Rapid access wet AmD referrals using teleophthalmology and a central retinal grading centre

Introduction: We have adapted the existing , optometry diabetic retinopathy screening pathway and software , so that it can be used for wet AMD fast track referral. Purpose: To compare the conventional, optometry wet AMD fast track referral service using FAX transmission, with a teleophthalmology service using colour fundus photography transmitted to a central retinal grading centre. Method: 40 optometry practices involved in diabetic retinopathy screening were enrolled and had modified computer software installed. Referrals were made by conventional fast track FAX to the macular clinic, and patients were photographed by the optometrist and images transmitted to a central grading centre Results of the two pathways were compared in terms of 1)speed of diagnosis and 2)sensitivity and specificity of diagnosis of wet AMD. Results: Over a ten month period, 62 consecutive patients were referred. The mean time for conventional pathway was 20.8 days (range 3-34),and for new teleophthalmology pathway was 6.9 days (range 1-13). Sensitivity of technician grading of images was 96%, Specificity 53%, and consultant ophthalmologist was sensitivity 96%, specificiity 87%. The technician showed a learning effect with specificity increasing from 30.7% for first 31 patient cohort, to 70.6% for the second cohort. One patient had images that could not be graded. Conclusion: Rapid referral of wet AMD cases by optometrists using modified diabetic retinopathy screening software, allows fast and accurate diagnosis, and may reduce unnecessary referrals. Retinal grading technicians can be trained to grade wet AMD images.

Visual signs and symptoms of dementia with Lewy bodies

Dementia with Lewy bodies ('Lewy body dementia' or 'diffuse Lewy body disease') (DLB) is the second most common form of dementia to affect elderly people, after Alzheimer's disease. A combination of the clinical symptoms of Alzheimer's disease and Parkinson's disease is present in DLB and the disorder is classified as a 'parkinsonian syndrome', a group of diseases which also includes Parkinson's disease, progressive supranuclear palsy, corticobasal degeneration and multiple system atrophy. Characteristics of DLB are fluctuating cognitive ability with pronounced variations in attention and alertness, recurrent visual hallucinations and spontaneous motor features, including akinesia, rigidity and tremor. In addition, DLB patients may exhibit visual signs and symptoms, including defects in eye movement, pupillary function and complex visual functions. Visual symptoms may aid the differential diagnoses of parkinsonian syndromes. Hence, the presence of visual hallucinations supports a diagnosis of Parkinson's disease or DLB rather than progressive supranuclear palsy. DLB and Parkinson's disease may exhibit similar impairments on a variety of saccadic and visual perception tasks (visual discrimination, space-motion and object-form recognition). Nevertheless, deficits in orientation, trail-making and reading the names of colours are often significantly greater in DLB than in Parkinson's disease. As primary eye-care practitioners, optometrists should be able to work with patients with DLB and their carers to manage their visual welfare.

Delivering optometric care in the UK

Optometrists play an important part in delivering eye care in the United Kingdom; however opportunities for practitioners to extend their role through co-management of patients with ophthalmologists vary across the country. Devolution in Scotland and Wales has led to greater emphasis on community based care in these regions. This thesis reviews the current situation and, by examining ophthalmic outpatient clinic data, discusses further opportunities to reduce demands on secondary care and the cost savings that can be made. To assess whether the profession is currently in a position to adopt an extended clinical role, changes in the availability of optometric instrumentation are assessed over a two year period. An increased prevalence of fundus cameras and contact tonometers places optometrists in a good position to take on further responsibilities in glaucoma management, however future investment could be impacted by the current economic climate as value for money became increasingly important to practitioners looking to purchase equipment. Methods of training optometrists in the necessary skills to utilise new technology to extend their role are evaluated in terms of both learning and cost effectiveness. Interactive distance learning is proposed as a convenient and effective method to deliver continuing professional development. Any changes to optometric practice must take account of the need for a sustainable business and the importance of attracting and retaining patients. The views of patients are assessed through a validated service quality questionnaire, SERVQUAL. The questionnaire is found to be valid for use in an optometry setting. Patients have a generally positive view of the service quality they receive from their optical practice and consider the intangible aspects, in particular responsiveness and empathy, most important. Optometrists are well placed to increase their role in patient management; however a viable business model must exist to enable investment in instrumentation and training.

Ophthalmic engineering:the development of novel instrumentation to further research in the field

The principle theme of this thesis is the advancement and expansion of ophthalmic research via the collaboration between professional Engineers and professional Optometrists. The aim has been to develop new and novel approaches and solutions to contemporary problems in the field. The work is sub divided into three areas of investigation; 1) High technology systems, 2) Modification of current systems to increase functionality, and 3) Development of smaller more portable and cost effective systems. High Technology Systems: A novel high speed Optical Coherence Tomography (OCT) system with integrated simultaneous high speed photography was developed achieving better operational speed than is currently available commercially. The mechanical design of the system featured a novel 8 axis alignment system. A full set of capture, analysis, and post processing software was developed providing custom analysis systems for ophthalmic OCT imaging, expanding the current capabilities of the technology. A large clinical trial was undertaken to test the dynamics of contact lens edge interaction with the cornea in-vivo. The interaction between lens edge design, lens base curvature, post insertion times and edge positions was investigated. A novel method for correction of optical distortion when assessing lens indentation was also demonstrated. Modification of Current Systems: A commercial autorefractor, the WAM-5500, was modified with the addition of extra hardware and a custom software and firmware solution to produce a system that was capable of measuring dynamic accommodative response to various stimuli in real time. A novel software package to control the data capture process was developed allowing real time monitoring of data by the practitioner, adding considerable functionality of the instrument further to the standard system. The device was used to assess the accommodative response differences between subjects who had worn UV blocking contact lens for 5 years, verses a control group that had not worn UV blocking lenses. While the standard static measurement of accommodation showed no differences between the two groups, it was determined that the UV blocking group did show better accommodative rise and fall times (faster), thus demonstrating the benefits of the modification of this commercially available instrumentation. Portable and Cost effective Systems: A new instrument was developed to expand the capability of the now defunct Keeler Tearscope. A device was developed that provided a similar capability in allowing observation of the reflected mires from the tear film surface, but with the added advantage of being able to record the observations. The device was tested comparatively with the tearscope and other tear film break-up techniques, demonstrating its potential. In Conclusion: This work has successfully demonstrated the advantages of interdisciplinary research between engineering and ophthalmic research has provided new and novel instrumented solutions as well as having added to the sum of scientific understanding in the ophthalmic field.

Functional and perceived benefits of wearing coloured filters by patients with age-related macular degeneration

Background: The aim was to investigate the visual effect of coloured filters compared to transmission-matched neutral density filters, in patients with dry age-related macular degeneration. Methods: Visual acuity (VA, logMAR), contrast sensitivity (Pelli-Robson) and colour vision (D15) were recorded for 39 patients (average age 79.1 ± 7.2 years) with age-related macular degeneration, both in the presence and absence of glare from a fluorescent source. Patients then chose their preferred coloured and matched neutral density transmission filters (NoIR). Visual function tests were repeated with the chosen filters, both in the presence and absence of glare from the fluorescent source. Patients trialled the two filters for two weeks each, in random order. Following the trial of each filter, a telephone questionnaire was completed. Results: VA and contrast sensitivity were unaffected by the coloured filters but reduced through the neutral density filters (p < 0.01). VA and contrast sensitivity were reduced by similar amounts, following the introduction of the glare source, both in the presence and absence of filters (p < 0.001). Colour vision error scores were increased following the introduction of a neutral density filter (from 177.6 ± 60.2 to 251.9 ± 115.2) and still further through coloured filters (275.1 ± 50.8; p < 0.001). In the absence of any filter, colour vision error scores increased by 29.1 ± 55.60 units in the presence of glare (F2,107 = 3.9, p = 0.02); however, there was little change in colour vision error scores, in the presence of glare, with either the neutral density or coloured filters. Questionnaires indicated that patients tended to gain more benefit from the coloured filters. Conclusions: Coloured filters had minimal impact on VA and contrast sensitivity in patients with age-related macular degeneration; however, they caused a small reduction in objective colour vision, although this was not registered subjectively by patients. Patients indicated that they received more benefit from the coloured filters compared with neutral density filters. © 2013 The Authors © 2013 Optometrists Association Australia.

Effect of target distance on accommodative amplitude measured using the minus lens technique

Background: The aim was to investigate the effect on the measured amplitude of accommodation and repeatability of using the minus lens technique with the target at distance or near. Methods: Forty-three students (average age: 21.17 ± 1.50 years, 35 female) had their amplitude of accommodation measured with minus lenses on top of their distance correction in a trial frame with the target at far (6.0m) or near (0.4m). The minus lens power was gradually added with steps of 0.25D. Measurements were taken on two occasions at each distance, which were separated by a time interval of at least 24 hours. Results: The measured amplitude at six metres was significantly lower than that with the target at 40cm, by 1.56 ± 1.17D (p < 0.001) and this varied between individuals (r = 0.716, intraclass correlation coefficient = 0.439). With either target distance, repeated measurement was highly correlated (r > 0.9) but the agreement was better at 6.0m (±0.74D) than at 40cm (± 0.92D). Conclusion: The measurements of the amplitude of accommodation with the minus lens technique using targets at far or near are not comparable and the difference between the target distances may provide clinically relevant information. © 2013 Optometrists Association Australia.

Evaluation of the auto-refraction function of the Nidek OPD-Scan III

Background: The aim was to evaluate the validity and repeatability of the auto-refraction function of the Nidek OPD-Scan III (Nidek Technologies, Gamagori, Japan) compared with non-cycloplegic subjective refraction. The Nidek OPD-Scan III is a new aberrometer/corneal topographer workstation based on the skiascopy principle. It combines a wavefront aberrometer, topographer, autorefractor, auto keratometer and pupillometer/pupillographer. Methods: Objective refraction results obtained using the Nidek OPD-Scan III were compared with non-cycloplegic subjective refraction for 108 eyes of 54 participants (29 female) with a mean age of 23.7±9.5 years. Intra-session and inter-session variability were assessed on 14 subjects (28 eyes). Results: The Nidek OPD-Scan III gave slightly more negative readings than results obtained by subjective refraction (Nidek mean difference -0.19±0.36 DS, p<0.01 for sphere; -0.19±0.35 DS, p<0.01 for mean spherical equivalent; -0.002±0.23 DC, p=0.91 for cylinder; -0.06±0.38 DC, p=0.30 for J0 and -0.36±0.31 DC for J45, p=0.29). Auto-refractor results for 74 per cent of spherical readings and 60 per cent of cylindrical powers were within±0.25 of subjective refraction. There was high intra-session and inter-session repeatability for all parameters; 90 per cent of inter-session repeatability results were within 0.25 D. Conclusion: The Nidek OPD-Scan III gives valid and repeatable measures of objective refraction when compared with non-cycloplegic subjective refraction. © 2013 The Authors. Clinical and Experimental Optometry © 2013 Optometrists Association Australia.

Specialist contact lens fitting

What is meant by the term ‘specialist contact lens fitting’? Or put another way, what would be considered non-specialist contact lens fitting? Is there such a thing as routine contact lens fitting? Soft or silicone hydrogel fitting for daily wear would probably be considered as routine contact lens fitting, but would extended or flexible wear remain in the same category or would they be considered a specialist fit? Different eras will classify different products as being ‘specialist’. Certainly twenty years ago soft toric contact lenses were considered as being speciality lenses but today would be thought of as routine lenses. Conversely, gas permeable lenses were thought of as mainstream twenty years ago but now are considered as speciality lenses. Although this would not be the same globally, as in some countries (such as Netherlands, France and Japan) gas permeable lens fitting remains popular and is not on the decline as in other countries (Canada, Australia and Sweden) [1]. Bandage soft lenses applied after surface laser refractive procedures would be considered as therapeutic lenses but in reality they are just plano thin hydrogel lenses worn constantly for 3–4 days to allow the underlying epithelium to convalesce and are then removed [2]. Some patients find that wearing hydrogel lenses during periods when they suffer from seasonal allergies actually improves their ocular comfort as the contact lens acts as a barrier to the allergen [3] and [4]. Scleral lenses have long been considered speciality lenses, apart from a time when they were the only lenses available but at that time all contact lens work would have been considered speciality practice! Nowadays we see the advent of mini-scleral designs and we see large diameter gas permeable lenses too. It is possible that these lenses increase the popularity of gas permeable lenses again and they become more main stream. So it would seem that the lines between routine and speciality contact lens fitting are not clear. Whether a lens is classed a specialist fit or not would depend on the lens type, why it was fitted, where in the world the fitting was being done and even the era in which it was fitted. This begs the question as to what would be considered entry level knowledge in contact lens fitting. This may not be an issue for most BCLA members or CLAE readers but certainly would be for bodies such as the College of Optometrists (UK) or the Association of British Dispensing Opticians when they are planning the final registration examinations for budding practitioners or when planning the level of higher level qualifications such as College Certificates or Diplomas. Similarly for training institutions when they are planning their course content. This becomes even trickier when trying to devise a qualification that spans across many countries, like the European Diploma in Optometry and Optics. How do we know if the training and examination level is correct? One way would be to analyse things when they go wrong and if patterns of malpractice are seen then maybe that could be used as an indicator to more training being needed. There were 162 Fitness to Practice Hearing at the General Optical Council between 2001 and 2010. Forty-seven of these were clinically related case, 39 fraud related, and 76 others. Of the clinical ones only 3 were contact lens related. So it would appear that as whole, in the profession, contact lens clinical skills are not being questioned too often (although it seems a few of us can’t keep our hands out the cookie jar!).

Genetic risk factors and age-related macular degeneration (AMD)

Age related macular degeneration (AMD) is the leading cause of blindness in individuals older than 65 years of age. It is a multifactorial disorder and identification of risk factors enables individuals to make lifestyle choices that may reduce the risk of disease. Collaboration between geneticists, ophthalmologists, and optometrists suggests that genetic risk factors play a more significant role in AMD than previously thought. The most important genes are associated with immune system modulation and the complement system, e.g., complement factor H (CFH), factor B (CFB), factor C3, and serpin peptidase inhibitor (SERPING1). Genes associated with membrane transport, e.g., ATP-binding cassette protein (ABCR) and voltage-dependent calcium channel gamma 3 (CACNG3), the vascular system, e.g., fibroblast growth factor 2 (FGF2), fibulin-5, lysyl oxidase-like gene (LOXL1) and selectin-P (SELP), and with lipid metabolism, e.g., apolipoprotein E (APOE) and hepatic lipase (LIPC) have also been implicated. In addition, several other genes exhibit some statistical association with AMD, e.g., age-related maculopathy susceptibility protein 2 (ARMS2) and DNA excision repair protein gene (ERCC6) but more research is needed to establish their significance. Modifiable risk factors for AMD should be discussed with patients whose lifestyle and/or family history place them in an increased risk category. Furthermore, calculation of AMD risk using current models should be recommended as a tool for patient education. It is likely that AMD management in future will be increasingly influenced by assessment of genetic risk as such screening methods become more widely available. © 2013 Spanish General Council of Optometry.

Patterns of refractive change in myopic subjects during the incipient phase of presbyopia:a preliminary study

Purpose: Changes in refractive error are well documented over the typical human lifespan. However, a relatively neglected period of investigation appears to be during the late fourth decade; this is at the incipient phase of presbyopia (IP), where the amplitude of accommodation is much reduced and approaches the level where a first reading addition is anticipated. Significantly, informal clinical observation has suggested a low incidence of an unexpected abrupt increase in myopia during IP. Methods: We investigated this alleged myopic shift retrospectively by mapping the longitudinal refraction histories of normally-sighted 35-44years old British White patients previously examined in routine optometric practice. The refractive trends in the right eyes of healthy myopic subjects (spherical equivalent refraction, SER =-0.50D: N=39) were analysed relative to that point at which a first near dioptric addition was considered to be clinically useful. Results: A refractive change was evident in some subjects during IP; viz, an abrupt increase in myopic SER of between -0.50 and -0.75D. These individuals (N=8) represented 20% of the study population of myopic incipient presbyopes. Beyond the pivotal point of the first near addition the longitudinal refraction stabilized in these subjects. In contrast, and as the extent of the available longitudinal data would permit, the remaining myopic eyes maintained an approximately stable refractive trend throughout IP and beyond. Conclusions: The anatomical or physiological basis of this specific late (non-developmental) abrupt myopic refractive change is an intriguing issue. Axial (vitreous chamber elongation), corneal (contour) and lenticular (profile and index) power bases, alone or in concert, might be considered candidates for this hitherto unexplored refractive phenomenon. Although necessarily obtained under conventional conditions of central (0deg) fixation, our data might also be a reflection of the recent recognition of the possible influence of the peripheral refraction upon the axial error. Consideration of this material provides an impetus for further research, including ocular biometry, a reappraisal of ciliary zonular functional anatomy, renewed investigation of the AC/A ratio, and the extent of a centripetal refractive influence on myopia development. © 2011 The College of Optometrists.

Nearwork-induced transient myopia (NITM) in anisometropia

Objective: To assess the magnitude of nearwork-induced transient myopia (NITM) under binocular viewing conditions separately in each eye of individuals with mild to moderate anisometropia to determine the relationship between NITM and their interocular refractive error. Methods: Forty-three children and young adults with anisometropia [cycloplegic spherical equivalent (SE) difference >1.00 D] were tested (ages 9-28 years). NITM was measured with binocular viewing separately in each eye after binocularly performing a sustained near task (5 D) for 5 min incorporating a cognitive demand using an open-field, infrared autorefractor (Grand-Seiko, WAM-5500). Data were averaged over 10 s bins for 3 min in each eye. Initial NITM, its decay time (DT), and its decay area (DA) were determined. A-scan ultrasound ocular biometry was also performed to determine the axial length of each eye. Results: The more myopic eye exhibited increased initial NITM, DT, and DA as compared to the less myopic eye (0.21 ± 0.16 D vs 0.15 ± 0.13 D, p = 0.026; 108.4 ± 64.3 secs vs 87.0 ± 65.2 secs, p = 0.04; and 17.6 ± 18.7 D*secs vs 12.3 ± 15.7 D*secs, p = 0.064), respectively. The difference in DA and the difference in SE between the more versus less myopic eye were significantly correlated (r = 0.31, p = 0.044). Furthermore, 63% (27/43), 56% (24/43), and 70% (30/43) of the more myopic eyes exhibited increased initial NITM, longer DT, and larger DA, respectively, than found in the less myopic eye. Conclusions: In approximately two-thirds of the anisometropic individuals, the initial NITM and its decay area were significantly increased in the more myopic eye as compared to the less myopic eye. NITM may play an important role in the development of interocular differences in myopia, although a causal relationship is yet to be established. Furthermore, the findings have potentially important implications regarding accommodative control and interocular accommodative responsitivity in anisometropia, in particular for anisomyopia. © 2013 The College of Optometrists.

Evaluation of Melbourne Edge Test contrast sensitivity measures in the visually impaired

Aim: Contrast sensitivity (CS) provides important information on visual function. This study aimed to assess differences in clinical expediency of the CS increment-matched new back-lit and original paper versions of the Melbourne Edge Test (MET) to determine the CS of the visually impaired. Methods: The back-lit and paper MET were administered to 75 visually impaired subjects (28-97 years). Two versions of the back-lit MET acetates were used to match the CS increments with the paper-based MET. Measures of CS were repeated after 30 min and again in the presence of a focal light source directed onto the MET. Visual acuity was measured with a Bailey-Lovie chart and subjects rated how much difficulty they had with face and vehicle recognition. Results: The back-lit MET gave a significantly higher CS than the paper-based version (14.2 ± 4.1 dB vs 11.3 ± 4.3 dB, p < 0.001). A significantly higher reading resulted with repetition of the paper-based MET (by 1.0 ± 1.7 dB, p < 0.001), but this was not evident with the back-lit MET (by 0.1 ± 1.4 dB, p = 0.53). The MET readings were increased by a focal light source, in both the back-lit (by 0.3 ± 0.81, p < 0.01) and paper-based (1.2 ± 1.7, p < 0.001) versions. CS as measured by the back-lit and paper-based versions of the MET was significantly correlated to patients' perceived ability to recognise faces (r = 0.71, r = 0.85 respectively; p < 0.001) and vehicles (r = 0.67, r = 0.82 respectively; p < 0.001), and with distance visual acuity (both r =-0.64; p < 0.001). Conclusions: The CS increment-matched back-lit MET gives higher CS values than the old paper-based test by approximately 3 dB and is more repeatable and less affected by external light sources. Clinically, the MET score provides information on patient difficulties with visual tasks, such as recognising faces. © 2005 The College of Optometrists.

Binocular fusion, suppression and diplopia for blurred edges

Purpose: (1) To devise a model-based method for estimating the probabilities of binocular fusion, interocular suppression and diplopia from psychophysical judgements, (2) To map out the way fusion, suppression and diplopia vary with binocular disparity and blur of single edges shown to each eye, (3) To compare the binocular interactions found for edges of the same vs opposite contrast polarity. Methods: Test images were single, horizontal, Gaussian-blurred edges, with blur B = 1-32 min arc, and vertical disparity 0-8.B, shown for 200 ms. In the main experiment, observers reported whether they saw one central edge, one offset edge, or two edges. We argue that the relation between these three response categories and the three perceptual states (fusion, suppression, diplopia) is indirect and likely to be distorted by positional noise and criterion effects, and so we developed a descriptive, probabilistic model to estimate both the perceptual states and the noise/criterion parameters from the data. Results: (1) Using simulated data, we validated the model-based method by showing that it recovered fairly accurately the disparity ranges for fusion and suppression, (2) The disparity range for fusion (Panum's limit) increased greatly with blur, in line with previous studies. The disparity range for suppression was similar to the fusion limit at large blurs, but two or three times the fusion limit at small blurs. This meant that diplopia was much more prevalent at larger blurs, (3) Diplopia was much more frequent when the two edges had opposite contrast polarity. A formal comparison of models indicated that fusion occurs for same, but not opposite, polarities. Probability of suppression was greater for unequal contrasts, and it was always the lower-contrast edge that was suppressed. Conclusions: Our model-based data analysis offers a useful tool for probing binocular fusion and suppression psychophysically. The disparity range for fusion increased with edge blur but fell short of complete scale-invariance. The disparity range for suppression also increased with blur but was not close to scale-invariance. Single vision occurs through fusion, but also beyond the fusion range, through suppression. Thus suppression can serve as a mechanism for extending single vision to larger disparities, but mainly for sharper edges where the fusion range is small (5-10 min arc). For large blurs the fusion range is so much larger that no such extension may be needed. © 2014 The College of Optometrists.

Age-related macular degeneration and nutritional supplementation:a review of randomised controlled trials

Age-related macular degeneration (AMD) is the leading cause of severe vision loss in the developed world. The lack of effective treatment modalities, coupled with evidence supporting an oxidative pathogenesis, has increased interest in the potential preventative role of nutritional supplementation. This article reviews seven randomised controlled trials (RCTs) that have investigated the role of nutritional supplementation in AMD. Three of these trials reported a positive effect of nutritional supplementation on AMD; the Age-related eye study (AREDS), the Lutein Antioxidant Supplementation Trial (LAST), and the oral zinc trial by Newsome et al. (1988). However, the oral zinc trial by Newsome et al. (1988) was unlikely to detect any difference between treatments smaller than 72%, and the AREDS results were based on a subgroup of their study population. Lutein was considered for the AREDS formulation, but was not commercially available at that time. The findings of the LAST support a possible therapeutic role of lutein in AMD. © 2004 The College of Optometrists.

Management of allergic conjunctivitis and dry eye

Ocular allergy is a common eye condition encountered in clinical practice. However, little is known how seasonal allergic conjunctivitis (SAC), the most common subtype, is managed in clinical practice. Further, dry eye, another common eye condition, may be misdiagnosed as SAC and vice-versa as they share similar signs and symptoms. In addition, despite the frequent recommendation of non-pharmacological treatments for SAC, evidenceto support their use has not been identified in the scientific literature. The aim of this thesis was therefore to determine the actual diagnosis and management of SAC and dry eye in clinical practice and investigate the efficacy of non-pharmacological treatments for these conditions. The diagnostic and management strategies for SAC and dry eye employed by pharmacy staff are found to be inconsistent with current guidelines and scientific evidence based upon a mystery shopper design. Cluster analysis of tear film metrics in normal and dry eye patients identified several clinically relevant groups of patients that may allow for targeted treatment recommendations. Using a novel environmental chamber model of SAC, the use of artificial tears and cold compresses, either alone or combined is an effective treatment modality for acute and symptomatic SAC, on a par with topical anti-allergic medication, and has been demonstrated for the first time. In addition, eyelid warming therapy with a simple, readily available, seed filled device is an effective method of treating meibomian gland dysfunction (MGD) related evaporative dry eye, perhaps the most common dry eye subtype. A greater focus on ophthalmology must be implemented as part of the formal education and training of pharmacy staff, while greater professional communication between community pharmacists, optometrists and the population they serve is required. Artificial tears and cold compresses may be considered as front line agents for acute SAC by pharmacy staff and optometrists, to whom pharmacological treatment options are limited.