The ophthalmic imager
My role as an ophthalmic / medical photographer has evolved, dramatically, since I began my career at Manchester Royal Eye Hospital, 30 years ago. Long gone are the days of developing and hand printing fluorescein angiograms in the darkroom, mixing chemicals and loading 35mm film onto spirals – only to find a kink in the film. Those were the days!
Although I now manage the department of ophthalmic and medical photography at Aintree Hospitals in Liverpool, I very rarely take clinical photographs, other than those of the eye. My whole day, my whole week is spent in the eye clinic, which I thoroughly enjoy. My job title has also changed to reflect my evolving working pattern: lead ophthalmic science practitioner.
I have worked at Aintree Hospitals NHS Foundation Trust for 23 years and have witnessed the many changes in ophthalmology first hand. New treatments have revolutionised how we see patients and the sheer number of patients coming through our doors is staggering.
My day normally starts at 8am, every Friday morning at this time we have a teaching session for the junior ophthalmologists. I source interesting cases for this meeting the day before from the previous weeks’ patients who have undergone ocular angiography. I also keep a teaching file – where we have lists of interesting and rare cases. This hour long session is relaxed and informal and the juniors seem to enjoy it.
“A snap shot survey showed that patients being seen by me, as opposed to a doctor, were happy and confident in my clinical judgement.”
Before the first patient is seen in clinic, I test all our imaging systems – ensuring everything is clean and our network connections are functioning. All our imaging results are networked to over 20 clinic rooms, including theatre. If our systems fail, our clinics will grind to a halt. Once all have passed, I will check our PAS to print clinic lists off for the day. This will give me an indication of our workload for the day and whether we can offer a same day ocular angiography service. We aim to provide a same day service, but it is not always possible when we have four medical retina clinics running during the same session. If a patient has to return for their angiography, the appointment will be made within two or three days and the patient will be seen by the requesting doctor at the same time to ensure continuity of care.
We use the Heidelberg Spectralis optical coherence tomography (OCT) and angiography imaging system and have two in our clinic. We also have a third Spectralis for use in the diabetic eye screening service and a Heidelberg Retinal Tomograph (HRT) in the glaucoma unit. One of my roles is as a link between our IT systems support and Heidelberg (and our other imaging suppliers). Having a close working relationship with our IT department and our suppliers is crucial in delivering a modern ophthalmic diagnostic service.
My work pattern is split between undertaking ophthalmic diagnostic procedures and running my own age-related macular degeneration (AMD) photographer-led review clinics [1,2]. I have four sessions a week, seeing up to 10 patients per session. I also have one admin session per week to manage the ophthalmic and medical photography service. Using the skills of a health care scientist (ophthalmic photographer) required an organisational shift in the acceptance of others doing the role previously undertaken by a doctor. I normally see patients four weeks post their last intravitreal injection for AMD. The patient remains under the care of a consultant ophthalmologist. I utilise one of the clinic rooms and patients usually attend on quieter clinic days. Full visual acuity testing is carried out in addition to OCT and colour fundus photography. I assess their previous history, noting any change in vision, how many injections they have had, frequency of injections and whether they experience any subjective change, and finally assess their images. A decision is then made to list for further treatment or review back in clinic. As a failsafe, their next appointment will be with the consultant. By using a dedicated electronic patient record (Medisoft) for all our patients, I can immediately see a full history of treatment and a change in their visual acuity since they began treatment. Medisoft has the ability to print out a summary clinic visit sheet which negates the need to write in the patients’ case-notes and also generates a letter to the patient’s GP.
In order to ensure we are operating a safe and robust service, we undertook a pilot clinic. Results showed 100% agreement with the consultant on OCT analysis and 94% agreement on clinical outcome (n=52) . In January 2013, we repeated the audit (n=69). The results still showed 100% agreement on OCT analysis but now 99% agreement on clinical outcome .
I really enjoy seeing patients from a different perspective. For many patients, I have built up a good rapport with them. One month I may be taking their images and the next visit they may see me in clinic reviewing their scans. For many, we are on first name terms. As my clinics are on quieter days, they appreciate attending a calmer clinic. A snap shot survey showed that patients being seen by me, as opposed to a doctor, were happy and confident in my clinical judgement. There is always an ophthalmologist in clinic to give a second opinion on a difficult case or to assess new findings on the patient’s fellow eye.
When I do not have my own clinic, I am back in the imaging suite, performing OCTs or ocular angiography. Since taking my first retinal images on film over 30 years ago, I still find imaging the retina a rewarding challenge. To image, in vivo, blood circulation and pathology is fascinating. One aspect of this role is stereo photography. Stereo imaging can produce some spectacular results, for example, showing retinal to choroidal anastomosis in the case of retinal angiomatous proliferation (RAP) lesions or assessing the elevation of PEDs.
One of my team or I will stay until the last patient has left the clinic. This can be variable! We normally then do a count of how many imaging procedures have been done that day – needless to say, that figure increases weekly!
I suspect the next 30 years will be as revolutionary in ophthalmology as the last 30 years in terms of new imaging techniques and new treatments, and I look forward to evolving my role further to meet these new challenges.
The orthoptic assistant
My role at Frimley Park Hospital has dramatically changed over the years. When I first joined as a bank housekeeper in 1996 I did not imagine that I would be in the role I am in now as an orthoptic assistant. I had moved into a clinical role as a care assistant in 1997 and had taken on extra skills over the years working on the wards and discharge lounge before settling in the eye clinic in 2007.
I initially worked as a care assistant in the eye clinic, which gave me the confidence and knowledge to carry out vision tests and interact with patients. I then progressed onto visual field assessments.
I learnt how to assess the visual fields of patients presenting in the eye clinic, and when necessary for other departments, to be able to give clear instructions to patients regarding the undertaking of the visual field test, as well as guiding them through the test. This includes patients with impaired comprehension, hearing difficulties or delayed mental development, to accurately document visual field findings and to ensure at all times that a patient’s correct spectacle prescription lenses are used during testing.
This would involve using either the manual or automated focimeter to assess the strength of the patient’s spectacle lens. I am also required, when necessary, to perform autorefraction to ensure the correct prescription spectacle lenses are being used and to make sure patients attending the visual field clinic have a follow-up appointment in the eye clinic.
I was assessed against a competency document that included a period of observations and then supervised sessions. After being assessed by a senior orthoptist I was soon running my own visual field clinics using two machines seeing 14 patients in session.
In 2011 I applied and was appointed as an orthoptic assistant. I had always been fascinated by the ever-evolving ophthalmic technology and tests that were performed by both orthoptists and imagers. The experience of performing visual fields had made me much more confident to develop my skills further and after a period of shadowing and further competency assessment on OCT, fundus photgraphy and HRT, I was soon supporting other clinics such as the AMD and diabetic clinics.
I also enjoy working in the glaucoma assessment clinics (GAC) where I work alongside an orthoptist and ophthalmologist in a one-stop new referral clinic for glaucoma patients.
In my role as an orthoptic assistant I am also responsible for a number of other duties such as several administrative duties, collating statistics, ordering stock, ensuring the appropriate paperwork is available for the orthoptic clinics, as well as making sure notes are tracked and returned to Medical Records once complete. I also attend the teaching sessions led by the consultant orthoptist, which are interactive and have given me the confidence to present cases or conditions to my peers.
We are encouraged to maintain and develop personal and professional skills, and more recently have been invited to join the British and Irish Orthoptic Society (BIOS), where we can enjoy the benefits of special interest groups to learn about a wide range of conditions. There is also a continual professional development (CPD) system, with events and training geared to our needs.
With BIOS, we have our own trade union representative for the department, who is able to take issues to the hospital panel to improve our working lives.
When I’m not at Frimley I may be travelling to peripheral clinics to support the orthoptist or ophthalmologist off site performing visual field assessments in glaucoma clinics.
My week is busy and I often have to work under pressure, but I look forward to the exciting challenges it brings.
1. Hancock R, Clark D, Dengler-Harleset M. A new model of care for the management and surveillance of patients with treatable age related macular degeneration. Eye News 2011;18(2):30-6.
2. Hancock R. Ophthalmic photographer led age related macular degeneration review clinics: a pilot study. Int Journal of Ophthalmic Practice 2013;4(5):196-201.
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