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 questions@rhef.com.au 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 *** 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 and click on 'RHC TV Guide' on the left-hand side�