobus Gomes, MC for
the event(Gertroud met Rugby),Claudia Henkel (ex-Miss SA),
Courtney Truebody (Little Miss World SA, Miss Petite Africa 2008),
YO-TV presenters and lead singer of popular local band
John-Henry Opperman lending their support. John-Henry
also performed the song he wrote about eye care for the
first time. Free eye screenings were performed by Greenstone
resident optometric practices, Rene Vrey and Grand Optical.
Models
aged 4-8 years from Pageants SA/House of Style
modelling school modelled Fisher Price (donated by Jessen
Fashion) and Kidz Banz( donated by Kidz Banz) sunglasses. Safilo
SA sponsored Cobus with a pair of Carrera sunglasses.
The day was packed full of fun, entertainment, giveaways
and competitions. Children were also able to meet the delightful
PNA mascot, Penny and the huggable Mr Pritt.
“ ‘Give The Gift of Sight’ campaign is all about PNA
Giving back to our future leaders. We are proud to
support a cause that creates opportunities for a better life through sight and thus being able to read .”
Herman Botha - General Manager - PNA
13
PRESS RELEASE
Bausch &
Lomb
- launch -
Bausch & Lomb launches new soflens
daily disposable toric for astigmatism
and revitaleyes campaign.
Johannesburg, Pretoria, Cape Town, Durban, Port Elizabeth
and Bloemfontein, whereby the new Soflens Daily Disposable
Toric for Astigmatism and the Revitaleyes Campaign were
revealed. Optometrists enjoyed time to socialize with their
colleagues before being treated to a relaxing evening out
Bausch & Lomb recently unveiled their
at the movies with complimentary popcorn and cooldrinks
latest innovation in the contact lens market,
SOFLENS DAILY DISPOSABLE TORIC FOR
ASTIGMATISM. Building on the company’s
strong heritage and footprint in toric lens
technology, this is the first time that this
unique design can now be offered in
a daily disposable lens for astigmatic
patients, helping to ensure easy fit and all
to go with the movie.
day comfort.
In conjunction with the launch of the new lens, Bausch and
Lomb also revealed the launch of the new exciting Revitaleyes Campaign. The campaign is being run in conjunction
with Starlight Cruises and winners of the competition stand a
chance of winning a 4 night stay aboard the new MSC
Sinfonia-the newest luxury vessel added to the Starlight
Cruise portfolio. The MSC Sinfonia epitomizes world class 5
star luxury, catering for everyone’s perfect holiday and
ensuring sun filled days and fun soaked nights.
A launch evening, attended by optometrists, was held at
various Ster Kinekor cinemas around the country including
14
The launch events proved to be very successful with great
excitement and hype being shown around this new
campaign. This initiative from Bausch and Lomb is one of
the largest the industry has seen and is specifically aimed
at growing the contact lens market and increasing
optometrists business by drawing more feet to their practices
while striving to perfecting vision and enhancing life.
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HEADLINE NEWS
headline
news
Compiled by Harry Rosen - [email protected]
The guidelines for this article have been acredited by the HPCSA.
VISION SCREENING, ITINERANT PRACTICES AND MOBILE CLINICS
INTRODUCTION
The ever increasing numbers of practitioners competing
for “business” within the urban areas has resulted in them
experiencing the constraints of over-serviced markets. This
has resulted in numerous attempts being made to increase
the individual share of the diminishing market and hence
one sees the introduction of mobile practices and corporate
vision screening. As these initiatives are being undertaken in
already well serviced areas, they contain elements of
canvassing and touting as they attempt to lure patients away
from colleagues within the areas. This unfortunate scenario has
resulted in the PBODO identifying a need look into protecting
the public from the negative effects of these practices. These
guidelines cover vision screening, mobile practices.
DEFINITIONS:
Primary Care Practitioner:
A primary care practitioner is defined as one “who knows
the patient, is available for first contact and continuing care,
and who offers a portal of entry to specialists for those
conditions warranting referral”1.
error, binocular abnormalities and diagnose primary ocular diseases or
ocular diseases secondary to systemic problems.
Itinerant Practice:
A practice which a practitioner conducts on a regular basis at a
location other than at his or her resident practice addresses (i.e. a
satellite practice).
Mobile Clinic:
A practice which a practitioner conducts out of a vehicle. This vehicle is
used to move from place to place to offer care. The goal of rendering
service from a mobile clinic is to make health services accessible to
communities who are otherwise under serviced.
A. VISION SCREENING
Protocols for industrial, corporate, community and school screening
In serving its role of protecting and educating the public and guiding
the professions - the PBODO has identified a need to develop guidelines
for vision screening activities performed within the industrial, corporate,
community and school environments.
Preliminary Disciplinary Committees are frequently faced with various issues
pertaining to activities performed under the guise of vision screening.
The comprehensive examination of the eye and surrounding
tissues, with or without special equipment enables the practitioner
to diagnose primary ocular diseases or ocular diseases
secondary to systemic problems. For this reason, Optometrists
are regarded as primary eye care practitioners.
These aberrant activities include canvassing and touting of patients,
exploiting medical aid benefits of members, over-reaching for services
rendered (i.e. performing a screening, but invoicing a full examination
fee), over-servicing and misleading employees into believing that the
screening is compulsory, to name a few.
Vision Screening:
A vision screening is an assessment made to discover and
refer individuals who may need a comprehensive eye
examination and further management by an eye care
professional.
Vision Screening vs. a Comprehensive Eye Examination
Eye Examination:
A comprehensive investigation of the eyes, surrounding
tissues and visual system, to identify and correct refractive
16
Vision screening is an entry level investigative procedure where the
goal of the activity is to identify individuals in need of referral for a
comprehensive examination. As such - no definitive diagnosis, management
or prescription is issued from the screening procedure. Outcomes of the
screening process include the provision of referral notes to the individuals
identified as requiring further investigation and generation of statistical
reports for the respective corporate, industrial or school management.
I =:6 G ID;: N : L : 6 G
NEWS & EVENTS HEADLINE NEWS
During this “visual screening” exercise, should a diagnosis be
made, and a prescription given and/or dispensed, the
service can no longer be regarded as a vision screening and
should be seen as a comprehensive service. In this case the
professional service and responsibility should comply with
the standards of care for a comprehensive eye examination
as determined by the PBODO of the HPCSA. (Appendix 1)
Elements of a Vision Screening Procedure
A basic screening should include the following elements:
1. Brief history
2. Uncorrected VA (R, L, Both) at 6m and 40cm
3. Habitual VA (R, L, Both) at 6m and 40cm
4. Pinhole VA (R, L, Both) at 6m and 40cm
(where VA<6/9) + lens evaluation (latent Hyperopia)
5. Oculomotor evaluation (9 cardinal positions of gaze)
6. Accommodative tests
7. NPC
8. Pupil responses
9. Colour vision
10. Stereopsis
11. Visual fields
12. External Health
13. Internal Health
14. Tonometry
Depending on the goal of the screening and the population
screened, the test battery used might vary considerably and
may be limited to only a few of the procedures mentioned
above. In such a case it should be made clear to the population being screened what the goal of the screening is and that
the services rendered are ‘For Screening Purposes Only’. e.g.
Goal: School screening
a. Should the population be young children, emphasis might
be placed on skills related to academic performance
and concentration. The practitioner may need to include
or exclude additional procedures e.g. include perceptual
tests or exclude tonometry for children.
Goal: Glaucoma screening
b. Should the goal of the screening be to identify patients
at risk for the development of e.g. Glaucoma – the tests
selected for the screening protocol will be selected for
their particular isolated diagnostic value and individuals
screened must be informed that only one aspect has been
screened and that a vision screening or comprehensive
visual examination must still be undertaken.
The use of auto-refractors has become commonplace and
an easy and fairly accurate way to determine the relative
change in refractive error compared to a patient’s current
prescription. However the use of an auto-refractor as part of
a standard screening procedure is by no means a necessity and
must be used in conjunction with all the other tests needed
to conduct the necessary tests for vision screening. Autorefractors must not be used on their own as they do not fulfill
the required components of vision screening.
18
Canvassing and Touting
Within the current rules of conduct pertaining to professions
regulated by the HPCSA, the solicitation of ‘business’ by
practitioners under the guise of vision screening would
contravene the principles of touting and canvassing.
Should practitioners wish to screen employees of a corporate
entity or learners at schools, this would need to be instituted
as a community service initiative, preferably under the
auspices of their professional body or with the collaboration
of other resident practitioners.
Educational pamphlets with markings ‘sponsored by….
Screening Optometrist’ or a referral note stating “further
examination by your optometrist or eye care practitioner
is recommended – sponsored by …Screening Optometrist”
would be acceptable.
At no time should the screening be deemed compulsory.
Many of the employees or learners might have their own
preferred optometrists or eye care practitioners whom they
might rather choose to see. Any attempt to direct patients
to your practice will be considered canvassing and touting
and will also contravene the regulations on supercession.
NB: Should a business, corporation or school approach the
practice and/or practitioner and invite the practitioner to
render a screening service at their facility the practitioner
has the responsibility to advise the institution about the
regulations governing the practitioner and to ensure that
necessary procedures have been followed e.g. informed
consent from individuals (parents/guardians) to be screened
and unacceptable advertising or promotion of the practitioner
has not occurred.
2. MOBILE CLINICS
Noting the need to improve access to eye care services in
underserved areas in the country, the PBODO identifies
mobile services as an interim means to achieve this until
permanent health facilities are developed. The PBODO
additionally realises its responsibility to ensure that initiatives
to improve access are conducted within a regulated framework and employs the same standards of care that pertains
in areas where eye care services are adequate. .
Currently, mobile practices are fraught with various
professional transgressions such as inadequate level of care,
canvassing, touting etc.
Disciplinary Preliminary Committees are regularly faced with
complaints concerning mobile units and have difficulty tracing the responsible practitioner. The practice of “hit and run”
is not ethically or professionally acceptable. It has been noted
that mobile units are conducting services in areas that have
adequate numbers of practices and hence servicing
already over-serviced areas, exacerbating the neglect of
underserved areas of the country.
Mobile practices should at least comply with the following
basic rules:
1. Practices should be registered for operation within a defined underserved area only.
2. Equipment must be as defined for a comprehensive visual
examination
3. Optical appliance dispensing must be conducted by the
original practitioner at the site visited.
NEWS & EVENTS HEADLINE NEWS
4. Practitioner concerned must have an established office/
practice from which the mobile clinic is operated. Patients
must be able to contact the practitioner at this office
should they require further assistance or care. Patients
should be provided with details of the practitioners fixed
address and closest health facility for emergency ocular
health care. The registered practitioner owning the mobile
unit must make arrangements with the respective health
facility to accept the patients in cases of emergency.
5. Stand alone mobile clinics are not encouraged.
6. Practitioners must at all times comply with the ethical as
well as advertising rules laid down by the HPCSA.
The Professional Board of Optometry and Dispensing Opticians
does not support this method of practice unless it complies
with the guidelines. Practitioners and institutions wanting to
use this method of service must apply with motivation to the
HPCSA Professional Board for Optometry and Dispensing
Opticians for approval.
Applications will be considered by the Professional Board
and should the application meet the criteria, registration will
be granted for a 3 year fixed period. Applicants will be
required to re-apply every 3 years.
All practitioners (including NGO’s) must apply prior to setting
up a mobile practice. All practitioners rendering care at the
time of promulgation of this legislation should ascertain their
compliance to the regulations and should apply for registration
with a period of four (4) months from date of promulgation.
3. ITINERANT PRACTICES
Noting that mobile practices is in essence a form of itinerant
practice - it is the view of the PBODO that a mobile practice
should comply to all regulations relevant to itinerant practices.
It shall therefore only be permissible for a practitioner to
conduct a regularly recurring itinerant practice at a place
where another practitioner is established if, in such itinerant
practice (or mobile practice), he or she renders the same
service to his or her patients, at the same fee or fees, as the
service which he or she would render in the area in which he
or she is resident.
4. SUPERSESSION
In rendering care at a mobile or itinerant practice - no
practitioner shall supersede or take over a patient from
another practitioner if he or she is aware that the patient
is under treatment of another practitioner, unless he or she
takes reasonable steps, as a matter of courtesy, to inform
the practitioner who was originally in charge of the case
that he or she had taken over the patient at that patient’s
request and to establish from the original practitioner what
treatment the patient previously received, and, in such a
case, the original practitioner shall be obliged to provide the
required information.
The PBODO endeavours to uplift and maintain the standards
of care of the practice of the profession, irrespective of the
context within which the service is undertaken.
in the case of a minor, the parent or guardian of such minor,
from obtaining the opinion of another practitioner or from
being treated by another practitioner.
APPENDIX 1
THE GENERAL EYE EXAM
The BASIC eye exam that an optometrist conducts should
comprise the following:
1. CASE HISTORY
An in depth case history is taken to elicit the patients chief
complaint. Questions relating to general and ocular health
history, relevant family history, medication, allergies and
visual needs are asked. At the end of the case history, the
optometrist should have a preliminary diagnosis.
2. CLINICAL EXAMINATION
• Taking Visual Acuities at distance and near (aided and unaided)
• Visual Skills Investigation – saccades, pursuits, NPC, accommodative skills
• External Ocular Health Examination – Slit lamp examination
of external ocular structures & papillary reflex evaluation
with penlight torch
• Visual Fields Screening
• Objective Refraction
• Subjective Refraction
• Binocular Vision Evaluation
• Internal Ocular Health Examination
• Intra Ocular Pressures
• Dispensing of optical appliance, if required
3. PATIENT EDUCATION
Patients should be adequately informed as to their current
visual status, use of the optical appliance prescribed and
relevant health information. Advice should be provided on
related health issues.
• Appropriate referral if necessary
NOTE: These clinical diagnostic procedures are the MINIMUM
REQUIREMENTS of a basic eye examination. Additional investigative techniques would be expected should the case
require these e.g. taking of blood pressures, dilated fundus
examination for diabetic patients or detailed colour vision
investigations for truck drivers etc.
MINIMUM OPTICAL DISPENSING REQUIREMENTS
1. Case History (either as part of the optometric exam or a
separate case history if the patient has not had an eye
exam).
2. Performance of ocular measurements for the purpose of lens
centration (vertical, horizontal, binocular & monocular).
5. IMPEDING A PATIENT:
3. Performance of facial/head measurements for the purposes of correct frame selection and fitting.
A practitioner rendering screening services or rendering
services from a mobile clinic shall not impede a patient, or
4. Assessment of vertex distance and pantoscopic angle
fitting.
20
HEADLINE NEWS NEWS & EVENTS
5. Analysis of the prescription for the most appropriate lens
and frame selection.
6. Analysis of the patient’s lifestyle in terms of vocation, occupation, working distance, environment and safety factors
for the purposes of prescribing the optimum lens/frame.
MINIMUM EQUIPMENT REQUIRED FOR CONDUCTING A BASIC
VISUAL EXAMINATION
In order to charge a patient the consultation fee for a visual
examination and/or prescribe a visual appliance, the practitioner
must possess and utilize the following equipment:
1. VISUAL ACUITY CHARTS: Distance and Near
2. BINOCULAR VISUAL SKILLS ASSESSMENTS: Age appropriate
targets
3. PENLIGHT TORCHES
4. RETINOSCOPE or AUTO-REFRACTOR
5. OPHTHALMOSCOPE
Should contact lenses be prescribed, the procedures must
be as defined in the Guidelines for Fitting Contact Lenses
available on www.hpcsa.co.za
6. SLIT LAMP BIOMICROSCOPE
7. PHOROPTER or TRIAL LENSES and TRIAL FRAME
References
8. COLOUR VISION TEST
1. Catania L.J. Primary care. In: Newcomb RD, Marshall EC, eds. Public
Health and Community Optometry, 2nd ed. Boston: Butterworth’s,
9. VISUAL FIELD SCREENING TEST
1990:295-310
2. Explanatory notes will be sent out to everyone in due time.
10. TONOMETER
Cape Global Eye Care Centre and Professional Placements
Are you an optometrist looking for a position?
Do you need an optometrist for your practice?
Contact us today!
Head Office Vredenburg
Tel: 022-715 3200
Fax: 022-715 3200
After Hours: 083 375 0909
Email: [email protected]
www.capeglobaleyecare.com
PRESS RELEASE
Transitions
Optical
- guarantees 100% satisfaction -
Transitions Optical is continuing its ‘Satisfied
or Exchanged’ programme which enables
consumers to return their Transitions lenses®
with Advanced Performance, in exchange
for clear lenses, if they are not entirely
satisfied with the photochromic characteristics of the product.
The campaign, first released in October 2006, was one of
the key drivers in the growth of Transitions Optical that year.
Since then the programme has resulted in an increase in
sales with a minimal number of returns during the time
period in which it runs.
In 2007 the programme was
re-released for a 3 month period and in 2008, with the r elease of the much anticipated Transitions VI technology (which
consumers know as Transitions lenses ® with Advanced
Performance), Transitions Optical opted to support all
Transitions VI lenses with the programme. “The ‘Satisfied or
Exchanged’ programme benefits dispensers by giving them
an opportunity to recommend Transitions lenses ® with
Advanced Performance risk free, to all consumers, thereby
increasing sales, profits, and consumer satisfaction,” says
Richard Pearson, Country Manager Transitions Optical SA.
“We are so confidant that consumers will be completely
satisfied with our new technology that we are prepared to
guarantee it,” continues Pearson.
The ‘Satisfied or Exchanged’ guarantee states that if the
consumer returns their lenses – within 30 days of purchase –
due to dissatisfaction as a result of the lenses’ photochromic
22
performance, the consumer will receive replacement clear
lenses, in the same prescription, index, design and coatings
at no cost, and will be reimbursed the difference.
The ‘Satisfied or Exchanged’ programme will benefit dispensers and optometrists alike by giving them an opportunity
to recommend Transitions lenses® with Advanced Performance with complete piece of mind and renewed confidence.
Ultimately th i s w i l l l e a d t o i n c r e a s i n g s a l e s a n d m o r e
importantly consumer satisfaction. “We know from
experience that if consumers try our lenses we will have
practically no returned product. This will help nurture the long
term growth of the photochromic category,” adds Pearson.
For more information on the programme please contact
either your local lens caster, or one of the local Transitions
Representatives.
APULA (A11846)
Transitions VI lenses perform as promised, guaranteeing
100% satisfaction
You stand behind your work, and we stand behind ours. Not only do we promise outstanding performance with every pair
of Transitions lenses, we back it with a 100% satisfaction guarantee.
Now you can introduce Transitions lenses to all your clear lens patients with complete piece of mind. Our offer proves that
when given the choice, patients prefer all the added benefits of Transitions lenses over regular lenses. Increasing sales and
boosting customer satisfaction couldn’t be easier with Transitions lenses.
Transitions lenses are convenient everyday clear lenses that do more: When outdoors they automatically adapt to changing
light, they darken to reduce glare so you can see better today and they protect from harmful UV rays so you can see better
tomorrow. In addition you now have the satisfied or exchange promise, where if they are not 100% satisfied with the
performance of the technology within 30 days of purchase Transitions will exchange the product for a clear pair.
Transitions VI lenses enhance the everyday visual quality and help preserve the health and well-being of your patients’ eyes,
so they can see better today and tomorrow.
1
#
recommended
Transitions and the swirl are registered trademarks of Transitions Optical, Inc. Healthy sight in every light is a trademark of Transitions Optical, Inc. © 2009 Transitions Optical, Inc.
spectrum
- advanced optometry superior care -
Since winning the Visionary Award in 2006, Spectrum has taken
the South African eye care industry by storm. With the backing
of Transitions Optical™ and over 10,000 patients being tested
monthly, Spectrum is slowly becoming the gold standard in eye
care. A recent study conducted among South African users and
their patients revealed the following:
Equipped with a wider variety of
diagnostic tests, Spectrum© saves
you time in consultation.
older technologies such as wall mounted charts and projectors, are
now accessible giving you greater accuracy and ease of testing in
less time than ever before.
Nothing in the same price range
has grown your practice as much
as Spectrum©
Definately
Yes
Definately
Unsure
Yes
No
Unsure
Not at all
No
0
Not at all
0
20
40
60
80
100
As global optometric trends continue to filter into the South
African market the modern optometric practice is under all kinds
of pressure. With profit margins under constant scrutiny, increasing
overheads and more optometrists in urban areas it has become a
challenge to maintain the good days of yesteryear. With medical
aid and medical aid administrators enforcing product supply
at lower profit margins, combined with less patient disposable
income, how is the profession to survive these changing times?
Either increase the number of transactions per day or decrease
the cost of service delivery. With annual overhead increases,
practitioners increasing volume often becomes the only
option. Saving time without compromising on clinical tests and
procedures becomes a new challenge as patient confidence
and loyalty often run out the door when patients leave feeling
rushed. Specialized tests previously unable to be performed with
24
20
40
60
80
100
As the scope of optometry continues to increase, outlay costs
in the modern day optometric consultation room continue to
escalate. Spectrum© has brought all the clinical tests and those
forgotten ones of the past into one software solution. Now staying
ahead of the game no longer means purchasing outdated costly
instruments, wall mounted charts, booklets and other tests, as
Spectrum© delivers it all at the click of a button. Equipped with
an entry level PC or laptop, Spectrum© installs within minutes and
you are ready to go. For less than the cost of an eye test and
with almost no capital outlay, we guarantee Spectrum© will be an
invaluable investment.
“Spectrum has closed the gap between
patient and practitioner. I have many
compliments and referrals”
Christina Mc Gregor – Optometrist Plettenberg Bay
“Spectrum has made eye-testing
fun again”
Spectrum© has equipped you with
the diagnostic and refractive tools
you need.
Carl Slabber – Optometrist Port Elizabeth
With Spectrum© eye testing system
you have noticed an increase in
the number of new patients through
word of mouth marketing.
Definately
Yes
Unsure
No
Not at all
Definately
0
20
40
60
80
100
“I really enjoy Spectrum for the
variety of tests available. We do a
lot of LV, and we find it very useful
to be able to scroll to 6/300, and
randomize the letters”
Karen Beneke – Optometrist Randburg
Yes
Unsure
No
Not at all
0
20
40
60
80
100
What is the main reason when
choosing an eye care practitioner?
How would you rate the eye test you
had today?
Cost
Location
Eye Test
Best
Fashion
Good
Other
Average
0
Poor
0
20
40
60
80
100
We are living in the digital age and business without computers is
obsolete. Optometry has evolved from paper charts, illuminating
boxes with mirrors, and projectors to LCD monitors and computerized
systems. Previously we were restricted by the equipment and its
limitations. In order to offer any new specialized diagnostic tests or
show products, additional equipment had to be purchased, and
switched on and off at the appropriate moments. Spectrum© has reintroduced many of the older tests, and the practitioner now has the
advantage of cross referencing his results. Many tests only offered
at near, are now available in the distance, with the convenience of
conducting the tests without removing the phoropter.
The advancement of the internet can never be overstated and
Spectrum© has taken full advantage by building in functionality
to auto-update the application, keeping you abreast of new
innovative tests, upgrades, product information as well an
interactive website. With Spectrum©’s commitment to ongoing
research & development within our leading university, clinics and
optometry practices you can be rest assured your optometric
knowledge in modern diagnostic and refractive techniques are
at the forefront of the latest in eye care.
20
40
60
80
100
Moving into the information age has seen a change in customer
loyalty and the practice relationship. As the optometric industry
has become more commercialized, the product and the prices
thereof have become more competitive. Nowadays creating a
sense of loyalty among patients is not as simple as the past. More
so now than ever, we need more constructive and innovative ways
to maintain patient loyalty. Judging from the responses from the
patient survey, it is apparent that patients’ feels that the quality
of the eye test is the number one reason for choosing a particular
practitioner. It is therefore vital that we maintain and nurture this
perception as a way of ensuring that the patient returns to the
practice.
“I specifically like the randomize
feature for patients with early cataracts
or early AMD. I get accurate VA
measurements which are useful to
assess and monitor small changes.
This helps detect early pathology. An
excellent tool for any practice”
Dr. Dean Barclay – Ophthalmologist Port Elizabeth
25
Would you recommend this practice
based on the eye test you had
today?
Get Started
Definately
Possibly
1
Never
Install Spectrum
• Full version included with free 14 day Trial
0
20
40
60
80
100
“Spectrum is very easy to use, I like
the different options available on
the various tests it offers, and most
importantly my patients are impressed”
Gavin Buchalter – Optometrist Cape Town
Using the Spectrum© Info centre
has increased the average patient
spend
2
Sign-up for 1year
• Save 34% and receive your free 19“ LG
LCD Monitor
3
Start Testing
• Simply mount your free monitor in your
consultation room.
• Start impressing your patients today.
e
e
r
F
or
Definately
Monit
Yes
Unsure
No
Not at all
0
20
40
60
80
100
With medical aid benefits reducing, the first areas where cutbacks
occur are premier products and lens enhancements. These have
sadly been labeled as “extras” and “add-ons”. Practitioners and
dispensing staff now have to sell, and convince patients of the
benefits of these products, rather than including them as part
of the prescription at the recommendation of the practitioner.
Patients are entitled to have a valid reason as to why these
enhancements are necessary. Spectrum©’s comprehensive info
centre with product, health and other related eye-care information
is available to educate and improve patient understanding
while still in the consultation room. Combined with customizable
“take home” printable brochures, your patients will leave feeling
confident in your diagnosis and trust your recommendations.
Products and lens enhancements are no longer a patient decision
but rather a trusted prescription.
“Spectrum is definitely an asset to
any optometric practice”
Anel Trollip – Optometrist Cape Town
For more information about Spectrum, please visit our website
www.digitaloptometry.com and take a tour of the award winning software
included in this EYESITE.co.za issue.
26
Advanced optometry. Superior care.
www.simonsays.co.za
Improved Visual Acuity testing.
Fixation Disparity testing.
Achieve a lot more.
With a lot less.
Contrast Sensitivity testing.
Color Vision testing.
Distance Stereo Acuity testing.
Interactive Videos, Images and information.
With Spectrum Software you can offer your patients the highest level
of care, using the most advanced optometric software in the world.
Replacing the projector, Spectrum reduces refraction time and includes the most comprehensive
variety of optometric charts & tests. Spectrum automatically calibrates based on your testing distance,
making wheel-chair testing easier than ever, and offers tests sequences to suit occupational standards
or examiner requirements e.g. pilots, fork-lift drivers, kids, low vision, BV, etc. How will it benefit you?
Spectrum impresses and educates patients, leading to increased turnover and profitablity.
Free Monitor
19” LG - LCD
with 1 year Spectrum subscription*
Nothing available in the same price range will grow your practice as much as
the Spectrum Software Solution.
tel: 0861 393 837 | [email protected] | www.digitaloptometry.com
*Available while stocks lasts
Advanced optometry. Superior care.
PRESS RELEASE
Transform
downturn
- into an upturn with
Optifin Finance -
You’re no doubt feeling the squeeze of
the economic downturn as the number
of patients coming into your practice
decreases.
Remember Optifin will bring
additional profit you would not
normally earn as you would
have to turn clients who cannot afford glasses away.
In addition medical aids are cutting back even more on
optometry benefits. Some restrict the optical benefits or
insist that these expenses are paid from the medical
savings account.
Everyone can afford to see
with Optifin Finance
Brandon Sieff, MD of Optifin Finance commented that in
the past, medical aids accounted for more than half of
optometric practice turnovers. This is no longer the case.
“Therefore optometrists should be looking to align themselves
with financial credit providers such as Optifin Finance,”
explains Sieff.
Offer your clients 8 months to pay interest free
Optifin Finance is a smart financial solution that enables
optometrists to enhance your service to clients, while
increasing your own turnover.
How Optifin Finance can save your practice
Optifin Finance will benefit your practice in the following ways,
• Gives you the ability to offer your clients 8 months to pay.
Interest free
• You don’t have to do any collections
• You don’t have to take on any of the risk
• More clients with the means to afford glasses
• Increased turnover for your practice
• Local awareness marketing
• In-store branding
28
Clients who cannot afford
glasses can now afford to
see with 8 months to pay for
their glasses. Interest free.
“In South Africa 20% of the
population use some form
of vision correcting services
devise, but at least 50% of
refractive errors are undetected and untreated,” says
Yashika Inderjeet from the
International Centre for Eye
Care Education.
As an independent optometrist, you have the necessary
skills to assist South Africans
with their visual difficulties
and with Optifin Finance
you have the solution to
assisting them with finances
to afford glasses.
For more information visit
www.optifin.co.za or
call 0860 106 215
SPOTLIGHT
LASIK
- boosts eye surgery safety
and efficacy -
Eye surgery technology has come a
long way since its inception: in the
1930s, under instruction from the Emperor, Japanese imperial army recruits
had a number of small incisions made
on the cornea to resolve their nearsightedness! While this practice continued
into the 1960s, the introduction of photorefractive laser surgery 20-odd years
ago, and the steady improvements in
this technology, has resulted in treatment that is safer, more precise, and
available to a much broader range of
patients.
The LASIK (laser-assisted in situ keratomileusis) procedure in
particular is the most popular refractive surgical technique
performed today. LASIK represents an evolutionary step forward from photorefractive keratectomy (PRK). Whereas PRK
reshapes the outer surface of the cornea only, the LASIK procedure changes the shape of the cornea. Approved only
15 years ago to treat mild to moderate nearsightedness, a
number of revolutionary hardware and software innovations
mean LASIK can also help relieve eye diseases. Nearsightedness, patients with astigmatism, and farsightedness can now
be treated to a higher degree than ever before.
LASIK has been made even safer and more effective in
treating severe refractive conditions through a variety of
innovations. One of the most significant advances is the new
IntraLaseTM FS laser system, which sees a femtosecond laser
replacing the blade traditionally used to create the corneal
flap. Its 60kHz performance delivers microkeratome speed
and laser precision, but it has proven better biomechanical
30
stability compared to a microkeratome, as well as lower
induced high-order aberrations and better refractive
outcomes.
The IntraLaseTM FS laser system delivers unmatched control
over flap diameter, depth, centration and morphology,
resulting in an unprecedented combination of potential
advantages, including controlled flap structure, uniform flap
thickness and superior visual outcomes. Eyes treated with the
IntraLaseTM FS Laser System have fewer visual disturbances
(haze, glare, sensitivity), less pain, and less dryness when
compared to a microkeratome.
In a recent study (Sub-Bowman’s Keratomileusis with IntraLaseTM
FS Laser System vs PRK), IntraLase-treated eyes demonstrated
clinically and statistically better visual acuities (uncorrected
and best corrected) through one month postop compared
to surface treatment. Retrospective analysis comparing LASIK
results with IntraLaseTM FS laser system also performed better
in three areas important to LASIK results and safety: flap
thickness, induced astigmatism and cell injury. In a nutshell, the
IntraLase Method results in fewer flap-related complications.
The most advanced LASIK procedure which incorporates the
IntraLaseTM FS Laser System is iLASIK, the world’s only bladeless vision correction technology. It is the result of a decade’s
worth of technical refinement and the first and only method
approved by NASA to improve the vision of U.S. astronauts.
It is also the only LASIK procedure which combines the
IntraLaseTM FS Laser System with WaveScanTM wavefront 3-D
mapping technology, a groundbreaking innovation which
captures the unique imperfections in each individual’s eye.
Waves of light precisely map the anatomy of the patient’s
eye to identify individual visual errors with measurements
25 times more accurate than standard techniques used to
measure glasses and contact lenses. Surgeons can now reliably
customise the laser vision correction to the patient to the
SPOTLIGHT
exact curvature of the cornea and the microscopic hills and
valleys within the tissue that contribute to poor vision.
Another significant step forward in vision correction technology
is the new “Custom Vue” computer software which uses state
of the art light analysis to provide more accurate prescriptions.
Referred to as the crown jewel of the customized iLASIK
procedure, the Advanced Custom VueTM treats for the
reduction or elimination of low to moderate myopic
astigmatism up to -6.00 DMRSE, with cylinder between 0.00
and -3.00 D in patients 21 years of age or older, with an
Optical Zone of 4.0 to 9.0mm and treatment of 4.5 and 9.5
with an Optical Zone of 4.0 to 9.0 mm and a Treatment Zone
of 4.5 to 9.5 mm.
An added benefit of the IntraLaseTM FS Laser System is that
it has opened a new era in corneal transplantation.
Leading corneal surgeons report that IntraLaseTM enabled
keratoplasty allows them to precisely create uniquely shaped
corneal incisions, which heal faster with improved visual recovery.
Establish Secure Grafts,
Requiring Less Suture Tension1
1 week
after surgery
3 months
after surgery
6 months
after surgery
Early experience indicates that IEK incisions create less irritation, form hermetic wound seals, and produce crystal-clear
corneas at 1, 3, and 6 months. In addition, all sutures were
removed before 6 months vs. 1 year with standard trephine
techniques.2
Reduce the Incidence of Induced Astigmatism
Zig-zag incision
IEK result at 3
Trephine 1 year
months after surgery after surgery
after surgery
The zig-zag-shaped
incision has shown
a smooth corneal
contour immediately after surgery,
with less distortion
of the corneal
optics and less
astigmatism.1
IEK result at 3
months after
surgery = 0.5 diopter
of astigmatism.1
In addition, they are able to perform multiplanar custom
incisions that, due to the hermetic sealing properties, require
less suture tension, thereby resulting in less astigmatism and
better healing.
The better initial incision technique, limits the excessive
structure tightness that causes optical distortion, allowing
approved wound healing and therefore also early structure
removal.
The femtosecond laser can cut many different incision
patterns (Mushroom incision profile, Top-hat incision profile
& Zig-zag incision profile). The Zig-zag configuration has the
best promise for being the most biologically stable and
secure to use, as it allows the donor and host tissue to
interlock and create a watertight seal. It is surgically easy to
do and is proving faster recovery results and less astigmatism
than the conventional penetration techniques.
Create Customized Incisions
with Advanced Edge Profiles
Mushroom incision
profile
Top-hat incision
profile
Zig-zag incision
profile
The mushroomshaped incision
preserves more
host endothelium
than the traditional trephine
approach.1
The top-hatshaped incision
allows for the
transplantation of
large endothelial
surfaces.1
The zig-zagshaped incision
provides a smooth
transition between
host and donor
tissue and allows
for a hermetic
wound seal.1
Typical result with
standard trephinecut PKP at 1 year
after surgery = 8
diopters
Dr Mark Deist is one of the first ophthalmologists in South
Africa certified to use the blade-free iLASIKTM procedure. “The
iLASIK procedure is incredibly impressive surgical technology,
and is one of the most precise medical procedures performed
today,” explains Dr Deist.
“More patients can now achieve vision that is 20/20 or
better as well as improved night vision, when compared
with glasses and contacts. The ultra-fast IntraLase FS laser
eliminates virtually all of the most severe, sight-threatening
complications arising from blade surgery and gives surgeons’
unparalleled control over the flap. Given the many benefits
of the iLASIK procedure, there really is no need for people to
continue having their lifestyle restricted by the need to wear
glasses and contacts. iLASIK gives people a new level of
independence, can boost confidence, and will lead to
vision that is generally better than that with glasses and
contacts,” concludes Dr Deist.
31
FEATURE
Essential
- contact lens practice http://www.eyesite.co.za/magazine
Part 1 — Initial patient assessment
In this first article Jane Veys, John Meyler
and Ian Davies look at patient selection
and pre-fitting assessment.
Public awareness of the benefits of contact lens correction
is arguably higher today than at any time in history, thanks
largely to advertising and public relations. And significant
advances in contact lens technology, materials and design
mean that more patients can comfortably wear contact
lenses. Yet despite these factors, the number of contact lens
wearers in Europe remains significantly less than in the US,
Japan or much of the Pacific Rim. There are two main factors keeping this penetration to the low levels. Firstly, there is
a lack of proactive recommendation by eye care practitioners and, secondly, there is a high incidence of contact lens
drop-outs. Correct patient selection and pre-screening is a
key element in addressing both these issues.
The initial patient selection for contact lenses must be made
in conjunction with the patient in the context of explaining to
them that contact lenses could be a viable vision correction
option. Several studies confirm that proactive contact lens
prescribing introduces contact lens wear to patients who
previously assumed they were unsuitable. 1, 2 Market
research continues to show the number one concern of most
patients is the perceived discomfort/fear of having a lens on
the eye. The challenge facing practitioners is to match these
physiological and emotional needs to products.
Although ocular topography is rarely a barrier to modern
contact lenses, ocular anomalies, pathology and patient
motivation remain significant factors restricting the number
of contact lens wearers. Many of the factors should, and
can, be screened for at the initial fitting. Beyond the desire to
increase the number of patients successfully wearing contact
lenses, the practitioner has ethical and legal obligations.
32
Patients must be offered the most suitable and safe correction for their needs and practitioners must ensure their
records clearly note pre-assessment and baseline measurements of the contact lens wearer. The need to communicate
with the patient is heightened with the increasing choice in
materials, designs and replacement frequencies available.
The practitioner has an ethical obligation to inform patients
of any new material, modality or lens design that could improve their wearing success. Failure to do so could result in
legal issues should the patient later have problems with their
lenses. It also ensures that practitioners are seen to be up to
date with new developments.
Aftercare begins before the first contact lens is even placed
on the eye. Patient selection and pre-screening thus
become part of the aftercare process.
Table 1: Influence of contact lenses in different environments
from Nilsson5
Environment
Lens Type
Soft
Hard
Metal splinters
++
-
Burning grit particles
++
-
Particle contamination, moderate
+
-
Particle contamination, heavy
-
-
Strong infra-red radiation
-
?
Underwater, splashes
+-
+-
Dry environments
+-
+-
Extreme cold
+
+
Solvents, gases, short exposure
++
++
Solvents, gases, long exposure
?
?
Acids, strong, splashes
++
++
Acids, weaker, splashes
++
++
Alkalis, strong, splashes
+-
?
Alkalis, weaker, splashes
+-
++
FEATURE
ment and measurements of horizontal visible iris diameter
(HVID) and pupil size. Measurement using the graticule is
ideal as it is easy and accurate. The crude technique of
using a hand- held ruler is not to be recommended. Problems of parallax, vertex distance and lack of divisions on
the millimetre scale reduce accuracy and reliability.
Baseline measurements and initial assessment of ocular
tissue appearance can be more accurate and repeatable by using grading scales such as the CCLRU (Figure
1), or Efron grading scale.3 The increased accessibility of
digital photography should also be considered in taking
base line measurements. Use of a photographic slit lamp
enables the practitioner to photograph any pre-existing
lesion so that this can be compared with any subsequent
changes. Consideration must also be given to the keratometer as more than an instrument solely for measuring
corneal radius. The keratometer can be used to measure
non-invasive break-up time (NIBUT) of the tear film, well
established as a more accurate record of tear film stability
than the use of fluorescein.
Techniques
Figure 1 CCLRU photographic grading scales
As in refraction, it is important that a standard routine is
followed during the contact lens screening examination.
Developing a routine ensures a full procedure is carried
out efficiently. While there are no hard and fast rules as
to the order of a routine, it is customary to start with the
patient discussion before moving on to the preliminary
examination.
Patient discussion
Initial discussions with the patient are arguably the single most
important aspect of a preliminary examination. A correct
understanding of the patient’s working environment and
lifestyle is important, as well as an understanding of the
patient’s vision requirements and expectations.
Figure 2 Corneal desiccation secondary to incomplete
blinking
Instrumentation
Pre-screening contact lens wearers requires three basic
techniques: observation, measurement and communication. The key instruments – the slit lamp and the
keratometer – will be discussed in detail in later articles.
However, a few pertinent points relating to pre-assessment
are mentioned here.
Ideally, the slit lamp should be fitted with an eyepiece
graticule, or at least have an adjustable slit height to assist in recording both the size of lesions in the anterior seg-
With presbyopic vision correction any option will have its
limitations, so an informal discussion about the patient’s
needs will assist in choosing the most suitable option. For
example, the benefits of gaze independent vision offered
by simultaneous vision contact lenses may outweigh any
small reduction in vision clarity. Establishing this before
fitting will save both practitioner and patient considerable
time and money. Each piece of information gathered at
this stage should be collected with a purpose and should
help the practitioner decide which contact lens is best
for the patient.
Before considering individual aspects of the history and
symptoms, it is worth underlining the importance of
questioning technique. Questions can be defined as
‘open’ or ‘closed’. A closed question – for example, ‘Is
your general health good?’ – is less likely to get a comprehensive response than an open question such as: ‘Tell
me about your general health.’ The second question
invites the patient to divulge information, whereas a
negative answer to the first requires more probing by
the practitioner.
33
NEWS & EVENTS
FEATURE
An even better approach would be: ‘How would you
describe your general health? This is important to help
me decide which lenses are most suitable for your eyes.’
This explains why the practitioner needs the information
and is more likely to prompt a full answer.
Effective communication also relies on responsive
listening and appropriate body language on the part of
the practi¬tioner. It is critical that the practitioner looks
interested in hearing what the patient has to say. Studies have shown that, on average, it takes a patient 90
seconds to fully explain why they are visiting a surgeon. On
average, the surgeon interrupts after just 18.4 The practitioner should maintain eye contact whenever possible.
Notes should be made in a deliberate and considered
manner, and if there is ambiguity about a point then the
practitioner needs to stop the patient and make sure that
the point is understood by both parties.
In medical environment patients remember just 30 per
cent of what they hear. The practitioner must make sure
that all important and salient points are understood by
the patient.
The main areas for consideration in patient discussions
are as follows.
Occupation
In some occupations contact lens wear is not permitted,
in others it may be contraindicated. Occupational
requirements can be found from various organisations
and the prospective contact lens wearer should be
made aware of any occupational restrictions. Contact
lenses may be contraindicated for patients working in
dusty environments or environments in which toxic fumes
are present.
Consideration should also be given to patients working
long hours at computer screens. Studies have shown the
blink rate reduces during computer use, which can lead
to corneal desiccation. The increase in air-conditioned
offices is a further exacerbating element in contact lens
dryness often associated with long term computer screen
work.
While computer use is usually not a contraindication for
lens wear, the practitioner will want to ensure this does not
become a problem by alerting users to the importance
of blinking. Many patients will put up with the discomfort
associated with office work in the belief that there is little
that can be done to remedy the situation. Traditionally
the options to the practitioner were largely limited to
re-wetting drops, but today the increase in choice of
materials, some of which include wetting agents, means
that there are multiple ways to manage contact lens dryness. Significant difference in patient comfort exist when
different lens types are used for computer activities.6
Recreational activities
The desire to wear contact lenses for playing sport may
be an important motivation for the potential contact lens
34
wearer. There are certain simple points which should be
taken into consideration when fitting a patient who wants
to wear lenses for sport.
Soft lenses are usually the first choice for most sports and
contact sports in particular. However, while all contact
lenses have some protective effect on the eye, they are
not as efficient as protective eyewear for some high-risk
sports, such as squash.
For water sports, the patient must be made aware of the
need for high levels of hygiene due to the potential for
the increased risk of infection. Swimming in contact lenses
may carry a higher risk of microbial keratitis and the risk of
Acanthameoba keratitis is highly associated with swimming in contact lenses. In both cases the accommodation of microbes on the lens surface during swimming is
a likely cause of the infection.7 Patients must be warned
about the increased risk when swimming and should be
advised, if they still wish to swim in lenses, to wear tight
fitting goggles and pay particular attention to their lens
cleaning regime or advise daily disposable lens wear. The
onus is on the practitioner to provide the patient with the
information required and all patients should be informed
that swimming pools, and jacuzzis in particular are higher
risk environments. Contact lenses have been successfully
worn for sub-aqua pursuits.8
There is increasing evidence to suggest that UV radiation
can be harmful to ocular tissues. UV-blocking contact
lenses help provide additional protection to the cornea,
lens and retina, especially against entry of UV light at
the temporal limbus. However, in pursuits involving exposure to high concentrations of ultra-violet light, such
as skiing, the patient should be advised to wear wraparound sunglasses or goggles to offer glare protection
and to prevent damage to the conjunctiva, lid margins
and surrounding skin.
Patient’s age
While there is no maximum age, or indeed minimum age,
at which a patient can wear contact lenses, the practitioner has to appreciate the changes that take place
in the ageing eye. The physiological changes that occur
with ageing are summarised in Table 2. The presbyopic
patient will require special management. However, the
practitioner should also consider the effect changing
from spectacles to contact lenses would have on all
contact lens wearers. Most myopes of more than –4.00D
will notice the increased accommodation and convergence needed for close work with contact lenses and
should be forewarned of this.
Fitting contact lenses to children can be especially
rewarding, and most commonly considered from the
age of eight upwards. When considering fitting children
with contact lenses the practitioner needs to assess
the maturity and ability of the child to look after the lenses.
This discussion needs to take place with the child’s
FEATURE
parents. Patient dexterity also needs to be considered,
but deficiencies can often be overcome by greater attention to the teaching of patient handling techniques.
Complexion
Patients with auburn hair and freckled skin have increased corneal sensitivity. Blue-eyed and fair-skinned
patients also have relatively sensitive corneas and are
more likely to have problems adapting to lenses, especially rigid lenses.
Motivation
Assessment of a patient’s needs and degree of motivation for contact lenses must be made. Nelson and West11
concluded from a small study that stable, well-adjusted
extroverted people were more likely to adapt to contact
lenses without difficulty than anxious, introverted and less
stable personalities.
Patients who are highly motivated and comply with
instructions have an increased probability of success.
Discussions should take place to allow the practitioner
to assess the expectations of the patient with regard to
contact lens wear. Part of the discussion should also
include the opportunity to discuss refractive surgery.
Many patients who have had problems with contact
lenses in the past might register an interest in surgery without realising how much contact lenses have changed. It
is important that the patient be given a balanced and
objective perspective of all the vision correction options
that are open to them.
Unrealistic expectations need to be discussed and the
limitations of any chosen lens type and wear modality
explained. Patient expectations are a key factor in the
success or failure of contact lens wear.
Table 2: The effects of ageing on the eye
(adapted from Woods9,10)
Ocular changes
Visual performance
Decrease in visual
Decreased tonus of upper and acuity (reductiongreater for low
lower eyelids
contrast targets and
under low luminance)
Reduced palpebral aperture
Reduction in contrast
sensitivity for higher
Decreased lacrimal secretion
Potential reduction in
stereo acuity spatial
Reduced tear stability
Increased glare
sensitivity
Corneal changes decreased sensitivity • increased fragility
Ocular media changes
Decreased pupil diameter
Effects of increased intake of systemic drugs
Increased incidence of corneal
age-related disorders
NEWS & EVENTS
Financial considerations
Practitioners should not pre-judge a patient’s ability
to pay. The main focus should be on the prospective
wearer’s visual needs. The practitioner should present
the most suitable lens to the patient, but it is the patient
who should make a decision with regard to the financial
commitment.
Never assume financial status. Patients must be made
aware of the ongoing costs of contact lens wear and
care.
Smoking
Studies show that smokers are more likely than non-smokers to
develop microbial keratitis.12 Patients who smoke should
be warned of this.
Ocular pathology
Contact lens fitting is indicated in the management of
several ocular conditions – keratoconus and monocular
aphakia, for example. Fitting in the presence of active
pathology should never be undertaken without the prior
approval of an ophthalmologist.
Previous contact lens wear
The high number of contact lens dropouts in Europe
means a high likelihood of previous contact lens wearers presenting to the practitioner. In many cases these
patients will not broach the subject of contact lens wear
as they will feel that, having failed once, they are not
suitable. It is important for the practitioner to probe the
reasons why the lens wear was discontinued and see if,
assuming that these reasons could be overcome, the
patient would be interested in resuming lens wear. The
most common reasons for contact lens drop-out include
discomfort, dryness and poor vision. In many cases these
conditions can be addressed with new materials, for
example, silicone hydrogel, or updated replacement
frequencies, such as daily disposables, or modern toric
lens designs.13
Dry eyes
Possibly one of the most common reasons for failure to
wear contact lenses is dry eye. Much debate remains
as to the best way to assess the dry eye. This will be explored in later articles. The use of specific questionnaires
has received some validation in the literature and is recommended as a way of screening for potential dry-eyed
patients. One of the most established questionnaires
used to aid clinical judgement is that of McMonnies.14
This questionnaire has been modified by Guillon et al15 to
allow prediction of required replacement frequency for
patients wearing disposable extended wear lenses.
Overall health and medication
As well as considering general health and the effects of
systemic medications on overall ocular performance,
practitioners should be aware of conditions and medications which may have a direct impact on a patient’s ability to wear contact lenses. Table 3 outlines some of these
conditions and suggests management options.
Allergies
Approximately 25 per cent of the population suffer allergies
35
NEWS & EVENTS
FEATURE
at some time in their life. This number varies as a function
of the climate and will also be complicated seasonally
with around 10 per cent who report they suffer from
hay fever. It is important for the practitioner to understand the atopic history of the patient as this can impact
lens and care product selection.
Daily disposable lenses should be the first choice for
patients who have ocular symptoms associated with
allergies.16
Ocular history
Full consideration should be given to a patient’s ocular
history as well as to pathology, dry eye and motivation
given the degree of ametropia. Potential problems due
to muscle imbalance should be considered, given the
lack of prismatic effect (assisting or not) in contact lens
correction. Any previous contact lens-wearing history
should be fully explored, and any reasons for past failures
noted. Details of any previous refractive surgery should
be investigated.
Patient examination
Before examining the anterior segment, the practitioner
must obtain a baseline refraction, perform a binocular
assessment and undertake an ophthalmological examination of the patient’s eye. Refraction must be recorded
as the ocular refraction, taken as the spectacle refraction with compensation for back vertex distance. It is
important that in an astigmatic correction both meridians are treated independently in cross cylinder form.
For example:
-5.00/-2.00x180 @ 10 mm
transposes to:
-5.00x90/-7.00x180 @ 10 mm
which from vertex correction
tables becomes:
-4.76x90/-6.54x180
and then
-4.75/-1.75x180
Figure 3 A method
of recording the
position of the limbus with respect
to the eyelids
This becomes particularly important in the ordering of soft
toric lenses and calculation of tear film powers in rigid
gas-permeable (RGP) lenses.
Anterior segment measurements
The improved accuracy of measurements with the slitlamp graticule has already been discussed. The following
measurements should be recorded.
Horizontal visible iris diameter (HVID)
The horizontal visible iris diameter underestimates the
horizontal cornea by just under 1mm. Its value lies only
in ensuring that a soft lens total diameter is sufficient to
maintain full corneal coverage.
Table 3
Possible effects of systemic medications and general health status on contact lens wear
Condition
Potential problem
Allergies
Preservative reactions
Atopic reaction to
deposit build-up
Skin condition
(e.g. eczema)
Excessive deposits
Medication
Antihistamines
Potential problem
Atopic conjunctivitis
Contact lens associated papillary
conjunctivitis
Reduced contact
lens tolerance
Advice
One-day disposable
or non-preserved systems
with frequent replacements lenses
Monitor - check for dry
eyes
One-day disposable or
frequent replacement lens
Thin edge design
Avoid contact lens wear
until clear
Monitor - do not fit if clinically significant
Lid irritations
Blepharitis
Punctate keratitis
Diabetes
Reduced epithelial
healing
Close monitoring
Thyroid dysfunction
Tear deficiency and
poor blinking
Avoid contact lens wear
Vitamin A deficiency
Mucus deficiency
deposit build up
Monitor - possible soft
frequent replacement
Systemic hypertension
ß-blockers, diuretics
Dry eye
Monitor
Psychosis
Contact lens
adaptation
Psychotics
Dry eye
Monitor - contact lens
wear possibly
contraindicated
Hormone changes
e.g. Birth control, Pregnancy
Menopause
Dry eye
Corneal contour
changes
Changes in corneal
sensitivity
Oral contraception
Dry eye
Monitor
36
FEATURE
Vertical palpebral aperture
The measurement of palpebral aperture is of questionable
value in contact lens fitting other than in the monitoring
of its size longitudinally. Of more relevance, especially for
RGP and bifocal lens fitting, is the position of the lids with
respect to the limbus. This can be recorded as shown in
Figure 3.
Pupil size
Pupil size measurement allows the practitioner to predict,
and manage, any likely flare from a misalignment of the
pupil diameter with the back optic zone diameter of a
rigid lens. It is also an important variable in predicting rigid
bifocal contact lens success. An estimation of maximum
pupil diameter may be made by viewing with the Burton
lamp in a darkened room.
Tear prism height
The height of the inferior tear meniscus gives a useful
guide to the volume of tears on the eye. The slit-lamp
graticule or slit height can be used to judge the height of
the tear meniscus formed at the margin of the lower lid.
A normal value would be around 0.4mm.
Keratometry
While keratometry values have no corre¬lation to soft lens
fitting performance, it is nevertheless important that these
should be recorded, whatever the type of lens to be
fitted. K-readings should be monitored on a regular basis
throughout the aftercare. They should be compared to
baseline values taken at the initial fitting. As well as the
values, the clarity of the mires must also be recorded. This
gives an indication of corneal clarity and is a sensitive
monitor of early corneal distortion.
Non-invasive break-up time (NIBUT)/
tear thinning time (TTT)
As well as its use in measuring corneal radius and assessing corneal contour, keratometry may also be used to
measure tear film stability. The technique involves recording the time taken for the reflected mire image (the first
catoptric image) to distort (TTT) and/or break up after a
blink (NIBUT). Tolerant contact lens wearers average a
NIBUT of around 20 seconds.
The advantages of this technique, as opposed to fluorescein, are its accuracy and repeatability. Instillation of
fluorescein into the eye causes disruption of the lipid layer
and, as well as stimulating reflex tearing, decreases the
stability of the tear film.
Anterior segment examination
The slit-lamp examination is probably the most important
procedure in both preassessment and aftercare of the
contact lens wearer. It is sufficient to stress here that a
full slit-lamp examination should be conducted and the
results recorded in full. Use of a grading scheme will
enable the practitioner to quantify the results and should
be routinely used. Table 4 lists the main structures to be examined. The table also suggests how variations from the
norm may be considered to help the practitioner identify
the most suitable lens.
Patient information
Once the decision as to the type of contact lens has
been made, the practitioner must take responsibility for
explaining the reasons. The discussion should include in-
NEWS & EVENTS
formation on the benefits and risks of the particular wear
modality and type of contact lens chosen, as well as advice
on the likely ongoing maintenance costs, the importance
of regular aftercare, emergency procedures and the
need for patient self-monitoring. This is made easier by
the use of a patient instruction book and acknowledgement form.
Patient discussion
Patient examination
Personal details
• name, address
• age
• dexterity
• complexion
• occupation, recreation
Full eye examination
• vision
• refraction
• binocular assessment
• ophthalmoscopy
Contact Lens specific
• expectations
• motivation
Measurements
• corneal curvature
• corneal diameter
• pupil size
• palpebral aperture
General History
• systemic disease history
• familial disorders
• motivation
Ocular history
• refraction correction past
and present
• ocular disease history
• ocular symptoms
Examination of anterior
segment
• lids and lashes
• conjunctiva
• tears
• cornea
epithelium
stroma
endothelium
Assessment of suitability
Figure 1.5
Flow chart of the preliminary contact lens examination
Figure 4: F low chart of the preliminary contact lens
examination
Summary
Contact lens aftercare begins with the preassessment of the
prospective wearer. By considering patient requirements,
motivation, history and symptoms, and the physiological
state of the eye as parts of a jigsaw, the practitioner can
compile a picture of the best management option for an
individual patient. Time spent at this stage helps avoid
unnecessary failures. Figure 4 is a flow chart, showing
how objective and subjective findings are considered
in turn to reach the final decision.
Key Points
‘Open’ questions rather than ‘closed’ ones should be
used to encourage each patient to provide as much
information as possible
All aspects of the subjective and objective questioning
and examination should be conducted with a clear idea
of how the information will either assist in the choice of lens
or help in the future monitoring of the contact lens wearer
Throughout the examination, the patent should be kept
informed of the procedures being conducted and the
reasons for any decisions. An informed patient is a better
patient
For references visit: www.eyesite.co.za/references1
37
OPTOMETRY
recovery
- of function after head injury/
brain damage Part 2 -
findings from these earlier
studies.
Michelle Hlava- SRN (Zim)SRM (SA) Dip OptomFOA (SA)
MCOVD (USA)
As mentioned in the previous edition, proof
of the ‘Cell theory of the brain’ required
technological progress, thereby requiring
the development of the ‘Light (as in illuminating) Microscope’ in order to image the
cells that make up brain matter, and being
able to describe their individual characteristics. Obviously in a crude format, the microscope was invented and used by Schwann,
Purkinje and Ramon Cajal. Do you recall the
Schwann and Purkinje cells?
Ramon Cajal’s work includes the ability
of cells to migrate in early brain development, in particular the first 2-3 weeks of
brain development. He noted the cell to
move similarly to that of an amoeba: extending a part itself, and then dragging
the rest behind, pushing aside anything in
its way in order to reach the appropriate
area, thereafter the cell differentiates.
During the latter part of the 19th century and early into the 20th
century, further development and studies which were originally
based on Sherrington’s original studies of sensory and motor
physiology showed the ‘connection’ [for want of a better word]
38
between ‘sensation’ and
‘movement’ for humans.
It was during the same period,
that ‘Head, Franz and Lashley’ did the first work underlying neuropsychology and
neurologic rehabilitation.
It was during the latter two
thirds of the 20th century
that improved medical
care
followed the ability to study the brain that
led to an increased survival of ‘brain-injured’ soldiers, i.e. during and after
World War II. The result was
an increase in survival of
civilian patients who suffered with brain damage
and that directly impacted
public concern over the
effects of brain damage
on “human function”.
Development of improved
technology facilitated more
sophisticated experimen-
At present, many treatment
paradigms in use for Rehabilitation are based on the
tal paradigms. In addition,
more stable political and
economic systems in the in-
OPTOMETRY
dustrialised nations of the world have allowed further resources to be available for research.
The result of these actions resulted in increased interest in
Neuroscience and increased availability of research funds,
eventually producing an extraordinary increase in our understanding of the nervous system and our ability to use this information for treating persons with disorders of the nervous
system. Although clinical practice variably lags behind basic science by several years, science rem a i n s t h e b a s i s
for improved medical care and treatment paradigms for
neurological rehabilitation.
muscular contractions within
days to weeks of the stroke.
Systemic Reaction
to Damage:
• Headache
• Dizziness
• Impaired concentration
• Impaired Memory
• Fatigue
In order to understand what Traumatic Brain Injury is, one
would need to have some understanding of how the nervous
system controls function/behaviour. Furthermore, every
individual that has had a head injury, albeit a closed head
injury, will have a nervous system that has been compromised
to some extent. Therefore the nature of the damage is
important when viewing the course of rehabilitation.
• Anxiety
• Depression
• Irritability
• Indecisiveness
• Impaired self-confidence
• Lack of drive
• Impaired Libido
When we as Optometrists
Nature of Damage:
look at this list of systemic
Trauma
reaction to damage and
Infection
we take a step back before
Tumour
we leap into just ‘selling
Haemorrhage secondary to affliction.
spectacles’ and we really
Open or closed head injury.
Damage caused by movement and rotational stresses of the
brain within the skull, or resulting from fracture of bone.
Symptoms:
Understandably, the symptoms vary dramatically.
listen to what our patients
are telling us when we
probe for a Case History,
it would be interesting to
know just how many cases
we have let ‘slip through
our
fingers’
when
that
patient we thought was
Birth Injury may only show symptoms months later. As the child
an ‘odd-ball’ could have
grows, developmental milestones are expected owing to the
been helped. Now, we
inhibition of primitive reflexes and the appearance of postural
may never know!
reflexes. Should these reflexes be delayed, or the postural
reflexes not appear, investigation thereof is essential. Time
Yes, you may ask
being of the essence as rehabilitation will transpose primitive
“Why Optometry?”
reflexes into postural reflexes much faster at an earlier stage
than if left untreated for a much longer period of time. Look
In the next addition things will
no further than the problems arising out of Amblyopia that is
appear clearer as we take a
left untreated.
walk on the ‘wild side’ with
Abu Ali Alhazen. For those of
Severed spinal cord damage, on the other hand, will show
you who don’t know of him,
immediate loss of all sensation and muscle action below the
he is, or I should rather say:
level of the lesion.
was one of the founders of
Optometry. He was born in
However, a person who has had a closed head injury, such
Basra, during the 10th cen-
as a Cerebro Vascular Accident (stroke), may or may not
tury. Gosh, we have come a
lose consciousness. They may also present with a loss
long way!!!
of sensation and muscle action, although not necessarily
complete loss. They could demonstrate spasticity, muscular
weakness, loss of dexterity and sometimes involuntary
39
SPOTLIGHT
Drug use
- and its effects on the eye
and visual system - Part 2 Leoni Joubert (M.Phil Optom (RAU); B.Optom; MBCO(UK); CAS
(NECO - USA)); FOA(SA)
Long term use can lead to optic atrophy as well as toxic
amblyopia.
I will be continuing the article on illicit drug
use and the effects on the eye. Part 2 will
include barbiturates, LSD, inhalants, ecstasy and methamphetamines.
1. BARBITURATES:
Barbiturates are mainly sedative medications and are central
nervous system depressants. They are usually prescribed to
aid sleeping and as anti-anxiety medications. Their onset
and duration of action differs from long to ultra-short acting.
Due to their highly addictive potential they are now seldom
prescribed and have been replaced by alternatives for
example the benzodiazepines which include the most commonly
prescribed tranquilizer, Valium (diazepam). These benzodiazepines have however also emerged as street drugs especially
Rohypnol (flunitrazepam, street name “Roofies”) which is
known as the “Date Rape Drug”. Rohypnol (see Figure 1) is 710 times more potent than Valium and has an effect in 15-30
minutes leading to the person being tranquilized but having
no memory of any event during that time. Many countries
have banned its use.
On the street barbiturates are referred to as “Barbs” or
“Downers”.
They have a host of ocular side-effects. They usually affect the
oculomotor system leading to irregular pursuits, nystagmus
and weakened convergence. They can also induce ptosis
and blepharoclonus. Their use also induces blurred vision
and nerve palsies.
One of the strangest side-effects is Lilliputian hallucinations.
During these hallucinations people often have the perception
that objects and people are minified and appear really small
compared to themselves. Barbiturates also induce auditory
hallucinations which are very disturbing and can persist for
weeks.
40
Figure 1: Rohypnol
2. LSD (Lysergic acid Diethylamide)
LSD was manufactured in 1938 by Albert Hoffman using
lysergic acid which is found in a fungus that grows on rye.
It is an extremely potent drug and very small quantities are
needed to cause an effect (25 micrograms). Unfortunately,
Mr. Hoffman decided to try the drug on himself and took
250 micrograms! This led to a spectacular “trip” which he
called his “bicycle day”. Suffice it to say being doped up on
10 times the recommended dose of LSD and then climbing
on a bicycle is not recommended! Fortunately it was 1938
and the traffic wasn’t quite what it is now. It is a colourless,
odorless liquid which is typically added to blotting or other
absorbent paper. This paper is divided into small squares and
decorated so that each square represents one dose (see
Figure 2). One of the problems with LSD is that its effects are
unpredictable and depend on the user’s personality, mood,
expectations and surroundings. It takes about 90 minutes to
start working. LSD will increase body temperature, heart rate,
blood pressure and perspiration. It will lead to loss of
appetite, sleeplessness, dry mouth and tremors.
LSD causes spectacular visual hallucinations which include
intense colour. It is almost kaleidoscope-like in its appearance.
SPOTLIGHT
These hallucinations vary from other drug induced visual
hallucinations in that they occur due to spontaneous retinal
potentials.
It also induces mydriasis. The worst problem with the drug is
that these trips can recur months later. Needless to say this
can be very unsettling. Another problem with LSD is that
people who are on it tend to sun-gaze and cause severe
retinal burns from this.
4. INHALANTS:
People have generally tried to inhale pretty much anything that can be inhaled to get high (see Figure 4). One
can only imagine the damage that gets done to the lungs
from this habit. A new favorite among children is to inhale
“Spray and Cook” to get high. Most inhalants will cause conjuntival hyperemia and lacrimation. Some may even lead
to retinal haemorrhages, papilloedema and optic atrophy.
Nystagmus and blurry vision have also been reported. When
mothballs are inhaled over a long term, cataracts can be
caused.
Petrol inhalation will lead to mydriasis, nystagmus, coma,
colour vision disturbances and lead encephalopathy.
Methanol is known to be toxic to the retina and optic nerve.
The medication Amyl nitrate (street name “Poppers”) which
is used to treat angina has been put in room deodorizers and
air-conditioning units by unscrupulous club owners. When it
is breathed in it causes tachycardia, vasodilation, mydriasis,
decreased vision, headaches, but also thirst which causes
club users to drink more! Poppers also enhance the intensity
of sexual climax.
Figure 2: LSD
3. ECSTASY (Methylenedioxymethamphetamine - MDMA):
Ecstasy (other street names “E, beans, rolls, X, XTC”) is one of
the most popular club drugs in recent times. It is classified as
both a stimulant and a hallucinogenic. It is found mainly in
tablet form which can be any colour and shape
(see Figure 3).
It is commonly known as the “Love drug” because it induces
potent feelings of empathy and well-being. Unfortunately the
illicit tablets are often combined with unknown compounds in
unknown quantities. These compounds can include ketamine
and caffeine mixed with normal methamphetamine. Users
are therefore typically unaware of the exact combination of
drugs they are taking. Most users take up to 5 tablets in a 12
hour drug session.
Visual side-effects include mydriasis, distorted colour vision,
decreased accommodation and blurred vision.
It also causes hallucinations, vomiting, increased blood pressure and heart rate and short term memory loss due to brain
damage. Brain cells producing serotonin die after 10 uses.
Ecstasy use causes teeth grinding and jaw clenching so users
often use “dummies” (pacifiers) while on the drug. Users also
often consume vast quantities of water while on the drug
and have died due to metabolite imbalance from drinking
too much water.
Unfortunately Ecstasy causes a bad “downer” when it wears
off and suicides have been reported following its use. It leads
to physical and mental exhaustion, depression, irritability,
poor concentration, forgetfulness and paranoia.
Figure 3: Ecstasy tablets
Figure 4: Various Inhalants
5. METHAMPHETAMINE:
Street names include Tik, Ice, Crystal meth, Crank, Chalk,
Speed and Glass. Methamphetamine is a highly addictive
central nervous system stimulant. It was developed early in
the 20th century from its parent drug amphetamine, which was
originally used as a nasal decongestant and bronchial inhaler.
Its effects can last up to 8 hours and include decreased
appetite, increased activity and a general sense of wellbeing. It is easy to manufacture at home using various chemicals and inexpensive over the counter ingredients. Numerous
“meth labs” have been found in upmarket homes. Unfortunately due to the dangerous nature of the chemicals involved
explosions of these labs are common. The danger of this drug
is that it is cheap, easy to manufacture and highly addictive.
The powdered form of methamphetamine is commonly
referred to as “crystal meth” or “crank”. It is usually white and
is sniffed but can be mixed with liquid and injected. “Tik” is a
crystalline form (see Figure 5) of the drug and is commonly
smoked usually in an emptied light bulb (see Figure 6). The
sound of the heated drug hitting against the glass produces
a ticking sound which is where the name “Tik” comes from.
This form of the drug is thought to be extremely addictive
and even a single use can lead to addiction.
Figure 5: Crystal meth
41
NEWS & EVENTS
SPOTLIGHT
Figure 6: Tik “pipe”
Methamphetamine doesn’t produce an odour when it is
smoked and there have been cases of children smoking Tik in the
classroom while the teacher has stepped out for a moment!
It causes hallucinations. Ocular side-effects include mydriasis.
Long term users of methamphetamine experience terrible
side effects including a feeling that something is crawling on
their skin. This causes them to constantly pick their skin and
face leading to terrible sores (see Figure 7). They also suffer
from a dry mouth which ultimately leads to tooth decay due
to lack of saliva. Due to this decay they suffer from “Meth Breath”.
This drug has destroyed lives of seemingly responsible people
due to it s addictive nature. They will literally do anything to
get their next fix.
Figure 7: Self-inflicted sores from picking skin
References:
1. Bartlett JD, Jaanus SD. Clinical Ocular Pharmacology – Fourth edition 2001. Butterworth Heinemann. Boston, Oxford, Auckland.
2. Havener WH. Ocular pharmacology – Fifth edition 1983. Mosby. St Louis, Toronto.
3. Kanski JJ. Clinical Ophthalmology- Sixth edition 2007. Butterworth Heinemann. Edinburgh, London, New York.
4. Yanoff M, Duker JS. Ophthalmology 1999. Mosby. London, Philadelphia, St Louis.
5. Rhee DJ, Pyfer MF (editors). The Wills Eye Manual – Third edition 1999. Lippincott,
Williams and Wilkins. Philadelphia, Baltimore, New York.
6. http://www.drugtestsuccess.com
7. http://drugrecognition.com
8. http://www.usdoj/dea
9. http://www.justthinktwice.com
10. http://www.drugabuse.com
11. http://www.drugfree.org
12. http://www.freevibe.com
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42
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Contract positions for Optometrists
SPOTLIGHT
Case
report:
- convergence insufficiency A 22 year old female presented for a
general eye examination. She was a
final year student at a tertiary institution
in KwaZulu-Natal.
Nishanee Ramersad - B Optom degree (UKZN)
Her last eye test was 3 years ago where she was dispensed
a pair of spectacles. She reported that her spectacles did
help her to some extent but she still had to strain her eyes.
The patient reported having headaches which she located
over the temporal aspect of her head. She reported that
at times the pain was quite severe and she therefore often
needed a pain killer for relief.
She also indicated that sometimes when studying the reading print became double. This symptom of diplopia was only
present when she was reading and occurred mostly at the
end of the day. The patient was unable to recall whether
the diplopia was in the vertical or horizontal direction. When
probed about the onset, she was unable to recall when she
had first began noticing it, however indicated that now it
had become more frequent. She had no previous injuries
and/or surgical operations involving her eyes and/or head.
No other symptoms were reported. Her medical history was
insignificant and she was not on any medication. Her family
ocular and medical histories were also insignificant. At the
end of the visual acuity measurement, she hesitantly reported that the diplopia may have first been noticed when she
was at school but was not certain.
Clinical results:
Visual acuity: unaided
OD
Distance:
6/9
Near:
0.6M
Current prescription:
OD: -0.50 / -0.50 x 180 (6/6)
OS: -0.50 / -0.50 x 180 (6/7.5)
44
OS
6/12
0.6M
External examination:
Near point of convergence (NPC)
•
Red lens test: Break: 10 cm Recovery: 16 cm
•
RAF rule: Break 6 cm Recovery 9.5cm
Ocular motilities
Accurate, full and extensive
Subjective refraction:
OD: - 0.50 / - 0.75 x 180 (6/6)
OS: - 1.00 / - 0.75 x 180 (6/6)
Cover test (with prism bar)
DISTANCE
NEAR
Without Rx
4 Exophoria
10 Exophoria
With new Rx
3 Exophoria
7 Exophoria
Accommodative status:
Amplitude (RAF rule): OD: + 12.50 D Lag (MEM): OD: +1.00D
OS: + 12.50 D OS: +1.00D
Facility:
PRA: -2.00D
Distance (∞/ - 2.00): 13 cycles / min
NRA: +2.25D
Near (+2.00 / ∞): 6 cycles / min
(∞/ - 2.00): 7 cycles / min
AC/A Ratio:
1. Calculated: 4.2 : 1
2. Gradient (maddox): 4: 1
Fusional reserves: base out step vergence using a prism bar
Distance: 10 / 16 / 14
Near: 12 / 14 / 12
Fixation disparity: Negative (No suppression)
Functional tests:
1. Ishihara (24 plate): pass (24/24)
2. Randot stereotest: 100” (No suppression)
3. Ocular health and Tonometry: No abnormalities detected
SPOTLIGHT
Diagnosis:
1. Compound myopic with-the-rule astigmatism (OU).
2. Convergence Insufficiency.
This diagnosis of convergence insufficiency was based on
the symptoms of headaches and diplopia together with the
following clinical findings:
1. Receded NPC.
2. Near exophoria greater than distance exophoria.
3. Reduced positive fusional reserves (BO) at near, failing
Sheard’s criteria thus resulting in an uncompensated phoria at near.
Management:
• Dispense new pair of spectacles.
• Vision training indicated for convergence insufficiency.
Considering the context of this case in terms of visual
characteristics, the patient’s age and high levels of motivation,
the prognosis for visual training was considered to be
favourable. Thus “three cats for convergence” training was
selected as the training exercise which was taught and administered to the patient. She was advised to perform the
exercise 4 times a day for a period of 8 weeks before returning for re-evaluation.
Re-evaluation:
The patient returned 12 weeks later for the re-evaluation.
She reported that she had been doing the exercises regularly. She indicated that initially she found it difficult to perform the exercise however with practice it became easier
for her to perform and ‘see the third cat’ (to the clinician, this
implies that she was able to maintain fusion). When asked
about the diplopia, she indicated that only when she was
really tired did she notice the reading print starting to swim.
She explained that when the print doubled, the words literally ran over each other (horizontal diplopia) but this rarely
occurred since she had started with the training exercises. In
addition, she reported that the frequency and severity of the
headaches had decreased as well.
Visual acuity (aided): RE: 6/6 LE: 6/6
Near point of convergence
• Red lens test: 4 cm / 8 cm • RAF rule: up to nose
Cover test: with Rx
Distance: 3 exophoria
Near: 4 exophoria
Fusional reserves: base out step vergence
Distance: 12 / 20 / 18
Near: 18 / 30 / 28
Randot stereo test: 70” (No suppression)
Convergence Insufficiency
Epidemiology
Convergence insufficiency (CI) is just one of the many nonstrabismic binocular vision disorders. Traditionally it is described as a syndrome consisting of a receded near point
of convergence, exophoria at near and reduced positive
relative vergence at near.1 Convergence insufficiency is
probably the most frequent non-strabismic binocular vision
disorder encountered by optometrists.2 Clinical studies reporting on the prevalence of CI show a large variance in the
figures reported.3, 4, 5, 7, 8 Duke-Elder3 reported that CI occurs in
1% of children and 15% of adults.3 Whilst Kratka4 found that
25% of a sample of 500 patients presenting for a routine eye
examinations demonstrated clinical results consistent with
that of CI.4 In this study by Kratka4, even though the range of
participants’ ages was not included, it was reported that
CI was most frequently seen in patients between 20 and 40
years. In a separate study by Dwyer5 who reported on the
patients presenting to his optometric practice, it was found
that 33% of the 144 patients between the ages of 7-18 could
be classified as CI. Dwyer5 used both fixation disparity curves
and Sheard’s criterion6 in making the diagnosis of CI. Norn7
reported the prevalence to be 1.75% on his study of 10 022
patients between the ages of 6-70 that presented to his
practice over a 2 year period.7 Norn7 found that a majority
of female patients between 10 and 29 years displayed clinical
signs consistent with CI. A study using university students by
Porcar and Martinez-Palmera8 reported a prevalence rate
of 7.7% of CI. These differences in findings can be attributed
to various factors namely the populations being considered,
the methods of measurements, the number of clinical signs
and criteria that are used to make the diagnosis of CI.9
Convergence insufficiency is thought to manifest during the
second or third decade of life. This is attributed to individuals being required to perform considerable amounts of near
work during this period. Subsequently they may seek help
if the visual demands placed on them result in discomfort
when performing these near activities.
Duke-Elder3 reports the following as possible causes of CI
namely, delayed or poor development of convergence or
accommodation, wide interpupillary distance, presbyopia,
endocrine disorders, toxaemia, anxiety neurosis, closed head
trauma, lesions involving the pretectal area of the brain and
any disease that may alter the blood supply to the extra
ocular muscles. The exact cause of CI is not entirely clear
however a possible hypothesis could be the connection
between accommodative dysfunctions and the subsequent strain on the vergence system. In a separate study by
Daum10, it was found that CI was present in 60% of individuals with accommodative dysfunction. It appeared
most commonly with accommodative insufficiency (65%)
and less frequently with accommodative excess (43%).
An additional anomaly of convergence that warrants
mentioning is that of convergence paralysis.2 In this condition, the patient is able to adduct the eye (monocularly)
however is unable to converge them. Consequently,
the patient reports experiencing constant diplopia at near.
Convergence paralysis may be caused as a result of significant
45
NEWS & EVENTS
SPOTLIGHT
closed head trauma, lesions in the midbrain and toxic
encephalopathy. Management of these patients includes
prescribing base-in prisms in a separate pair of reading
spectacles. Convergence insufficiency needs to be differentiated from convergence paralysis and the history of the
diplopia may assist in making this differentiation. In convergence paralysis, the symptom of diplopia is recent whilst in
convergence insufficiency is likely to be long-standing.2
Symptoms
Common symptoms reported by patients with CI include
asthenopia associated with performing near tasks,
headaches and diplopia.2, 11 Other symptoms that may
be reported include heavy eyelids, sleepiness, perceived
movement of print and a loss of concentration when
reading.12 However, in certain cases patients presenting
with clinical signs of CI may be asymptomatic. This lack of
subjective symptoms may be as a result of suppression, an
avoidance of undertaking near visual tasks or possibly a high
pain threshold.13
Clinical Signs
Clinical signs associated with CI include but may not be
limited to the following2, 9
1. Receded NPC.
2. Uncompensated exophoria at near, according to Sheard’s
criterion.6 At times, an intermittent exotropia may also be
seen at near.
3. Distance exophoria or no latent deviation.
4. Reduced positive fusional vergence range at near.
Other clinical signs that may be seen include1:
5. Low AC/A ratio.
6. Reduced or normal stereopsis threshold.
7. Suppression, at near which is most likely to be intermittent.
Management
The treatment modalities for CI include prescribing base-in
relieving prisms, reading spectacles and vision therapy.11
These base-in prisms compensate for the phoria reducing the
amount of fusional vergence needed to be exerted.14 Vision
therapy is regarded as the primary mode of treatment for CI.
2, 14
It has been reported that vision therapy exercises shows
over 90% success rates in reducing symptoms in patients
with CI.1, 13 Furthermore apart from a decrease in subjective
symptoms, vision therapy also results in an improvement in
the objective clinical findings in patients with CI .13, 15
vergence ranges using the synoptopher, vectograms and
stereograms. Some of the more common home-based exercises include pencil push-up exercises and the ‘three cats
for convergence’ exercise.
A study in 2002 was conducted in the United States of America
to determine the most common mode of therapy used when
managing patients with CI. This study included both optometrists and ophthalmologists in the study population and used
a survey as the data collection instrument. It was determined
that pencil push-up therapy was the most common treatment
option used to manage patients presenting with CI.11 The
results showed that even though optometrists and ophthalmologists acknowledge the potential of office-based vision
therapy exercises, home-based therapy exercises are most
often prescribed. Considering the nature and context of this
study, caution should be exercised in generalising these
results to a South African context. In addition, this may serve
as a possible area that needs investigation within a South
African context including the need for data relating to the
prevalence rates of CI.
Factors which advocate the use of home-based exercises
include the simple and cost-effective nature of such exercises.
Both pencil push-ups and ‘cats for convergence’ exercises
can be taught to the patient in a short period of time and
does not require any technical equipment both on the part
of the optometrist and patient. In addition, these exercises
are cost convenient and less demanding in terms of time for
both the patient and the optometrist.
In conclusion, pertinent aspects to the diagnosis and management
of CI include the performance of a careful case history and a
thorough accommodative and vergence assessment. Like
most other non-strabismic binocular vision disorders, CI can
be considered to be insidious in that it does not present with
obvious cosmetic defects. However, if undetected and
untreated, it may result in an impairment of the productivity
and efficiency of the affected individual and thus warrants
the integration of clinical results and subjective symptoms in
order to holistically diagnose and efficiently manage
patients presenting with CI.
References: www.eyesite.co.za/casestudyref
A study by Cooper et al15 showed that vision therapy exercises
were effective in reducing symptoms of asthenopia and
improving the vergence ranges of effective patients. Thus
the study by Cooper et al15 advocated that a traditional
approach should be used when managing these patients,
such that it leads to a transfer of these vergence skills to the
patient’s working environment.15 In a retrospective study by
Daum1, it was found that traditional vision training exercises
increased the positive fusional vergence by approximately
10∆ in patients (n =110) diagnosed as having CI. This change
was in addition to a statistically significant decrease in the
exophoria at near and a reduction in symptoms being experienced when undertaking near tasks.
These orthoptic procedures can be separated into officebased and home-based vision therapy exercises. Officebased vision therapy includes training base out fusional
46
Above: Examples of Therapy Cards used for convergence training
SPOTLIGHT
Importance
of lens
measure &
lens form
A S Carlson. University of Johannesburg, Department of
Optometry,P O Box 524 Auckland Park 2006 South Africa
A lens measure is a very important tool in an
optical laboratory and in an optometric practice. However, it appears to be an under-rated tool that can give a wealth of information
about a lens. The lens measure has three pins
or points of contact with the lens surface. See
Figure 1. The outer two are stationary and the
centre contact pin moves in or out. This tool
shows the dioptric value of convex and concave surfaces of ophthalmic lenses.
F(nm) = (n1 – n)mat FLM
(1)
(n2 – n)LM
where
Fnm is the surface power of the lens in air
For (n1 – n)mat
n1 is the refractive index of the material and n = 1
(when in air).
For (n2–n)LM
n2 is the refractive index that the lens measure is
calibrated for (1.530) and n =1 (when in air)
FLM is the surface power measured with the lens
measure.
By simple re-arrangement of Equation 1 any one of the
other components can be found.
Figure 1. The lens measure
The lens measure is calibrated for a refractive index of 1.530
(irrespective of the type of material) and can determine
the surface powers of ophthalmic lenses. This can then
determine the form and the actual powers, provided that
the centre thicknesses are known. It can also be used to
determine the refractive index of the lens material. Many
clinicians, however, don’t realize or consider the importance of lens form and those who do would usually leave
this up to their dispenser/ technicians or laboratory to sort
out. The lens measure may also be used to determine if
lenses are aspheric in design. The lens measure Equation
is as follows1
48
As mentioned elsewhere before2, when dispensing a new
prescription, one has to decide on the choice of lens form
and material. When the lenses are mounted in front of the
eyes in such a position that the optical axes of the lenses
coincide with the visual axes, the form of the lenses is of
no consequence. The eyes are then viewing through the
optical centres of the lenses and the images formed by the
lenses are not affected by any lens defects or aberrations
that may be present. For distance vision, in the absence of
prescribed prism, the optical centres are positioned on a
line that passes through the centre of the pupils. However,
this is the case for one direction of gaze only. The eyes are
usually in a state of motion and also view objects through
off-axis visual points. The off-axis optical performance of
the lenses should be the same as the optical performance
along the optical axis. However, this is not usually the case,
the off-axis images are affected by various aberrations that
spoil the quality of the images, and it is under these circumstances that the form of the lenses is of great importance.
The aberration of significance to spectacle wearers that
are caused by the lens material is transverse chromatic
SPOTLIGHT
aberration. Aberrations caused due to the form of lenses
are oblique astigmatism, curvature of field and distortion.
These aberrations have also been discussed elsewhere2.
Laboratories usually stock semi-finished blanks with front
surface powers in 2 D steps, Plano, 2 D, 4 D, 6 D, 8 D and 10
D, and so on. The front surface power would be selected by
means of the simple rule3
FSP = ½ F + 6 D.
(2)
where FSP is the front surface power of the lens and F is the
power of the lens. If the lens has an astigmatic component,
F is the sphere component when the prescription is written
with a negative cylinder.
When ordering a replacement lens or supplying the wearer
with a new or second pair of spectacles some time after
the initial order, one factor in wearer acceptance of the
new spectacles is consistent duplication of the form (base
curves) of the lenses. Any change in the form, refractive
index or even changes from a back to a front surface toric
form of construction will change the way peripherally viewed
objects are perceived. Moreover, higher index lenses are
usually flatter in form when compared to lower index lens
materials. The purpose of this article is to make clinicians
and ophthalmic dispensers aware of how important lens
form is. This has been discussed in depth before2, but the
main focus of this article is to concentrate more on
prescription wrap sunglasses and inserts that are placed
behind them, and also how to help rectify problems that
may result.
Prescription sunglasses in wrap design frames with different
wrap angles and frames, together with inserts placed
behind the lenses, although not new, are very popular as
well as prescription sportswear sunglasses with both full
frames and inserts. See Figures 2. It can be seen that
especially with medium to high myopic prescriptions (this
is where most of the problems occur) the front surface
powers of the lenses that are fitted to the full wrap frames do
not comply with best form design lenses (see Equation 2).
Firstly, I am referring mainly to the 8 D and 9 D curve frames
without an insert. For example, if a prescription reads OU
– 4.00 D, according to Equation 2 the front surface powers
(FSP) should be 4 D. Labs cut 8 or 9D FSP lenses which do
not comply with this. I personally (with tongue in cheek) do
not think that the technicians/laboratories are aware of
the problems this causes or how to solve them. This causes
a lot of unwanted oblique astigmatism and distortion that
many wearers fail to adapt to. This is more noticeable when
wearers change from their normal non-tinted lenses to their
sunglasses. Besides the sunglass lenses not complying with
best form, the wrap angles of these frames vary between
20-25º thus causing even more distortions. One will find that
their normal non-tinted lenses may be of a higher refractive
index material than their sunglasses, thus compounding the
problem. If one were to examine the latest wrap sunglasses, for example Carrera, Ray-Ban, Porsche Design, Oakley
and Bollé, it would be found that they incorporate about
¼ prism dioptre base in for each lens into their lenses to
compensate for the displacement effects caused by the
higher FSP and wrap angle. Imagine the combined effects
that could be caused by placing a prescription in them.
The other situation that sometimes leads to problems is fitting medium to high power lenses into the inserts. Higher
powers, higher refractive indices that include antireflection
coatings and also aspheric designs are now available in
stock or straight off the shelf. They no longer have to be
surfaced. I have also noticed that some of these lenses are
slightly flatter than best form. The inserts are not as curved
as the frames and just about any form will fit into them. What
I have noticed is that many labs do not take into account
that when these lenses are fitted into inserts, air gaps occur
between the curvatures of the lenses in the inserts and the
curvatures of the actual sunglasses. Moreover, when fitted,
the inserts are also tilted according to the wrap angle of
the frame causing unwanted oblique astigmatism and distortions. This is illustrated in Figure 3.When aspheric designs
are fitted, this also adds to the distortions.
(a)
(b)
Figure 2. Different wrap angle sunglass frames in (a) and
a wrap frame with an insert for prescription lenses placed
behind the lenses in (b)
Figure 3. Wrap frame with insert curvature with flatter lenses
not matching the front surface curvatures of the sunglass.
Notice the tilt angle ø and the air gap between the insert
and actual sunglass lenses. (The air gap and ø are slightly
exaggerated for clarity.)
49
NEWS & EVENTS
SPOTLIGHT
How do we attempt to resolve these problems? What I do
to alleviate the problem (with great success) is first analyze
the prescription, examine the frame type and then decide
what FSP lenses to use. If the prescriptions are low to
medium positive or negative powers I will in most cases use
normal stock or 6 D FSP lenses. In many cases I use ordinary
stock lenses and try to avoid where possible, the use of 8 or
9 D FSP. There are cases when due to the curvature of the
frame, this is not possible. This will only, in my opinion, be
in extreme cases. If the prescriptions are medium to high
positive powers, the FSP of the lenses work in favor with
best form designs. However, when the lenses are medium
to high negative powers, and normal stock lenses are not
suitable, I will usually order a 6 D FSP rather than an 8 D or 9
D. I would then, depending on the prescription, incorporate
approximately 0.3-0.5 pd base in in each lens to compensate for the wrap tilt. On many occasions, I have used a
4.50 D FSP stock lens for powers up to –5 D. (Obviously one
would have to first examine the frame very carefully). You
are now probably thinking that by doing this the wrap is being reduced and it is making the frame very close to a normal frame. This is partially true. Bending the frame in slightly
at the bridge and also bringing (or bending) the temples
in slightly takes care of this. It cannot, however, be done
with all frames. One would have to examine the frame first
to see if this could be done before using the 4 D FSP lenses.
Another consideration would be to decide whether to give
a compensated prescription because of the face-form
(wrap) tilt. This would usually depend on the prescription.
One would find that for all tilted lenses some compensation
is required. I do not always give this. One would have to
see whether the change in prescription is significant or not.
Depending on the prescription and the obliquity of the axis
there are many cases where the compensated axis also
changes. Now I can imagine many of you asking how or
when it would be necessary to give the compensated
prescription. It is more complicated than a simple answer in
this article. However, to assimilate effective power changes,
all one has to do is take a lens and place it on a vertometer and then tilt it accordingly to see what effect the tilt
has on the power. The greater the tilt, the greater the induced cylinder. Remember that the power of the lens does
not change, only the vergence leaving the lens changes.
You can then decide what to do. When a compensated
script is necessary, consult with the lab which should hopefully provide you with the necessary information. When the
spectacles have been made a copy of the compensated
prescription should always accompany the spectacles.
Some of the laboratories offer products that are especially
designed for wrap sunglasses4. Carl Zeiss Vision has the
SpazioTM lenses (see Figure 4). These lenses are atoric in
design with decentred optic zones and Rodenstock offer
the free-form atoric Mono-SportTM. I think these are the
better options but they are more costly.
The problems that sometimes occur with the inserts are
similar. The inserts are not as curved as the sunglass lenses so the labs fit normal stock lenses that are usually best
form in design. What some of them do not realize is that
once the inserts are placed inside the frame, they are
also tilted according to the curvature of the frame. If the
powers of the lenses are fairly high in negative power, the
same problems are going occur as previously discussed. Air
gaps between the inserts occur as shown in Figure 3. Once
again when the wearer switches from their normal distance
viewing spectacles to the sunglasses they notice the difference immediately. What I usually do (with a good success
rate,) once again depending on the prescription, is to use a
50
slightly higher FSP, not an 8 D if possible, and maybe a compensated power. I try to reduce the air gap, not necessarily
close it, but never to give a Plano or 2 D FSP.
Figure 4. (a) A profile of the SpazioTM Sola Wrap design lens
illustrating the decentred optic zone. The nasal area of the
lens is less curved than the temporal side. (b) A side view of
the Wrap design illustrating the secondary peripheral curvature producing a thinner edge when compared with the
conventional edge.
In summary, before prescribing any lenses in order to
prevent and resolve problems, I do the following:
a) Analyze and interpret the prescription.
b) Avoid changing the form of the lenses from the previous
ones.
c) Be aware of complications that may occur when changing
lens materials from low to hi-index.
d) Be aware when changing from spherical to aspherical
design lenses.
e) When prescribing wrap sunglasses, avoid 8 D FSP where
possible. Where possible use 6 D FSP.
f) Try where possible to deviate as little as possible, from
best form without deforming the frame.
g) Consider a compensated prescription where necessary.
h) With inserts, where possible avoid flat lenses.
i) Consider the Free-form or SpazioTM design lenses if the
price is of no consequence.
I do not claim to be the expert in this area, but aim to
provide you with information that works well for me. There
are no hard and fast rules that I follow, I use my own
initiative and take each prescription on its own merits. Not
all wearers are as sensitive as others to form changes or
changes in lens materials. Remember to make use of the
lens measure as it can provide you with valuable information on the lenses, which will assist you in avoiding many
unnecessary problems.
References.
1. Jalie M. The Principles of Ophthalmic Lenses. 4th Ed. The Association
of British Dispensing Opticians London 1984.
2. Carlson AS Best-form lenses. Eyesite April 2005 55-57
3. Jalie M. Ophthalmic Lenses and Dispensing. 2nd Ed. ButterworthHeinemann Edinburgh 2003.
4. Carlson AS Wrap lenses. Eyesite December 2004 58-59.
OPTOMETRY
a glimpse
- into South African
optometric history, part 4 By J M Carey ([email protected])
Box 177, Krugersdorp 1740, South Africa
The Golden age of Optometry in South Africa
This was the appellation used by optometrist
Reuben Terespolsky when the age had
passed away. Why did he use this description?
Optometry had only relatively recently
received statutory recognition and was
trying to establish a “professional image”
to enhance status in the eyes of the public
as well as the medical profession.
To achieve this end advertising was banned, “shopticians”
were frowned upon so no window displays were allowed and
any optometrists in shops had to fit curtains so that the interior
of their premises could not be seen from the outside. This was
to prevent the practice of some who had purchased a
phoropter and a fancy chair and arranged that this was well
illuminated so that the public could see from the street how
“modern and up-to date” that practitioner was with only the
best equipment. Remember that in those days many only
had a trial frame and a case of lenses and not even an
internally illuminated Snellen chart and were often itinerants,
setting up shop in premises lent to them by a pharmacist or
jeweller. Medical aids were recent entities and fees were very
variable. A story in this connection that did the rounds was
the optometrist looking intently at the face of the patient and
discussing his account: “Mrs Jones the price is x” ; no reaction
on patient’s face; “for the frame”- still no reaction “and the
lenses will be y” – no reaction “each”.
The SAOA was the leader in the campaign to enhance the
image of the optometrist and they also set fees and
52
negotiated with the medical aids. Registration was not compulsory and not all practitioners had the necessary qualification
to register but as the contract with the medical aid was with
the SAOA, optometrists who were not members of the SAOA
would not be paid. The SAOA immediately had to face
the obstacle that medical aids were loath to pay what
optometrists considered to be a reasonable fee for their
professional time with the result that to be viable optometrists
had what many considered to be exorbitant mark-ups on
lenses and frames. However the fact remains that supplying
a frame or lenses involves many more factors than selling an
item in a box which is advertised and supplied in the original
pack by the retailer. This resulted in the concept of “RSV”
(relative service value) so the markup on a varifocal was a
higher percentage than on a simple single vision lens as more
time was involved. The SAOA then prepared fee and price
lists based on the RSV and also divided these prices into three
different price lists. A white for private patients and non-contracted medical aids, a blue (discounted) tariff for
contracted medical aids and a green even more discounted
tariff for the SADF and Social Welfare patients. A medical aid
only qualified if it had sufficient members and strangely the
SADF tariff was lower than the SAP who were on blue
(although both were government departments). I always felt
that it was unfair on the private patient who paid cash up
front or on delivery and was penalized by paying more than
the MA patient where the optometrist had to wait up to
3 months for payment. Although there were very many
medical aids billing was simple because there was a choice
of only three alternatives.
The problem of a reasonable professional fee remained and
the SAOA was put in the position that ophthalmologists also
had a fee for “refraction” and they very cleverly kept this low
so medical aids would say to the SAOA “you can’t charge
more than the “specialist”. On closer examination however
the ophthalmologist’s account was padded with lots of
OPTOMETRY
extras so the total bill was far greater than the SAOA
tariff. We learnt by this and very soon IOP was added
as an extra charge (previously many optometrists had invested in a non-contact tonometer but included this service
in the examination fee). Optometrists were still inclined to load
the price of frames and this created a gap for a business
called “Frames Unlimited”. This business was not practising
as optometrists so could and did advertise extensively remember optometrists were limited to a small sign at the
entrance to their building and no display widows were
allowed. It then became a common practice for patients
to present with a frame from Frames Unlimited and the
optometrist did the examination and fitted lenses to that
frame. This of course upset optometrists especially those
whose main income source was fancy frames with large
mark-ups. Optometrists were also upset because they were
the mugs who had to fit and adjust the frames and of course
in some cases the frame chosen was unsuitable for the lenses
needed by that individual. Some optometrists even refused
to use a Frames Unlimited frame. To fight against patients
arriving with their own new frame the SAOA introduced a
dispensing fee for frames not supplied by the prescriber. The
SAOA also recommended a maximum mark-up on frames of
60% to counter claims by Frames Unlimited that they were
cheaper but the 60% limit could never really be enforced.
The SAOA also tried to have spectacle frames declared as
items controlled by the professional board but this was not
supported by the courts. The so-called “designer” frame did
not exist and the optometrist would select a frame for the
patient according to the face shape, the type of lens and
the pocket of the patient. No patient ever told the optometrist that they wanted a specific make of frame because
no manufacturer advertised to the public because if they
did advertise the optometrists would probably boycott that
brand as it undermined what the optometrists felt was part
of the professional ‘we know best” opinion. (Readers will understand this attitude better if they realise that in those days
medical doctors “knew” what was best for the patient so the
patient took any prescribed medicine blindly and was not
even told the name let alone side effects of what had been
prescribed.). The SAOA tried the same exclusive approach
with ready-made readers and a great fuss was made of the
harm they could do to the patients by not being exact (it was
not realised that refractive status varies in any case and often
readers are more efficient without the cylinders) and that the
PD was not accurate (again it was not realised that the visual
system easily tolerates small amounts of horizontal prism) but
of course the optometrists had vested interests here so they
used any argument they could find.
The Professional Board as well as the SAOA wanted to
enhance the professional image of optometrists in the eyes
of the public as well as other professions, so sharing of
premises with e.g. pharmacists or jewellers was outlawed,
no advertising to the public was allowed, no window
displays, so those in shops had curtains to cover the interior
of the premises and the bigger practices tended to move
into upstairs rooms in the same way as applied to medical
doctors and dentists. Conditions were very different from today’s scene; optometrists worked regular hours usually from
8.00h or 9.00h until 17.00h often closing for an hour’s lunch
break, sometimes closed on Wednesday afternoons as did
the banks and medical practitioners. Some optometrists even
closed on Saturday mornings but in those days patients made
and kept appointments and a busy optometrist would have
a patient every 30 minutes over the whole day so patient flow
was very well controlled. Of course these trading conditions
were made possible by the fact that the ratio of optometrists
to that section of the population that could afford their
services was small and the training institutions were turning out
a limited number of new graduates. As can be seen,
optometry was a desirable way of earning a living: pleasant
& clean working conditions, controlled work flow, working
hours not onerous, very adequate remuneration, interesting
problems to solve for a large assortment of people, and above
all patients enjoyed a visit to the optometrist as there was no
pain or injections as in the case of the doctor or dentist.
Honey attracts bees so matriculants started to be more aware
of optometry as a future profession for themselves. Back in the
1950s classes were in the region of 10 to 20 and there was only
one institution training optometrists. As the demand from
matriculants for optometric training rose, more training
institutions started to offer an optometry course. The institutions
received state sponsorship according to the number of students
enrolled so there was a tendency to accept as many as
possible even if clinical conditions for students were not ideal.
The rate of supply of graduating optometrists then started to
exceed the population growth so competition increased.
Newly qualified optometrists wanted new cars as well as only
the best equipment and finance houses were happy to
load them with debt. These young optometrists had to
earn a living so competition increased and the SAOA
found itself and its ethical rules under increased pressure for
change. Shopping malls appeared on the scene and optometrists moved into shops. First of all the curtains disappeared,
signs started to appear and increase in size. The Professional
Board and the SAOA resisted these changes all the way but
commercial pressure kept increasing: controlled advertising
was sanctioned but proved impossible to police adequately,
franchises appeared so the culprits were no longer individuals
who could be intimidated and advertising grew and grew.
“Marketing” became the in-thing with special offers such as
2 for the price of 1 and the gullible public never realised that
in fact they ended up paying for the special offer by loading
of the price in other ways, such as unnecessary coatings and
very expensive high mark-up frames.
What a rosy picture back then - limited opposition, fees and
prices controlled by the profession, medical aids too small to
exert real pressure on prices, office (not shop) rentals, prescription
wholesalers in a cosy cartel where prices were kept high so
unofficial kickbacks could be given to optometrists with large
turnovers and ideal controlled working environments with
patients seen by appointment only.
TRULY THE GOLDEN AGE OF OPTOMETRY!
54
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NEWS & EVENTS
OPTOMETRY
carey’s
corner...
By J M Carey ([email protected])
Box 177, Krugersdorp 1740, South Africa
Something new on something old
This time we are looking at retinoscopy. What do YOU see
as the purpose of retinoscopy? I hope your answer is NOT
“to give an objective measure of the refractive status”. To
give you an idea of how much more is involved, I once
went to a COVD congress where there were numerous full
45 minute lectures with different types of retinoscopy as the
sole topic. Originally retinoscopy only involved the patient
looking at a distant target but far more important is near or
dynamic retinoscopy where the visual system is operating under real-life types of demand. There is 1) Book retinoscopy, 2)
Stress point retinoscopy, 3) Bell retinoscopy, 4) MEM retinoscopy, 5) Nott retinoscopy, 6) Mohindra retinoscopy. Different
practitioners may be comfortable with different techniques
but personally I prefer “book” which involves the patient
reading type at their developmental level and the optometrist scopes through a central hole in the reading card
paying particular attention to the brightness and colour
of the reflex. A dull reflex means a low level of cognition and
the “bright” young patient has a bright silver coloured reflex with a seemingly large pupil. Interested readers will do
themselves a favour by buying a copy of Getman’s “Developmental Optometry (from Bernell or OEP or possibly Danker)
p 69 for the ret reflexes but the whole book is well worth
reading. To illustrate how important the colour & brightness
are take one of your children or staff; scope them while
giving them mental arithmetic sums. Do a few easy ones
e.g. 2 x 2 =? x 4 = ? divide by 5. 16 divided by 5 is not easy
so the reflex goes dull. In fact the retinoscope can be used
as a lie detector as the reflex dulls when a lie is told. You
will notice cycloplegic retinoscopy is not even mentioned.
The behavioral optometrist has no use for this as we are not
interested in results with a paralysed ciliary muscle and an
artificially large pupil. In any case a thumb suck allowance
has to be made for the tonic accommodation and Mohindra
gives more accurate results on a very small child but neither
Mohindra nor cycloplegic is very accurate.
However spectacles are only prescribed for very small
children if there is gross ametropia and we must never forget
that with very small children there can be huge swings in
refractive status. This means that prescribing spectacles
may in fact do harm as the refractive status you found has
in fact changed and you have also interfered with
the emmetropisation process. Another unsettling factor for
many is that despite what the rep selling retinoscopes told
you at the time a spot ret gives far more information than
a streak. While on the subject, optometrists should react
strongly to some of the conditions laid down in Optisight
News; the official optometric newsletter of the HPCSA. We
all know that the board means well but they should be more
careful before they rush into decisions and lay down regulations.
Particularly objectionable to me is “if strabismus, esophoria or
other visual developmental abnormalities were indicated
56
from the case history and/
or preliminary examination,
a cycloplegic examination
would be compulsory”. A
cycloplegic examination is
unpleasant even for an adult
and although it is not compulsory in the USA a colleague
from the USA explained the
dilemma optometrists face
in the USA. The influence of
avaricious lawyers has made
all health care practitioners
very wary of malpractice allegations so the optometrist
dilates routinely although it
is not necessary and nothing
abnormal is suspected or
revealed. However, if something crops up in the future
then the optometrist could
be faulted if no dilation had
taken place, so dilate everybody and make what used
to be a pleasant regular visit
to your friendly optometrist
become a dreaded chore.
Many other criticisms of the
HPCSA minimum equipment
and practice standards can
be cited and optometrists
should be making their voices heard on the subject. In
addition the HPCSA should
learn a lesson that before
sweeping standards are laid
down there must be wide
consultation and allowance
made for professional diversity.
Interesting cases
1) Patient: Master KM seen
5/12/08 age 7 yrs, Grade 1,
son of an ENT specialist. Appointment made for a full
binocular vision evaluation.
Problem: school screening
found a problem. Optometrist prescribed spectacles
R & L +0.50/-2.00 cyl x 180
but child hardly ever uses
these.
Case history: no school
problems- reading, spelling, arithmetic, handwriting and concentration all
good. Normal birth, normal
developmental milestones,
good coordination as well
as ball catching and bicycle riding. Healthy with
a balanced diet, likes TV
and normal posture for TV
watching as well as when
writing. Some headaches in
the afternoons, no diplopia
or eye turn noticed. In summary a very normal history.
Findings: confrontation test
revealed excessive head
movement for pursuits but
otherwise nothing of importance. Auto refractor R
+1.00/-2.00 x 179 L + 1.25/2.25 x 18 confirmed with retinoscopy but less + and less
cyl. Unaided VA 6/9 in each
eye. Refraction R +0.75/1.00 x 180 =6/6 L +1.00/-100
180 = 6/6. Brock Posture
Board = 4 XO. Book retinoscopy surprisingly gave +
0.75 SPH in each eye.
Binocular probes:
On blurred as well as clear
OPTOMETRY
Conclusions: nobody is perfect and there is no such thing
as a perfect visual system. KM is functioning well without his
specs and he is a bright, enthusiastic active healthy child.
Admittedly his VA is slightly better with his Rx but a child in
the lower grades can function very adequately with a VA
of 6/9. He doesn’t wear his specs because he doesn’t feel
any benefit and wearing specs is a fag especially for
a young active child. Remembering the admonitions to all
health care professionals of “no symptoms, no treatment”
and “above all do no harm” in the back of my mind my advice was:
1) discard the specs (first of all prescribing the cyl would tend
to imbed this in the growth pattern and prevent any
emmetropisation, secondly my book retinoscopy finding
of spheres made me doubt how stable the astigmatic finding
really was and we now all know that refractive status varies
particularly in a young child and thirdly spectacles are a
nuisance especially to a young active child.
“spectacles are only
prescribed for very small
children if there is gross
ametropia”...
2) on the other hand his binocular system could be improved
so he was given a course of gross and fine motor exercises.
He was to return after 3 months for Brock String, Square/
circle torch and Clear Circles home exercise programming
and if he showed any signs of academic or sporting problems. In any case return in two years for a routine check.
I will be very interested to see what his astigmatism looks
like then. I know this approach makes no sense to the CRE
(correct the refractive error mentality) optometrist but the
behavioral approach is to try and look at the whole person
and not just the visual system in isolation.
2) P
atient: Mrs AWK, aged 36 years, seen 20/11/08, referred
by optometrist in Rustenburg because of diplopia.
Problem: has seen double for as long as she can remember;
there is a variable vertical element and it is worse when she
is tired, experiences difficulty in changing focus from near to
far and vice versa.
Case history: she was given her first pair of spectacles at age
15 years. She has tried prism treatment, had a squint operation at age 19 years but after this the eye turn was worse. A
second operation has not made any difference to her diplopia, in fact it became worse. She reads a lot but has always
been a very slow reader. Presented with Rx R-1.00/-0.25 x 155
L -0.75/-0.25 x 155.
Findings: With the confrontation test she had a marked upward incomitance of the L eye on R gaze. In the primary
position she seemed to be able to hold both eyes straight for
a short time but on convergence there was a strange rapid
alternation. Her distance refractive status was very similar to
her spectacles with R -0.75/-0.50 x 180 L -.050/-0.50 x 180. Her
unaided VAs were R a poor 6/12 and L 6/12+. Aided was not
a lot better with 6/9 in each eye. The Brock Posture Board
gave a large XOP with no suppression reported (?) and an
improvement with 12 PD
base in. With this same prism
she reported binocular
responses to the peripheral fusion as well as gross
stereopsis on the peripheral
Polatest distance targets.
The binocular probes were
no SILO or SOLI with distance
Quoit vectograms. With near
vectograms she reported fusion without central suppression in a base out reading of
M on both Humpty Dumpty
and Topper. This was supported by results with the
square/circle torch where
she reported diplopia without suppression at 10 cm
and closer. +15 Anaglyph
test revealed a split field
anomalous correspondence
response.
Conclusions: this case is a
wonderful illustration of how
complicated and varied the
binocular system is and how it
can adapt in many different
ways. The usual response to
a problem such as Mrs AWK
had (probably since birth)
would be central suppression
of one eye resulting in amblyopia and avoiding diplopia.
It is impossible to say at this
stage what her problems
were prior to age 15 years as
she can’t remember but she
may have been one of those
children who didn’t complain
because she thought everybody had double vision and
this would explain why she
had always been a very
slow reader. However the
surgery exacerbated the
problem and also made her
incomitant and she had no
choice but to continue to
endure diplopia. She had
been referred to me in
desperation by the optometrist. - what could I do to
help? My policy has always
been to fight as hard as I
could for binocularity but on
the other hand this is sometimes an impossible goal.
In this case I was forced
to accept that binocularity
was an impossible goal.
This meant either occlusion
of one eye with resultant amblyopia in the occluded eye
or the better option; monovision. I therefore prescribed R
-0.75/-0.50 x 180 (distance
Rx) and L +1.00/-0.50 x 180
(near Rx) with clear nail
varnish on the lower half
of the R lens and on the
upper half of the L lens. She
was to wear this continually for 6 months and then
to return to see if the nail
varnish could be removed.
(The brain becomes less flexible and adaptable with age
so at age 36 years this was
unpredictable). The nett
result for her was that the
condition had and would
never be cured but at least
the symptom (diplopia) had
been removed.
Isn’t optometry exciting?
Quoit vectograms on the OHP gave no SILO or SOLI only
sideways movement. Near vectograms revealed no central
suppression on any of the Mother Goose figures and on Topper also no SILO or SOLI only sideways movement. Square/
circle torch gave some intermittent suppression at distances
closer than 10 cm and further than 50 cm.
57
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June 2009
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Instructions to
participants
ARTICLE: Essential contact
lens practice , Part 1 - Page 32
Please enter your HPCSA
registration number in the
blocks below:
1. Which of the following parts
of, or attachments to, the slit
lamp may be used to make
objective measurements?
–
–
Dispensing Optician
Answer: a
• There are 3 separate (MCQs)
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Multiple Choice / True / False
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b
c
d
a) Is your general health good?
b) Are you on any tablets or
medication?
c) Tell me about your general
health
d) Do you have any health
problems?
b
c
d
3. Which of the following reasons
explains a cause of contact
lens problems in computer
operators?
a) UV radiation from the screen
b) IR radiation from the screen
c) Static field from the screen
d) Reduced blink rate
Answer: a
b
c
d
4. In terms of corneal sensitivity,
which of the following eye
types would you expect to
have most problems adapting
to hard contact lens wear?
Contact Details
Name:
Practice Name:
Telephone: Area Code (
Fax: Area Code (
Cellular Number:
E-Mail Address:
Physical Address:
Postal Address:
) Number (
) Number (
b
c
d
a) Decreased pupil diameter
b) Reduction in corneal fragility
c) Decreased tonus of lower lid
d) Increased corneal sensitivity
2. Which of the following
questions is the preferred
means of getting initial
background information about
a patient’s general health?
Answer: a
Answer: a
5. Which of the following does
NOT occur in the ageing eye?
a) Wratten blue filter
b) Graticule
c) Focusing rod
d) Neutral density fitter
Optometrist
a) Blue irides
b) Aphakics
c) Brown irides
d) Hyperopes
)
)
Answer: a
b
c
d
6. Which
of
the
following
general health conditions and
associated treatments can
influence contact lens wear?
a) Diabetes
b) Systemic hypertension
c) Eczema
d) All of the above
Answer: a
b
c
d
a) –5.50/–2.25 x 180
b) –6.00/–2.00 x 180
c) –5.50/–2.00 x 180
d) –6.50/–2.50 x 180
b
c
d
a) Refer for surgery for pinguecula
and medication for the MGD
before fitting
b) Fit without treatment
c) Fit thin soft lenses once MGD
has been treated
d) Do not fit lenses
b
c
d
9. Which of the following statements
is false about keratometry?
b
d
c
10. What is the preferred method
for measuring the size of a
corneal lesion?
a) Hand-held mm rule
b) Grading scale
c) Slit-lamp eyepiece graticule
d) Slit-lamp beam width/height
adjustment
b
c
d
11. Which of the following is
likely to make no difference
to either RGP or soft lens
wear?
a) Metal splinters
b) Extreme cold
c) Acid splash
d) Burning grit particles
Answer: a
8. A potential contact lens patient
presents
with
meibomian
gland dysfunction (MGD) and
a pinguecula. Which of the
following management options
is advised?
Answer: a
Answer: a
Answer: a
7. Which of the following is closest to
the ocular refraction of a patient
whose spectacle refraction is
–6.00/–2.25 x 180?
Answer: a
a) K eratometry
is
a
good
indication of hard lens base
curve selection
b) K eratometry
is
a
good
indication of soft lens base
curve selection
c) The keratometer can be used
to assess tear quantity
d) Keratometry measures the
central of cornea
b
c
d
12. Approximately what
percentage of the population
suffer allergy at some time in
their life?
a) 10 %
b) 25 %
c) 50 %
d) 75 %
Answer: a
b
c
d
EyeSite Bank Details
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Please fax a deposit slip to
0866138290
EyeSite Postal Address
PO Box 445 Melrose Arch 2076
59
CPD PROGRAM
Article: Drug use and its
effects on the eye and visual
system - Part 2 - Page 40
1. H
ow many times more potent
than Valium is Rohypnol?
a) 2-3
b) 7-10
c) 10-20
d) 5-8
Answer: a
b
c
d
2. What is the street name for
Rohypnol?
a) Roofies
b) Barbs
c) Downers
d) Nembies
Answer: a
b
c
b
c
d
b
c
d
a) Ecstasy
b) Tik
c) LSD
d) Barbiturates
b
c
d
6. What agent can cause
cataracts?
a) LSD
b) Ecstasy
c) Mothballs
d) Petrol
b
c
d
b
c
d
a) LSD
b) Methamphetamine
c) Barbiturates
d) Amyl nitrate
b
c
b
c
d
1. Which is the most incorrect
answer?
The lens measure can determine
the following
a) The dioptric value of convex and
concave surfaces of ophthalmic
lenses.
b) The refractive index of a lens.
c) Can determine the power of thin
lenses.
d) It is calibrated for a refractive index
of 1.523.
Answer: a
d
b
c
4. Aberrations caused due to the
form of lenses are:
a) T ransverse chromatic aberration,
and Distortion.
b) Coma and Spherical aberration
and distortion.
c) Oblique astigmatism Curvature
of field and Distortion.
d) Longitudinal and transverse
chromatic aberration.
Answer: a
b
d
2. F or distance vision, in the
absence of prescribed prism,
the optical centre of lenses are
positioned on a line that passes
through the centre of pupils for
all positions of gaze.
a) True
b) False
c
d
5. When manufacturing a lens of
power –4 D in best form, the
front surface power should be;
a) 4 D.
b) 6 D.
c) 8 D
d) Plano.
Answer: a
a) LSD
b) Ecstasy
c) Methamphetamine
d) Barbiturates
Answer: T
7. “Poppers” is another name for:
60
d
Article: Importance of a
lens-measure and lens form.
- Page 48
5. Which drug causes jaw
clenching?
Answer: a
c
9. Which agent is toxic to the
retina and optic nerve?
a) Methanol
b) Petrol
c) LSD
d) Methamphetamine
Answer: a
a) Valium
b) Tik
c) LSD
d) Rohypnol
Answer: a
b
d
4. Retinal burns are a side-effect
of which drug?
Answer: a
Answer: a
10. Which drug is often mixed with
caffeine?
a) 25 milligrams
b) 25 micrograms
c) 250 milligrams
d) 250 micrograms
Answer: a
a) Prescribed form
b) Injected form
c) Sniffed form
d) Smoked form
Answer: a
3. What is the smallest dose of
LSD necessary to produce an
effect?
Answer: a
8. Which form of methamphetamine
is most addictive:
b
c
d
6. F itting aspheric design lenses
require different procedures
when compared to fitting
ordinary spherical design
lenses.
a) True.
b) False.
Answer: T
F
7. SpazioTM lenses are lenses with
decentred optic zones.
a) True.
b) False.
Answer: T
F
8. Rodenstock offers Mono-SportTM.
Lenses that are spherical in
design for wrap design frames.
a) True.
b) False.
Answer: T
F
For answers from the January
2009 EYESITE.co.za CPD
Program visit www.eyesite.
co.za/cpdanswers
THE EYESITE.co.za CPD
PROGRAM IS SPONSORED BY:
F
3. The aberration of significance
to spectacle wearers that are
caused by the lens material are:
a) Transverse chromatic aberration
and Distortion.
b) Coma and Spherical aberration.
c) Oblique astigmatism and curvature
of field.
d) Longitudinal and transverse
chromatic aberration.
Answer: a
b
c
d
•O
nce you have completed
this form, please return it by
registered post by September
30, 2009
• For further information, please
contact EYESITE.co.za at
+27 11 728 3307 or 082 320 6431
or [email protected]
Everything you love about ACUVUE ® OASYS
... now also for Astigmats.
New ACUVUE® OASYSTM for ASTIGMATISM.
You may think that toric lenses are complicated and take time to fit? Not with ACUVUE® OASYSTM for
ASTIGMATISM. Thanks to the unique Accelerated Stabilisation Design which in clinical trials achieved 95%
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159/2
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1. Johnson & Johnson Vision Care Data on file, 2006. ACUVUE® and ACUVUE® OASYS™ with HYDRACLEAR® are registered trademarks of Johnson & Johnson Vision Care. © JJVC 2009, a division of Johnson & Johnson Medical (Pty) Ltd.
TM
NEWS & EVENTS
DIRECTORY
Company Name:
ALCON LABORATORIES SA
(PTY) LTD
Company Name:
BUSHNELL PERFORMANCE OPTICS SA
Telephone:
011 840-2300
Telephone:
011 792-5408
Facsimile:
011 840-2301
Facsimile:
011 792-5258
Email/URL:
[email protected]
Email/URL:
Address:
65 Peter Place, Bryanston Ext.13
PO Box 3198, Randburg, 2125
[email protected]
www.serengeti-eyewear.com
www.bolle.com
Address:
Unit 6 Rodium Industrial Park, Fabriek str
Strijdom Park, Randburg
Brands/Products/
Services
Bollé, Bollé Optics, Bollé Safety, Serengeti,
Serengeti Rx, Bushnell, Tasco
Company Name:
CARL ZEISS VISION
Telephone:
Johannesburg 011 538-4200
Cape Town 021 464-5400
Facsimile:
Johannesburg 011 402-9340
Cape Town 021 461-8195
Email/URL:
[email protected]
Brands/Products/
Services
Company Name:
OPTI-FREE® Express® MPDS No Rub,
OPTI-TEARS® Comfort Drops,
OPTI-FREE® Daily Cleaner
BAUSCH & LOMB (SA)
Telephone:
011 259-2600
Facsimile:
011 259-2651
[email protected]
www.bausch.co.za
Email/URL:
Address:
Brands/Products/
Services
19 Autumn Street, Rivonia, 2128
CONTACT LENS SOLUTIONS
Lens Lubricant, Boston Simplus,
Concentrated Cleaner, Saline Plus, ReNu
MultiPurpose, ReNu MultiPlus, Conditioning
Solution, Daily Cleaner
CONTACT LENSES
SofLens Multi-focal, PureVision
SoftLens 38, SofLens 59, SofLens Toric,
SofLens Daily Disposable, SofLens Colors
PureVision Toric, PureVision Multifocal,
Soflens Daily Disposable Toric for
Astigmatism
PHARMACEUTICALS
Ocuvite, PreserVision Soft Gels AREDS,
PreserVision Soft Gels Lutein,
Ocuvite PreserVision, Ocuvite Lutein,
Moisture Drops, Medilar Dry Eye Capsules
Moisture Eyes PM
Company Name:
BEV MEEKEL CONSULTING
Telephone:
011 468 3134
Facsimile:
011 468 3322
Email/URL:
[email protected]
www.optivet.co.za
Address:
PO Box 656, Kyalami Estates, 1684
Brands/Products/
Services
62
Recruitment & Placement of Optometrists,
Dispensing Opticians, Practice support
staff - frontliners, admin & technical plus
‘Industry’ employees, incl. Sales Reps,
Management, Admin, Technicians etc. in
Southern Africa. Permanent & Locum
International Division - UK, The Netherlands,
Middle East, Australia, New, Zealand,
Trinidad/Tobago and Mauritius, Practices
for Sale, Marketing Services, Educational
Seminars, Event Management and In-house
Training.
CAPE TOWN
Genop House, 53 Commercial Street,
Cape Town, 8001
Address:
JOHANNESBURG
GENOP Centre
2 Ove Street
New Doornfontein
2094
Brands/Products/
Services
Clarlet Gradal Individual, Clarlet GT2,
Clarlet Gradal Brevis, Clarlet Gradal Top
E, Sola Compact Ultra, Sola One, Sola
Graduate XL, AO B’Active, Spazio, Finalite,
Polylite, Hyperlite, LotuTec, Carat, Teflon,
SHMC, Transitions, Clarlet GT 2 3D, Sola
Synchrony and Zeiss Clarity
Frames and Sunglass brands including Tom
Ford, Roberto Cavalli, Just Cavalli, Puma,
Kenneth Cole, Esprit and Charmant.
Company Name:
CAPE GLOBAL EYE CARE CENTRE
Telephone:
022 715 3200
Facsimile:
022 715 3201
Email/URL:
[email protected]
www.capeglobaleyecare.com
Address:
Suite 11, Medical Centre, Hill street,
Vredenburg, 7380
Brands/Products/
Services
Recruitment of all Personnel in the Optical
Industry, Temporary Placements, In-House
training, HR Management etc
Company Name:
thegreencompany IMPORTERS (PTY) Ltd
Telephone:
086 111 4852
Facsimile:
086 606 4788
Email/URL:
[email protected]
www.greeneyewear.com
Address:
9 Cypress Road, Newlands Cape Town
Brands/Products/
Services
David Green, MOONSTONE, TGC Ultrasonic
Cleaners, Sandwalk
DIRECTORY
Company Name:
ESSILOR SOUTH AFRICA
Company Name:
JESSENFASHION (PTY) LTD
Telephone:
Facsimile:
Telephone:
011 793 6260
Facsimile:
0866 219 372
Email/URL:
011 453 1602
011 454 1705
[email protected]
www.essilor.com
Address:
137 Kuschke Str., Meadowdale, Germiston
Email/URL:
[email protected]
www.bellinger.dk
www.jessenfashion.co.za
Brands/Products/
Services
Varilux Physio, Varilux Comfort, Varilux
Ellipse, Varilux Libery, Crizal and Crizal A2,
Nikon, Transitions, as well as High and Ultra
High Index material such as Airwear 1.59,
Stylis 1.67 and Lineis 1.74
Address:
4 Hein Kranhold
Malanshof, Randburg
PO Box 3296 Rivonia 2128
Brands/Products/
Services
Bellinger, Kamaeleon, BLAC carbon fibre
frames, Children’s Optics: Barbie, Hot
wheels, Actionman, FisherPrice, Bbig
Sunglass couture: Barbie “50 year
anniversary’’ adult sunglasses, Slights
– one piece titanium
Company Name:
EUROTECH OPTICAL
Telephone:
012 370-4175; 012 370-3951 or
082 414 1472
Facsimile:
(012) 370 -1557
Email/URL:
[email protected]
www.eurotechoptical.com
Address:
PO Box 13893, Laudium, 0037
Brands/Products/
Services
Autorefractor/Keratometer, Automatic &
manual vertometer, all types of slitlamps,
Digital slitlamps, Fundus cameras, corneal
topographer, visual field, chart projector,
phoropter, Chair & Stand, spare parts, Dyes
wheel, patternless and Automatic Edges
and any other optical equipment. Frames,
disposable/permanent toric colour contact
lenses. All products available at competitive
prices.
Company Name:
GERRY VAN WINSEN OPTICS
Telephone:
011 793 4667
Facsimile:
011 793 4671
Email/URL:
[email protected]
www.goptics.co.za
Address:
Brands/Products/
Services
Company Name:
JONATHAN SCEATS SA cc
Telephone:
021 439 1903
Cell: 082 808 8634
Facsimile:
Email/URL:
021 439 1903
[email protected]
www.jonathansceats.com
Brands/Products/
Services
Sceats RX, KDZ, and Sunglasses
Company Name:
JOHNSON & JOHNSON VISION CARE
Telephone:
011 265 1174
Facsimile:
011 265 1330
Email/URL:
[email protected]
www.acuvue.co.za
Address:
2 Medical Road, Midrand, 1685
Brands/Products/
Services
ACUVUE® Brand Contact lenses:
ACUVUE® OASYS™ with HYDRACLEAR®
Plus, Acuvue®Oasys™ for
ASTIGMATISM, ACUVUE® ADVANCE™
with HYDRACLEAR®, 1•DAY ACUVUE®
MOIST™, 1•DAY ACUVUE®, ACUVUE®2,
ACUVUE® BIFOCAL
No.6 Naaf Street,
Strijdompark, Randburg
South Africa.
Icare. Medop. Potec.
Complete range of Optometric and
Ophthalmic Instruments, Frame Displays
and Lab Equipment.
Supply, Service and Repair of new and
pre-owned instruments. I.T. Services
including HealthBridge & Eminance
installation & training.
Company Name:
HARCHAD CC t/a High Opti-Fashion
Telephone:
(011) 781-8239
Facsimile:
(011) 781-8239
Email/URL:
[email protected]
Address:
14 Park Towers Corner Grey Abingdon Road
Kensington B, Randburg 2094
Brands/Products/
Services
Anne et Valentin, Lollipops, Redskins,
Sezz, Ted Lapidus, Le Tanneur & Xenith
Optical Frames, Bet Optical Frames,
Agatha Ruiz De La Prada Optical Frames
and Sunglasses, Flo Polarized Clip-ons,
Lens Cloths and V-Plus Lens Cleaner
Company Name:
KEN PAYNE OPTICAL CC
Telephone:
0861 106 384
Facsimile:
0800 221 355
Email/URL:
[email protected]
Address:
P.O. Box 147, Howard Place, 7450
Frame and Sunglass Suppliers for brands
CARDUCCI, COLIBRI, PLAZA, RED PONY,
CRAVE
Brands/Products/
Services
Company Name:
LUXALITE (PTY) LTD
Telephone:
(011) 483 1200 and
(011) 402 2020 (from July 4th 2009)
Email/URL:
[email protected]
Address:
3rd Floor Morkel House
31 Voorhout Street between 2nd & 3rd street
(behind Std bank arena)
New Doornfontein JHB 2094 (from July 4th 2009)
Brands/Products/
Services
STEPPER, Stepper’S & Fusion by Stepper,
Faconnable, Clark, PANTONE Universe
Eyewear, Angel Eyes, Champions, i-spy
Luxalite, Neric & Neric B (Budget Line),
“HEAD”, Grant, and I.D. by Neric
NEWS & EVENTS
DIRECTORY
Company Name:
LUXOTTICA SA
Telephone:
(011) 676 7700
Facsimile:
(011) 784-1680
Email/URL:
Company Name:
SPHERICAL OPTICAL
Telephone:
(011) 440-0960
[email protected]
Facsimile:
(011) 440-8244
Address:
30 Impala Road, Chislehurston, Sandton.
Private Bag X 10022, 2146
Email/URL:
[email protected]
Ray-Ban, Ray-Ban Junior, Vogue, Arnette,
Luxottica, Versace, Versus, Prada, Prada
Sport, Dolce & Gabbana, D&G, Chanel,
Bvlgari, Tiffany & Co, Burberry
Address:
Brands/Products/
Services
Brands/Products/
Services
Generic Products
Company Name:
SDM EYEWEAR A DIVISION OF THE HOUSE
OF BUSBY (PTY) LTD
Telephone:
(011) 334-7020
Facsimile:
(011) 334-6026
Email/URL:
[email protected]
www.busbyhouse.com
Address:
Express House, 28 Durban Street,
City & Suburban, Johannesburg, 2000
Brands/Products/
Services
Guess, Polaroid, Shadows, X-Tra Vision,
Blue Rush, Bad Boy, Bad Girl,
Funky Reading Glasses , Ted Baker,
I-TEC, Vera Wang, Paco Rabanne, Carolina
Herrera, 212
Company Name:
OAKLEY AFRICA
Telephone:
041-5010200
Facsimile:
041- 5855510
Email/URL:
[email protected]
Address:
Humerail Business Park, Oakworth Drive,
Humerail, Port Elizabeth
Postal Address:
PO Box 5550, Walmer, Port Elizabeth, 6065
Brands/Products/
Services
Sunglasses, Prescription frames & lenses,
Sun Prescription, Goggle, Wearable
Electronics, FOX Sunglasses
Company Name:
PROGRESS OPTICAL
Telephone:
Elanza: 079 875 2047
John: 082 447 1485
Tel/Facsimile:
011 452 2710
Email/URL:
Elanza: [email protected]
John: [email protected]
Address:
16A Potgieter Road, Eastleigh, Edenvale
Brands/Products/
Services
Rodenstock lenses & frames
Porsche Design
Company Name:
SAFILO SOUTH AFRICA (PTY) LTD
Telephone:
+27 11 457 3500
Facsimile:
+27 11 608 2293
Email/URL:
[email protected]
www.safilo.com; www.carrerasport.com
www.smithoptics.com
Address:
Unit 5B, Galaxy Park, 17 Galaxy Avenue,
Linbro Park, Johannesburg
P.O. Box 541, Kelvin, 2054
Brands/Products/
Services
Safilo, Bluebay, Diesel, Gucci, Giorgio
Armani, Emporio Armani, Carrera, Smith,
Christian Dior, Oxydo, Max Mara, Valentino,
Pierre Cardin, Yves Saint Laurent, Hugo
Boss, Boss, DSL 55, Hugo.
Company Name:
SHAMIR OPTICAL SA
Telephone:
(011) 440-0960
Facsimile:
(011) 440-8244
Email/URL:
[email protected] www.shamir.il
Address:
Brands/Products/
Services
Shamir Piccolo, Office, Insight, Autograph
and Genesis
64
Company Name:
TRANSITIONS OPTICAL
Telephone:
011 795-0001
Facsimile:
086 617-1590
Email/URL:
[email protected]
www.transitions.co.za
Address:
308 Unit 8 Boundary Road, Honeydew, 2063
Johannesburg
Brands/Products/
Services
Photochromic lenses
Company Name:
YOUNGER OPTICS
Telephone:
084 509 1188
Facsimile:
086 649 9152
[email protected]
www.youngeroptics.com
www.drivewearlens.com
Email/URL:
Address:
15 Duke Street, Observatory, 7925
Brands/Products/
Services
Image®, Trilogy™, NuPolar®, DriveWear®,
Transitions®, Easy Lite™ , Polycarbonate,
Clear Hard Resin, Specialty Bifocals
If you would like to advertise in EYESITE.co.za
directory, contact us on Tel: 011 728 3307 or
email: [email protected]
EYESITE.co.za JUNE 2009

Free Monitor - EYESITE.co.za

Transcription

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