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RX FACTOR ProFile July 2013 Specsavers global journal for all professional staff & students All smiles in Sydney Success for second ANZ clinical conference Pathway to partnership Meet tomorrow’s store directors Talking shop The value of a store visit Hearcare Try our pathology CPD crossword tive c a r e t n I CET part 2: Red eye errals ref Urgent s and DOs tom - for op Contents This month’s ProFile really demonstrates what a ‘best practice without borders’ kind of organisation Specsavers is. Fundamental to this is the belief that a great idea is a great idea, regardless of where it originates, and that – with the right cultural tweaks and in-country execution – innovation will always travel well. Pathway, RX Factor, the establishment of our industryleading clinical conferences… even ProFile itself… are all great examples of Specsavers initiatives launched in one country and then shared globally. Let us know what initiatives are working well in your region – and any you’d like to see replicated elsewhere. Contacts Email: [email protected] Editorial UK/Europe: Michaela Wakeford Tel: 01481 232494 Distribution UK/Europe: Debbie Williams Tel: 01481 234897 Clinical editor: Nigel Best MCOptom FBCLA FAAO [email protected] Editorial board Nigel Best MCOptom FBCLA FAAO Dr Catharine Chisholm PhD BSc (Hons) 4-5 Specsavers news Round-up of Group and store-related stories 6 Industry focus A look at what’s happening in optics 7 Professional Advancement Conference (UK) Plenty of reasons to book for October event 8-11 Specsavers Clinical Conference (ANZ) People, pictures and clinical pearls from SCC2 in Sydney 12 Optometry case study Transient visual loss 13 DRP / Dispensing case study Store image of the month, plus Dispensing Q&A 14-15 Pathway partnership programme Meet the JVPs of tomorrow 16 Talking shop The value of a store visit 17 Management matters Survival of the fittest 18 Contact lenses Making your contact lens conversations memorable 19 Hearcare news Specsavers showcases AQP services at largest commissioning event 20 Hearcare CPD Pathology crossword 21 BSHAA Congress 2013 Latest findings on digital noise reduction and frequency compression MCOptom 22-27CET Paul Morris BSc (Hons) Optometry MCOptom Peter Larsen BSc Optometry Chris Steele BSc (Hons) FCOptom DCLP DipOC DipTp (IP) FBCLA ©2013 Specsavers Optical Group Ltd. All rights reserved. The contents of this publication are strictly confidential. The information is provided for Specsavers only and must not be given to any persons or companies outside the Group. Published with the support of the Specsavers Product Support Fund. 2 RX FACTOR PROFILE July 2013 Red eye part 2: Urgent referrals – interactive CET for optoms and DOs 28 In the spotlight with… Welshman and Spanish store director Leighton Griffiths Welcome Show of strength Our 2013 Clinical Conference (‘SCC2’) held in Sydney last month rightly figures large in this month’s issue of ProFile (pages 8-11). Across the globe, Specsavers continues to embrace leadership in clinical and professional education as part of the portfolio with which we maintain our indomitable position as the eye care provider of choice. Our Professional Advancement Conference, attended by practitioners from the UK and Republic of Ireland, has built a reputation over many years as one of the premier clinical conferences in the world. It is no exaggeration to claim that last month’s conference in Sydney now establishes Specsavers as the international leader in optometric continuing professional development in both hemispheres. Having managed to wrestle Doug’s invite from him, I was fortunate to be able to travel to Australia and spend a few days with colleagues in the run-up, as well as attending the conference itself. And what I was able to observe was truly inspirational. The clear ambition to build on already phenomenal success, the optimism that Specsavers can provide the platform and culture to truly meet the eye care needs of the nation, plus the boundless energy to achieve more, came across time and time again when speaking with many of the delegates. It is clear that, wherever in the world we have a presence, Specsavers people jointly live up to the values of being passionate about our customers, our people, our partners and the communities in which we work. This month’s ‘Talking Shop’ column, by Simon Dunn, (Swap shop – page 16) continues the theme of learning from each other – something that can be applied in all countries. So, too, does the report on the exciting progress made with our Pathway partner programme (page 14) – yet another example of how joined-up thinking can benefit like-minded staff across the globe. It is no exaggeration to claim that last month’s conference in Sydney now establishes Specsavers as the international leader in optometric continuing professional development in both hemispheres. A further shared experience – and one made abundantly clear to me by attending the SCC – is the emergence of a closer working relationship with other health professionals (and ophthalmology in particular). This is as apparent in Australia/New Zealand as it is in Europe. Faced with an aging population, and the number of over-60s growing twice as fast as the number of ophthalmologists, it is obvious that there will be an increasing demand for our products and services. It is equally obvious that, with our culture of focusing on the customer, Specsavers is the ideal partner for engagement by those responsible for commissioning healthcare services in all the markets and sectors in which we operate. With one clinical conference under the belt, there is another in the making, with just over three months until the UK’s Professional Advancement Conference on 13 October – and over 1,200 delegates already booked to attend. This year’s event will be really ground-breaking and more relevant than ever with a programme that embraces the new CET requirements for all practitioners. Plus – as our Australian colleagues showed last month – it can provide an excellent catching-up opportunity for busy and geographically disparate professionals. I would urge you and your clinical teams to sign up – see page 7 for more details. Paul Carroll Specsavers Director of Professional Services (UK & ROI) RX FACTOR PROFILE July 2013 3 Specsavers news RX Factor roadshow reaches Nordics Content for the workshops was largely based on the UK model, with input from UK course tutor David Brett-Williams who worked with the Nordic training team and local optometrists to tailor the content to the relevant regions. Store partners have also been trained to help deliver the workshops alongside the Nordic Academy training team. ‘Specsavers equals good customer service. We want satisfied customers who get professional help from service-minded practitioners. The RX Factor is all about sharing ideas on how we deliver this,’ said Retail Development Manager Søren Ringmann, who helped to facilitate one of the Danish workshops. Here’s what some of the delegates had to say: ‘It’s always interesting to share experiences with colleagues. This time we got to listen to how other opticians express themselves in the eye exam room and in the purchasing situation.’ Tone Myhren, Specsavers Trondheim Following on from its success in the UK and Australia/New Zealand, the RX Factor for Optometrists development programme continues to gather momentum with its first tailor-made workshops for Specsavers practitioners in Norway and Denmark, and more to follow in Sweden and Finland next month. I really enjoyed the ‘Finish strong’ section which was about how to finish an eye exam in the best way. This material was completely new to me and we have never talked about it in courses or school.’ Frode Leborg, Specsavers Sandefjord ‘The best part was, as a partner, taking on the leadership hat, daring to try some new things. Also making sure we have the right people in the right place in store.’ Anne-Lene Møller, Specsavers Middelfart The first round of workshops, attended by optometrist and optician partners, received incredibly positive feedback. A second round will see all employed opticians invited to attend. ‘I’d definitely recommend RX Factor – I have already signed all my optometrists up for Round 2. They will learn a lot and bring new ideas back to the store.’ Mia Kjær Albertsen, Specsavers Hobro Sweden launches contact lens ‘webb-butik’ Working smarter Customers in Sweden can now buy their contact lenses online direct from Specsavers for the first time, with the launch of Specsavers’ ‘webb-butik’ (online store). It follows the success of the launch of online contact lens retailing in Australia and New Zealand last year. A key message behind the new offering is that customers can buy contact lenses online – as they can with other retailers – but still have the back-up of help and advice from the opticians and teams in store. Project leader for the launch, Matt Armitage, said: ‘It has been a huge team effort to get the concept live, with heavy involvement from colleagues in Sweden, the UK and Guernsey, the Copenhagen support office and, of course, essential input from Australia. ‘Engaging with our partners has been a key focus, as it was in Australia, and it was a definite high point when it got the full backing of all our partners at the launch meeting.’ We all know that first impressions count and how we look at work is just as important as how good the store looks when presenting a professional image to customers. Specsavers iWear business wear was launched to maintain consistent brand standards across the whole team and is now our signature dress code across the world. Seeing non-uniformed members of staff – especially senior staff – is confusing for customers and dilutes the impression that the team represents ‘one brand’. Which is why all senior staff, including supervisors, managers and optometrists, are expected to wear iWear. Self-employed practitioners are asked to wear a dark blue business suit and white shirt/blouse to work and should be provided with a Specsavers tie or scarf when they get into the store. See Connect for how to order and get credit on iWear – plus, if you’re in the UK, how you and your colleagues could win a prize of £1,000 for the bestdressed store. 4 RX FACTOR PROFILE July 2013 SCC2 raises cash too Zealand’s South Island – some six hours’ flying time and one required stopover from Alex’s home base of Sydney! Excitingly, this fund-raising exercise took Specsavers ANZ’s total figure raised for The Fred Hollows Foundation over the $500,000 benchmark for the first time. A big thank you to everyone who contributed A fantastic weekend was had by all at the second hugely successful Specsavers Clinical Conference in Sydney last month. The event combined not just the clinical (see our full report in pages 8-11) but also the charitable in the form of a raffle in aid of charity partner The Fred Hollows Foundation. An amazing $25,000 was raised by partners in the two weeks leading up to the conference, with some fantastic prizes drawn at the welcome cocktail party at the Sydney Opera House the night before the conference. These included an all-expenses paid trip to the PAC – our sister conference in the UK – won by Chadstone optometry partner Parmjeet Mirwa (pictured front cover, with ANZ Director of Professional Services Peter Larsen), and a ‘golden ticket’ prize of having top designer Alex Perry in-store for a super styling session. This was won by Amy Winter (pictured, above, with Peter Larsen), optometry partner at Specsavers Invercargill which, for those not in the know, is at the very bottom of New Over 1,200 already booked More than 1,200 optics and audiology delegates have already booked for our 19th Professional Advancement Conference – a record number with still three months to go. This year’s event, on Sunday 13 October in Birmingham, UK, offers a really innovative programme catering for all practitioner competencies and with fully interactive CET in all sessions. Some sessions, including peer discussion and facilitator training, require pre-booking and have been filling up fast, so make sure you and your clinical teams don’t miss out. Check out page 7 for more details of what’s in store and how to book, and keep an eye out for the full programme in next month’s ProFile and on Connect. Norwegian optometry students win trip to PAC Also winning a trip to the Professional Advancement Conference in October were a team of final year optometry students from Norway. Specsavers has, for the last four years, sponsored the prize for best poster at the Buskerud University College Institute for Optometry and Vision Science. This year’s winning project looked at ‘How visual functions are affected by pupil size after dilation with Tropicamide’. The team concluded that pupil size has minimal effect on visual acuity in young healthy patients, thus patients’ visual acuity after dilation should not be an obstacle to using Tropicamide. The project group (pictured) were: Shugufa Asefi, Gima Rehani, Lisa Therese Campanile, Beate Kjeldstadli Solfjeld, Petter Danielsen and Jon Vegard Eliassen. Enhanced CET explained If you’re still trying to get to grips with what the UK’s Enhanced CET Scheme means for you, check out this useful guide from the General Optical Council – posted out as a booklet to all GOC-registered practitioners at the end of last month, and available electronically on the GOC’s website www.optical.org, and on Specsavers UK Connect. The booklet clearly lists the number of points and competencies required by different practitioner groups, explains the peer discussion requirement and how to manage your online CET portfolio. Remember – all CET articles published in ProFile, and all sessions at this year’s Professional Advancement Conference, carry interactive points under the new scheme. Win a conference + hotel weekend package Send in your best fundus and anterior eye images to this year’s Specsavers Digital Photography competition, and you could be one of the lucky winners of a top-ofthe-range PENTAX digital SLR camera, or even bag yourself a free pass with hotel accommodation to your nearest Specsavers clinical conference (e.g. October’s PAC in the UK, or next year’s SCC in Australia) This year’s competition has gone global and the search is on to find the best images captured in Specsavers stores around the world. There’s plenty of chances to win a prize, with categories for UK/ROI and ‘Rest of the world’. But hurry, you’ve only got until the end of August to send in your entries. Simply email your images with a few details about what’s shown, along with your name and store no. to gg.fundus@ specsavers.com, making sure you remove any customer information. For full entry requirements and tips on what the judges are looking for, see Connect. RX FACTOR PROFILE July 2013 5 Industry focus Eye care dominates ministerial must-read mag Last month saw publication by leading political and cultural magazine New Statesman of a supplement dedicated to eye health. The magazine is required reading in the UK for MPs, Peers and the decision- makers in local government. Included within was an article by government minister Lord Howe saluting the excellent eye care which occurs in high streets across the country every day. Although many of his comments would apply to the whole of the UK, his own responsibility is restricted to England. Here, he argues, it is crucial that we get eye care right and keep striving to improve it. He points out that opticians, working with doctors and others, now have the power to plan and design local eye health services that are better tailored to local need. In recognition of this, the Royal College of General Practitioners has made eye health one of its clinical priorities for the next three years. Lord Howe highlights that Local Professional Networks (LPNs) will be a significant factor in improving eye health services because they will encourage more joint working across sectors. All good reasons why an increasing number of Specsavers stores are becoming involved in the delivery of an expanded range of commissioned services. 6 RX FACTOR PROFILE July 2013 Welsh pharmacists dispense wider health advice Cross-sector working is alive and well in Wales, where pharmacies are stepping in to lend a hand in getting the message about the importance of good eye health. Throughout July, pharmacies will be running a month-long campaign which will highlight risk factors that can cause sight problems in a joint programme with Public Health Wales – further evidence that public health professionals are recognising the significance of eye health alongside other major public health issues such as dementia and obesity. While pharmacists will be highlighting factors such as diabetes and smoking to their customers, they will also be making referrals where necessary to community optometrists, with local Specsavers stores ideally placed to provide more detailed advice and guidance on good eye care. Australia exposes non-approved lens importers One of Australia’s main three optical trade publications – mivision – ran a good oldfashioned expose story last month that has had tongues wagging across the profession. It turns out that quite a number of ophthalmic lens suppliers – including some well-known ones – are importing lenses into Australia that are not yet registered with the Australian Therapeutic Goods Administration (TGA). All medical devices, including lenses, must be included in the TGA’s Australian Register Road testing older motorists’ fitness to drive While the UK awaits the outcome of the Driver and Vehicle Licensing Agency tender process for the contract for visual field testing, the UK’s Optical Confederation has reported on a seminar hosted earlier this year by motoring charity The RAC Foundation about the potential for self-assessment tools to be used by older drivers in order to determine their driving fitness. As in other forums, ongoing concerns about the effectiveness of the number plate test were expressed and the fact that it was often necessary to wait until people were completely unsafe before action could be taken. of Therapeutic Goods prior to being sold in Australia. While not naming names, the article then points to the list of registered importers via the tga.gov.au website. The report that accompanied the seminar makes for interesting reading as it contains analysis by some of the leading researchers in the field. We may intuitively believe that vision is the major consideration, but the report explains why changes in other cognitive, sensory and psychomotor abilities can have a greater impact. The paper will make fascinating reading for all practitioners interested in the important societal need to enable people to drive safely for longer – and can be found at http://fodo.com/downloads/ Driving-Choices-for-the-Older-Motorist.pdf Professional Advancement Conference 13 October 2013, ICC Birmingham, UK Over 1,200 already booked for PAC 2013 No-one likes to feel CET is a drudge, which is why we’ve pumped up the value on the PAC programme this year, taking full advantage of the competencies and learning styles now part of the UK’s Enhanced CET Scheme. So if you are short of interactive points or a competency or two, you will be able to track them down and gain your full year’s requirement of CET points in the process. Totally interactive CET, and all competencies covered… Other great reasons to bring the whole team…. However you choose to spend your day, you will be assured that all sessions offer interactive CET points, and all practitioner competencies are covered during the day. • Full day audiology programme for qualified and trainee hearing aid dispensers and hearing care assistants. • Year-specific TDO sessions, including exam preparation; plus supervisor news from the GOC • Full day pre-reg optom programme • Professional development and product sessions • Motivational personal development for all, led by Specsavers partner David Brett-Williams • Extra CET quizzes Peer discussions & workshops… • Networking with Specsavers colleagues from across the Group Engage with a fascinating programme of case studies and conundrums developed by Specsavers partners Paul Morris and Dr Nigel Best. Peer discussion topics include: • Chance to meet industry representatives, external suppliers and Specsavers support teams Enjoy a fully flexible programme of both practical and clinical subjects from a superb team of illustrious guest presenters including Professor Christine Purslow, Professor Stephen Parrish, Dr Anna Kwartz, Mr Teifi James, Caroline Christie, Mr Leon Au, Nick Atkins, Nik Sheen, Mr Daniel Morris, Dr Jo Watkins, Sally Bates, Paul McCarthy and Head of Education and Standards at the General Optical Council, Linda Ford. • Contact lenses for old and young (book on the 9-11am sessions). • A choice of clinical topics including AMD and BV (book on any session except 9-11am). • Dispensing peer discussions on communications, paediatric dispensing and professional conduct competencies (no need to pre-book). Note: Peer discussion facilitator training must also be booked in advance via Connect. Pre-register and beat the queues! Important changes to PAC registration process GOC auditing of this event means that only practitioners who are present for the entire session will get their CET points. We do not have any scope for flexibility on this. If you are not in the session by the time the presentation starts, unfortunately you will not be eligible for points. Detailed programme information for all professional groups will be published in August’s ProFile and on Connect. Thanks very much to our sponsors for making it possible. How do I book? Search for ‘PAC’ either in the Optics or Hearcare tabs on the UK Connect site and fill in the relevant booking form. You will also find information on booking accommodation at preferential rates. Email confirmations of delegate places and peer discussion places booked before 30 June are being sent out after 1 July. To ensure that queues at morning registration on the day do not prevent anyone getting to the start of the first session, we will send you pre-registration details in advance of the day. Please keep this information safe and treat it like a boarding pass for a plane! IT ADM ONE Success in the city for SCC sequel Clinical cases, CPD, cocktails and catching-up with colleagues at the Sydney Opera House. Our second Specsavers Clinical Conference offered an impressive educational and social programme for Australian and New Zealand practitioners, as Neale Pugh reports. This year’s Specsavers Clinical Conference (known locally as SCC2) swapped Melbourne for Sydney to welcome more than 400 people for a weekend of professional development and networking. Moving the event from mid-week to a Sunday also allowed delegates to enjoy a welcome cocktail party at the Sydney Opera House the evening before the conference – a great start to what has already become a great event. More than 320 Specsavers optometrists from Specsavers stores all over Australia and New Zealand travelled to the event, which also played host to 40 ‘guest’ optometrists, and a number of optometry school students. As well as a very illustrious speaker line-up – drawn almost exclusively from the world of ophthalmology – VIP guests included Colin Waldron (Chair of statutory body The Optometry Board of Australia), Andrew Harris and Genevieve Quilty (President and CEO respectively of Optometrists’ Association Australia) and representatives of the Schools of Optometry and the College of Optometrists. A full-house of optical trade journalists was also present with Insight, mivision, Australian Optometry and NZ Optics represented by a total of seven writers and editors. Sunday’s clinical programme provided attendees with the latest research and advice on subjects ranging from glaucoma to vitreoretinal surgery (see pages 14 & 15 for clinical highlights). During breaks in the day, delegates were able to catch up with old friends, meet new ones and visit supplier stands as well as try out the latest consulting room equipment in fully equipped mock-up rooms. Sponsored by: 8 RX FACTOR PROFILE July 2013 Peter Larsen, ANZ Director of Professional Services, said that he was delighted with how the day had gone. ‘Certainly the feedback we had during and after the event has been extremely positive. The addition of the Opera House welcome party met with universal approval and the CPD programme has, I believe, hit the nail on the head in terms of content and practical application. There was so much useful material for optometrists to take back to their consulting rooms. CPD is great but the whole purpose of CPD is to improve our clinical knowledge. Sunday at the Hilton did just that for me and, I am sure, all of our optometrists.’ SCC3 is planned for 14/15 June 2014 and will be eagerly anticipated – wherever it might be. SCC has managed in two years to leapfrog the competition and confirm its standing as a leading optometry conference in Australia and NZ. An excellent event uniting Specsavers optometrists, promoting professionalism and supporting the community through solid fundraising. Rob Pietrini, optometrist partner, Shell Harbour Supported by: The weekend was great; I thought the conference and speakers were very informative and relevant. I’ve definitely picked up a few extra tips and it really makes me, as an optometrist push towards clinical excellence. Overall it gave me such a positive vibe towards becoming a Specsavers partner. Peter La, optometrist, Upper Mt Gravatt Not only did we enjoy a ‘cocktail or two with a view’ at the Sydney Opera house on Saturday, but it proved to be a very informative, interesting and CPD packed Sunday session. Great chance to catch familiar faces and trade notes with fellow directors. Can’t wait for SCC 2014. Matthew Bennett, optometrist partner, Rosny This year’s SCC was again proof of Specsavers’ commitment to delivering world class optometry advancement in Australia. Clinton Fisher, optometrist partner, Rundle Mall RX FACTOR PROFILE July 2013 9 Specsavers Clinical Conference (ANZ) Tips from the top Camberwell optometry partner Neale Pugh offers his take-home highlights from the Specsavers Clinical Conference in Australia. Myths and misconceptions that can lead to suboptimal outcomes in glaucoma diagnosis and management Professor Jonathan Crowston, Director, Centre for Eye Research Australia, Head of Ophthalmology, University of Melbourne Back by popular demand, Prof. Crowston presented a critical approach to the parameters used for glaucoma diagnosis and monitoring and a broader perspective on management of the condition. The main messages for the audience were: • Careful examination of the optic disc is essential. • No single sign is pathognomic of glaucoma. • • • Visual field anomalies need to be confirmed and repeated. Monitoring of the optic disc and retinal nerve fibre layer is essential in managing a patient with glaucoma. These requirements are patient specific and the frequency of review should be determined by levels of IOP. An update on the management of AMD and diabetic retinopathy Dr Alex Harper, Head of Medical Retina, Eye and Ear Hospital, Melbourne Dr Harper covered the most recent research and views on prevalence, new classifications, clinical features and the latest treatment options for both conditions. Particular relevance was presented to the optometric audience on clinical decisions they could make on investigations they should undertake on these patients and referral criteria they should consider including: • • Always dilate diabetic patients with even a single haemorrhage. • • Be cautious when referring diabetic patients • with cataract – 1 in 5 have an increase in their DR post cataract surgery. Optimise vision and review regularly. New classification of small drusen (63 microns or half diameter of central retinal vein) “Drupelets”. Drupelets – not AMD. Normal age related changes, no clinical risk of developing AMD. Essential to instruct patients in use of Amsler Chart at home. Any acute symptoms – urgent referral. Vitreoretinal surgery made surprisingly understandable Associate Professor Dr Alex Hunyor, Associate Professor of Ophthalmology, Macquarie University / Vitreoretinal Surgeon, Sydney Eye Hospital / Director, Retina Associates Dr Hunyor discussed the major elective vitreoretinal problems, such as: • • • The clinical features, diagnosis, and treatment of macular hole, epiretinal membrane, and vitreomacular traction. The essentials, symptoms, signs and treatment of retinal tears, posterior vitreous detachments and retinal detachments. Referral guidelines for ERM. If there are no 10 RX FACTOR PROFILE July 2013 symptoms and VA is normal – review using retinal photography/imaging.. • 60% of retinal detachments are in the superior temporal quadrant. • The clinical red flags for retinal detachment are: −− Any retinal/vitreal haemorrhage. −− Cells in the vitreous. −− Shadows in vision or reports of vision looking like ‘oil on water’. Can eye, can’t eye? Dr Trevor Gray, Consultant Ophthalmologist, Auckland Hospital Eye Department, Clinical Senior Lecturer in Ophthalmology, University of Auckland This was a review of the latest techniques for corrective surgery, the procedures, their safety outcomes and results achieved for the patient. • LASIK is the most common procedure, but wavefront PRK is preferred for low myopes at risk of trauma (police, armed forces personnel, some sportsmen). • The partnership between the ophthalmologists and the optometrist is very important in co-management of the post-surgery patient. Genetics and myopia Professor David Mackey, Professor of Ophthalmology / Director, Centre for Ophthalmology and Visual Science, University of Western Australia Prof. Mackey reviewed the latest literature on the genetic and environmental factors associated with myopia. These included: • Epidemic of myopia in Asia. • The heritability of myopia. • Syndromic myopia. • Genome wide association studies for myopia and its component measures. • Outdoor activity and its influence on the development of myopia. Acute inflammatory eye disease Associate Professor Anthony Hall, Director of Ophthalmology, Alfred Hospital Melbourne This presentation gave guidelines on how to assess, diagnose and manage acute ocular surface inflammation and properly assess intraocular inflammation. Referral guidelines were given for each condition, which included: • Seasonal allergic conjunctivitis, viral conjunctivitis and bacterial conjuctivitis. • Keratitis – marginal keratitis, sterile contact lens related keratitis. • Episcleritis. • Acute anterior uvietis. All conditions required a detailed organised history followed by a detailed examination for differential diagnosis. • When examining for potential anterior uveitis: −− Always dilate. −− Turn the lights down and the slit lamp magnification up. −− Can not diagnose without also examining the posterior eye. Evolving the eyecare model to meet changing needs Paul Carroll, Specsavers Director of Professional Services (UK/ROI) Paul outlined the evolution of optometry in the UK over the past 25 years, which has seen significant development of local co-management initiatives between optometry, ophthalmology and other stakeholders such as GPs. Key points were: • Demand for eye examinations set to increase by 20% over next 25 years. • Increase in number of glaucoma cases by approximately 1/3. • • • • 50% of loss of sight in the UK preventable. Demand for ophthalmology services is increasing faster then ophthalmologists can be trained. Co-management systems in Scotland and Wales have reduced need for referrals, thereby reducing load on ophthalmology. Co-operation between ophthalmology and optometry through co-management to be developed further to meet the increased demand. RX FACTOR PROFILE July 2013 11 Optometry case study Transient visual loss by Giles Capmbell, optometrist, Specsavers North Lakes, Australia History • A 56 year old male presented c/o blurring in the inferior nasal quadrant of the left eye for 3 days which then resolved but returned again after 1 week. • GH – hypertensive • POH – none • FOH – none • Carotid artery ultrasound • Fasting blood sugar • Cholesterol Discussion A Hollenhorst plaque is a cholesterol embolus seen in a retinal artery. Signs and symptoms • Bright yellow/ white plaque often seen at a retinal arteriole bifurcation. • These plaques tend to break up and move and may not be seen at subsequent visits. • Patients may be asymptomatic or experience transient episodes of partial or complete monocular visual loss (amaurosis fugax). Aetiology • The embolus is composed of cholesterol often from an ulcerated ipsilateral carotid artery plaque. • Associated with hypertension and hypercholesterolaemia. • If blood flow is sufficiently impaired retinal ischemia can result in the tissue distal to the blockage. Examination Management by optometrist/ ophthalmologist • Best corrected visual acuity RE 6/6 LE 6/7.5 • The emboli themselves require no treatment as blood can often flow through an apparently complete blockage. • Amsler – blurring inferior nasal corner left eye • Retinal embolus indicates significant systemic vascular disease. • IOPs R 13mm Hg, L 12mm Hg • Refer to GP for further investigation / possible onward referral. • See left eye digital retinal photo Provisional diagnosis • Hollenhorst plaque lodged at bifurcation of superior temporal artery. Referred to ophthalmologist for further investigation • Confirmed diagnosis and requested following tests: 12 RX FACTOR PROFILE July 2013 Investigations / treatment • Carotid ultrasound • Fasting glucose and lipids • Blood chemistry with cardiac enzymes • Treat underlying vascular disease • Treat carotid stenosis if required (carotid angioplasty) • Aspirin therapy DRP - Image of the month Optic nerve head drusen by Sophie Simmmonds, optometrist, Specsavers Teignmouth, UK Diagnosis: Optic nerve head drusen Aetiology: Calcified concretions at the level Differential diagnosis: Papilloedema, of the lamina cribrosa believed to result from an accumulation of axoplasmic derivatives. glial tissue on the optic nerve head, myelinated nerve fibres, high hypermetropia. Prevalence: Approximately 0.5-1% of the Signs: Bilaterally (in approximately 70% of cases) elevated optic discs with irregular margins and retractile hyaline deposits visible on the disc and surrounding area. The drusen are often not visible in children only becoming detectable with ophthalmoscopy by the mid teens. For this reason, in childhood, the appearance can be confused with early papilloedema. Symptoms: Often patients are asymptomatic and remain so throughout the progression of the condition. Occasionally a mild reduction in best corrected visual acuity is found. general population, primarily Caucasians. Significance: Optic nerve head drusen can compress both the nerve fibres and blood supply in the lamina cribrosa resulting in visual field loss. The most common visual field defects are nasal steps, enlarged blind spots, arcuate scotomas, sectoral field loss and altitudinal defects. They also increase the likelihood of choroidal neovascular membranes forming close to the optic nerve. Management: Refer to ophthalmology for confirmation of diagnosis (often with ultrasonography) and ongoing monitoring every 6-12 months. Patients should be advised to self monitor their vision periodically because of the risk of choroidal neovascular membrane formation. Dispensing case study The importance of ‘wearing in’ progressives by Steve O’Leary, Director of Product for Australia & New Zealand Female Cx: Bernadette Murphy Age: 48 years old Occupation: Receptionist at a veterinary practice RX: RE: +0.75/- 0.50 x 70 LE: +0.25/ -0.25 x115 Add +1.75 DS Bernadette has previously worn single vision reading glasses but has recently decided to give progressives a go as she needs to keep taking her glasses off to speak to customers at the counter, which she finds quite annoying. She was dispensed a pair of Independence Pro HD (B corridor) in a 30mm deep frame. She was hesitant about them at collection, but decided to give them a try. Ten days after collecting them she returned to the store, complaining about not being able to use them as she was not getting clear vision when looking at the computer screen or processing credit card payments. The distance vision seemed fine. Steve says: I would start by marking up the lenses with Bernadette’s PD and the ordered heights and confirm that the placement is in line with Bernadette’s line of sight. Checking confirms that this is the case. Where to now? The next check should be to see how Bernadette is using her glasses – we may have made incorrect assumptions about the placement of her computer screen. It turns out that she has her screen standing low on the desk, placing the top of the screen in line with her collar bone, much lower than one would expect. It is important to demonstrate and explain to Bernadette the layout and requirements for her (or in fact any) progressive lenses. This can be achieved by asking her to fix her gaze at a point on the screen and observe the changes that occur as she moves her head up and down. When checking the position of the credit card machine standing on her desk, it turns out that it is to the left of her computer. She is only turning her eyes towards it, not her head, which results in her looking through the lens periphery, the soft focus area of the lens. It needs to be re-iterated that the lens is a great all rounder, but has a number of different focal points, the correct one needing to be used for different tasks. It’s a bit like new shoes that need to be worn in, before they become ‘comfortable slippers’. Like those shoes, it is important to put the new glasses on in the morning and leave them on all day, even if it is a bit uncomfortable to start off with! It is always important to mention this during the dispensing process as it is much easier to convince customers of this sometimes necessary process if they have been given this info before they encounter those challenges. RX FACTOR PROFILE July 2013 13 Pathway Ready to take the next step What is Pathway? Pathway is a free, intensive 24-week course which identifies and prepares experienced Specsavers practitioners and managers to become the JVPs of tomorrow. This ground-breaking programme represents a massive investment in current employees who live our values and culture, to provide them with the knowledge and development they need to take up the reins, and play a lead role in the future of the business. Pathway – our new recruitment process for aspiring JVPs – has proved a huge success in the UK and Australia/New Zealand, with the first intake of candidates now primed for partnership. As the scheme prepares to go global, we talk to some ‘Pathwardians’ to find out what they and their stores have got out of it. The course has been so successful in the UK that it was launched in Australia and New Zealand late last year and there are further plans for it to be rolled out in the Nordics and the Netherlands this year. What’s involved? Pathway takes six months and consists of an Intake day followed by three two-day modules (Culture & Brand, Finance & Business Awareness, and Leadership). Students also work on a specific project, and attend a final assessment centre, where they are gauged on their suitability to become JVPs. How do I find out more? For more information, visit: specsaverspathway.co.uk UK contact: [email protected] ANZ contact: [email protected] Netherlands contact: [email protected] There is more than one intake a year. After completing an application form, would-be candidates undergo a telephone interview and/or face-toface assessment before being formally invited to participate in the next Pathway group. 14 RX FACTOR PROFILE July 2013 ‘Pathway has made me a better employee’ Amanda Bazzacco, Specsavers Robina, Australia ‘Pathway has given me knowledge and experience in areas that I wouldn’t be able to access anywhere else. Networking with people from different stores and learning from experiences is fantastic. With Pathway, I am building a strong foundation of knowledge that is helping me gain the right tools for my future (hopefully!) as a Specsavers JVP. ‘The best thing I have learnt so far is what it takes to be a better leader and help a team go towards success. I know what the tools are, how I can access them and what support I have within Specsavers. Pathway has made me a better employee – I am a lot more aware of what I can do and how to help people in different areas.’ ‘I will stay in touch with my fellow students. We speak quite often and it’s great to see how we are all going.’ ‘Pathway has shown me I could be a great JVP one day’ Karen Cluness, Specsavers Aberdeen, UK opportunity to improve whenever I can. It was Chris Howarth [UK Director of Professional Recruitment] who talked me through the potential that Pathway could provide. I was sold. How did you prepare for the course – any tips? The first induction day really set the scene and gave me clear expectations that it was going to be a fulfilling yet challenging course. I was under no illusions that this was going to be an easy ride! My advice would be, be prepared to work hard and put the time in and you’ll come out of it with exciting new and enhanced skills. What were your first impressions of the course? What’s your background? I worked for Vision Express for 17 years and had started to become frustrated by the low priority that was placed on the values of the people by the company. I joined Specsavers in September last year as business development manager at the Aberdeen store, and with the longer term option of becoming a joint venture partner. Why did you apply for the Pathway course? It’s really important to me that, after a long time in the industry, I continue to broaden my knowledge, be better organised and learn how to improve profits and have a better business. The economic climate in retail is also a stark reminder that I need to keep ahead of the game, maintain core skills and take the This is, without a doubt, the best development course I’ve ever undertaken. It’s miles above any other in the way it’s structured and organised. My loyalty to my store is heightened and I know I can help develop the business, the practice and the team, so we’ll all benefit from Pathway. I will pursue a JVP opportunity in the future, but in the short term I’ll be putting into practice everything that I’ve learnt and be making the most of the network of support going forward. What has the course given you? This is, without a doubt, the best development course I’ve ever undertaken. It’s miles above any other in the way it’s structured and organised. Pathway is a fantastic development tool and the whole course was far better than I expected. The quality of the course content, the contributors and the sessions are outstanding. I realised immediately this was going to be challenging, absorbing and very intense. I met some amazing people and had fantastic support. The speakers were charismatic and inspiring and the support network is vast. My business acumen has improved and I have a far better understanding of the financial aspects. I have learnt so much more and enhanced the skills I already had – I know I can add a great deal of value to Specsavers in a variety of ways. It’s made me realise how important culture and values are for a successful business and has proven to me that I could be a great JVP in the future. What was the time commitment required to succeed? What was the final assessment like? If you really want to get the most out of the course and succeed, you need to put in 100% in throughout the whole six months. As well as the series of two-day events, you also complete a project – all on top of your day job. So, there is a lot of personal time you need to put in, especially to complete the project. You need to organise yourself and your day job, take advantage of the great resources, such as the reading list, and really make a start on your project right at the beginning. The time really does fly, so get a head start early on. This part is a real test of your strengths. It’s not just about what you’ve learnt along the way, but also tests the way you conduct yourself in a team and during the group exercise. It was fun and intense at the same time. You’re being assessed throughout the whole course so you need to stay switched on and keep with the pace. If you like a challenge, this is for you! What would be your advice to others considering Pathway? You need to understand your commitment to this development programme. You need to really want it and be prepared to put passion, time and energy into it. That way you’ll get the most out of it. Now that you’ve qualified, what does the future hold? My loyalty to my store is heightened and I know I can help develop the business, the practice and the team, so we’ll all benefit from Pathway. I will pursue a JVP opportunity in the future, but in the short term I’ll be putting into practice everything that I’ve learnt and be making the most of the network of support going forward. RX FACTOR PROFILE July 2013 15 Talking shop Swap shop Doing a store visit – or hosting one – is a great opportunity to take stock, says Simon Dunn. I started my career in optics as a trainee dispensing optician with Dollond & Aitchison. In those days, like most 19-year-olds, after being in the job for a year or so, I thought I knew it all. D&A was a very big company and had been around for a long time. My view of the optics world was very clearly defined and I knew exactly what customers wanted and how opticians sold spectacles and contact lenses – easy! That is, at least I thought I did until I left and started work for American Optical as a lens consultant. My job was to travel the length and breadth of the country talking to multiples and independents, persuading them to use our spectacle lenses and surfacing laboratory. The first thing I quickly learnt was how differently other opticians viewed the world. Where I had previously believed there was only ‘one true way’ to run an optical business, within weeks I began to realise that there were actually hundreds. Everyone had a different idea on what best practice should look like. And the great thing for me was that it forced me to change my previously very narrow view of the optics world. Fast forward a few years and I find myself as a joint venture partner with Specsavers. In the initial start-up and first couple of years there was an in-built need to seek guidance from Specsavers’ support teams and other more experienced directors. After a while, I found I had become comfortable with the business and, without realising it, had once again found my ‘one true way’. This time I had even drawn it myself, but the limitations and damage to my business were the same – stagnation of ideas. As committed and passionate as I was about my store, there was no substitute for visiting other great Specsavers stores. As a global super-brand it seems crazy not to tap into the wealth of experience that so many fellow JVPs have. We have all heard the classic “I learned more in the bar the night before than at the meeting” comment. Being able to visit those people As a global super-brand it seems crazy not to tap into the wealth of experience that so many fellow JVPs have. from the bar in their store is often an amazing experience as you see a version of their ‘one true way’ that you haven’t even thought of. Many successful businesses have mentor programmes. It is pretty easy to create something similar ourselves, though. Visiting other stores and having them visit yours creates enormous opportunity to learn. But in my experience, to get the best results it has to be a ‘warts and all’ open visit. Probably the two most common reasons we don’t do this as often as we should are: 1. Time – Too busy. Keep meaning to. Never quite happens. If it’s important, you find a way – if it’s not, you find an excuse. 2. Fear – Very few people like to be told they are wrong. It can be, well, challenging. The point is, it isn’t about being right or wrong, just different. There simply isn’t ‘one true way’. In 13 years, I have only ever been refused a store visit once and find that my peers are only too pleased to share their experience with me. I have played host to hundreds of visits from other JVPs. Often they take ideas away with them but they also always leave ideas for me to develop too. A real win-win. In such a difficult economic climate, are we getting the best value from one of the most valuable, under-utilised resources Specsavers has – us!? Simon Dunn is DO director at Specsavers Nottingham, UK. 16 RX FACTOR PROFILE July 2013 Management matters Survival of the fittest by Emma Davis, Head of Retail Leadership & Management Training It doesn’t seem like nearly a year since London hosted the Olympic Games, with its motto of ‘Inspire a generation’. From the Games emerged many stories of triumph and excellence that have the capacity to inspire us all, not just in a sporting context. In the UK, for example, we recently heard from former Paralympic swimming gold-medallist Mark Woods who spoke at the Specsavers Partners and Managers seminars – delivering a clear message about the need for leaders to ensure the whole team is striving for the same result. Looking back at last year’s Olympics, one story stands out for me as a shining example of how what was once great performance can, over time, move into mediocrity. Two Slovakian brothers, Pavol and Peter Hochschorner, were the team to beat in their chosen sport, C-2 slalom canoeing. These guys won gold in 2000, 2004 and 2008. They were competing in the 2012 Olympics as the triple gold medal winners, world champions and, arguably, the best in their class. In 2008 their winning time of 190 seconds was 17 seconds quicker than their winning time in 2004, and 47 seconds faster than their gold medal winning time in 2000. Looking at their previous results and form, the gold was theirs…. So, on 2 August 2012 the Hochschorners raced down the waters in a time of 108 seconds – an amazing 82 seconds quicker than their gold medal-winning time of 2008. Yet 108 seconds did not get them gold, it didn’t even get them silver. A time 82 seconds quicker than 2008 only warranted a bronze for Pavol and Peter. You see, even though the Hochschorner brothers had been training and improving, so had everyone else. Two teams from the same country – Great Britain – romped home with gold and silver, with times just two seconds quicker than the brothers. To rub salt into their wounds, Great Britain hadn’t even got onto the podium since the sport was introduced in 1972. Clearly some serious work had been going on in the ‘Team GB’ camp in the four years prior to the Games. It’s both an inspirational and cautionary tale. If you are the best you can be, and never give up, the prize can eventually be yours… even after years of striving. But also, being number one isn’t a time to become complacent. Like Pavol and Peter, you can be beaten by the unexpected. At Specsavers, we’re already number one in many of our markets, and striving for top position in those that we aren’t – i.e. the gold When the smallest of margins can mean the difference between winning and losing, how do we keep improving on our past performance? standard professionals on the high street. We know who our rivals are, we know they are striving to achieve record weeks and sight test volumes like ours, and provide world-class health care to all. So, when the smallest of margins can mean the difference between winning and losing, how do we keep improving on our past performances? By inspiring our teams to want to be the best they can be, to keep raising the bar so our performance never becomes mediocre. And to always be watching over our shoulder. Want to know more about the management development available to you in Specsavers? Why not check out Connect Learning for the workshops running in your region. RX FACTOR PROFILE July 2013 17 Contact lenses Making your contact lens conversations memorable As part of this year’s ‘GRO your contact lens business’ initiative, Reah Hughes from the UK Product Team takes a look at some practical ways practitioners can influence contact lens growth. Discussing contact lenses at handover stage means that patients are more likely to remember your recommendation. Talking contact lenses MAZE figures for April 2013 showed that, while nearly 82% of our customers received a handover from the test room, only about a third remember discussing contact lenses. Despite most patients being suitable for contact lens wear, the option isn’t being routinely offered. Are there any tools to contribute to a memorable contact lens conversation? Recommendation during handover has a powerful impact. As a trusted practitioner you can discuss contact lenses in relation to the patient’s optical needs and personal requirements. Including the Purple Ticket (an invitation for customers to take advantage of a contact lens free trial) at the handover stage is a tangible reminder of that recommendation. More than 90% of customers are suitable for contact lens wear, even if it’s on an occasional basis, and all patients expect to have all options offered to them. Routine discussion of contact lenses during handover will lead to increased interest. Highlighting the benefits of contact lenses – especially when linked to the customer’s needs and interests – builds on the customer relationship and encourages loyalty. So how can you effectively personalise the recommendation? Needs and preferences There are many opportunities to link contact lens wear to specific needs and interests. Listen out for activities and interests your patients have which could be made easier with the use of contact lenses. Activities/hobbies – Sport is an obvious one, but there are plenty of other types of activity, e.g. walking (especially in the rain!), decorating or simply going on holiday. More than 90% of customers are suitable for contact lens wear, even if it’s on an occasional basis, and all patients expect to have all options offered to them. 18 RX FACTOR PROFILE July 2013 Technology – Clear vision at both near and far is increasingly important with the growth in use of tablet devices such as iPads, especially while watching TV. Talking to your early presbyopic patients about the advantages of multifocals expands their options and plants the seed for future fits. Cosmesis – There are clear cosmetic benefit, especially for high prescriptions. Patients don’t have to be either spectacle or contact lenses wearer. Why not offer contact lenses as an additional product to glasses for a change of look? Maximising trials The free trial continues to be an important tool in encouraging interest in contact lenses. However, research shows that over 50% of customers either fail to complete the trial or stop wearing lenses within a couple of weeks of completion. There are three key reasons for dropping out: • Service • Comfort • Handling A follow-up phone call during the trial will build on the relationship developed in the test room and will help tackle issues before they become a reason to cease wear. Outlines for these calls are included in the GRO pack received by stores. Should the customer have clinical concerns – perhaps with vision, comfort or an ocular issue – the staff member making the call has been directed to inform a qualified member of staff. This more informal contact with the patient at an early stage is an ideal opportunity to develop customer loyalty, leaving a lasting impression and instilling confidence in the practice as a whole. Sharing ideas For more information and ideas, ask the contact lens champion in your store for access to the ‘GRO your contact lens business’ folder in your store. There are also extra resources in the ‘GET more contact lens customers’ section of Connect, see Products > Contact lenses > GRO > GET. Hearcare news Catching the ear of GPs and commissioners AQP services on show at high profile commissioning event Colin Campbell, Prof. Kevin Munro and Dr Sarah Jarvis at the Specsavers plenary session. Anyone wishing to be considered as a provider of NHS services was at the Excel Conference Centre in London last month for The Commissioning Show 2013 – the largest national event for clinical commissioning, attended by the majority of GPs and commissioning groups with an interest in Any Qualified Provider. As such, Specsavers Hearcare had a substantial presence in the form of an exhibition stand in the main hall, where delegates could learn about the success of Specsavers’ audiology services and look at the patient satisfaction scores in their own areas, whilst GPs were able to undertake an interactive audiology quiz on a Specsavers giant iPad. Specsavers also hosted a plenary session entitled ‘AQP and adult hearing loss - warts and all’ for attendees to feedback on our current AQP service or to find out more about the service for future access. The Q&A session was framed by three presentations delivered from three perspectives on the first phase of AQP for adult hearing loss. Prof. Kevin Munro (Ewing Professor of Audiology) made the economic argument in favour of addressing unmet hearing needs; GP and media medic Dr Sarah Jarvis gave the GP view of commissioning services from Specsavers, while Director of Professional Services Colin Campbell offered thoughts on Specsavers’ own experience of Phase 1 AQP. The consistent view from all present was that, whilst the changes to the NHS resulting from the Health and Social Care Bill – and, in particular, the changes introduced by the AQP initiative – have been both complex and controversial, the initiative works well in relation to adult hearing loss and makes sense to both GPs and patients. Opening up the service is helping to increase customer knowledge, reduce stigma and improve outcomes. So, in this respect, AQP for adult hearing is in many ways transcending the controversy and is being seen as a victory for the current government adjustments to NHS provision. Said Colin: ‘It was a tremendous two days for Specsavers Hearcare, and extremely worthwhile in terms of cementing our credentials as the provider of choice for NHS hearing aids. The plenary session was a real highlight and created useful dialogue and debate which will enable us to inject even more innovation into our customer and GP-facing service.’ RX FACTOR PROFILE July 2013 19 Hearcare CPD Pathology crossword Co as p mplete art o f yo ur C PD for t his mon th Once you have completed the crossword, take a copy and keep it in your CPD portfolio, along with a completed CPD record – these can be found on Connect Learning. Answers will be published in next month’s ProFile. Across 3 Property of pinna 5 Abnormally sensitive hearing 7 Pain in the ear 12 Chalky patches of scarring on the ear drum 13 Bony growths 15 Inflammation of the skin lining of the outer ear 16 Having rapid onset 17Pinna 19 One of the nerves supplying the outer ear 21 Means double hearing 24 An auto immune cause of hearing loss 26 The practice to reduce or eliminate contaminants 28 Surgical repair of the tympanic membrane and ossicular chain 29 A loss that arises before the acquisition of language skills 30 A very contagious viral infection that involves the parotid and salivary glands - may lead to permanent hearing loss 31 Discharge, infected pus 32 A hormonal cause of hearing loss 20 RX FACTOR PROFILE July 2013 Down 1 2 4 6 8 9 10 11 14 18 20 22 23 24 25 27 The end result of long-standing pressure or infection problems in the middle ear. This forms when the ear drum is sucked inwards to form a pocket in which skin cells collect The degeneration in hearing we experience as we get older Where the sufferer’s subjective sensation of loudness increases with increasing input stimuli at a more rapid rate than normal Metabolic disorder that may manifest itself in enlarged hands and feet Benign tumour of the eighth nerve Remodelling and overgrowth of bone in inner or middle ear A type of non-organic hearing loss Rapid eye movements This produces episodes of fluctuating low frequency sensorineural hearing loss accompanied by a feeling of fullness in the ear, vertigo, tinnitus and nystagmus Fungal infection of the outer ear In both ears Condition causing an excessive white cell count in the blood – this can affect the cochlea through the stria vascularis, producing a bilateral sensorineural hearing loss Disturbance of balance Condition described by Thomas Willis in the 17th Century Arising from medical treatment Increased fluid pressure in the inner ear BSHAA Congress 2013 Separating the gen from the noise Nick Taylor looks at some of the latest findings on digital noise reduction and frequency compression, from world-renowned expert and BSHAA Congress speaker Dr Todd A. Ricketts. Dr Ricketts’ BSHAA Congress presentation – Hearing aid features across manufacturers: what really works and clinical implications – discussed current hearing aid technologies such as digital noise reduction, digital feedback suppression, wireless signal routing, high frequency extension and frequency lowering, from the perspective of their effectiveness in the laboratory and what we know about their impact on user benefit and satisfaction. This included recent data examining how the open fitting interacts with the prescriptive method, and patient-specific factors affecting preference for open versus traditional custom styles, along with implications for selection, adjustment and counselling related to specific features. Here are his thoughts and findings on two of those features: 1. Digital noise reduction Dr Todd Ricketts 2. Frequency compression Frequency compression works by the application of a linear frequency transposition with cut-off frequency/compression ratio relationships usually set by manufacturer. For the typical target of patients who have a high frequency loss to the extent that audibility through traditional amplification would be difficult, the potential benefits of this type of ‘frequency lowering’ are: • Improved speech recognition for certain high-frequency speech sounds. The two most common forms of digital noise reduction are: −− Due to limited audibility in the traditional frequency range. • −− Due to limited audibility in the “extended” frequency range. • Gain lowering: Reduce gain in a given channel if the primary signal (in that channel) is estimated to be noise (often based on amplitude modulation and other factors). Fast filtering (Spectral subtraction, Wiener filter, etc): An attempt is made to reduce/cancel/subtract noise that occurs in the frequency gaps between speech information and/or the temporal gaps between words and syllables • Improved awareness of environmental sounds. • Potential to reduce feedback - if fitted open, feedback may be an issue limiting gain in the traditional high frequency region (2 - 4.5 kHz). Important: The processing does nothing when speech is present in a channel (even if noise is also present). No effect on SNR within any channel at that instant. What we know from many years of DNR hearing aid research (primarily from lab tests) is: • Numerous lab studies have all found the same thing: No advantage for DNR for speech understanding in background noise. • There are data showing significant improvement for ease of listening and preferred signal quality. • So the evidence for the effectiveness of DNR is: • • Real and clear positives! −− Most customers expected to improve listening comfort. −− Some systems will improve sound quality for speech in noise. A few limitations −− Limited audibility in this region is expected to affect speech recognition. −− If audibility is not limited in this region, frequency compression is expected to have no benefit for high frequency band limited signals and potential decrement. For full band signals, receiver limitations may prevent audibility in the extended (4.5 - 9 kHz) high frequency range. −− Limited audibility in this region may affect speech recognition: particularly for /s/ −− If audibility is not limited in this region frequency compression is expected to have no benefit. From the research available, Dr. Ricketts concluded that frequency compression: • Provides better audibility for /s/. • Doesn’t seem to ‘help or hurt much’ for the average hearing aid user. Can improve feedback issues with open fittings. −− A significant improvement in speech recognition in noise is generally not expected. • −− DNR can reduce audibility for steady state signals (sometimes this includes music). Dr Ricketts is Associate Professor at Vanderbilt Medical Center, Director of Graduate Studies in the Department of Hearing and Speech Sciences, and Director of the Dan Maddox Hearing Aid Research Laboratory. In conclusion: Whilst there are certainly benefits, we hoped for a little more! RX FACTOR PROFILE July 2013 21 CET / CPD Country Code CET/CPD Points UK C-32006 EV-13182 1 general, interactive CET point ROI Audience Competencies MCQs Available via Deadline 6 Connect Learning: lms.specsavers.com 24 June 2014 All articles are CPD accredited in the Republic of Ireland 6 Connect Learning: lms.specsavers.com 24 June 2014 AUS Pending. Contact [email protected] 10 Connect Learning: lms.specsavers.com.au tbc NZ Pending. Contact [email protected] 10 Connect Learning: lms.specsavers.com.au tbc Red eye part 2: Urgent referrals by Chris Steele, BSc(Hons) FCOptom DCLP DipOC DipTp(IP) FBCLA Outline: Red eye is the cardinal sign of ocular inflammation, many patients presenting to their eye care practitioner in the first instance. There are myriad causes of red eye ranging from the self limiting and innocuous to those which can threaten sight and even life. Eye care practitioners must be able to differentially diagnose the benign from the serious and manage appropriately. This article will remind the eye care practitioner of urgent causes of red eye which can present to community optometric practice ensuring that, when patients present with red eye disease, the urgent cases can be identified and managed appropriately. About the author: Chris Steele graduated from City University in 1988 and qualified in July 1989 after his pre-registration year at The Royal East Sussex Hospital, Hastings. He is Consultant Optometrist, Head of Optometry at Sunderland Eye Infirmary (SEI) in Sunderland. Over the past 19 years he has developed a wide range of extended roles involving hospital optometrists undertaking cataract, anterior segment, diabetes, glaucoma, paediatrics and medical retina case loads. He has authored over 50 publications re: glaucoma, diabetes, specialist medical contact lenses, refractive surgery and clinical risk management and has undertaken many presentations both nationally and internationally on these topics. Introduction Gonococcal conjunctivitis In the first part of this series conditions requiring emergency (same day) referral were discussed. In this second part, a range of red eye conditions requiring urgent referral (within 48 hours) are considered. Gonoccal conjunctivitis is a rare disease characterised by an acute purulent conjunctivitis with lid oedema, marked conjunctival hyperaemia, chemosis with or without membrane formation and prominent per-auricular adenothathy. Treatment involves systemic and topical antibiotics. Conjunctivitis Most cases of conjunctivitis, from whatever cause are usually selflimiting, but there are a few exceptions where urgent referral may be required. Infective conjunctivitis Infective (bacterial) conjunctivitis usually does not actually require medical treatment as most cases spontaneously resolve in 10-14 days. However topical antibiotics are often prescribed to expedite the resolution of bacterial conjunctivitis by as much as a few days. An exception to this is where the infective conjunctivitis is caused by a sexually transmitted infection (STI) e.g. chlamydial (sero-types D and K), or gonococcal infection. 22 RX FACTOR PROFILE July 2013 Chlamydial conjunctivitis In chlamydial infection which typically affects sexually active young adults, eye lesions present about one week following sexual exposure which is often associated with a non-specific urethritis or cervicitis. There is a mucopurulent discharge and large opalescent follicles seen in the fornices, or in more severe cases, across the entire tarsal plate. Pre-auricular adenopathy is a common finding but fever and pharyngitis are absent. A drooping lid may also be present. Epithelial keratitis is the most frequent finding with associated marginal infiltrates and a superior micropannus. Treatment involves the use of topical tetracyclines antiobiotic ointment four times a day for 6 weeks and systemic antibiotics including Azithromycin 1mg single oral dose, Erythromycin 250mg four times a day for 6 weeks or Doxycycline 100mg a day for 2 weeks. Liaison with the GenitoUrinary Clinic, to exclude other STDs and advise on treatment of patient and partner(s), and on future avoidance is an essential part of the management. Untreated chlamydial infections may lead to pelvic inflammatory disease (PID) and infertility in women, and infertility and joint inflammation in men. Neonatal conjunctivitis Babies under 4 weeks with neonatal conjunctivitis should be referred to secondary care urgently. Neonatal conjunctivitis may be caused by infection or be a toxic response to topical eye treatments. The most important causes are: gonorrhoea (which can result in a serious localized infection) and chlamydia (which can be associated with the development of pneumonia). Vernal keratoconjunctivitis There are five main types of ocular allergy: seasonal allergic conjunctivitis, perennial allergic conjunctivitis, vernal keratoconjunctivitis (VKC), atopic keratoconjunctivitis (AKC), and giant papillary conjunctivitis (GPC). VKC and AKC are chronic, bilateral, and severe forms of allergic ocular surface inflammation affecting mainly children (typically boys up to 14 years of age) with exacerbation often during spring time but it can occur at any time of year (figure 1). These two relatively uncommon types of allergic eye disease can cause severe damage to the ocular surface, leading to corneal scarring and vision loss if not treated properly and promptly, thus making urgent referral appropriate in acute exacerbations of the condition. Symptoms typically include intense ocular itching, lacrimation, stringy mucus discharge causing blurred vision, photophobia and difficulty opening eyes on waking. The severity of symptoms is often asymmetrical. The initial conjunctival reaction consists of hyperaemia and chemosis, followed by diffuse papillary hypertrophy (> 1mm in diameter) most marked on the superior tarsus. The papillae then become even larger developing a “flat-topped” cobblestone appearance. The limbal area becomes hyperaemic, odematous and irregularly thickened giving rise to mucoid nodules containing eosinophils and degenerative epithelial cells, known as Trantas’ spots. Corneal changes usually involve the upper third with the development of a punctate epithelial keratopathy. These may lead to macroerosions (coalescent epithelial loss) and ultimately plaques deposited on Bowman’s layer that prevent re-epithelialisation. Sub-epithelial scarring may also result which is often ring-shaped. In milder cases (without active limbal or corneal involvement) mast cell stabilisers e.g. gutt. Sodium Cromoglicate 2%, gutt. Lodoxamide 0.1%, gutt. Nedocromil Sodium 2% may be prescribed. If there is active limbal or corneal involvement urgent referral to an ophthalmologist is required. Acute exacerbations usually require use of topical steroid e.g. gutt. Predsol 0.5%, plus regular monitoring: hence the need to refer to an ophthalmologist. Adenoviral conjunctivitis Adenoviral conjunctivitis is the most common cause for a red eye[1]. Viral conjunctivitis is often associated with a recent infection of the upper respiratory tract, a common cold, and/or a sore throat. Symptoms include watery discharge and variable itchiness. Viral conjunctivitis usually starts in one eye that later becomes bilateral. For many cases general alleviation/ palliative treatment is within the scope of all practising optometrists. The initial principal treatment usually involves ocular lubricants. It is important to consider the use of preservative free ocular lubricants where patients are expected to be on long term treatment. This is to avoid development of sensitivity reactions to active ingredients or the preservatives used. Where pseudo-membrane or keratitis is involved in more severe cases, then urgent referral is required[2]. The spectrum of disease encountered varies from mild to severe which is dependent on the serotype involved[5]: • Serotypes 1-11 and 19 primarily cause a follicular conjunctivitis; • Serotypes 3, 4, 5 and 7 cause a pharyngoconjunctival fever; serotypes • Serotypes 3, 4, 8, 11, 19 and 37 typically cause acute conjunctivitis • Serotypes 8, 9, and 37 typically cause epidemic keratoconjunctvitis • Enterovirus 70 causes acute haemorrhagic conjunctivitis (very rare) The variety of serotypes and their varying initial polymorphic presentations are often those of a non-specific “pink eye”. This disease will spread quickly where the following pre-disposing factors arise[3]: • Recent cold or other upper respiratory tract infection • Low standards of hygiene • Crowded conditions e.g. schools, clinics, camps, military barracks • Eye clinics (transmission by virus on clinicians’ fingertips, slit lamp biomicroscopes, tonometer prism heads etc.) Adenovirus infections consist of a biphasic process during which an infection cycle is followed by an inflammatory phase. The inflammatory phase tends to begin 7-10 days post infection. In the late phase clinical diagnosis may become more reliable but, even if an accurate diagnosis is made it is often too late. Virus can be shed and patients may be contagious for at least 2-3 weeks as the virus is so resilient and easily transmitted. This is mainly by hand to eye contact, respiratory droplets and commonly through contact with ophthalmic equipment. Figure 1 Where a patient has been diagnosed with the condition the consulting room concerned should not be used for any other patient until all surfaces and instruments have been washed down with Milton, then thoroughly rinsed with detergent. One study showed that nearly 50% of infected persons had positive cultures grown from swabs of their hands[4]. RX FACTOR PROFILE July 2013 23 CET / CPD To minimise the spread of infection, clinicians’ hands should be rubbed with alcohol hand gel between every patient and ideally washed with soap and water, adhering to all local infection control guidelines. Alcohol gel however is not effective against adenovirus. Although Gutt. Chloramphenicol 0.5% four times daily for 7 days is sometimes recommended, the use of antibiotics in viral conjunctivitis is usually unnecessary and is not supported by the evidence base[5]. Use of antibiotics may sometimes cause allergy or other adverse reactions that can complicate the clinical picture. The rationale for clinicians to consider prescribing antibiotics is where it is believed there is a risk of concomitant bacterial infection. Severe adenoviral infection with corneal involvement is characterised by focal white sub-epithelial opacities which develop beneath epithelial lesions (figures 2&3). These are thought to represent an immune response to the adenovirus, which sometimes can give rise to a transient mild anterior uveitis. Topical corticosteroids e.g. Gutt. Predsol 0.5% four times daily or Gutt. Fluorometholone (FML) four times daily will help reduce pain, photophobia and reduced vision owing to potential corneal scarring. However their use may also reduce the body’s ability to eliminate the virus, prolonging viral shedding. Some reports suggest that disabling sub-epithelial infiltrates are increased when steroids are used[6]. Therefore timely use of topical steroid has to be carefully considered but justified in cases where there is significant potential risk of scarring and vision loss which may be permanent. Unless there is a definitive diagnosis caution should be exercised with the initial use of steroids during the acute stage. This is because acute herpes simplex virus (HSV) infection (3-5% of cases) without associated skin lesions or corneal involvement (dendritic ulcers) can present clinically indistinguishably from adenoviral conjunctivitis. Inadvertent corticosteroid use in presumed adenoviral conjunctivitis which is actually HSV (or even acanthamoeba infection) may lead to keratitis, severe corneal damage and grounds for medico-legal action in some cases. Herpes simplex keratitis Herpes simplex virus (HSV) eye disease is an important cause of ocular morbidity and a very common cause of corneal opacification and visual loss worldwide. Approximately 90% of the UK population is seropositive for this double stranded DNA virus. HSV eye disease can have a highly variable and unpredictable course. HSV eye has a predilection for mucous membranes innervated by the trigeminal Vth cranial nerve and this disease may manifest as blepharitis, conjunctivitis, epithelial keratitis (dendritic or geographic), stromal keratitis (necrotizing or non-necrotising), endothelitis and or iridocyclititis. History of previous attacks of herpes simplex infection is a key diagnostic feature. Inflammation with attendant structural damage and scarring is responsible for most of the visual impairment encountered with HSV eye disease. Topical and systemic antiviral agents e.g. Aciclovir are the mainstay of treatment. Corticosteroids are powerful anti-inflammatory agents which must be used cautiously and appropriately with this condition. HSV is categorised into two main types: HSV-2 generally infects the genitalia i.e. ‘below the waist’ and is sexually acquired. The much more common HSV-1 generally infects ‘above the waist’ and has a predilection for the orofacial area (i.e. lips, face, eyes). Primary infection usually occurs in childhood, following which the virus lies dormant in the trigeminal ganglion. Although initial attack is subclinical and is often unnoticed by the individual, recurrence can lead to destructive sequelae. Reactivation of the virus is often triggered in HSV seropositive individuals if their general health is poor, stressed or fatigued and particularly if there is immunodeficiency. Systemic or topical steroids, or other immunosuppressive drugs may also be possible aggravating factors[7]. Once reactivated the virus travels along branches of the trigeminal nerve to cause local infection e.g. cold sores or herpes keratitis. Potential reactivating stimuli include: sunlight (UV), fever, extreme heat or cold, infection (systemic or ocular) and trauma (ocular). Figure 2 HSV not only affects the anterior segment, but can also affect (rarely) the posterior segment causing retinal necrosis. It is therefore recommended that consideration is given to performing a dilated pupil, vitreous (checking for haze) and fundus examination is performed on all patients exhibiting signs of HSV eye disease. HSV eye disease can be divided into four main categories: • Epithelial • Stromal • Disciform keratitis • Metaherpetic ulcer (trophic keratitis) Herpes simplex epithelial keratitis Figure 3 24 RX FACTOR PROFILE July 2013 Typically, patients with HSV keratitis present with blurry vision, extreme photophobia, pain, redness, and epiphora. If on clinical recurrences 4% v 9% respectively. One of the consequences of this important study is that now patients with more than one attack of HSVK in a year are commonly managed with long term oral Aciclovir. After resolution of dendritic epithelial keratitis, non-suppurative sub-epithelial infiltration and scarring can occur just beneath the area of previous epithelial ulceration, resulting in a “ghost” image of the previous dendrite within the anterior stroma. The lesion usually resolves without additional therapy, but may leave a permanent imprint of prior epithelial keratitis. Figure 4 Where herpes simplex epithelial keratitis only is involved this condition is well within the scope of practice of a community based independent prescriber[11]. However for community based optometrists urgent referral is recommended if the condition is “acute, or if recurrent but severe or with stromal involvement” (figure 5) [11]. In cases where the epithelium is not healed after seven days referral to an ophthalmologist is also recommended in the College of Optometrists Clinical Management Guideline. examination only the epithelium is involved, this is characterised by arborising fluorescein staining dendritic ulcers. Terminal end bulbs distinguish from other possible causes of dendritiform lesions e.g. varicellar zoster, healing corneal abrasions and acanthamoeba infection. As with many corneal conditions corneal sensitivity may also be reduced (figure 4). Herpetic epithelial keratitis may occur unilaterally or bilaterally (most often in patients with atopic disease) and accompanied by a blepharoconjunctivitis, involving lesions of the lid and a follicular response of the conjunctiva. In addition, a palpable pre-auricular lymph node may be present. Medical management is relatively straight forward with HSV epithelial disease. Topical Aciclovir 3% instilled five times daily for two weeks is usually sufficient to resolve the dendritic ulcer(s) in most cases. Oral Aciclovir is not indicated if the patient is prescribed topical Aciclovir 3%. In cases where patients are unable to instill eye drops or where corneal epithelial toxicity develops, oral Aciclovir 400mg five times daily is just as effective as topical treatment[8]. Sometimes corneal debridement with a cotton bud soaked in anaesthetic is useful to remove virus laden epithelial cells, thus reducing the viral load present and speeding up recovery. This may also reduce the risk of spread to the stroma leading to inflammation and potential scarring[9]. Topical corticosteroids are contraindicated in the treatment of active HSV epithelial keratitis. Herpes simplex stromal keratitis Since treatment of stromal keratitis may become prolonged with use of steroids and associated with significant ocular morbidity, all patients seen in community practice with stromal HSVK should be referred urgently to an ophthalmologist within 48 hours. The effectiveness of topical steroids in the treatment of stromal disease associated with HSV was demonstrated in the Herpetic Eye Disease Study. This double masked, placebo controlled trial provided unequivocal evidence for the use of topical steroids in treatment of active stromal HSV eye disease. In the steroid plus trifluridine (antiviral) group, resolution was significantly reduced i.e. 26 days compared with 72 days for sham controls, with no difference in recurrence rates[10]. A second Herpetic Eye Disease Study, published in 1998, investigated the effects of using oral Acyclovir (400mg twice daily). This study revealed a significant reduction in a single recurrence (19% v 32% in the Aciclovir and placebo groups respectively and for multiple Figure 5 Scleritis Scleritis is an inflammatory disease affecting the sclera, which may involve the anterior and/or posterior segments of the eye. Anterior scleritis is characterised by diffuse redness and severe eye pain, whereas posterior scleritis only, will not present with redness of the anterior segment or with any significant pain. Anterior scleritis accounts for 90% of cases. This is characterised by hyperaemia of superficial and deep episcleral vessels which do not blanch when vasoconstrictors e.g. as gutt. phenylephrine 10% are applied. The 4 sub-types of anterior scleritis are as follows: Diffuse anterior scleritis is characterised by widespread inflammation of the anterior sclera accounting for approximately 60% of cases. This is the most common form of anterior scleritis as well as the most benign (figure 6). Nodular anterior scleritis is characterised by one or more erythematous immovable, tender inflamed nodules on the anterior sclera (figure 7). On cursory examination this may resemble nodular episcleritis. Approximately 20% of cases progress to necrotizing scleritis. Necrotizing anterior scleritis with inflammation is the most severe form of scleritis which presents with a gradual onset of pain (later becoming extreme) and localized redness with potential for marked RX FACTOR PROFILE July 2013 25 CET / CPD scleral damage (figures 8a &8b). This form frequently accompanies serious systemic collagen vascular disorders including rheumatoid arthritis. Necrotizing anterior scleritis with corneal inflammation is also known as sclerokeratitis. Necrotizing anterior scleritis without inflammation most frequently occurs in patients (females > males) with long-standing rheumatoid arthritis; it is due to the formation of a rheumatoid nodule in the sclera and is notable for its absence of symptoms. Necrotizing anterior scleritis without inflammation is also known as scleromalacia perforans. Scleritis coexists with a serious systemic disease in almost one half of cases; the underlying problem is frequently a connective tissue disorder[12]. Figure 6 Rheumatoid arthritis is the underlying disease for approximately one sixth of patients suffering from scleritis, and approximately 1% of patients with rheumatoid arthritis will develop scleritis at some point in the course of the disease[13]. Scleritis associated with RA is due to the development of a rheumatoid nodule on the sclera and is associated with an increased risk of mortality[14]. Posterior scleritis (10% of cases) involves sclera posterior to the equator and the eye is often white. This is associated with a high risk of exudative retinal detachment, macular oedema and optic disc oedema. Scleritis is a sight-threatening condition. The College of Optometrists Clinical Management Guideline recommends first aid measures (e.g. analgesia) only and immediate referral, preferably by telephone to the on-call ophthalmologist[15]. Other connective tissue and autoimmune diseases seen with scleritis include the following: Figure 7 • Systemic lupus erythematosus (SLE) • Polyarteritis nodosa • Seronegative spondyloarthropathies - Ankylosing spondylitis, psoriatic arthritis, reactive arthritis • Wegener granulomatosis • Relapsing polychondritis • Sarcoidosis • Inflammatory bowel disease • Sjörgen syndrome Episcleritis Episcleritis is a common benign, self-limiting, frequently recurrent Figure 8a Figure 8b 26 RX FACTOR PROFILE July 2013 Figure 9 disorder that typically affects young adults (figure 9). It is seldom associated with a systemic disorder and never progresses to a true scleritis. In recurrent cases where discomfort is annoying, topical steroids may be considered. Referral is not usually necessary. Other non red-eye conditions requiring urgent referral include: • Symptoms or signs suggesting CMV and Candida retinitis • Commotio retinae • CRVO with elevated IOP • Acute dacryoadenitis • Acute dacryocystitis • Disc haemorrhage (although a splinter haemorrhage in a patient with known glaucoma does not require urgent referral) • Sudden onset diplopia; IOP>35 mm Hg (and <45mmhg); • Retinal detachment if not an emergency • Acute metamorphopsia • Proliferative diabetic retinopathy • Retinal transient ischaemic attacks (TIAs) (amaurosis fugax) • Retrobulbar/ optic neuritis • Suspected ocular malignancy • Oculomotor nerve palsy (sudden onset diplopia) • Retinal vein occlusion Conclusion The second part of this series has discussed a range of red eye conditions that require urgent referral by the optometrist. Appropriate clinical signs and symptoms are discussed for each condition. In the third part, those red eye conditions requiring less urgent referral (within a month) will be discussed. References A full reference list is available to view with the online version of this article on Connect Learning (lms.specsavers.com). GOC’s Enhanced CET Scheme The UK’s Enhanced CET Scheme requires practitioners to reflect on learning. The learning objective for this unit of CET is: • Practitioners will have an enhanced understanding of the signs, symptoms and management of red eye conditions requiring urgent referral. Consider how you will use the learning from this article to enhance your patient care and what changes reading this article will make to the way you practise. Further reflection questions will be asked on the GOC website. Considering these questions and entering your reflections on the website will help you gain more from your CET, and enable you to fulfil the Enhanced CET requirements. Global Digital Photographic Competition Could you be the best Specsavers photographer in the world? WIN a new PENTAX Q10 Digital SLR camera Fundus & anterior images • 1 overall global winner – digital SLR camera, plus entry and hotel accommodation for you or a colleague from your store to attend your nearest Specsavers clinical conference • 2 x UK/ROI – camera prizes • 2 x Rest of the world – camera prizes Email your 2012/13 images to: [email protected] Including: Your name / store name & no. / brief clinical description For full competition details, see Connect RX FACTOR PROFILE July 2013 27 In the spotlight with... Leighton Griffiths Four-time UK store partner on setting up in Spain What is your history with Specsavers? I’m probably one of the longest-standing Specsavers partners. Back in 1979, I worked for Doug Perkins for a few years before opening up my first store in Wales in 1988. During my years in Wales, I was partner in four Specsavers stores - Newport, Spytty Road, Cwmbran and Pontypool – and had three when I decided to make the move to Spain to open up a new store in Marbella. What prompted the move? I have always wanted a change of lifestyle and Spain ticked all the boxes, offering a new challenge, a new language and a new culture. How easy was it to open a store in a different country? The experience I gained from running my Specsavers stores back in the UK gave me the knowledge I needed, as the store model is basically identical and we adopt the same processes and levels of professionalism. The business development team were there to support myself and my business partner, Nerea Galdos-Pujana, from start to finish, making the process run as smoothly as possible. There have been a few issues since opening, as legislation in Spain is very different, which is why it’s so important to have a Spanishspeaking business partner and support from head office to help with communications. ‘The best part has got to be the people contact. My store in Spain is a lot smaller than I was used to, so it means I get to do a bit of everything and be more hands-on.’ Describe your typical working day My working day is very different to the usual 9-5. I work shifts – one week I will start at 10am and finish at 6pm, and the following week I will work 1pm until 9pm. This gives me the opportunity to enjoy the Spanish way of life. I can finish at 6pm and still enjoy the sunshine as it’s light until 9pm in the evening, and when I have the mornings off I can have a round of golf before work, which is a great start to the day. I have so much more time to enjoy hobbies and relax with my family. Leighton and fellow Marbella partner Nerea Galdos-Pujana. What is the best part of having a store in Spain? The best part has got to be the people contact. My store in Spain is a lot smaller than I was used to, so it means I get to do a bit of everything and be more hands-on – similar to the early days of when Specsavers opened in the UK. I have found that the working environment here in Spain is more relaxed. Each day you meet a mix of nationalities that come into store, who are very well travelled and interesting. Even the drive to work each morning is a lot easier. I now own a scooter and it takes me five to 10 minutes to get to work with parking outside the store all year round. And what about the challenges? Conducting tests in Spanish is certainly very challenging but managing to achieve this gives me a lot of job satisfaction. I have started Spanish lessons twice a week and have picked the language up fairly quickly. The majority of people here in Spain do speak English but I am enjoying learning it. Is it a career move you’d recommend? Having a Spanish partner is crucial, along with Spanish speaking staff. We are very lucky we have four Spanish staff working in store, two of them have optical qualifications and the other two are new. Running the actual store over here has given me a great change of lifestyle; I would recommend it to anyone. How has your family found the move? How have you been accepted in your new community? It was quite easy for both me and my wife as our children are at an age where they are self-sufficient – two of them are living in Australia and the other two are studying in the UK, making Spain a regular holiday home for them – so we only had ourselves to consider when making the move. We’ve been really welcomed by both the ex-pat and local communities. We have an excellent store team here, and the support and training from Specsavers is gratefully received. In Spain, Specsavers can provide employees with good rates and stable conditions, making it a good working environment for all.