Case 3 ILOs

 What are the current Optometry Australia guidelines for outlining emergency
ocular care? How can these guidelines be made short and directive (handouts) for
optometry staff/patients to implement these concepts to practise?
Optometry Australia implemented a set of protocols and guidelines to delineate the
set of conditions in order for a px to be considered to require urgent care in 2021
during Covid-19. The following questionnaire is used during case history:

https://www.optometry.org.au/wp-content/uploads/Professional_support/
Practice_notes/A-guide-for-triaging-for-urgent-and-critical-care.pdf

There is a reference guide to indicate the severity of a px conditions outlined by

RANZCO (Royal Australian and New Zealand College of Ophthalmologists) whereby
the severities are classified into low, medium and high urgencies. Low may be
treated by an optometrist, medium requires face to face optometrist care and may
require ophthalmologist opinion, and high requires an in person consultation with a
qualified ophthalmologist.

https://www.optometry.org.au/wp-content/uploads/Professional_support/
Practice_notes/Reference-guide-for-clinical-urgency-of-eye-disease_for-OA-
members_Final.pdf
 The Australiasian Triage Scale (ATS) is a guide that indicates the ‘maximum waiting
time’ for a medical assessment. There are 5 categories of severity with 1 indicating a
life threatening pathology that needs immediate tx, to category 5 indicating a minor
condition

https://acem.org.au/Content-Sources/Advancing-Emergency-Medicine/Better-
Outcomes-for-Patients/Triage

Examples of what is considered into each category is demonstrated in below link:

https://aci.health.nsw.gov.au/__data/assets/pdf_file/0004/154975/
eem_education_session4.pdf

 What are the onset, duration and uses of 3-5 most common anaesthetic ophthalmic
drugs (Lignocaine, proxymetacaine, amethocaine, oxybuprocaine)? Are there any
contraindications/side effects with these drugs? What are the concentrations/doses
for each of these drugs? Where are the sites of the receptors that the anaesthesia
acts on? (Table)

Local Contraindications/side Concentrations per Receptor

anae effects dosage/duration
sthe
tic
Ligno According to an RCT Different dosage for The Na+ channels on the
caine (2007) examining the various required pupil inner surface of nerve
effects of topical lidocaine sizes: cell membrane
(Aka hydrochloride 4% in
lidoc health volunteers found Very dilute concentrations Uncharged molecule
aine lidocaine to have 0.05-0.1% diffuses into neural
unde ‘significant mydriatic sheaths to the axoplasm
r effects’, that is Dilute (cytoplasm in a neural
bran characteristically rapid 0.25-0.5% axon)
d and prolonged (Intravenouss regional, where it is ionised.
nam into subcutaneous tissue)
e https:// Cation binds reversible
xyloc pubmed.ncbi.nlm.nih.gov Regional nerve blocks to Na+ channels
aine) /18001249/ 1-2% internatlly
(also available
This tx is contraindicated intravenous https://
with reactions: www.ncbi.nlm.nih.gov/
- Methamoglobine books/NBK539881/
mia
(more likely with
higher doses)

Toxic anemia that

features a lack of
methemoglobina
proteins
(Headaches,
nausea)

https://
www.ncbi.nlm.nih.gov/
books/NBK539881/

Prox Drug has been reported Subtarsal examination Acts on the transient
ymet to cause contact Apply proxymetacaine receptor potential
acain dermatitis upon contact 0.5% channel of the Vannillyl
e to the skin by the group receptors
practitioner. Case report If fluorescein applied as
(Mar where a 49-year old well, may indicate https://
kete ophthalmologist conjunctival defects www.ncbi.nlm.nih.gov/
d as developed fissuring and pmc/articles/
Alcai bleeding of fingertips https:// PMC4676230/
ne, after contacting 0.5% www.sciencedirect.com/
Ak- concentration science/article/pii/
taine proxymetacaine and B9781416025726500101
) hydrochloride
Used for corneal
https:// anaesthesia
www.sciencedirect.com/ Which is achieved after
science/article/pii/ 15-26mins
B9780444537171013664
https://
Should not be used on www.sciencedirect.com/
 open wounds, as it can science/article/pii/
cause oedema and tissue B9780702027932000050
swelling
Onset usually starts after
https:// 30s, with the maximum
www.sciencedirect.com/ effect being reached at
topics/veterinary-science- 5mins
and-veterinary-
medicine/proxymetacaine https://
www.ncbi.nlm.nih.gov/
pmc/articles/
PMC4676230/

Amet No cases of systemic Used for cutaneous Equally as effective as

hocai toxicity with topical procedures lidocaine According to
ne application RCT studies
Usually produces And can last for 0.5-
https:// anaesthetic effects after 3.5h, average being 1.5h
pubmed.ncbi.nlm.nih.gov 30-45 minutes
/15777110/ https://
Contains 4% (w/w) www.rch.org.au/
Safe to use on neonatal amethocaine base uploadedFiles/Main/
skin according to an RCT Content/pharmacy/
Application for less than AnGel-PI.pdf
https://fn.bmj.com/ 30 minutes have not
content/82/1/F42 indicated association with Inhibits sodium ion
reliable anaesthesia influx along the nerve
axons
https://
pubmed.ncbi.nlm.nih.gov
/15777110/

Oxyb Can cause severe allergic 0.025-0.4% dosage Binds to Na+ channel
upro reactions, burning and stabilises the
caine sensations, iritis, https:// neuronal membrane
moderate corneal pubmed.ncbi.nlm.nih.gov reversibly to reduce
(OBP swelling, and effects of /27590991/ permeability to Na+
C) the CNS depending on the
dosage level https://
pubchem.ncbi.nlm.nih.g
https:// ov/compound/
www.sciencedirect.com/ Oxybuprocaine
referencework/
9780080552323/xpharm-
the-comprehensive-
pharmacology-reference
 Found to induce
apoptosis in corneal cells
and arrest corneal cells at
S phase

https://
pubmed.ncbi.nlm.nih.gov
/27590991/

OBPC also causes plasma

membrane dysfunction

https://
journals.sagepub.com/
doi/pdf/
10.1177/0960327116665
676

 What are the mechanisms that cause photophobia? Does green light help reduce
photophobia, and if so how does it help?

Photophobia is the:
- Increased sensitivity to glare
- Exacerbation of headaches
- Ocular pain/discomfort

The pain associated is dependent on the functional integrity of the optic and
trigeminal nerves. Lebensohn suggests that the pain is from the the contraction of
the iris and the promotion of vasodilation in pain-sensitised extracranial and
intracranial vessels. The vasodilation occurs due to the axon reflexes of sensitised
trigeminal nerves.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6461529/

The green light (red free) filter has a short wavelength and will still illuminate some
of the fun due and vitreous features to allow sufficient examination of pathological
conditions by eliminating the red hue in white light, while being a more comfortable
light setting for the patient as it reduces light scattering

https://pubmed.ncbi.nlm.nih.gov/17417153/

https://www.heine.com/en_AU/medical-specialties/ophthalmology/application-and-
diagnostic-tips/diagnostics-with-the-indirect-ophthalmoscope/colour-filters-indirect-
ophthalmoscope
 How do optometrists deal with photophobia in patients when doing clinical testing
which requires shining light in patient eyes? How can we reduce patient discomfort
due to photophobia in slit lamp, ophthalmoscope, retinoscopy and open torch
examination?
- Slit lamp: we can use the red free filter, use a lower brightness setting, ensure the
light beam is away from the pupils when not required to, lower surround light, allow
time for breaks, use 1% fluorescein dye
- Amethocaine can be applied to ease photophobic symptoms
- Penlight test should be performed to distinguish between the severity of eye
pathologies such as uveitis and keratitis
Photophobia may suggest involvement of the uveal tract which includes the iris,
ciliary muscles and choroid, iritis, abrasion, acute glaucoma
- Gritty, sandy pain implies anterior structures are compromised
- Blue light to distinguish between variations of keratitis, abrasions and evidence of
foreign bodies

https://pubmed.ncbi.nlm.nih.gov/12876115/

https://coreem.net/core/the-red-eye/

https://www.racgp.org.au/getattachment/b1615e06-9e05-4b8b-9087-
ce15c9535b76/A-painful-red-eye.aspx

 Where are the mechanisms of proxymetacaine and what are the barriers to prevent
the mechanisms? How does it get through the lipid barrier, stroma and how is it
metabolised or eliminated?
Topical anaesthetics work by being reversibly blocking nerve conduction near their
site of application through targeting free nerve ends in the mucosa and dermis. This
causes a temporary loss of sensation in a localised region. The nerve impulse
conduction is reduced by lowering the plasma membrane permeability to Na+
through competitive binding with calcium-binding sites that are responsible for Na+
permeability. Hence depolarisation is reduced and increases the excitability
threshold until the neuron is unable to produce an action potential.

The composition of the drug is responsible for its lipid solubility which allows it to
diffuse through the lipid bilayer of the plasma membrane easily. Where
Proxymetacaine binds to is dependent on its aromatic ring shape and amine
segment.

https://www.researchgate.net/publication/288000510_Topical_anesthesia
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4676230/

 What are the specific diagnosis techniques for corneal abrasion, keratitis and uveitis?
What are the management and treatments for this? (Table: Signs, symptoms, tests,
management, prognosis, severity & classification)
Pathol Symptom Test Manage Prognos Severity/classification
ogy s ment is
Corne Photopho Slit Administ Quick https://www.ncbi.nlm.nih.gov/
al bia, lamp er topical treatme books/NBK532960/
Abrasi erythema fluoresc antibiotic nt will
on , ein, s, allow
Cobalt cyclopleg the
blue ics can abrasion
Seidel be used to heal
for larger quickly,
abrasion otherwi
s se if left
untreat
ed, it
may
result in
blindnes
s
Kerati Inflamma Slit Antibioti Treated, https://www.ncbi.nlm.nih.gov/
tis tion, lamp cs fast books/NBK559014/
corneal Sluoresc recover
edema, ein, pen y
ciliary torch
congestio Bacteria If
n l swab untreat
ed, can
lead to
eyelid
swelling
and
further
infectio
n of
Surroun
ding
glands,
trachom
a

Uveitis Blurry Slit Antibioti If https://www.nei.nih.gov/learn-

vision, lamp c drops treated, about-eye-health/eye-conditions-
photopho Fluoresc fast and-diseases/uveitis
bia, ein, pen recover
watery torch y, if
 eyes untreat
ed it can
lead to
blindnes
s

 Analyse the simulated situations

Time management
Respect
Preparedness
Quality of contribution
Teamwork