WhenWhen toto CareCare –– WhenWhen toto ReferRefer

AcuteAcute EyeEye ProblemsProblems inin thethe CommunityCommunity

FrankFrank MunroMunro TodayToday’’ss TalkTalk

n Acute Eye Problems

n Burden of – Making a Difference

n Shifting the Balance of Care?

n What do I do now – Could I do more?

n Clinical Decisions Making - When to Care – When to Refer ClinicalClinical decisiondecision MakingMaking

n DiagnosisDiagnosis

n ManagementManagement

n DemonstrateDemonstrate CompetenceCompetence

n WorkingWorking withinwithin scopescope ofof practicepractice

n DODO NONO HARM!HARM! Death

Birth

TheThe Challenge!Challenge! ScopeScope ofof PracticePractice

Chalazia Sub tarsal fb Viral Viral ‘Wet’ ARMD Ping / Corneal Erosion Marginal Allergic/Toxic Conjunctivitis Kerataconus int/post Corneal FB Penetrating Corneal Abrasion UV Burn Injury Bacterial Retinoschissis Microbial Keratitis Dry Eye Inclusion conjunctivitis Inclusion WhereWhere amam I?I? Cellulitis Ant / Post PVD Corneal Retinal Dystrophy Detachment Conjunctival Hge Keratitis/ Keratopathy Chemical Burns Anterior Anterior Neoplasia /Epilation Uveitis Ischaemic Optic Dry ARMD Dry ARMD Neuropathy

ENTRY ADVANCED EXPERT HES GIES Patient Categories

Category No % Category No % Category No %

NAD 112 9.6 Blepharitis 39 3.4 Ocular 16 1.4 Anterior Dry Eye 111 9.6 Glaucoma 37 3.2 uveitis 15 1.3

Conjunctivitis 90 7.8 Retinal 35 3.0 14 1.2

Diabetes 72 6.2 Tear duct etc 31 2.7 Cyst 12 1.0

Cataract 68 5.9 Episcleritis 29 2.5 9 0.8

Vitreo-ret 52 4.5 Keratitis 22 1.9 Others 225 19.4

Corneal/Ulcer 48 4.1 Visual disturbance 20 1.7

PVD 44 3.8 Macular 17 1.5

Headache/migraine 43 3.7 Ocular 16 1.4 Total 1161 100 GrampianGrampian WalkWalk--InIn CasualtyCasualty

11 5 1 6 5 1 AAU ACG 121 2 2 10 AION ALLER 1 1 2 ARMD BELL'S 6 BLEPH BLOW # 17 15 15 C CYST C ULCER 1 1 CAT CHE INJ 2 1 3 CL KERA CNOTWT 1 20 CO ABRA CONJ 2 12 CSR DRY EYE 4 46 2 EPISCL ERM 4 FB GCA 2 6 GL PERF H ACHE 16 HSV KE HZO 1 13 IOFB L CYST 1 M GRAVIS MACULO 6 MARG K MIGRAINE 9 MINOR TR MYO CNV 2 NIL ON 15 PAPILLO PCO 38 6 POST OP P SEP CEL PSII PTERY 9 PVD CRAO RC CO ER 1 RD RET SCHI 18 1 DR RUB GLA 1 45 CRVO SCH SCLER SINUS 5 18 SLK TIA 122 1 10 TR AAU TR HYPH 52 1 9 TRICHIA VIT HE TopTop 1010 –– EyeEye Casualty!Casualty!

1. SeasonalSeasonal allergicallergic conjunctivitisconjunctivitis 2. AnteriorAnterior UveitisUveitis 3. InfectiveInfective ConjunctivitisConjunctivitis 4. CornealCorneal AbrasionAbrasion 5. DryDry EyeEye 6. EpiscleritisEpiscleritis 7. CornealCorneal FBFB 8. HSKHSK 9. MarginalMarginal KeratitisKeratitis 10. PVDPVD 11. TrichiasisTrichiasis ContactContact LensLens WorkWork CURRENTCURRENT PRACTICEPRACTICE

Meibomian

TRICHIASIS THYGESONS EXTERNALEXTERNAL EYEEYE

Dry Eye Allergy Infection Auto Trauma Toxic Other Immune Mechanical

Evaporative Non Evaporative Non Chronic Acute Viral Episcleritis Foreign Chemical Angle Evaporative Chronic Acute Viral Episcleritis Foreign Chemical Angle Evaporative Body Closure Body Closure Glaucoma Vernal Seasonal Bacterial Pemphigoid Glaucoma Vernal Seasonal Bacterial Pemphigoid Injury Microbial Injury Microbial Atopic Perennial Inclusion Toxins Atopic Perennial Inclusion Uveitis Toxins Uveitis Rosacea GPC Parasitic GPC Parasitic Vasculitis Trichiasis Vasculitis Trichiasis Fungal Fungal Scleritis Scleritis ClinicalClinical DecisionDecision MakingMaking

DIAGNOSIS

REFERRAL COMMON CONDITIONS not normally sight threatening sight threatening

Prescription Immediate First Aid Alleviation Prescription & Referral + - & Referral Urgent Referral Palliation Management

Blepharitis Microbial keratitis Acute glaucoma Anterior uveitis Corn. abrasion External Patient Pathway

Patient Presentation Optometrist / GP Suspected external Suspected external eye eye disease disease

Optometrist Diagnosis

Conditions that are normally Common conditions that are sight threatening (should not normally sight threatening If sight threatening condition is therefore be managed in (can therefore be managed in Condition not normally Diagnosis identified secondary care) for example: the community) for example: sight threatening uncertain Anterior Uveitis Dry Eye Inclusion Corneal Abrasion Scleritis Foreign bodies Endophthalmitis Blepharitis Optometrist/GP Cellulitis Episcleritis URGENT REFERRAL Management Microbial Keratitis Bacterial conjunctivitis Advice Angle Closure Glaucoma Conjunctival haemorrhage Prescription Chemical Burns Hordeola Marginal Keratitis Allergic, Toxic or Viral Neoplasia external eye conditions If no response or there is concern

Hospital Eye Service Optometrist/GP Refer to Hospital Eye Service for diagnosis Follow up & discharge and appropriate management

Self Care Primary Care Secondary Care HistoryHistory n AgeAge // SexSex n GeneralGeneral HealthHealth n POHPOH n FamilyFamily HistoryHistory n RecentRecent HistoryHistory n OnsetOnset // DurationDuration // SymptomsSymptoms stablestable oror varyingvarying oror regressingregressing n PainPain // rednessredness /vision/vision //photophobia n PresentationPresentation –– recurring/recurring/ // Intermittent?Intermittent? WhatWhat isis thethe problem?problem? n PainPain vv NoNo PainPain -- ?? severityseverity n RedRed vv WhiteWhite n VisualVisual LossLoss vv NormalNormal VisionVision n ?? FloatersFloaters // PhotopsiaPhotopsia n Duration:Duration: RecentRecent vv LongLong TermTerm ExaminationExamination n VAVA /Pinhole/Pinhole n PupilsPupils n OcularOcular MotilityMotility n AnteriorAnterior SegmentSegment –– lids/lashes/red?/conj/cornea/anteriorlids/lashes/red?/conj/cornea/anterior chamberchamber n InternalInternal –– /vitreous//macula/opticLens/vitreous/retina/macula/optic nervenerve n ApplanationApplanation tonometrytonometry n SlitSlit LampLamp n VolkVolk –– DILATE!DILATE! n GonioGonio n VisualVisual FieldsFields // confrontationconfrontation PointsPoints toto PonderPonder

Upper Lower Lashes Tarsal

Fornices Limbus Plica

Lid Margin Adnexa FolliclesFollicles vv PapillaePapillae

Papillae consist of hyperplastic conjunctival tissue full of inflammatory cells, normally seen in the palpebral . Associated with bacterial, and

Follicles consist of hyperplastic lymphoid tissue & appear as elevated lesions encircled by blood vessels. Typically seen in reaction to topical agents, adenoviral & chlamydial disease ExternalExternal EyeEye ProblemsProblems DryDry EyeEye

Tear EvaporativeEvaporative Tear DeficientDeficient

Meibomian Lid Problem Other Gland Disease Non-Sjogren’s Sjogren’s Exposure Glands Lacrimal Disease Missing CL (Distichiasis) Primary Primary Ocular Surface Ant / Post () Secondary Blepharitis Secondary

Abnormal Blink Obstruction Auto Immune Abnormal Disease Aperture Loss of Reflex Tearing Incongruous Surface TestsTests

n SchirmersSchirmers type1type1 withwith anaesthesiaanaesthesia typetype 22 asas 11 withwith nasalnasal irritationirritation whatmanwhatman nono 4141 filterfilter paperpaper << 10mm10mm abnormal.abnormal. << 3mm3mm conculsiveconculsive n TearTear BreakBreak UpUp timetime fluorsceinfluorscein stainstain tearfilmtearfilm << 1010 secsec abnormalabnormal (average(average ofof 33 tests)tests) TreatmentTreatment overviewoverview Castor oil Tear secretors Meibomium lid disease

Artificial Immunosuppressive Warm compresses Plugs or occlusion Omega 3 fatty acids Moisture chambers Mucin secretors Androgen drops MechanicalMechanical StimulationStimulation

Hot Compresses

Lid Massage

Lid Scrubs LubricantsLubricants PromotePromote Healing!Healing! Goblet Cell Density & Preservatives

Normal They’re goblet cell decreased density in Dry Eye

Treated with preservative free lubricants Lubricant preserved with Benzalkonium Chloride Choices?Choices? Choices?Choices? Choices?Choices?

Avoid Benzalkonium Chloride! TreatmentTreatment retentionretention –– PunctumPunctum PlugsPlugs

PlasticPlastic oror siliconesilicone plugsplugs oror CollagenCollagen Removable?Removable?

CanCan fallfall outout CanCan irritateirritate Infection?Infection? CanCan convertconvert aa drydry eyeeye toto aa wetwet oneone BlepharitisBlepharitis

AnteriorAnterior

PosteriorPosterior BLEPHARITIS 1. Anterior • Staphylococcal • Seborrhoeic

2. Posterior • Meibomianitis • Meibomian seborrhoea

3. Treatment Staphylococcal blepharitis

• Chronic irritation worse in mornings • and telangiectasia of anterior lid margin • Scales around base of lashes (collarettes) • Scarring and hypertrophy if longstanding Complications of blepharitis

Trichiasis,,poliosis Recurrent

Marginal keratitis Tear film instability Seborrhoeic blepharitis

• Shiny anterior lid margin • Greasy scales

• Hyperaemia of lid margin • Lashes stuck together Treatment of Blepharitis

1.1. LidLid hygienehygiene // LidLid ScrubsScrubs withwith 50%50% babybaby shampooshampoo // SuprannettesSuprannettes // LidLid CareCare

2.2. TearTear substitutessubstitutes -- forfor associatedassociated teartear filmfilm instabilityinstability

3.3. WarmWarm compressescompresses -- toto meltmelt solidifiedsolidified sebumsebum inin posteriorposterior blepharitisblepharitis // ?? EyebagEyebag

4. Topical antibiotics (Fucidic Acid) & steroids

5.5. SystemicSystemic tetracyclinestetracyclines // TopicalTopical SteroidsSteroids -- forfor severesevere blepharitisblepharitis HordeolaHordeola

InternalInternal

ExternalExternal (meibomian cyst)

Painless, roundish, firm lesion May rupture through conjunctiva within tarsal plate and cause granuloma Acute hordeola Internal hordeolum External hordeolum () ( acute chalazion )

• Staph. abscess of meibomian • Staph. abscess of lash follicle and glands associated gland of Zeis or Moll • Tender swelling within tarsal plate • Tender swelling at lid margin • May discharge through skin • May discharge through skin or conjunctiva Treatment of chalazion

1. Hot compresses / hot spoon bathing

OR 2.

Injection of local anaesthetic Insertion of clamp Incision and curettage Trichiasis

Signs Complications

• Posterior misdirection of normal lashes • Inferior punctate epitheliopathy

• Most frequently affects lower lid • Corneal ulceration and pannus Treatment Options for Trichiasis

1. Epilation - but recurrence within few weeks

2. Electrolysis - but frequently repeated treatments required

3. Cryotherapy - for many lashes

4. Laser ablation - for few scattered lashes

5. Surgery - for localized crop resistant to other methods Px AJ Phthiriasis palpebrarum

• Infestation of lashes by pubic crab louse and its ova (nits) • Typically affects children in poor hygenic conditions?

Lice gripping base of lashes Nits and empty shells adhere to base of lashes Treatment - removal, destruction and delousing ConjunctivitisConjunctivitis

BacterialBacterial ViralViral AllergyAllergy ToxicToxic Simple bacterial conjunctivitis

Signs

Crusted and conjunctival Subacute onset of mucopurulent injection discharge

Treatment - broad-spectrum topical antibiotics eg Chloramphenicol AdenoviralAdenoviral KeratoconjunctivitisKeratoconjunctivitis

Pharyngoconjunctival fever • Adenovirus types 3 and 7 • Typically affects children • Upper respiratory tract infection • Keratitis in 30% - usually mild

Epidemic • Adenovirus types 8 and 19 • Very contageous • No systemic symptoms • Keratitis in 80% of cases - may be severe Adenoviral conjunctivitis

Usually bilateral, acute watery Subconjunctival haemorrhages and discharge and follicles pseudomembranes if severe

Treatment - Symptomatic / lubricants / NSAIDS eg Acular/? Steroids? Signs of Adenoviral keratitis

• Focal, epithelial keratitis • Focal, subepithelial keratitis

• Transient • May persist for months

Treatment - topical steroids if visual acuity diminished by subepithelial keratitis Adult chlamydial keratoconjunctivitis • Infection with Chlamydia trachomatis serotypes D to K • Concomitant genital infection is common

Subacute, mucopurulent follicular Variable peripheral keratitis conjunctivitis

Treatment - topical tetracycline and oral tetracycline or erythromycin Allergic rhinoconjunctivitis

• Hypersensitivity reaction to specific airborn antigens • Frequently associated nasal symptoms • May be seasonal or perennial

Transient oedema Transient conjunctival oedema

Treat. H1 blocker (topical/systemic) / Mast Cell Stabiliser / Topical Steroids RecurrentRecurrent CornealCorneal ErosionErosion RecurrentRecurrent CornealCorneal ErosionErosion SyndromeSyndrome

CornealCorneal defectdefect mightmight looklook likelike thisthis CornealCorneal epitheliumepithelium basementbasement membranemembrane

BasalBasal cellscells secretesecrete basementbasement membrane,membrane, andand havehave hemidesmosomehemidesmosome attachmentsattachments throughthrough thethe basementbasement membranemembrane toto thethe underlyingunderlying stromastroma CornealCorneal epitheliumepithelium basementbasement membranemembrane Spontaneous ~ Anterior Basement Membrane Dystrophy (map-dot-fingerprint dystrophy) Traumatic Assymptomatic ~ Branch/ twig in eye, childs fingernail RecurrentRecurrent CornealCorneal ErosionErosion SyndromeSyndrome

TypicalTypical therapytherapy onceonce correctlycorrectly diagnoseddiagnosed isis oftenoften somethingsomething like:like:-- -- LacrilubeLacrilube beforebefore goinggoing toto sleepsleep -- ArtificialArtificial tearstears egeg ViscotearsViscotears oror SystaneSystane asas requiredrequired throughthrough thethe dayday -- (For(For upup toto 33 –– 66 months)months) -- SiliconeSilicone HydrogelHydrogel BandageBandage CLCL RecurrentRecurrent CornealCorneal ErosionErosion SyndromeSyndrome

Alternative therapies for those who fail with “basic therapy”:-

- Mechanical Debridement/ Diamond Burr (to “polish” Bownams Membrane) - Anterior Stromal Micro-Puncture - Excimer laser phototherapeutic – keratectomy - Nd:YAG laser treatment - Superficial phototherapeutic keratectomy Marginal keratitis

• Hypersensitivity reaction to Staph. exotoxins • Often associated with Staph. blepharitis • Normally unilateral, transient but recurrent Progression

Subepithelial infiltrate Circumferential spread Bridging vascularization separated by clear zone followed by resolution

Treatment -- short course of topical steroids / topical antibiotic eg Fucidic Acid AcneAcne rosacearosacea Rosacea keratitis

• Affects 5% of patients with acne rosaeca • Bilateral and chronic Progression

Peripheral inferior Subepithelial infiltration Thinning and perforation vascularization if severe

Treatment - topical steroids and systemic/topical tetracycline or doxycyline EPISCLERITIS AND SCLERITIS

Episcleritis • Simple • Nodular Anterior scleritis • Non-necrotizing diffuse • Non-necrotizing nodular • Necrotizing with • Necrotizing without inflammation ( scleromalacia perforans ) Posterior scleritis Applied anatomy of vascular coats

Normal Episcleritis Scleritis

• Radial superficial episcleral • Maximal congestion • Maximal congestion of vessels of episcleral vessels deep vascular plexus • Deep vascular plexus • Slight congestion of adjacent to episcleral vessels Simple episcleritis • Common, benign, self-limiting but frequently recurrent • Typically affects young adults • Seldom associated with a systemic disorder

Simple sectorial episcleritis Simple diffuse episcleritis Treatment • Lubricants • Topical steroids • Systemic flurbiprofen if unresponsive) Nodular episcleritis • Less common than simple episcleritis • May take longer to resolve • Treatment - similar to simple episcleritis

Localized nodule which can be moved over sclera Deep scleral part of slit-beam not displaced PhenylephrinePhenylephrine TestTest Diffuse anterior non-necrotizing scleritis • Relatively benign - does not progress to necrosis • Widespread scleral and episcleral injection

• Oral NSAIDs Treatment • Oral steroids if unresponsive Nodular anterior non-necrotizing scleritis More serious than diffuse scleritis

On cursory examination resembles Scleral nodule cannot be moved over nodular episcleritis underlying tissue

Treatment - similar to diffuse non-necrotizing scleritis CaseCase SLSL -- HistoryHistory n Age 56, female n Referred to GIES n Presented with painful n Hx recurring red eye n Vision down R 6/7.5, L 6/5 n Good General Health n Early cataract n Health fundi n IOP 10mmHg, L 14 mmHg n Presbyopic SlitSlit LampLamp

n PerilimbalPerilimbal rednessredness n MildMild painpain n BlurringBlurring n FlareFlare anterioranterior chamberchamber –– finefine n IrregIrreg pupilpupil n GPGP forfor checkschecks –– autoimmuneautoimmune diseasedisease (idiopathic)(idiopathic) TreatmentTreatment

n Cyclopentolate 1% n Pred Forte 1% n Review 1 week (check IOP – ? steroid responder) n After 2 weeks eyes quiet n Wean off steroid for one week (Rebound effect) UVEITISUVEITIS

71%

Anterior Uveitis Int. Uveitis

1% Posterior Uveitis

5%

Systemic Association / Infectious / Idiopathic CausesCauses ofof AnteriorAnterior UveitisUveitis

ACUTE v CHRONIC

50% Juvenile Ulcerative HLA-B27 Idiopathic Idiopathic colitis positive Arthritis Crohn disease Ankylosing Fuchs disease Heterochromic spondylitis Herpes Heterochromic Cyclitis Zoster Cyclitis Psoriatic Ophth. arthropathy

Reiters Secondary to Behcets Synd trauma or disease infection

Syphilis SIGNSSIGNS TreatmentTreatment ofof AnteriorAnterior UveitisUveitis n dilation n Topical Steroids - Cyclopentolate - Pain relief - - Inhibit migration of neutrophils - inhibit access - decrease number of B & T lymphocytes n Relieve pain - reduce histamine release n Avoid post syn - reduce fibroblast proliferation & n Break post syn collagen deposition n Reduce risk pupil block - inhibit inflammatory activity - inhibit tissue scarring & regeneratoin SteroidsSteroids DerivativesDerivatives

n Alcohol,Alcohol, acetateacetate andand phosphatephosphate basebase

n NeedsNeeds toto bebe biphasicbiphasic (to(to penetratepenetrate intactintact hydrophobichydrophobic andand hydrophylichydrophylic cornealcorneal layers)layers)

n AlcoholAlcohol && acetateacetate basebase –– betterbetter penetrationpenetration ofof thethe intactintact corneacornea AvailableAvailable TopicalTopical steroidssteroids

n Betamethasone sodium phosphate 0.1% – Betnesol (Celltech) n Dexamethasone Alcohol 0.1% - Maxidex (Alcon) n Dexamethasone sodium phosphate 0.1% - Minims (Chauvin) n Fluorametholone alcohol 0.1% - FML (Allergan) n Hydrocortisone acetate 0.5% - non proprietry n Prednisolone acetate 0.1% - Pred Forte (Allergan) n Prednisolone sodium phosphate 0.5% - Predsol (Celltech) n Rimexolone ? Acetate 1% - Vexol (Alcon) RiskRisk EffectsEffects -- TopicalTopical SteroidsSteroids

n CataractCataract formationformation n OHTOHT –– GlaucomaGlaucoma (steroid(steroid responderresponder –– 70%70% ofof 11st degreedegree F/HF/H ofof glaucomaglaucoma sufferers)sufferers) n RetardationRetardation ofof cornealcorneal healinghealing n KeratitisKeratitis ++ aggravateaggravate HSKHSK n CornealCorneal thinningthinning n PtosisPtosis n InfectionInfection –– fungalfungal n Uveitis!Uveitis! PxPx KMKM –– 4545 yearyear femalefemale n PainPain // RedRed RERE // Agony!Agony! n ArrivedArrived 1010 hourhour planeplane journeyjourney AsiaAsia n TenderTender toto touchtouch -- n NauseaNausea // blurredblurred // needsneeds toto closeclose eyeeye n GradualGradual increaseincrease inin painpain pastpast 1010 hourshours n MildMild similarsimilar eventsevents inin thethe recentrecent pastpast n ?? InfectionInfection n GoodGood GeneralGeneral HealthHealth ClinicalClinical PresentationPresentation n VAVA poorpoor 6/106/10 n SLSL grossgross bulbarbulbar rednessredness n SignificantSignificant cornealcorneal oedemaoedema n PupilPupil partiallypartially dilateddilated && fixedfixed n IOPIOP RR 48mmHg48mmHg LL 18Hg18Hg (Goldman)(Goldman) n NarrowNarrow angleangle –– ShaferShafer gradegrade 00 AngleAngle ClosureClosure GlaucomaGlaucoma == OcularOcular EmergencyEmergency

First Aid – Pilocarpine

Same Day - Rapid Referral

Systemic – oral & intravenous Diamox

YAG laser PI / ? Trabeculectomy Beta Blockers / Steroids / Hyperosmotic agents FLASHESFLASHES && FLOATERSFLOATERS ExamineExamine thethe patientpatient onon thethe slitslit lamplamp LookLook atat thethe anterioranterior vitreousvitreous

u DilateDilate thethe pupilpupil u ReduceReduce ¼¼ width,width, slitslit height

u DetachedDetached posteriorposterior hyaloidhyaloid faceface behindbehind lens,lens, rippledrippled mobilemobile undulatingundulating netnet curtaincurtain ‘‘TobaccoTobacco dustdust’’ oror ShaferShafer signsign

n pigmentpigment clumps,clumps, usuallyusually larger,larger, darkerdarker andand moremore irregularirregular

n CanCan bebe causedcaused byby ocularocular surgerysurgery AcuteAcute posteriorposterior vitreousvitreous detachment:detachment: thethe predictivepredictive valuevalue ofof vitreousvitreous pigmentpigment andand symptomatologysymptomatology

n ‘‘presencepresence ofof pigmentpigment inin thethe vitreousvitreous gelgel toto bebe aa reliablereliable indicatorindicator ofof thethe presencepresence ofof aa retinalretinal breakbreak inin associationassociation withwith anan acuteacute PVDPVD occurringoccurring inin 23/2523/25 (92%)(92%) patientspatients’’

n V. Tanner, D. Harle, J. Tan, B. Foote, T. Williamson, and A. Chignell Br J Ophthalmol. 2000 November; 84(11): 1264–1268. LookLook atat PosteriorPosterior vitreousvitreous

n WeissWeiss ringring LookLook atat PosteriorPosterior PolePole

nn PreretinalPreretinal haemorrhagehaemorrhage LookLook atat PeripheralPeripheral RetinaRetina uu RetinalRetinal tearstears F 10%10% ofof PVDPVD F UU--shapedshaped oror horseshoehorseshoe F redred discontinuitiesdiscontinuities F UpperUpper retinaretina 75%75% LookLook atat PeripheralPeripheral RetinaRetina

uu VolkVolk oror 33 mirrormirror uu RetinalRetinal holehole oror latticelattice degenerationdegeneration LookLook atat PeripheralPeripheral RetinaRetina

uu RetinalRetinal detachmentdetachment F ConvexConvex configuration,configuration, corrugatedcorrugated appearance,appearance, undulatesundulates UrgentUrgent ReferralReferral ifif symptomaticsymptomatic PVDPVD withwith anyany ofof thethe following:following:

u ‘‘TobaccoTobacco dustdust’’

u VitreousVitreous haemorrhagehaemorrhage

u RetinalRetinal teartear

u RetinalRetinal holehole oror latticelattice degenerationdegeneration

u RetinalRetinal detachmentdetachment ItIt’’ss AllAll AboutAbout DecisionDecision MakingMaking n AcceptAccept responsibilityresponsibility n WorkWork withinwithin youryour scopescope ofof practicepractice :: DoDo nono harmharm n DevelopDevelop GOSGOS ?? Grampian?Grampian? n DevelopDevelop youryour skillskill setset n MakeMake GOSGOS workwork n DemonstrateDemonstrate allall optometricoptometric competenciescompetencies n ShiftShift thethe balancebalance ofof care!care! n DevelopDevelop LevelLevel 22 // IndependentIndependent PrescribingPrescribing ConclusionConclusion –– CanCan wewe dodo More?More?

n ProfessionalProfessional AspirationAspiration n FullyFully UtiliseUtilise SkillSkill SetSet n PracticePractice DevelopmentDevelopment –– NicheNiche Opportunity?Opportunity? -- additionaladditional revenuerevenue n PatientPatient LoyaltyLoyalty n PracticePractice DiversityDiversity -- CanCan wewe seesee beyondbeyond specs?specs? n PublicPublic BenefitBenefit ThanksThanks forfor youryour kindkind attention!attention!