The sweet spot
Balancing the evidence on key topics within optics – from myopia and visual stress to increasing happiness at work
08 October 2022
We are all guilty of it. You’re busy describing how the scorch marks on your lacklustre brunch resemble Graham Norton when the waiter comes along to ask how your meal is.
The answer is of course: fine, thanks.
But telling a white lie when your Peaky Blinders-obsessed boyfriend asks what you think of his new flat cap is a different matter entirely to sugar-coating the truth in the world of work.
Optometrists have a professional obligation to be honest and trustworthy. When a patient walks into an optometry practice, they are seeking insight not on what colour of curtains best suit their living room or the most appropriate outfit for a job interview – but on how to maximise and protect their vision.
It makes sense that when the service in question is the very way that patients perceive the world, providing clear, objective and considered advice is of the utmost importance.
This is not aways easy. Conversion rates, limited testing times and the reality that optometry is an environment where healthcare and commerce combine can create challenges.
With the best of intentions, it is sometimes difficult to assess what guidance to give patients amid competing claims from industry, academia and professional bodies.
How should optometrists separate fleeting trends from a lasting development? How can pages of research be distilled into practical insight? In an effort to assist optometrists in taking an evidence-based approach to daily practice, OT approaches experts for their take on key issues within optics.
The idea that what a patient puts on their plate can help to protect their vision is an appealing one. But how much of this is based in evidence?
Associate professor Laura Downie, of the Melbourne Cochrane Eyes and Vision Centre for Evidence-Based Vision Care, highlighted that a person’s diet can influence their eye health.
“Extreme vitamin deficiencies can have severe, sometimes permanent, effects on eye health and vision,” she said.
In a nutshell: nutrition tips
Patients should be advised to eat dark, green leafy vegetables and fresh fruit daily, a serve of oily fish two to three times per week, a handful of nuts per week, choose low GI carbohydrates and limit the consumption of saturated fats and oils whenever possible.
Research by Downie et al in 2017 found that two thirds of patients expected their optometrist to ask about their general health, while three in four patients indicated they would feel comfortable speaking about their diet with their optometrist.
In another case published in 2021, a Singaporean woman suffered vision loss after developing severe iron deficiency as a result of a diet consisting of potato-based foods, and biscuits.
While not as extreme as these examples, the general UK population is also falling short when it comes to a nutritionally balanced diet.
In 2018, only one in four UK adults were eating five or more portions of fruit and vegetables per day.
Cigarette smoking and nutrition are the main modifiable risk factors for AMD, which is the leading cause of irreversible vision impairment in developed nations.
“Given that diet is a modifiable risk factor for sight-threatening eye conditions such as AMD, optometrists have an opportunity to provide general advice about dietary patterns that can reduce the long-term risk of eye disease,” Downie shared.
Evidence supports the role of foods that are rich in antioxidants limiting photoreceptor damage at the macula, while researchers have highlighted the anti-inflammatory and retinoprotective effects of omega-3 fatty acids.
Eating at least one portion of oily fish per week has been associated with a 50% reduction in the chance of developing wet AMD.
Optometrists have an opportunity to provide general advice about dietary patterns that can reduce the long-term risk of eye disease
Turning to the use of nutritional supplements, Downie highlighted the importance of optometrists assessing the potential risks and benefits for each patient.
“Nutritional supplements are not intended to act as food substitutes as they cannot replicate the full spectrum of nutrients,” Downie said.
“Importantly, by definition, and unlike prescription medications, nutritional supplements are also not intended to treat or prevent disease,” she added.
She highlighted the value of well-conducted and up-to-date systematic reviews in considering the best current research on a topic.
Nutrition: Cochrane systematic reviews
There is an exciting question at the heart of myopia management. What if optometrists could bring the world of short-sighted children into focus, not solely through refractive correction, but through limiting the progression of myopia in the first place?
What if they could reduce the risk of generations of children developing eye disease in old age – at a time when ophthalmology departments across the globe will be grappling with the health burden of an ageing population.
A range of myopia management interventions are now gathering momentum, backed by multi-year trials and, in some cases, regulatory approval.
However, without funding from the NHS, it is still up to patients to bear the cost of myopia management. There are unanswered questions within the field. Not all children will respond to myopia management interventions and the research is still unclear on why that is.
But as Professor Nicola Logan told OT when speaking about MiSight 1 day contact lenses, when you have an intervention that works in nine out of ten patients – surely, they should at least be aware that it is an option.
“At a minimum, I think ECPs should be speaking to children with myopia and their parents and saying there are interventions available,” she said.
“As a starting point, they can talk about behaviour and lifestyle changes that are likely to impact on myopia development and progression,” Logan shared.
For example, research has found that an hour more of outdoor time each day can reduce a child’s chance of developing myopia by 45%.
In August, the College of Optometrists published updated guidance on myopia management.
The College states that optometrists can provide myopia management as long as it is within their scope of practice – meaning that the practitioner has the relevant knowledge and skills to provide this intervention acquired through training and experience.
The guidance summarises reasons for practitioners to consider myopia management – including the availability of effective management options and the link between myopia and developing eye conditions later in life.
As with any form of therapeutic intervention, optometrists should obtain informed consent in order to proceed with myopia management.
The importance of keeping up-to-date with evidence about the effectiveness and safety of myopia management interventions is highlighted “as the evidence base is evolving at pace.”
“However, some children will continue to progress, and it is unclear why some children respond better to treatment than others,” she said.
She noted that myopia management interventions are well-tolerated and safe to use.
“In fact, there is better contact lens compliance in children than in adults resulting in lower rates of infection,” Kearney highlighted.
Conundrums facing optometrists who have introduced myopia management in practice include when to stop treatment and what to do if progression continues.
Kearney believes that optometrists should be discussing the likelihood of myopia progression with patients and parents, increased disease risk and the available management options.
If a practice does not offer myopia management, Kearney recommends that optometrists become familiar with practices that do so that patients still have the option of receiving treatment.
For practices that are offering myopia management, Kearney noted that subjective refraction can be variable and may not best suited for capturing the incremental effect of an intervention.
“There is a strong case that axial length should be measured. This non-invasive measurement is much more accurate and more directly correlates with disease risk,” she said.
Kearney shared that measuring axial length gives her confidence when deciding if a myopia management intervention is successful.
Turning to the future of myopia management, Kearney observed that in the near future low dose atropine may become available in the UK – offering hope to children who do not respond to optical treatments.
“For now, treatments will continue to be privately paid for by parents until further research exploring the cost effectiveness of treatment can be completed which can then be used to decide if public health funding could be considered,” she said.
Clinical and professional director at the AOP, Dr Peter Hampson, highlighted that currently only those who can afford to pay for treatment have the opportunity to see if myopia management will work for their children.
“If as a profession we are serious about reducing the potential future pathology risk, then we have to find a way to make it accessible to all who may benefit. To do that the evidence for how well it works has to be beyond challenge so that we can make the case that this should be NHS funded. It is therefore of the utmost importance that we proceed cautiously and continue to build the evidence base,” he said.
Hampson added that while the College guidance recommends that optometrists should have the ability to explain myopia management options, the guidance does not go as far as placing an obligation on practitioners to discuss myopia management with potential candidates for treatment.
It also does not require practices that do not provide myopia management to refer to another local practice offering the service.
“As this is an evolving area of practice it is likely that guidance will change regularly and it is important practitioners stay up to date,” he concluded.
As reliably as pumpkins are carved and the silhouettes of bats appear in windows, each October eye care professionals urge caution when purchasing contact lenses online.
Contact lenses purchased online may fall short of UK regulatory standards, while missing out on the guidance of an eye care professional can lead to risky contact lens behaviour.
The British Contact Lens Association’s Contact Lens Evidence-based Academic Reports (CLEAR), published in 2021, identified that the frequency of eye examinations is lower among individuals who purchase lenses exclusively online.
Professor James Wolffsohn highlighted that the evidence suggests among some demographics there are growing numbers of “self-taught” contact lens wearers, who may be at risk of non-compliance and poor practices.
“Unregulated purchasing behaviour of contact lenses is associated with ocular complications such as a higher rate of infection and microbial keratitis,” he shared.
Wolffsohn highlighted that a contact lens fit cannot be predicted by lens parameters alone.
“Assessment of a lens on eye by a registered eye care professional before prescribing is essential,” he emphasised, adding that poor fitting lenses are associated with contact lens complications and dryness symptoms.
Professor James Wolffsohn assesses the evidence on risks associated with the online purchase of contact lenses
- Evidence shows patients are likely to present less frequently for aftercare visits, increasing the risk of undetected adverse ocular reactions to lens wear
- Epidemiological studies demonstrate an increased risk of microbial keratitis
- Internet vendors may substitute the prescribed lenses with brands that they have available and believe to be equivalent, despite the fact that true equivalence is rarely possible, often leading to compromised vision, comfort and ocular health
- Patients may purchase lenses with incorrect specifications (eg based on spectacle prescription uncorrected for vertex distance).
Professor Nathan Efron, of the Queensland University of Technology, shared that in his view contact lenses should never be purchased over the internet.
“Contact lenses should be prescribed, fitted and assessed by a qualified eye care practitioner in a clinic equipped with all the necessary instrumentation to undertake proper clinical oversight,” he said.
However, Efron added that patients should be permitted to request contact lenses from their personal eye care provider either through the internet or by telephone.
Efron conceded that there are both conceptual and technical challenges in regulating the online sale of contact lenses.
“The conceptual challenge is finding a balance between allowing the public to purchase contact lenses from the vendor of their choice, versus the imperative of protecting the ocular wellbeing of the public by ensuring that contact lenses can only be purchased with proper oversight by a registered ophthalmic practitioner,” he shared.
Technical challenges centre around implementing an effective, but not overly-onerous, mechanism of implementing the oversight of contact lens sales.
“This would mean only providing a new supply of contact lenses according to a prescription from a registered provider, but also providing a resupply of the same lens type with proper professional oversight. Then there are questions about exactly what needs to be specified in the prescription and designating appropriate expiry limits on the validity of the prescription,” Efron observed.
Visual stress and dyslexia
Tasks that many complete without a second thought can present daily hurdles for those with dyslexia.
From deciphering menus, to taking a telephone message and writing a shopping list, the written world can be challenging to navigate.
Professor Bruce Evans shared with OT that the evidence suggests around one in five people with dyslexia may also experience visual stress.
Visual stress is characterised by experiencing symptoms when viewing certain stimuli, particularly text.
“The symptoms are often alleviated by individually prescribed coloured filters,” he shared.
There have been controversies within the field of visual stress. Evans highlighted that some people assume treating visual stress will “cure” dyslexia.
“Dyslexia is multi-factorial and only in some cases does visual stress seem to contribute to reading difficulties,” he said.
Examples of misleading statements
“Vision therapy treats dyslexia”
“We specialise in visual dyslexia”
“We treat dyslexia”
“Book a dyslexia test”
“Coloured filters are proven as a treatment for visual stress”
Source: Bruce Evans and Arnold Wilkins, Guidance for eye care professionals on publicity concerning dyslexia, visual stress, and related conditions
A publicly available appendix provides guidance for eye care professionals provides guidance for eye care professionals on publicity relating to visual stress and dyslexia.
Evans shared that a 2017 study suggested diagnostic criteria for visual stress that may help to avoid over-diagnosing the condition.
Patients should have at least three of the following six typical symptoms: words move, words merge, patterns or shadows in the text, text seems to stand out in three dimensions above the page, words or letters fade or darken and discomfort with certain artificial lights.
As well as the above, the patient should meet two of the following three signs from investigations: the patient voluntarily uses an overlay for three months or more, the overlay improves performance on the Wilkins Rate of Reading Test and the patient has a Pattern Glare Test score of greater than three with mid-spatial frequency grating.
The AOP perspective
Head of clinical and regulatory, Henry Leonard, highlights the need for caution following practice complaints about dyslexia and visual stress advertising
A number of optometry practices have recently received complaints regarding information they’ve published on their websites on the topic of visual stress and dyslexia. We recommend removing any references to diagnosing or treating specific learning difficulties such as dyslexia, but it would be reasonable to make the following points:
- Some people experience symptoms of visual perceptual distortions and eyestrain when viewing text, and this is often described as ‘visual stress’. Symptoms of visual stress include words appearing to move around or merge together when reading, patterns or shadows appearing within a block of text and a strong aversion to striped patterns
- The latest estimates are that visual stress is present in around 1 in 5 people with dyslexia, but although they may co-exist, visual stress and dyslexia are different conditions
- Some people who suffer from visual stress find that their symptoms are alleviated by coloured filters, either in the form of coloured overlays or tinted lenses. Coloured filters are normally only considered once a sight test has been performed, and any other potential causes of visual difficulty have been addressed.
Happiness at work
We all want to start our working day with a spring in our step.
But what does the evidence say about how to achieve workplace satisfaction?
The latest Registrant Workforce and Perceptions Survey by the General Optical Council found that 62% of optometrists and dispensing opticians were happy in their roles.
Professor Laurie Santos is a Yale University psychology professor and host of The Happiness Lab where she examines the scientific evidence on happiness.
Santos shared with OT that the concept of job crafting, pioneered by Professor Amy Wrzesniewski, can help to boost job satisfaction.
In order to find out what factors contribute to meaningful work, Wrzesniewski carried out interviews with a group of janitorial staff at a US hospital.
The cleaning staff who had the most satisfaction in their jobs expanded their job description beyond cleaning and saw themselves as playing an integral role in patient care.
For example, one cleaner would talk to patients who had not received visitors while another rearranged pictures in the rooms of comatose patients in the hope that it would have a positive effect.
“If you want to job craft as an optometrist, ask what you value, what strengths you have and consider the ways that you light up when you are doing certain things. Can you infuse that more into your work?” she shared.
Although it may be tempting to think that an increase in salary would boost job happiness, the evidence does not always support this assumption.
Research published in 2010 found that once an individual is on a salary of $75,000 USD (£47,000) at the contemporary exchange rate), even if their salary is doubled or tripled there is not a significant improvement in positive emotions – or decrease in negative emotions.
“The connection between money and happiness is a complicated one. Money does equal happiness if you are not making very much money – if you are living below the poverty line or you are not making a decent middle-class income,” Santos shared.
“However, the evidence suggests that for many on middle class or upper middle class salaries, getting more money isn’t necessarily going to help you become happier,” she highlighted.
The evidence suggests that for many on middle class or upper middle class salaries, getting more money isn’t necessarily going to help you become happier
Santos shared that there is evidence to suggest that there are certain behaviours and mindsets that can help to boost happiness.
“One of the biggest ones is social connection. Simply the act of engaging with other people tends to make us happier over time,” she said.
“There’s also evidence that being nice to people can improve our happiness – either reframing the kinds of things that you are doing right now to help people, or to focus more on helping people generally can improve your happiness,” Santos observed.
Lastly, Santos emphasised the importance of gratitude.
“A mindset of gratitude, being thankful for the things you have, can improve your happiness,” she said.
Turning to the issue of burnout, Santos noted that the term can be used flippantly in modern society.
Psychologists characterise burnout as a specific clinical syndrome that involves three features: emotional exhaustion, depersonalisation/cynicism and a lack of personal effectiveness.
“Even after a good night’s sleep you still feel exhausted,” she shared.
“You feel like you are at your wit’s end all the time and you are constantly frustrated with the people around you,” Santos said.
The GOC survey revealed that close to one in ten optometrists and dispensing opticians (9%) had taken a leave of absence due to stress.
Santos emphasised that once someone is experiencing burnout “this is a time where simple hacks don’t help that much.”
“You really need to take a good hard look at your job and how you are interacting with your work to see if you can make some big changes. That can include taking time off but it can also include restructuring your relationship with your job – making sure that you prioritise other areas of your life in addition to your work,” she highlighted.
“Every time you go the extra mile, your job satisfaction increases”
SpaMedica patient co-ordinator, Julie Trowell, knits intricate squares to ease the worries of anxious. She talks with OT about the motivating power of making a difference
Since November last year, Julie Trowell has created more than 20 knitted squares with intricate designs in her spare time.
The SpaMedica patient coordinator started making the miniature works of art – which she has dubbed twiddle squares – for anxious patients and patients with dementia who come through the waiting room and may have restless hands.
Before she picks up her knitting needles, Trowell imagines a design that may bring a sense of familiarity and comfort to patients – often using vintage materials.
There are squares with rows of carrots and flowers for gardeners, a design with a ballgown for an 87-year-old patient who talks of her dancing days and a beach scene for a colleague whose grandmother can no longer remember her name but recalls family trips to the seaside.
Each square takes a weekend to finish and is individually wrapped for patients to take home with them after their appointment.
“Every one of them is made with love, thought and care. Every time you are able to go the extra mile, your job satisfaction increases. I go home knowing I have made a difference to somebody’s day,” Trowell told OT.
Alongside the twiddle squares, Trowell has made more than 100 sets of worry beads which are available for any patient attending the clinic.
She noted that often patients will bring the worry beads back into the clinic when they have their second cataract operation.
“I would do anything for our patients. I would sit up until midnight making them because you can see what a difference it does make. You see them calm down. When they come out, they say, ‘It wasn’t as bad as I thought’,” Trowell shared.
Racial bias within eye care
Ophthalmology registrar and research fellow at King’s College London, Dr Varo Kirthi, is passionate about the need for clinicians to recognise the impact of unconscious bias within healthcare.
“Optometrists will be seeing people walk in off the High Street from a variety of different backgrounds. The only way of reducing bias is to talk about it,” he emphasised.
“If you see people being treated differently, it is important to challengethat,” Kirthi highlighted.
A 2020 study of patients attending King’s College Hospital NHS Foundation Trust described how black patients faced treatment delays for diabetic eye disease when compared with white counterparts.
Despite having a similar burden of disease at the point of referral, the time to treatment following a face-to-face consultation was significantly longer for black patients than white patients.
In his Eye article Black eyes matter – do we treat Black patients differently in ophthalmology?, Dr Varo Kirthi, highlighted that clinicians know how to identify bias when appraising research.
“Uncomfortable as it may be, current data suggest that we may also need to look for bias in our clinics. Addressing these difficult issues is the key to narrowing the inequity of care affecting those most in need of it,” he said.
Racial bias within healthcare is an issue that affects clinicians as well as patients. Within fitness to practise proceedings specifically, non-White healthcare professionals across a range of disciplines face a higher rate of professional conduct investigations than their White peers.
In 2020, the General Optical Council (GOC) reported that non-White optometrists and dispensing opticians were 1.7 times more likely to be subject to a fitness to practise investigation than White registrants.
Despite comprising 41% of registrants, non-White optometrists and dispensing opticians accounted for more than half (52%) of fitness to practise investigations.
The only way of reducing bias is to talk about it
The most recent monitoring report in 2021 revealed that this level of disparity has narrowed – with non-White registrants accounting for 39% of fitness to practise proceedings, broadly in line with their registrant profile of 37%.
Once an optometrist or dispensing optician is subject to fitness to practise proceedings, there are also racial differences in whether the case progresses to committee stage.
The 2021 monitoring report revealed that a higher rate (36.1%) of Asian and British Asian registrants are referred to a fitness to practise committee when compared to cases involving White registrants (28.5%).
A GOC spokesperson highlighted that the overall numbers involved in fitness to practise proceedings are very low.
More than one in ten registrants (14%) elected not to provide information on their ethnicity, meaning that the data may not reflect that actual split.
The regulator’s fitness to practise improvement programme for 2022 to 2025 contains a workstream to develop and implement guidance for decision-makers in recognising and addressing potential bias.
The GOC also plans to commission research into the impact of GOC fitness to practise processes on different registrant groups.
Tackling bias in pharmacy and medicine
The General Medical Council and General Pharmaceutical Council are working to reduce disparities in professional conduct investigations
Within the UK, BAME doctors are more than twice as likely to be referred to the General Medical Council than white doctors.
GMC director of fitness to practise, Anthony Omo, shared that the regulator is committed to eliminating disproportionality related to ethnicity and place of qualification in fitness to practise referrals by 2026.
The regulator also aims to eliminate differences in key measures of fairness in medical education and training by 2031.
“We’re working with employers and training bodies to make the health service a supportive and inclusive environment, which will be better equipped to train, attract and retain the doctors we already have, as the UK continues its post-pandemic recovery,” Omo shared.
Asian and British Asian pharmacists account for 55% of concerns received by the General Pharmaceutical Council (GPhC), despite accounting for 39% of registered professionals.
In comparison, White pharmacists accounted for 26% of concerns received, while comprising 40% of the register.
In meeting papers published in July 2022, the GPhC highlighted that there is a disproportionality in concerns received when compared to the profile of the register.
“We want to understand the underlying issues and contributory factors that result in the disproportionate concerns we receive, and to identify what we can do about this and where we can work with others to make a difference.”
The GPhC has carried out anti-Semitism training and is planning to hold further sessions on Islamophobia for members of its statutory committees.
From October 2022, information relating to a pharmacist’s ethnicity – including their name, place of birth, religion and university – will be redacted in the information presented to the investigating committee.
The project will be assessed on a monthly basis with a more comprehensive review after six months.
For optometrist and dry eye specialist, Sarah Farrant, the publication of the Tear Film & Ocular Surface Society’s DEWS II report in 2017 was a milestone moment.
For the first time, an international panel of dry eye experts outlined a definition of dry eye disease.
“Prior to that there was no universal definition of dry eye disease,” Farrant explained.
“That was a problem in academia because there was no standardised model to base the research on. You couldn’t easily compare data,” she said.
Farrant sees this definition as making progress towards debunking a common misconception about dry eye disease – that it is a minor inconvenience or an inevitable part of ageing.
“It’s not a normal state for the eye. We are now recognising that it is a genuine problem that we can’t ignore,” Farrant shared.
Alongside setting out the parameters of the condition, the DEWS II report can assist practitioners in taking an evidence-based approach to managing the condition in practice.
Experts assessed the available evidence on dry eye to inform a clear stage-based approach to treating the condition in practice.
TFOS is now finalising a new report, due to be published in 2023, that explores the wider context of how lifestyle factors are influencing key drivers of dry eye disease.
For example, air conditioned offices, reduced blink rates while working on screens and cosmetic use can all affect the development of dry eye disease.
“Our new TFOS report is called the ‘lifestyle epidemic’,” Farrant shared.
“There are many factors in our modern lifestyles that are either a direct or indirect cause of dry eye,” she added.
Bye, bye baby (shampoo)
My biggest bugbear is the legacy of using baby shampoo for blepharitis. Some ophthalmologists, optometrists and GPs still recommend it. It is counter-productive. For years and years, we have known that commercial products are much better. Because baby shampoo is a surfactant, it breaks down the lipid layer of the tears. In applying soap to your eyelids, you get spill over into the ocular surface, which completely disrupts the quality of the tear film.