WhenWhen toto CareCare –– WhenWhen toto ReferRefer
AcuteAcute EyeEye ProblemsProblems inin thethe CommunityCommunity
FrankFrank MunroMunro TodayToday’’ss TalkTalk
n Acute Eye Problems
n Burden of Disease – 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 Conjunctivitis Viral ‘Wet’ ARMD Cornea Ping / Pterygium Scleritis Corneal Erosion Marginal Keratitis Uveitis Allergic/Toxic Conjunctivitis Kerataconus int/post Corneal FB Penetrating Corneal Abrasion UV Burn Glaucoma Injury Bacterial Retinoschissis Microbial Keratitis Dry Eye Inclusion conjunctivitis Inclusion Episcleritis Endophthalmitis WhereWhere amam I?I? Cellulitis Ant / Post Blepharitis PVD Corneal Retinal Dystrophy Detachment Conjunctival Hge Keratitis/ Keratopathy Chemical Burns Anterior Cataract Anterior Neoplasia Trichiasis /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 Floaters 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 Eyelashes 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 PTOSIS 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 Rosacea 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 Eye Disease 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/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 –– Lens/vitreous/retina/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 conjunctiva. Associated with bacterial, and allergic conjunctivitis
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 (Xerophthalmia) Secondary Blepharitis Secondary
Abnormal Lacrimal Gland 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 tears 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 • Hyperaemia and telangiectasia of anterior lid margin • Scales around base of lashes (collarettes) • Scarring and hypertrophy if longstanding Complications of blepharitis
Trichiasis,madarosis,poliosis Recurrent styes
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 Chalazion (meibomian cyst)
Painless, roundish, firm lesion May rupture through conjunctiva within tarsal plate and cause granuloma Acute hordeola Internal hordeolum External hordeolum (stye) ( 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 eyelids 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 keratoconjunctivitis • 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 eyelid 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 inflammation • 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 sclera 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 red eye 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 Sarcoidosis
Reiters Secondary to Behcets Synd trauma or disease infection
Syphilis SIGNSSIGNS TreatmentTreatment ofof AnteriorAnterior UveitisUveitis n Pupil dilation n Topical Steroids - Cyclopentolate - Pain relief - Phenylephrine - Inhibit migration of neutrophils - inhibit macrophage 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!