From Anna Horwood, BIOS Research Director.

Around this time a lot of us would have been catching up with old and new friends and colleagues in Liverpool. The IOC was promising to be an exciting event, showcasing what BIOS members are doing to raise the profile of our profession. All is not lost, and we will be there in 2022. If you had an abstract accepted this year, please come back again in 2022 with and even better contribution!

But this is the time to congratulate and showcase the BIOS IOC Travel Award winners. They would have been supported to attend and present their work in Liverpool. When the conference had to be postponed, BIOS very quickly decided that the money should still be  awarded, for the winners to use as they chose for research-related activity or conference attendance (when we get to go to one!). Well done all!

The applications and awards were spread across wide range of research experience from student projects to PhD level. Kerry Hanna, Laura Ramm, Joe Smith, Martha Waters, Isabel Williamson and Jessica Wood were each awarded £250. We hope that the winners will consider publishing or building on their work, so onwards and upwards for the 2022 IOC.

Nearer the time BIOS hopes to be able to offer some more awards for 2022, so get working on your projects!  To give you a taste of what we are all missing, here is a quick rundown of their abstracts.

Kerry Hanna
Kerry Hanna

Purpose: Inequalities have been found to exist with the visually impaired stroke population on an individual level, in relation to demographic differences, unequal access to vision services, transport, employment and financial repercussions. The long-term impact of living with post-stroke visual impairments must be explored, in order to identify complications accessing NHS services and to inform possible changes to service planning and delivery in order to tackle such complications.

The aim of this research was to explore the extent of health inequalities within visually impaired stroke survivors in the North-West of England and discuss potential solutions to these.

Methods: Institutional ethical approval was granted in May 2016. The focus groups and interviews were conducted between October 2016 and January 2017. Transcription and thematic analysis of the transcripts was undertaken, using line-by-line coding, underpinned with Social Constructionism.

Results: Two focus groups and five individual interviews (n=13 stroke survivors and n=1 spouse) were conducted. The findings draw on the lived experiences of stroke survivors across their journey from pre-stroke to life after stroke. The overarching experience of stroke and vision impairment that emerged in respondent accounts were constructed in terms of ‘loss’, concerning the physical being, the psychosocial being and the systematic organisation of healthcare. Furthermore, the loss of the physical aspects of the respondents’ lives after suffering stroke-related visual impairments, such as driving and employment, subsequently impacted on the loss of their psychosocial being, as many of these physical loses attributed to their self-identities. For example, the respondents’ accounts showed a link between loss of driving/mobility and employment due to stroke/vision impairments, which resulted in loss of independence, income, social standing, social relationships and existentiality.

Conclusions: The visually-impaired stroke survivors frequently reported a complete lack of visual care, with many recounting apathetic experiences, often resonating power imbalance in the healthcare system. Where orthoptic care is being offered after stroke, a desire for a personalised approach to rehabilitation featured strongly in the accounts. These findings highlight an area for future orthoptic services to consider implementing within their rehabilitation programmes. Furthermore, the findings from this research highlight the longer-term implications of stroke related vision impairments, beyond those collected in the clinic setting, which appears to go unrecognised and unmanaged in many cases. These results emphasise a need to inform and educate both orthoptists and stroke survivors of the bigger picture of life after stroke, indicating what is to be expected and highlighting what support is available to patients following hospital discharge.

Laura Ramm
Laura Ramm

Purpose: Current management of congenital cataracts requires early surgery, preferably under 12 weeks of age. The IOL under 2 study showed implantation of intraocular lens at such a young age increases post-operative complications, and need for further surgery. Optical management of aphakia is limited to heavy, thick hypermetropic glasses or contact lenses (CL). CLs have optical advantages, so it is essential parents learn to insert and remove (I+R) CLs quickly and safely on a daily basis, to reduce infection risks.

Teaching parents to handle their child’s CL is a real challenge. We have had an orthoptic led training service for 25 years, where experienced orthoptists teach parents practical skills of CL I+R from 4 weeks post-operatively, with supporting literature.

We aimed to investigate parental perception of being taught this important skill.

Method: 20 families attending the contact lens clinic completed a satisfaction questionnaire to enquire about their experience of learning how to I+R their child’s CL.

All children had previously undergone either unilateral or bilateral cataract surgery as a baby (mean age of cataract removal 2.3 months). Each family had become independent at CL I+R and had been using them for a median of 2 years or more.

We asked about pre-operative counselling, practical teaching, emotional and additional support, and comments on our supportive patient literature. Qualitative data and free comments were analysed.

Results: 18/20 said we provided good practical I+R teaching. 19/20 felt we provided good emotional support. Only 6/20 families agreed with the statement that they found learning I+R difficult.

Families didn’t feel rushed, and could learn at their own pace. They emphasised the need for emotional and additional support at such a difficult time. They all felt they were appropriately counselled pre-operatively regarding the need for training and daily CL handling. They found written information useful. Most found removal easier than insertion.  Free comments suggested use of a mannequin and signposting to video tutorials online.

Conclusions: Teaching I+R skills is an important aspect of managing paediatric aphakia and presents many challenges. Most parents eventually cope well and achieve daily CL handling within a few months, with support from a multi-disciplinary team. Families surveyed were all competent and happy with care provided. Our next aim is to survey families who abandoned CLs to see if we could have supported them further. Our orthoptic-led service works well and parents are satisfied with their experience. Orthoptists have the knowledge and skills to provide technical training to parents alongside vital emotional support, and contact lens handling is a rewarding extended role for orthoptists in a multi-disciplinary team.

Joe smith
Joe smith

Purpose: Skew deviation (SD) is a vertical misalignment of the visual axes; it is caused by a prenuclear lesion disrupting otolithic input. SD is commonly associated with torsion and head tilt – this means it must be differentiated from fourth nerve palsy. However, tests used for differential diagnosis have been critiqued. The Bielschowsky head tilt test (BHTT) has been criticised by Kushner, as positive results are seen in both conditions. Recently, Lemos et al. suggested that the upright-supine test is not a sensitive method for differentiating SD from fourth nerve palsy. Furthermore, other tests such as the Maddox rod and fundus examination for torsion can be inconclusive. Therefore, at Manchester Royal Eye Hospital we have started to test the subjective visual vertical (SVV) – using the bucket test. The SVV bucket is a test that looks at what the patient perceives as being vertically orientated, and previous studies have found that 94% of patients with skew deviation had a tilt of their SVV towards the hypo-deviated eye

Methods: This prospective review was completed over a 12-month-period. All patients had a complete orthoptic and ophthalmological assessment, including the BHTT, upright-supine test, and the SVV bucket.

Results: The BHTT was negative in all cases of SD. The results also show that all patients with SD had tilts of their SVV, however, not all patients had positive upright-supine results. Therefore, if comparing both tests, it could be concluded that the SVV bucket has a higher sensitivity for diagnosing SD. However, there is currently a paucity of literature relating to the normal values – it is therefore difficult to diagnose SD by this method. Further research is required to develop normative data for the SVV bucket.

Conclusion: We must be are aware that in the acute stage patients with SD may potentially have a negative response to the upright-supine test. Often patients with SD will present with other neurological conditions to support diagnosis, nevertheless, in isolated cases, a test is needed to support the need for further investigations – the SVV bucket has the potential to be that test. However, further research is needed in this area to establish normative data.

Martha Waters
Martha Waters

Current literature reports synergistic divergence as a rare, congenital ocular motility pattern associated with adduction palsy. Its mechanism has been likened to Duane’s syndrome and some suggest it be referred to as Duane’s Type 4. There are no published reports of synergistic divergence as an acquired condition, making this case report seemingly the first of its kind.

This case report describes a 17 year old female who presented to clinic in 2013 with symptoms of diplopia and left eye turning outwards. Orthoptic assessment and MRI confirmed a third nerve palsy secondary to cavernous sinus schwannoma. Further monitoring showed progression of the cranial nerve palsy but a stable schwannoma and no aberrant regeneration noted in five years of follow up.

The patient was treated with multiple botulinum toxin injections and had squint correction surgery in 2017. Seven months later synergistic divergence was first noted and remained stable in all following assessments. While the aetiology of acquired synergistic divergence in this case is unclear, we can be confident it is unlikely to be of congenital origin as it was not noted until adulthood and after five years of investigations. This report will discuss possible aetiologies of acquired synergistic divergence and, in contrary to current literature, suggest clinicians should consider the possibility that synergistic divergence can be acquired, though is likely even rarer than its congenital form.

Jessica Wood
Jessica Wood

As a part of my dissertation research based at the University of Liverpool, my aim was to develop an evidence-based care pathway for adult orbital fractures. In particular, exploring the idea that many more patients may be able to be conservatively managed and still have equally as successful outcomes to those patients undergoing surgical intervention. My research was literature-based and included a range of UK and international studies. Due to ethical constraints, there was a difficulty in finding studies which directly compared the impact of surgical intervention versus conventional management. However, in most studies there was a small proportion of the population who had symptoms/imaging warranting surgical intervention but declined treatment. It is this group of patients who are particularly interesting as they provide scans and observations on the pattern of recovery without surgical intervention. As a result, this group of patients would be worth reviewing retrospectively in a sequential study.

Besides conservative methods, the timing of surgical intervention was reviewed. There was a lack of data for intervention between 4-8 weeks, with most studies advocating a 2-week observational period post-injury. However, from the small sample of studies that operated on their patients between 4-8 weeks, these patients achieved comparable results to those who were operated on immediately or within the first 2-weeks (deemed as ‘early intervention’). In this way, it may be possible to extend the observational period to 4-weeks allowing more opportunity for spontaneous resolution of diplopia and swelling, which could negate the requirement for surgical intervention in a sizeable portion of cases. Overall, more robust UK-based evidence is required, however the literature raised interesting points for further investigation.

Isabel Williamson
Isabel Williamson

Purpose: Bangerter Filters are commonly used for partial occlusion therapy in the treatment of amblyopia and for eliminating intractable-diplopia. There is disagreement in the literature with regards to the consistency of Bangerter Filters and their effects of visual functioning in both normal and amblyopic eyes. The aim of this study was to evaluate the effect of monocular blur induced by Bangerter Filters on visual acuity and stereoacuity in a normal adult population.

Methods: Twenty-three visually normal, healthy adult volunteers (aged 18-25, mean age 20.33 ± 1.79 years) participated in this prospective, randomised, repeated measures study. Eligible participants required right monocular and binocular best corrected visual acuities of at least 0.20 logMAR, with steroacuity of 10 seconds of arc or better. Monocular blur was induced by a range of Trusetal Bangerter Filters strengths (0.1, 0.2, 0.4, 0.6) applied to a plano lens. The right monocular and binocular distance visual acuities (logMAR) and distance stereoacuity (seconds of arc) using the FD2 were measured for each patient at each filter level. Results were analysed using one factor repeated measures ANOVAs, t-tests and a Pearson’s product moment correlation.

Results: Increasing filter strength caused a significant increase in degradation to the right monocular distance visual acuity (p <0.001). The effect of each of the Bangerter Filters strengths on right monocular visual acuity differed significantly for all filters, however this difference was more significant between the plano lens, 0.1, 0.2 and 0.4 filters than between the 0.4 and 0.6 filters (p<0.001 and p<0.01, respectively). The right monocular visual acuity values with the Bangerter Filters were in concordance with the labelled filter density. The monocularly placed filters significantly reduced the binocular visual acuity (p<0.05), however, the increase in degradation between filter strengths were not significant. Increasing Bangerter Filter strength caused a significant increase in degradation to the distance stereoacuity (p<0.001). The effect of each of the Bangerter Filter strengths on stereoacuity differed significantly for all filters (p<0.001) except between the 0.4 and 0.6 filters. A significant negative correlation existed between the degraded right monocular visual acuity and the steroacuity (p<0.02).

Conclusions: The right monocular visual acuity, binocular visual acuity and stereoacuity were degraded with the monocularly placed Trusetal Bangerter Filters. The right monocular visual acuity reduced with increasing filter strength in concordance with the labelled filter density. The negative effect on binocular VA was minimal, suggesting little impact on visual functioning in diplopic patients managed with Bangerter Filters. The degradation of stereoacuity was proportional to the degradation in visual acuity, contradicting the use of Bangerter Filters for improving stereoacuity outcomes in amblyopes.