Dr Anish Jindal on memorable cases and a ground breaking appointment

In October, principal optometrist at Moorfields Eye Hospital, Dr Anish Jindal, became the first optometrist to be awarded honorary associate professor status at University College of London (UCL).

He talks with OT about the differences between High Street and hospital optometry, managing ocular emergencies, and his daily routine.

How did you react to your appointment? What will this new role involve?

When I first received word that I had been appointed as an honorary associate professor I was over the moon, as this is the first time an optometrist has been given this status at UCL. This was breaking new ground for our profession and leading the way forward that others may follow in high-impact education and research. Furthermore, it was highly fulfilling to know that my work in these areas has been recognised by this great world-leading institution in ophthalmology.

This new role will extend my current responsibilities of teaching advanced clinical practice to allied health professionals regarding ocular emergencies to that of supporting and leading the provision of education for all allied eye health professionals at UCL and Moorfields. This will go hand in hand with my other new role, as joint associate education director for allied health professionals at Moorfields Eye Hospital This will help bridge and strengthen our relationships between these two great institutions in delivering the next generation of advanced clinical practitioners, that will enable them to deliver autonomous and enhanced clinical care to patients.

What would you say to optometrists working on the High Street about working in a hospital environment?

The role of the High Street optometrist has changed quite significantly in the last decade, especially with the provision of Minor Eye Conditions Services schemes and shared care opportunities, as previously the majority of healthcare was provided mainly in secondary care.

The line has now become blurred and barriers have been broken between secondary and primary care, which has been hastened by the COVID-19 pandemic and increasing numbers of optometrists gaining independent prescribing rights.

One memorable case was a patient who presented with a blunt traumatic injury… One would think that he may been involved in an assault or sports injury. On careful questioning, it was revealed that the culprit was a Ferrero Rocher that had been thrown at him

Working in a hospital environment has been incredibly fulfilling, as I relish working in a multidisciplinary team where we can share ideas and we are constantly learning from each other. In addition, optometrists are now leading clinical services in the hospital when they gain additional higher qualifications such as those offered by the College of Optometrists in glaucoma, medical retina, external disease and cataract.

In a hospital role, you are constantly learning about how to improve your clinical management decisions from the beginning. Furthermore, there is always an opportunity to broaden your portfolio such as by undertaking research, education and leadership opportunities. There are various pathways to enable career progression from a graduate optometrist to a consultant level.

How do you think glaucoma care will evolve over the next five years?

I think the biggest evolution has been the use of glaucoma virtual clinics, enabling diagnostic hubs to be set up and a greater number of patients to be evaluated by the reviewer when compared to traditional face-to-face examination with respect to low to moderate risk patients.

I envisage that the use of artificial intelligence will also have a part to play in supporting clinical decision making. That may indeed reduce the intensive task of reviewing multiple data points across several structural and functional devices and could be used in primary and secondary care to allow seamless care.

You teach a module on ocular emergencies. What are some of the most unusual presentations you have seen over the years?

Goodness, that's a tough question. There are so many interesting cases that have walked through the door at Moorfields A&E – some are conventional and others are not. Cases that are not commonly seen in primary optometric care are usually commonplace at Moorfields. I have been fortunate to work within a team to support the care of patients that present with conditions that can be sight or even life threatening.

One memorable case was a patient who presented with a blunt traumatic injury where there was evidence of periocular swelling, iris sphincter damage, IOP spike, 180 degrees angle recession and commotio retinae.

One would think that he may been involved in an assault or sports injury. On careful questioning, it was revealed that the culprit was a Ferrero Rocher that had been thrown at him.

Thankfully after initial medications and review, his vision and clinical signs had all but resolved, although his angle recession and iris damage meant that he would need regular monitoring as he would be at high risk of developing glaucoma.

Do you have rules of thumb that inform your approach to assessing ocular emergencies? Are their common mistakes that more inexperienced clinicians make?

History, history and history – I cannot emphasise how important this is. By taking a good history you would have approximately 70–75% of the data you need to form a provisional diagnosis.

Of course, clinical investigations are important and knowing which ones to use in various scenarios is also crucial in refining your diagnosis and management. A good starting point for most optometrists is to refer to the clinical management guidelines that are available on the College of Optometrists website as this covers a range of presentations that are typically seen in primary care.

The biggest thing I see from those who are less experienced is a lack of understanding regarding which patients need to be referred urgently or routinely. I have seen numerous cases where an urgent referral has been indicated to the GP, or they present to an emergency setting, where they did not need to be seen that same day.

Similarly, I've seen routine referrals that should have been categorised as urgent. I would strongly recommend for clinicians to be familiar with their local protocols when referring, whether this is via your LOCs or hospital pathways. If you aren't sure you can always contact the on-call ophthalmologist within the hospital service, as nothing is worse than sending a patient to A&E when they did not need to be there in the first place from both the hospital and patient’s point-of-view.

There is a wealth of CPD courses that tackle referrals and triage. I would recommend completing these, or even better, to attend a shadowing session at your local ophthalmic A&E.

In addition – and maybe I’m being biased – you can complete formal post-graduate MSc modules, such as those offered at UCL for ocular emergencies. These have been designed to support advanced clinical practice. The courses are applicable for those who have or don't have independent prescribing, and whether you are a new or experienced allied health professional.

Can you describe an average day for you?

My working week is quite varied. I typically have a day dedicated to each specific activity, such as two days for research, two days for education and perhaps one or two days for clinical-based activities. Sometimes the lines are blurred, as work from one area will encroach on another in order for various deadlines to be completed.

What are the moments that make your job worthwhile?

The moments in my job which make it worthwhile include patient satisfaction in the care that I provide, the look on a student’s face when they hit that Eureka moment of learning, and recognition that the work you are doing is making a difference to patients and wider society – whether it is clinical, research or educational activities.