Eye Health: The Current View

Hello, I’m Caroline West
and welcome to this program on Eye Health: The Current View, coming to you on
the Rural Health Channel 600. With World Sight Day coming up this
Thursday the 11th of October, we’re reminded that most vision loss
is preventable and treatable and regular eye examinations are
really the key to early detection. There are particular issues and risks for people
in rural Australia and there is a high incidence
of eye trauma amongst our farming communities. In this program, we’ll take a look at
the typical presentations to rural primary healthcare practice and review the Glaucoma Guidelines and the latest treatment
for macular degeneration, as well as other common
eye problems. This is a professionally accredited
program from the Rural Health Education
Foundation and more information about
the channel can be found on the Foundation’s website. So go to the web – And as with all our live programs, you can ask questions of the panel
by email, phone or fax. Now, I’ll be endeavouring to put
your questions forward, so send them through now and the details are coming up
on the screen. You can send your emails
to [email protected] or phone us on our toll-free line,
1800 817 268, you can also fax your questions
to us – 1800 633 410. As usual there are a number
of useful resources available on the Rural Health Education
Foundation’s website, once again, go to – Now let’s start this evening
by meeting our wonderful panel. And to start off with,
we have Phil Anderton. He was a research optometrist
and vision scientist at the UNSW of Optometry
before retiring in 2005. Although, I hear it wasn’t
much of a retirement. – You’re back in practice. Right?
– It’s true. He now practises part-time as a rural
optometrist in Manilla, NSW. So, welcome. You’ve got a lot of
experience in rural eye health. From your point of view, what should we be talking
about tonight? Well, I think the most important
thing about rural health, generally, is that –
for various reasons, we need to work very closely
as a network to provide the services
that are required. A multidisciplinary network,
in fact. In this case,
the case of eye health, the local GPs and the local
optometrists working together with regional ophthalmologists and ophthalmologists
visiting from city areas. So my message for tonight is actually
to make sure that we work and support in multidisciplinary networks
like that. Mm, ’cause I hear that again
and again that that’s one of the terrific
things about rural medicine is that collegiality, that network of team-members
coming together. In fact, you’ve got a team-member
right next door to you! John, Professor John Fraser. Now, you two work together –
just coincidence, really. Tell us about that. Well, we’ve been working for five
years, Phil just reminded me and we’ve got a nice collegiate,
uh… health centre and building on from Phil’s comments,
it’s a network. So, um, having
that chronic care focus, developing health plans involving optometrists
and other health professionals. Yes, and of course,
we’re speaking with John Fraser, Professor John Fraser… Now, he’s got a lot of experience
as a rural general practitioner and a public health physician,
that’s right, isn’t it? Extensive clinical, research
and teaching experience in remote and rural Australia. You’re also Adjunct Professor
at the University of New England and Visiting Professor
at the University of Newcastle. So welcome aboard, John,
and we’re looking forward… – ..to hearing your GP perspective.
– Thank you so much. Next on our panel is Jill Grasso, she brings to the team
a wonderful sense of experience. You’re a clinical nurse consultant
in ophthalmology. You’ve worked in healthcare
with healthcare professionals across all borders
within Australia and overseas. – That’s right, Jill?
– Yep. You’ve always been in the field
of ophthalmology working in education,
screening and eye promotion, eye trauma management
and injury prevention. So injury management
and prevention is really one of your passions,
isn’t it? Tell us about that. It certainly is. It’s the foundation
for vision preservation. So the correct management
at the time, the resources available
to make those decisions and the referral process
is critical in the first stages of eye trauma. So we can get the message across to
our colleagues, give them the resources
to do that. It’s just such a… a win-win
situation for everybody. Fantastic and, hopefully, tonight can extend that out
to a great network out there. Also joining us
is Professor Jill Keeffe OAM, Head of the Centre
for Eye Research Australia’s Population
Health Unit, specialising in prevention
of vision loss and blindness in Australia and our region, Low Vision
and Health Services Research. Professor Keeffe received an
Order of Australia Medal – OAM – in 2007 for services to eye care
education and practice. Obviously, prevention is something
that’s really very important to discuss tonight, isn’t it? Yes, we look forward to, certainly,
talking more about that and the message that was developed
globally for World Sight Day about 75%
of the vision loss and blindness being either preventable
or treatable is just as relevant
for all across Australia. So to be able to, um,
use the opportunities we have with patients
to, yep, ask the right questions. Yes, because
I think a lot of people would be surprised by that figure,
wouldn’t they? Yes! Yes. Certainly the most common causes,
we can either… We often can’t prevent
the disease but we can treat
or prevent the vision loss and that’s the really important
message. CAROLINE: Fantastic. Next, we have
Professor Hugh Taylor AC. He’s Melbourne Laureate Professor
at the University of Melbourne. Welcome aboard. He founded the Centre
for Eye Research Australia and has been a Board Member
of The Fred Hollows Foundation, the River Blindness Foundation
and the Vision CRC. His current work
is in Aboriginal eye health and the elimination of trachoma. Welcome to you all and where are we
up to with our trachomas? Very interesting area, isn’t it? Well, there’s a lot of work to do but with the commitment
made in 2009 to eliminate trachoma
in Australia, there is some real progress
being made. Certainly, in some of the remote
communities in Outback Australia, the rates of trachoma in children are dropping quite dramatically
over the last year or two. Mm, fantastically good news. Perhaps I can just stay
with you for a moment, Hugh, and you can give me an overview of what’s the current state
of eye health in Australia? Well, looking at Australia
as a whole, there are about 50,000 people
who are blind, legally blind, and about half a million people
who have poor vision. Remember, three quarters of that
vision loss is unnecessary – it can either be prevented
or treated. So that we’ve still got a lot
of work to go but, compared to the rest
of the world, Australia’s actually doing
pretty well. So in some ways,
the glass is both half full and it can be seen to be
half empty. But in the rest of the world,
the major cause of blindness, again, are preventable causes like
cataract particularly, the need for a pair of glasses
whether for distance or near, and then conditions
such as trachoma or onchocerciasis, river blindness,
childhood blindness, and those other factors. It’s particularly important
on World Sight Day, which is on Thursday,
as you mentioned, to recognise what a big impact vision
loss has. Mm. And, John, from your perspective
in the rural community, what’s the story there? Is it very different between urban and rural communities
in Australia? We have the same conditions. I guess the issue is that, um, it’s one of access
to health services and, often, because people have to
travel a long way or have to weigh up work
and other commitments, whatever, that you often see delayed
presentations. Plus, we have farming and other
industries in that rural area which impact upon some of the
presentations, such as injury. Yes, Jill, do you find that,
in rural communities, you get certain types
of eye trauma more commonly? Most definitely.
Depends on the season, as well, it depends on what they’re doing
at that time. So what would be some
of the seasonal injuries that you’d expect to see? Certainly,
during the fencing season, fixing up fences,
a lot of high tension wire, trauma that way. A lot of hammering –
metal upon metal – repairing equipment late at night
to get up the next morning for the harvest.
It’s a very common one. Uh, just generally lots of people not
wearing protective eyewear or wearing their own glasses,
thinking they’re protection. So you get a lot of trauma
from that. Um… seatbelts have made
a big difference but on the farm, sometimes, they actually don’t wear
their seatbelts, so you have a lot of people with windscreen and glass
and stuff. So it’s a variety of things. It certainly is very seasonal
what we see sometimes. So we do sometimes see more of the
injury group in a rural community, what about in other areas, when it
comes to preventable eye disease, do we see other risk factors
more so in rural communities? Jill Keeffe, what about smoking
in rural communities? Is that of concern
when it comes to prevention? I think most of the risk factors
are the same, but particularly, it’s age. Obviously, diabetes,
but, importantly, family history. One of the risk factors,
particularly, that John mentioned, is access. The work that we did
in the Visual Impairment Project was finding that men were less likely
to access services. So I think, yeah, a really important
message for GPs, you know, if you’ve got men
in these risk ages, or other risk factors, when they’re there,
ask them the questions! That’s really interesting. Why is it that men were less likely
to access health services? I think the barriers
that John spoke about. And we’ve done a lot of work
looking at barriers to seeking eye care and it’s whether
you can take a day off and, certainly,
if you’ve got a vision problem, you can’t drive yourself. So you need someone to take you. So there’s a whole lot of
social factors as well as cost, and, yeah, people not realising
necessarily that something can be done to quite often treat
or restore vision. Or sometimes underestimating
the seriousness of a small foreign body – but if that was rust left
in the eye for some time… – ..it could have significant damage.
JILL: Yep. You’d probably see that,
Phil, too? Yes, quite frequently. I was just going to say,
in the case of smoking, there’s been some recent data
from COAG that, while smoking is declining
in Australia, it’s not actually declining
in rural Australia, it’s staying at the same level. I don’t quite know
why that is the case but smoking is a risk factor
for many diseases including the chronic
degenerative eye disease. So is this something we need to be talking more to our patients about? Absolutely.
Yeah, along with other measures which can slow down the progress
of chronic disease in general such as exercise and diet
and the normal things that we do. Just to mention,
sometimes I might see one of these male farmers
to get reading glasses and I say, ‘When was the last time
you saw the doctor?’ And he’ll say, ‘I don’t need
to see the doctor. I’m pretty tough.’
I’ll look in his eye and I’ll see signs
of cardiovascular disease which you can see in the eye –
arteriosclerosis – and I’ll say, ‘Sorry, mate,
your time’s up. You’ve got to go see my GP friend.’ So it works two ways. CAROLINE: Yeah, so that’s very true,
isn’t it? And what about from the Aboriginal
perspective, Hugh? Well, Aboriginal and
Torres Strait Islander people, children have much better vision
than mainstream kids. They have much less short-sightedness and in fact their acuity
is often much sharper, much better than Caucasian. But by the time
they reach the age of 40, the Aboriginal adults will have
six times as much blindness and more than three times
as much vision loss. And 94% of that vision loss, again,
is unnecessary – being preventable or treatable. So there’s a huge gap in vision and, in fact,
11% of the health gap is due to vision loss. It’s behind cardiovascular disease
and diabetes but equal with trauma and
ahead of alcoholism and stroke. Unlike those other conditions, which are long-term chronic difficult
conditions to manage, much of the vision loss
can be corrected overnight. You give somebody a pair of glasses,
they see right away. You do cataract surgery,
they see the next day. So that’s something
very much amenable to immediate intervention
which would have a huge impact. So, really, talking about
how important prevention is and can you tell us more
about that? Well, it’s prevention
or timely treatment. So for cataract, you can reduce
the risk of developing cataract with sunglasses and stopping smoking
and so forth. But everybody will develop cataract
if they live long enough so the prevention
of cataract blindness is not so much the prevention
of cataract but making sure
that there’s timely surgery. And you’re not going to prevent
presbyopia unless you line up everybody
and shoot them at the age of 40! – (Laughs) Oh, there’s a plan!
(All laugh) But we rejected that plan. But the prevention of that disability is to give them a pair
of reading glasses that you can do
for a couple of dollars and, suddenly,
they can see properly. So that it’s that treatment
or early treatment or prevention of the disability
that’s the critical thing that makes it so cost-effective. CAROLINE: Yes, yes. And when it comes to Indigenous
communities and Indigenous eye health,
of course, we do have programs that viewers
can access via our website. The See Strong Focus on Indigenous Eye Health is a fantastic program. I actually had a look at this recently and I was really engaged by the way the story was put together of people working in these communities and getting back
to your trachoma work and how powerful
those interventions are in communities with a simple message. But let’s move on to our first
case study. Let’s take a look at Karl – he’s a 52-year-old wheat farmer from Western Australia who presents to his rural
general practitioner. Now, he’s complaining of sore eyes
and he’s finding it hard to focus and read and he thinks
he might need glasses. He often experiences high levels
of dust on the farm. So what do you think
might be going on here, John? You’re his GP, what do you think? It’s already ringing red flags
because, as we said, men tend not to access
health services unless they’re particularly concerned or worried at this age group
of 52. So… while it may be as simple
as an allergic conjunctivitis, or presbyopia at this age, we need to really assess him
and take a thorough history and examination… Uh, his family history
is very important. Is there a history of diabetes,
for example, or glaucoma? We need to do an examination where we assess his visual acuity but also try to have a good look
at his fundus, and from that, uh… try to… ascertain what’s going on but also begin to emphasise
this message of prevention. So this presentation gives us
opportunities as a GP not just for eye health but a lot
of those broader risk factors. So it’s interesting, isn’t it? He’s walked in your door
and you’ve almost got him captive. – It’s an opportunistic consultation.
-Very much so. What… On that sort of area
of family history, how else can we tease
that out of someone? Do they necessarily know that their grandmother had glaucoma,
do you think? No.When you talk about glaucoma,
often they don’t know. In fact, it’s one of our failings
as ophthalmologists, optometrists, GPs, pharmacists, that we give somebody a bottle or a repeat prescription
for their bottle of glaucoma drops but we don’t say to them,
‘Hey, you’ve got glaucoma and your first-degree relatives
are at eightfold increase of developing glaucoma too. So tell your brothers and sisters
and your sons and daughters, when they go for an eye exam
that they tell the practitioner that they have a family history of
glaucoma.’ So as someone who doesn’t know
their family history, the best way GPs
are going to pick it up is to look in the back of the eye and see the cupping
of the optic disc. That’s not a terribly sensitive way but it is a way that a GP
can readily do that. And encourage that message
of you may not have symptoms, you know, this is something you’ve
still got to review regardless. Glaucoma is classically known
as that silent thief of sight that people don’t know they’ve
got glaucoma until they go blind. Just two weeks ago,
I had a colleague of mine, an ocular pathologist
call up and say, ‘Hey, I’ve got something in my eye.’ And the ophthalmologist I saw said, ‘I’m almost blind
in one eye from glaucoma.’ So here’s a guy who’s lived
and worked in that field and not knowing a family history, who’s got quite significant loss
at a very young age. So I guess you’ve put glaucoma
on the radar, you’re going through a whole list
of possibilities but I guess glaucoma’s
one of those things you’d like to think about. When it comes to actually
investigating somebody for glaucoma, Phil, perhaps you could comment on
what we need to do, then. I guess, it would be lovely
if just in our general practices, we could… come up with some range
of investigations, but that’s not quite going to cut it,
is it? What do we need to actually do? Well, if John were to send Karl
to me for an opinion, um, if I hadn’t seen him before, I’d be vigilant for all of these
chronic conditions which can appear
including glaucoma. In the case of glaucoma,
a careful examination of the optic disc area,
of his fundus, to see whether he has any
of the morphological signs and I’d be measuring his intraocular
pressures as well with a tonometer and making
an assessment based on that. Also, in the case
of the family history, just a point, I’d be asking him
rather than, ‘Do you have a family history
of glaucoma?’ ‘Is there anyone in the family who’s had to have drops every night?
Or every day?’ Then sometimes, people will answer
a history one way, then when you trigger that memory,
they think, ‘Oh, yes, I did have an aunt,
an uncle who… I remember now, it was glaucoma.’ So… But, yes, pressures, the examination of the optic disc and if it looks suspicious
and it sounds suspicious… If there were, for example,
a family history, the pressures
and the disc changes, we might even there and then schedule a visual field examination. HUGH: I’d be a little bit different
from that. Oh, good! I like to hear somebody
with a different perspective. Half the patients with glaucoma
are undiagnosed and half the patients who are not
diagnosed have had an eye exam by an optometrist
or an ophthalmologist in the last 12 months
and they’ve been missed. The reason they’ve been missed,
one, they don’t know the family history
so they’re not alerting the doctor, but the real reason
they’re being missed is they’re not having
the visual field test done. And a screening visual field, something like a frequency
doubling test – not for the GPs, but certainly for optometrists
and ophthalmologists as a rapid screening test
of very high sensitivity… Jill and I did a study
in a great town for this study, it was called Seymour.
What a study!(Laughter) No, really?
In Australia somewhere? It was just outside of Melbourne! What a town
to do an eye study on! CAROLINE: If anyone from Seymour’s
watching… welcome. But the way to pick up
these unrecognised cases is really with
a frequency doubling test. OK. We’ve just had a question from a GP in rural Queensland
come through – Is there any link between glaucoma,
open-angle glaucoma, and a family history of myopia? HUGH: Uh, very, very weak links. There is a small association, statistically significant
but not clinically significant. And another one from Jan,
a nurse in Victoria, are there any particular medications that are contraindicated
with glaucoma or even the risk of glaucoma? What about steroids in terms of the
actual incidents of glaucoma? Certainly, steroids give you
secondary glaucoma, with a rise in pressure, and there’s a varying
sensitivity to that. It’s not so common
with systemic steroids but much more common with topical
or ocular steroids. But basically… The worry about glaucoma is precipitating angle-closure
glaucoma, and angle-closure glaucoma represents only a tiny percentage, a couple of percent of all
the cases with glaucoma. The vast majority of glaucoma
is the primary open-angle glaucoma which is not susceptible to drugs
other than steroids. CAROLINE: Mmm-hmm. OK. And once you’ve made
that diagnosis, what sort of treatment options
are available? Uh, the front… first-line therapies usually, uh, drops – eye drops – and they’re usually
the prostaglandin drops. They can be used in combination
with some beta-blockers or other drugs. Also people will use laser treatment
to the filtration angle of the eye as a primary treatment or as a supplement treatment
if the drops fail to work. After that, there are a variety
of surgical methods to try to reduce the pressure
in the eye with filtration or other methods that may put
a drain tube into the eye or reduce the amount of aqueous
produced by the ciliary body. But drops are, by far, the most
common first-line treatment. Mmm. John,
from your point of view, what are the referral pathways like
being a rural practitioner, actually getting your patients
in to see an ophthalmologist? There again, that’s the art
of rural practice – being able to pick up those that
need to go off straight away, so the closure glaucomas, compared… But it can be three to six months,
sometimes, to get an eye appointment so developing other networks
with Phil and involving
our ophthalmologist to… Yeah, it’s a matter of resources
and knowing what’s in your area and developing those networks
by phone if you need to triage. Just to answer Hugh’s point – that decision as to whether
to schedule an appointment for an ophthalmologist, um, depends on
the individual patient. It depends on what the disc
looks like. It depends on the family history
and the pressures. And it’s just… you know? But we tend to be more conservative. I tend to do a lot
of field screenings that are negative, Hugh. (Chuckles) But that’s better
than not doing them at all. CAROLINE: Yeah, fantastic. Now, Phil, this may be… our next
case study may be something that’s very close to home for you. It involves Marg,
a 70-year-old woman who presents to you, as her optometrist,
for her regular check-up. She says she’s been noticing
little dark spots in the centre of her vision and
her eyes have been weeping tears. Interestingly enough,
she’s a life-long smoker but, otherwise,
seems in good health. I don’t know whether anybody
can be deemed in ‘good’ health as a smoker, but nevertheless, she’s not complaining
of anything else. Does this sound familiar? It sounds very familiar. And thinking about the theme
for tonight – finding people who have… a condition which can be treatable to
prevent vision loss, what should be going through
my mind here is these visual changes
she complains of – how long have they been there?
What’s the time course? So in taking a history,
it’s very important to find out whether there’s been
a rapid change in vision. So if, you know, it could be… Also, I need to bear in mind
all the other things that could be affecting her vision, which may not be
macular degeneration. The answer to that
is a careful history and if I haven’t seen her before, because of her age, you really can’t
get a view of her macular without using dilating drops, so she would have a dilated fundus
examination particularly looking at the macular. And assess from then on what she looks like. The other thing I’d be doing
with her if I suspect she might have macular degeneration,
if I can use this, is I’d be using a test
which is called an Amsler Grid, a modification
of the Amsler Grid there, which is just a matter
of having her look at that with her reading glasses on,
one eye at a time, and as she looks at it,
she looks at the centre dot and I say to her, ‘While you’re
looking at the centre dot, notice what the grid around it
looks like? Do you see any holes in the grid?
Does it look distorted? Is there anything
that looks unusual? Just from recent experience,
this is actually quite sensitive – picking up the form
of macular degeneration, which can progress rapidly. CAROLINE: Yes. So, Jill Keeffe,
can you talk us through with perhaps some of the graphics
we have there, some of the visual changes
that someone might experience if they had macular degeneration,
if we can go to those graphics. Yes, I think, from what Phil
just spoke about, at the very early stages
in the Amsler Grid, which was actually shot
over the top of Dr Amsler… – ..who had developed it.
CAROLINE: There he is there. JILL: In the first one on the left,
what you’ve got is just some of those wavy lines,
the distortion, so instead of the regular squares, can you start to see those changes? And this actually comes
from a PhD student of mine who has macular degeneration who’s tried to simulate
what she found in the changes. Very subtle changes early on but, with hers… it certainly
couldn’t be treated. I think the point that was made
before about the referral and if that’s a sudden change
in vision, that’s an urgent referral, whereas,
you know… Particularly now when certainly some
patients can have treatment to if not reverse it but certainly
to maintain the vision and, importantly, what we’ve got
is another picture that… just a scene in Melbourne, and with the two pictures, one
of them, you’ve got the tram sign, telling you when it’s coming,
the other one, just objects missing. I think, for things like personal
safety, independence, as well as obviously
a marker of disease – really important. So taking that to a rural setting, what sort of implications
would that have, say on a farm, if you started to lose
that central vision? What might you be missing? For example, when you’re driving
or something like that? People talk about reading
and seeing faces but it is, it’s driving, and I’ve heard
some terribly graphic decisions, um, people’s descriptions
about when they were driving. ‘Oh, yes, I turned a corner
and the car disappeared and it finally appeared
a little later.’ So it’s everything that you’re doing. It’s not just fine, near work,
it’s certainly distance as well. So… yeah, really urgent
if it’s a sudden onset. But, yes, need for referral. And in terms of the risk factors,
what sort of risk factors did she have in her history that you’d be thinking about
in terms of macular degeneration? Age, certainly. But the person I was talking about is one of those who developed
macular degeneration in second decade of life. So it’s quite rare,
but generally it’s age. – But also family history.
– Family history and… PHIL: Smoking.
– And smoking. What does smoking do to the rates
of macular degeneration? -Earlier.
HUGH: Increases them threefold. CAROLINE: Yeah, threefold. – Threefold.
– Yes. So it makes a huge difference. I remember having a patient
of mine who was in her 70s who had macular degeneration who’d
been a heavy smoker all her life and she was really distressed because she couldn’t catch buses
anymore, she couldn’t read the bus destination and it really upset her
and she just said, ‘Gee, if I’d only understood the impact smoking was having
on my health…’ People think about
cardiovascular disease, don’t they, and they think about lung disease,
but very often they forget there’s this link between smoking
and eye health. HUGH: About a dozen years ago,
we got that graphic put on the cigarette packets
with ‘Smoking Causes Blindness’ and the initial TV video ad with that had the best recall of any
of the quit ads. (Laughter) That’s powerful messaging for you. Yeah, Caroline,
could I just mention, you talked about the impact
that it has on a person’s life, for some people, for many people, there can’t be either retention
or improvement in vision. The importance of referring
to organisations like Vision Australia to help either maintain or certainly help, whether it’s magnification,
is only one small part, but certainly devices and help
to maintain independence. What’s her prognosis like? Well, it depends a little bit on the type of macular degeneration
she has and whether it’s in both eyes
or just in one eye and, uh, how long it’s been there. There’s been a dramatic breakthrough in our therapeutic abilities
over the last five or six years with the injection
of these anti-VEGF drugs that inhibit or stop
the new blood vessels growing. So for the near vascular, or sometimes called wet macular
degeneration, these drugs can make
a dramatic difference. But they may need to be repeated sort of at monthly or two-monthly
intervals forever. So they’re enormously expensive but they do make a huge difference to a significant number of patients. But if you’ve got to have them
at all these regular intervals, how does that play out
in a rural setting, John? – It’s very difficult.
– Yeah. I have a case study of a patient
I saw two years ago who presented to me
because he noticed that one eye had lost vision
over the previous day, and I looked in his eye and saw
what happens when the wet version bleeds. And so I immediately rang
one of the ophthalmologists in the regional centre
that I’m close to, and even though he’s a very busy
ophthalmologist, he put something aside to fit
this person in that day. He received his first injection
that day. And when I saw him, he was 6.15
and he’s now 6.12 in that eye, so he’s actually improved a line. HUGH: About half of the blindness
in Australia is due to macular degeneration
because we can’t treat it all, we can only treat
a small fraction of it. And apart from the obvious one
of distance, are there any other barriers to getting early prevention messages
out there, treatment? HUGH: Smoking. (Laughs) We’re getting back to the lifestyle
issues of smoking. – What about diet?
JILLIAN: Good diet. Is there any kind of link there? ‘Cause I know that…
I can see a few faces sort of… Jill, do you have some thoughts
on that? Because it’s the sort of question
you get asked, isn’t it? When you’re in practice,
they come and they go, ‘What will make a difference?’ JOHN: I prescribe Macu-Vision
vitamins. Our local ophthalmologists do it.
I don’t know what the evidence is. Because that’s what we ask. ‘Do you think I should take this?’ The evidence is pretty flaky,
and it’s interesting, because the National Institutes
of Health in the US invested $100 million on a study, and the drug company
that makes the vitamins really wants to sell their drug,
and the scientists say, ‘Well, they really want to say
they found something.’ And the doctors,
when somebody comes in, they don’t want to say,
‘Look, you’re gonna go blind. There’s nothing
we can do about you.’ They’re much happier to say,
‘Listen, take these vitamins and there’s a good chance
you’ll see better.’ But the results were really… only
a sub-analysis showed an improvement which means the other half of people
didn’t get an improvement, which is why the FDA did not approve
the drugs for use for the treatment
of macular degeneration. They’re repeating the study,
doing another study, and the result should be out
in another six months, in May next year. But almost nobody takes
the full dose of the… ..Macuvite drug – very expensive, associated with increased risk
of the vitamin A, increased risk of cancer, so you can’t take in people
who smoke, the vitamin C is passed through, the zinc with it is associated
with prostate problems… CAROLINE: Oh,
you’re not selling this thing! They’re not going to use you
as company spokesperson. If you want to believe in buying it,
that’s fine, but it’s a very controversial area
that’s been marketed well. – A message from Hugh, thank you.
(Laughter) From one of our sponsors here. On that note, I think we’d better
move on to our third case study before we get into
any more deep water. Now, let’s look at a younger man. He’s 37-year-old David and he comes to his GP with sore eyes. He reports that he developed symptoms right after doing some hay baling a couple of hours ago and he thinks a bit of dust has lodged in his eye. Could be one of your patients, Jill,
by the sounds of things. He complains of a burning sensation, a scratchy feeling and has been suffering some blurred vision. As you examine his eyes, you notice a red spot, a little raised area
on the white of his eye. No other significant eye or general medical history problems. What’s going on here with David? John, what are your thoughts? JOHN: Again, he’s a male, Caroline. And males… CAROLINE: Getting back
to this male theme… Males tend not to come to the doctor
with eye problems unless it’s… Unless somebody else
has instructed them to. Or they’re deeply concerned. So he is actually starting to get
some blurred vision, so – the slide,
is that coming up yet or…? Yeah. So we’re going to take a history, but very much we want to know has
there been any additional objects – bits of metal or whatever –
hitting the eye, ’cause he may well have…
on the examination, there’s a pterygium…
but he may well have a second foreign body under a lid or he may have a scratch
to his cornea or, more importantly, I would want to exclude that
he hadn’t had a bit of metal penetrating the eye,
something like that, since it’s come on so quickly. Yeah, so he might not have noticed
his pterygium, but it could also be some sort
of foreign body, so you’d have to exclude that. But, say, you did come to decide
that, yes, it is a pterygium. How common is that in rural practice? It’s very common because of
the exposure to the UV light. Now, again, the theme of prevention. This raises another issue
of prevention. I have actually seen a few melanomas
of eyes in my practice over the years. But, also, if this patient
is developing pterygium… ..he could well be having
other exposures to UV light, such as skin cancer, you know, cancers around the eyes
and elsewhere in the body. So the issue of eye protection
is important. Yeah, it gives an opportunity to
raise preventative issues for David. So, in terms of treatment… We had another picture I think
as well of a pterygium which may come up
in a moment. But in terms of treatment options, when do we need to refer someone on
who’s got a pterygium? It may well have been there
for a long time, it’s not doing much. At what point do we flag it and go, ‘It’s really time to go
and see someone else about this’? HUGH: The first thing is to treat it
symptomatically, and that’s to wear glasses,
sunglasses, to stop some of the wind and
evaporation when you’re outside. And also to use the artificial tears
or lubricating drops, because often because of the raised
surface of the pterygium, it’ll dry out on the top
and it’ll cause irritation. And if that keeps it comfortable,
that’s all you need to do. But if it continues to be
red and irritated, and particularly if it grows or if it starts to affect vision
in any way, then it should be removed surgically, and that’s done
by an ophthalmologist. Now, very often –
I know this from my experience out in rural places – a person will present
to the pharmacist, and the pharmacist often does
a wonderful job in trying to triage patients
as they come in. What should a pharmacist be
thinking about in this situation? Well, I would think again
the first thing to do is to give them the artificial
tears or the lubricating drops, tell them to wear sunglasses
or wraparound glasses so they’re not exposed to wind
and dust in the same way
when they’re out working. And if that makes them comfortable
and their vision’s alright, then I think that’s all
they need to do. But if they’re having
continuing symptoms, then they need to go on and see
an optometrist or ophthalmologist and get into that referral pathway. And I guess very often what happens,
isn’t it, the people self-diagnose and
self-medicate too, don’t they? So they may even present
to the pharmacist and they’ve already made up
their own minds about what they have. Is that your experience, Phil? Well, red eye’s differential
diagnosis is actually a tricky area, and, you know, there are
so many different things that could be going on – allergic, viral, HSV, enteroviral, bacterial, dry eye. It’s a huge list,
and it’s very important that the ones which are dangerous
be identified and sent off for appropriate management. I’d like to mention here a case, if you have somebody
with a red, sore eye who’s a contact lens wearer, it’s very important they take the
contact lens out and leave it out and be sent off immediately
for examination. There is good evidence
that contact lens keratitis, microbial keratitis,
can be caused by pseudomonas, which of course isn’t touched by
chloramphenicol. So that needs a very high level
management and medication for treatment. If it’s not treated,
it can penetrate the cornea and the eye can be lost. This is very timely that
you’re talking about this ’cause we’ve actually had
a question through from John, who’s a pharmacist
in rural Queensland. ‘Is there a checklist I could
be using for red eye customers?’ (Chuckling) Hugh? Anybody who trained in Melbourne
over about a 39-year period will have heard John Colvin’s
lectures on Beware of the Unilateral Red Eye
and the trumpet blowing. CAROLINE: OK, so can you come up
with a checklist? Yeah, well, I mean,
it can be conjunctivitis. Which can be unilateral. And it can be allergy
that’s sometimes more unilateral… CAROLINE: Is that very common to see
allergy in just one? Well, people tend to rub their eyes
with their dominant hand, so if you’re right-handed,
your right eye… It can be. But those must be
your last two diagnoses. You really need to exclude first
of all keratitis or corneal ulcer, whether it be from herpes
or from bacterial or trauma. Trauma is another thing, whether
it be a corneal foreign body or penetrating injury. Inflammation of the eye,
iritis or uveitis, acute glaucoma, where you’ve got
high pressure of the eye. So a unilateral red eye
is a real warning sign for a GP or a pharmacist. Don’t just give them chloro drops,
don’t just give them steroids. Make sure that they go off
and get checked properly so you make a diagnosis
before you start treating them. So, I’ve got Jeff,
a GP from New South Wales. He said, ‘Most of the farming people
that are in my practice would not present
for a red and sore eye. Should we be organising
health promotion in the practice?’ – Yes, getting that message out.
-Clearly, yes. ALL: Yes.
– So yes, yes and yes. And you should be warning them too to protect themselves against
the foreign bodies. You know, it’s that ocular trauma. Yes, and we’ll be coming to that
in a moment with Jill. I guess also to give us a checklist – Jill, you’ve also got
an emergency manual. Can you tell us about that
and how that might be useful to all of us who may see someone
with a unilateral red eye? This is a great guide.
Gives you the first-line management and assessment for your patients
and it’s full of red flags, so it’s certainly
used to indicate to refer, and the urgency of referral,
so it’s very good. It’s also got an excellent section
on the red eye… And they made a mention of that. CAROLINE: It’s a New South Wales
Health partly funded publication. Does that mean that everybody
can access it? Most definitely,
it’s on the ACI website, Ministry of Health. It’s a free publication and
it can be downloaded at any time. So that’s one of the things that
you really like to have with you at all times to cross-reference. JILLIAN: Most definitely. And I guess all of us like to have
our certain bags of tricks. Phil, you’ve certainly got
a few bags of tricks that you like taking away with you
to remote communities. Can you share this?
This is a bit of a show-and-tell. – I brought along some toys.
– Oh, good! For examining an eye, there’s
no alternative to a slit lamp, and most slit lamps, as you probably
know, are big devices that sit on a table
on the clinical floor, and patient sits on one side and
the examiner sits on the other. Well, this little gadget
is a slit lamp. I won’t put it totally together. I take that to clinics
where I might be working in, for example a land council building,
seeing an Aboriginal community. So, for assessing things like
the level of progress of cataracts or for looking at corneal
or lens anomalies, you just need to have
this little gadget. Now, it produces
a slit illumination. I don’t know whether
you can see that there. And the slit illumination
passing through the transparent structures
of the eye, the examiner through the eyepiece
sees that under very high magnification, so you can almost see
the cellulardetail of the epithelium, stroma, etc., and whether things are
in the anterior chamber. You can’t do everything
with this little gadget, but it’s certainly a lot better
than not having one. And an awful lot cheaper than… PHIL: It is a lot cheaper
than the real thing but it’s certainly not cheap. – So you don’t want to drop that.
-No. So we’re coming now
to our final case study, and it centres on Aidan,
a 15-year-old farmer’s son from a small rural town. Aidan was riding his quad bike – they’re a risky little bike to be
riding occasionally, aren’t they? – when he ran into a barbed wire fence. His left eyelid has a laceration and he has ocular trauma with blood
in the anterior chamber. His father has brought him in
holding gauze to his eye, which is bleeding. Now, Jill, what does a nurse practitioner, nurse, GP do in this instance? What are the key messages here? The golden rule is that lid
laceration is a penetrating trauma until proven otherwise. So if anything’s protruding
from the eye, certainly don’t remove it. Don’t put any pressure on it, don’t… Make sure certainly the patient
doesn’t vomit, that’s one of the golden rules
as well, and timely referral, urgent referral
to an ophthalmologist. And for a lid laceration
particularly, it’s around the lacrimal system, certainly an urgent referral
to an ophthalmologist for surgical repair is critical. CAROLINE: OK, so that’s with the
laceration and any object in the eye. JILLIAN: Yes, it’s critical. CAROLINE: We’ve got the graphic up
now. You can see that
there’s a nasty piece of wire. JILLIAN: So certainly just lightly
pad, no pressure, and certainly urgent referral. CAROLINE: Never pull it out.
JILLIAN: Never pull it out. CAROLINE:We just have to emphasise
thatagain and again. MAN: I guess the other point is that’s a tetanus-prone wound. JILLIAN: Tetanus – very much so. Local tetanus, broad-spectrum antibiotics, antiemetics, analgesia. Certainly, the patient will need to be fasted
and certainly referred. CAROLINE: And we see lacerations with things like bike accidents, vehicle accidents. Where else might we see
lid lacerations? JILLIAN: From glass, animal bites. Animal bites, dog bites.
Human bites, even. CAROLINE: Human bites?!
– It’s amazing. So it can happen at any time, so the secret is to ensure
that it’s repaired correctly to prevent long-term complications
for these patients down the track. And what are some of the
other common injuries that we see in rural communities
apart from an object in the eye, penetrating trauma? Certainly, simple things
like hammering metal upon metal, lots of small intraocular
foreign bodies. Uh, lots of those. Certainly, you can have
any irregular pupil or any iris damage. So the graphs on there
at the moment, you’d think it might be
a foreign body on the cornea, so should you remove it, then you
can end up with a total hyphema and damage as well. Jill, what are your thoughts,
Jill Keeffe, on that last picture? Yes, it was… obviously
it was part of the iris coming from the puncture in the eye. Again, don’t take it out. But I think
the really important message, particularly in urban areas
in Australia, the rates of trauma have gone down
incredibly that are work-related, because of the employers
having to ensure safe working conditions. So it really is an issue
in rural areas that trauma is very different,
the severity of it, but the frequency particularly because of the workplace
requirements of employers. The work that we’ve done and
some things that we’re looking at with WorkSafe in Victoria has just made an incredible
difference in what’s happening. So it can be prevented as long as
it’s good protective eyewear. And how would you define
good protective eyewear? If we’re going to get that message
out there to practitioners watching, what should we be telling
our patients about that? There’s guidelines for that, so for some of the really dangerous, it’s a shield, and particularly goggles so that there’s protection
around the eyes and it’s the things at home too, gardening or whatever. But the quality of the goggles or shields are critical. ‘Cause I guess a lot of people reckon
they can just put on a pair of sunnies or something and get away with it.
Is that what you find? HUGH: People do that, but that’s foolish and dangerous. And if you go to the store,
the hardware shop or wherever where they’re selling
the protective eyewear, it has information about what type
of situation it should be used. And if you’re out there
with a whipper snipper, you know, it’s different
from if you’re doing some heavy-duty grinding or welding. And so that you need to match
your eye protection with the risky task
that you’re wanting to do. CAROLINE: Mm-hmm, OK. So, really,
I guess that we’ve got to get these messages of prevention
out there. And I suppose
in the standard procedures… You talked before, Jill, about what should be done
in an emergency situation. Can you just run that by us again to
reinforce what we’ve heard from you? I think that the most
important thing is if anything’s protruding
from the eye, don’t remove it. – Don’t remove anything protruding.
-Don’t remove anything protruding. Don’t put any pressure on it.
Lie the patient down. Stop nausea and vomiting –
that’s really critical. Pain relief, tetanus,
broad-spectrum antibiotic and certainly urgent referral
to an ophthalmologist for review. And so, be in consultation with the
ophthalmologist in your rural team to get them to the nearest
ophthalmic centre as quick as we can. -Hugh, I can see…
– I just wanted to say one thing on that last photograph we saw. The key to that photograph was the
pupil wasn’t central and circular. – It was displaced and peaked.
CAROLINE:Yeah, look at that. HUGH: So you don’t know what that is
on the cornea just looking at it, but that pupil tells you that
you’ve got a penetrating injury. – That’s the key there.
CAROLINE: That’s a beware. And I suppose on that topic of things
that we really need to be mindful of in emergencies, I guess, in practice, I’ve just had
another question through. ‘What are the worrying signs
for retinal detachment?’ I know this is
a slightly different area, but the question’s come through, and ‘Is there anything I can do
for patients suspected to have this condition
in regions not well supported by ophthalmologists? Thanks, Melinda Thornton.’ Well, the symptoms are
little black dots, but followed with sparks
or flashes of light in the eye, and they’re the real key. And then if you notice
a veil or a balloon coming up over your vision
or coming down over your vision. Those are the real things. And you need somebody to look
in the back of your eye to check it. Very commonly, as people get older, the vitreous gel that fills up
the eye – the eye’s hollow like a tennis ball, but instead of being full of air,
it’s filled with jelly – it will collapse and form little
lumps as it condenses over time, and that will often give these little black spots
that float around. Those on their own
are not a problem, but if the gel sticks to the retina, it’ll pull little holes
in the retina, and then the retina will just float
off as a retinal detachment. But if you get those black dots,
you need to go and have an eye exam, with an optometrist
or an ophthalmologist, but a proper dilated retinal exam. And if a problem’s seen there, then you do need to be referred
to an ophthalmologist. Maybe just for laser treatment
to seal around the hole, maybe for full-blown
retinal detachment surgery to put it all back together. And is this an area perhaps
where telehealth has a role? People will be able to take
photographs with retinal cameras and send them through for opinions? The retinal cameras tend to take
great photos of the back of the eye, but not such good photos
of the peripheral parts of the back of the eye, which is where most
of the retinal detachments are. So the telemedicine might help, but you actually would have to be
a very good operator of the retinal camera
or the slit lamp to get a good enough image
to be able to send it back for the ophthalmologist
to make a diagnosis. So with a retinal detachment,
you’re better to get the body, or the person or the eye, to the
optometrist or the ophthalmologist so they can do a proper exam. John, what in your experiences is the
case there with retinal detachment? Yes… I agree totally
with what you’ve said. However,
sometimes you have other flashes. You can have zigzag flashes,
which is more a migraine, so I guess any new-type symptoms
where there’s a short time frame, where there’s other risk factors
for haemorrhage. So cardiovascular-type symptoms that there may be haemorrhage
at the back of the eye, have a very low threshold
to get them off, because they just have
a vitreous haemorrhage, and the key to that
is there’s a black dot that will tend to move slowly
from time to time. But if it’s associated with flashes,
they have to go off, because you can’t exclude
a detachment. OK, and with something that’s
not quite as serious as that, perhaps a lesser condition that a nurse practitioner or
clinical nurse is treating, we’ve just had a question through
from Shelly, who’s a practice nurse
in New South Wales. ‘Any advice for rural patients
following eye treatments – wearing eye pads, etc. –
for driving, etc.?’ So they’re coming to see you
for some condition that’s required an eye pad
to be placed. What are we going to advise
our patients about what they can do
with that eye pad? Who’d like to take that one? Jill! Certainly not driving
with an eye pad on. – No driving with an eye pad.
-No driving with an eye pad. CAROLINE: That’s the first message. And if they really had to put
an eye pad on, we would show them how to do it and the ointment and the pad
to put on when they got home, if they really had to have
an eye pad on. Certainly, it’s a dangerous practice ’cause your vision’s changed
on the side, your side vision,
your depth perception, it’s just increased risk of falls, it’s just not worth it. So we’ve actually gone away
from using a lot of the eye pads these days. – It’s not a common practice.
HUGH:It’s also illegal. – Yes.
– It’s illegal! – So you won’t just ruin your health.
-Exactly. Yes, arrested as well. JOHN: One other common injury
is flash burns from welding, and you need to ask… ’cause
they’re probably going to have to have anaesthetic in both… So you need to ask them
how you’re going to get home if I actually do numb your eyes
before we go ahead. And so I guess for a lot
of practitioners out there who wish to upskill in the area
of eye health, Jill, what sort of extra training
is available for people to consider? We certainly have… the ACI has
a roving emergency one-day session, and that is for all people
across the State. It’s facilitated,
it’s a multidisciplinary course, and usually we try to keep it
on a Friday if we can… That sounds very civilised so it can
flow into a nice long weekend. HUGH: So you can play golf
on Thursday. Yeah, exactly. So we take it to them
in the rural areas, and they can actually access that
information on the ACI website once again as well. And they’re run regularly
throughout the year, so the 2013 program’s
already underway. Mm-hmm, OK.
So that’s a fantastic option. Of course, not everybody can get
to a place to have training. But there are
some other eye health programs on the Rural Health
Education Foundation website that I can highly recommend – And all these provide great resources and they can be accessed by you
for free. And so, we’re almost
at the end of our program. We’ve covered a lot of ground,
but let’s perhaps hear from our panel about
some of their take-home messages. Hugh, we’ve heard from you
on a range of topics. But what would be the thing that you’d like to leave
with our audience tonight when it comes to eye health? I think it’s a topic
we didn’t really talk about, but you just mentioned now,
and that was about diabetes. And as GPs and
as primary care providers, we cannot let any of our patients
with diabetes go for more than two years
without having an eye exam. And if they’re Indigenous,
they need to have that eye exam every 12 months. That’s critical. The thing is to get them
on board with that process, because very often
they won’t have symptoms, so as far as they’re concerned,
they’re OK. – Is that what your experience is?
– Absolutely right. It needs to be built in, it’s like
getting a haemoglobin A1C tested or urine tested or something.
It just has to be done. And the GPs may do it themselves, they may have somebody
with a retinal camera, they may refer them
to the local optometrist or the visiting ophthalmologist. It doesn’t matter who does it
as long as it is done, and done every two years
for mainstream and every 12 months
for Indigenous people. Fantastic. And I guess on that note,
as you say, we’ve done that program on diabetes
and eye health. So if people would like
to follow that up more, please go to our website. It’s a very important point, though,
for us to keep in mind. It’s also on that point of prevention which, Jill Keeffe, I know is a topic
very close to your heart, and I’m sure that your final words
will be in that area, am I right? Most certainly, yes. I think it’s recognising those
risk factors that we talked about – which is the population,
we’ve talked about age, we’ve talked about just diabetes, and family history,
really very important. So it’s using the opportunity
for people over 40 – have you had an eye exam
in the last five years? – over 50 – in the last two years. And if someone comes in, I mean,
simply test their vision as well. But even if vision is OK, still look at those risk factors
and consider the need for referral. CAROLINE: Mm. Fantastic. Jill Grasso. You sound as though you’re a woman
that’s always been out there spreading the word. What’s the word
that you’d like to leave us with, or the words, tonight? Certainly, the important role
of the ophthalmic nurse and the nurse within
the healthcare team in regards to education and support
for the patients. They play a major role in there. The timely management and the format
for ocular trauma is critical. Accessing resources,
accessing the education. And working within a team to ensure
that we give our patients the best quality outcomes. CAROLINE: Mm-hmm. John,
you know all about teamwork… – Very much so. ..working in a rural community
with practitioners like Phil. What would you like
to leave us with tonight? What do you think
is really important? Well, always beware
the unilateral red eye. But, increasingly,
in this day of teamwork, our patients are going to be
chronic and ageing, and their blindness is likely to be
asymptomatic. So we have to have
a high index of suspicion to identify those at risk and make sure that they’re having
regular appropriate eye checks. CAROLINE: Mm. Fantastic. And, Phil, you’re in the lucky position
of having the final word here. Well, my final word
is to just remind everyone who’s a rural practitioner –
you’re part of a network, use that network,
don’t try and work in isolation. It might be a little bit banal,
but it’s very important, if you do send somebody off
for an eye examination with an optometrist
or an ophthalmologist, they’ll probably have dilating drops, so they will need somebody to drive
them there and drive them back – sunglasses and a hat, so that’s a fairly technical
but important point. And this chart which I mentioned
previously comes from the Macular Degeneration
Foundation. It’s got a magnet on the back of it so that people who are at risk
can put that on their fridge and test themselves
as much as they like. (Caroline laughs) Fantastic. So I guess
what we’ve got tonight is that real sense of teamwork
as well from everyone here, so thank you very much. Now, if you’re interested
in obtaining more information about the issues
raised in the program tonight, there are a number of resources
available on the Rural Health Education
Foundation website at rhef.com.au. And there, you can also go
to tonight’s show – Eye Health: The Current View. Go to our program web page and click on the Resources link. If you’d like more information about
anything that you’ve heard tonight, you can also go to the NHMRC website
to access the Glaucoma Guidelines. Now, they’re quite substantial,
aren’t they? We were looking at them earlier
and the supportive material, but well worth reading. If you’re a health professional,
don’t forget to complete and send in your evaluation form – it’s very important –
which can be found on the website. You’ll receive
a certificate of attendance and, if eligible, CPD points. Thanks to the Australian Government
Department of Health and Ageing for making this program possible, and thanks also to you today for taking the time to attend
and contribute with all of your wonderful questions. And, once again,
thank you to our wonderful panel. It’s been terrific to have you
on board tonight. I hope that everyone else out there
has learned as much as I have, and I’ve really enjoyed your company. I’m Caroline West. Goodbye.
And join us again next time. See you then. Captions by
Captioning & Subtitling International Funded by the Australian Government
Department of Families, Housing, Community Services
and Indigenous Affairs. The Rural Health Channel broadcast
24 hours a week. To see what other programs
are showing on the Rural Health Channel
this week and next, go to the Foundation’s website
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