Article Date: 11/1/2007

Acknowledging the Need For Widespread Education
SPREADING THE MESSAGE

Acknowledging the Need For Widespread Education

Practitioners discuss the challenges of raising awareness of UV-radiation protection among educators, optometry students, clinicians and industry.

Dr. Cohen: As practitioners, how far should we take our educational efforts when it comes to UV protection?

Dr. Bergmanson: I educate three groups of people about the dangers of UV-radiation exposure: optometry school students, patients and other practitioners, including ODs and MDs.

The two most responsive groups are optometry students and patients. They're already aware of the threat of UV rays on the skin. Practitioners are less responsive. That may be because educators, state organizations, industry and possibly the government haven't done all they can to reach clinicians.

Continuing education programs need to focus more on the major cause of cataracts, such as UV radiation instead of other issues typically featured, such as the low grade of staining associated with certain solutions.

"I'd … like to see clinicians talking to patients about UV radiation just as they'd speak with them about visual acuity. And I'd like industry to develop tools we can use to … share information with patients."

Paula R. Newsome, OD, MS, FAAO

TARGETING TRAINEES

Dr. Cohen: Dr. Nichols, as an educator, what role do you believe clinicians can play in educating optometry students about the effects of UV radiation on eye health?

Dr. Nichols: I think it's critical that we educate students in training. We need to get the information on the damaging effects of UV radiation ingrained in them before they develop their own modes of practice. Students hear about UV and UV damage in a variety of different courses, such as environmental vision, ophthalmic disease, contact lens or optics courses. But I wonder if we're providing a consistent message, rather than presenting it in little bits here and there.

Dr. Newsome: Students model what they see in practice. So we have to set a good example for them before and after they graduate from optometry school. We're talking about a huge epidemiological issue here that has far-reaching implications. Because the hole in the ozone layer is getting larger, we're more at risk for long-term effects from UV radiation, so we really have to be vigilant in getting the message out.

Dr. Bergmanson: I teach first-year students about UV radiation in ocular anatomy and physiology. When I see them again in the clinic during their final year, I'm amazed by how much of this information they've forgotten. This may occur because they haven't been mentored by professionals who emphasize the importance of UV protection.

Dr. Nichols: It's important to take the effects of UV exposure more seriously. Some of our colleagues seem to regard cataract surgery as an expected procedure, which is a dangerous mentality to have, considering the costs to society.1

STANDARDS OF CARE

Dr. Cohen: What standards of care for UV protection would you like to see established a few years down the road?

Dr. Newsome: I believe we need to standardize how we discuss UV protection with patients as well as the curricula for students. In addition, I'd like to see solar ocular syndrome recognized as a disease as well as several procedures that would support that diagnosis. Currently, no procedures have been approved to diagnose solar ocular syndrome or to evaluate the amount of UV exposure a person has had throughout his lifetime or is presently receiving. This is where research can help. I also believe we need an ICD (International Classification of Diseases) code for solar ocular syndrome, which would be used to define a series of sequelae that can occur as a result of excessive UV-ray exposure, such as cortical encroachment, corneal encroachment (pterygium) or age-related macular degeneration (AMD). I'd also like to see clinicians talking to patients about UV radiation just as they'd speak with them about visual acuity. And I'd like industry to develop tools we can use to help explain and share information with patients.

Dr. Nichols: I'd like to see the issue of UV protection take center stage in our continuing education and optometry curriculums. Newer techniques for earlier diagnoses also would be exciting. And we need to educate patients about UV radiation and early ocular damage while explaining how to prevent it from getting worse.

Dr. Bergmanson: In optometry school, professors with different interests and backgrounds present information on UV protection. As a result, the information comes across as fragmented, which may explain some of the disinterest in the subject of UV protection among students and practitioners.

In my first-year ocular anatomy and physiology course at the University of Houston College of Optometry, I discuss the tissues that form the media of the eye, and I review what types of UV radiation is absorbed and not absorbed. The students know they'll have questions to answer about UV radiation and UV protection on their exams.

"Too often we focus on the potential deleterious effects of UV rays instead of on preserving eye health, which I believe dermatologists have done effectively with regard to skin health and the sun."

Stephen M. Cohen, OD

FOLLOWING DERMATOLOGY'S LEAD

Dr. Cohen: How can we prepare future practitioners to better grasp the diffuse information they receive in optometry school so they can present it more clearly to their patients?

Dr. Bergmanson: James E. Walsh, PhD, and I are promoting the idea of simplifying the message of how to present UV protection to patients. If practitioners have difficulty reading transmission curves of the eye, the cornea and the lens, then we can't expect patients to understand this information.

We're advocating the use of a simple numbering system to summarize the amount of protection a device provides, just as dermatology has done to measure the effectiveness of sunscreens. We can focus on a certain area in the waveband to establish that number and the protection factor by inverting the transmission in the waveband. Such a simplified, yet scientifically based numbering system will increase practitioners' understanding of the information. And it may motivate them to address the issue of UV radiation with patients.

We also have to accurately evaluate and label the degree to which lenses have UV-blocking capabilities, which, indeed, varies between lenses.

Dr. Newsome: Dermatology made the subject of UV protection simple for the public to understand and embrace. For instance, the "B" in UVB stands for burn. UVA radiation is the measurement you worry about because it's long lasting. UVA rays are more insidious because the damaging effects occur over a long period of time, and they're cumulative. UVA has been implicated in the development of cataracts.2 So we need to incorporate some of dermatology's best practices to present a clear message.

Dr. Cohen: Too often we focus on the potential deleterious effects of UV rays instead of on preserving eye health, which I believe dermatologists have done effectively with regard to skin health and the sun. This may be one of the secrets to their strategy. What are your thoughts about this?

Dr. Nichols: Several colleagues I know refer their patients to the UV index. The UV index is an international standard measurement of how strong solar UV is each day. It's commonly reported in most weather reports. It takes 30 seconds to say, "This is the UV index in today's newspaper. An 11+ means you're susceptible to extreme risk from UV-ray exposures."

ENDORSEMENTS COULD HELP

Dr. Cohen: What are your thoughts about public service announcements and endorsements from industry associations to help spread the word about the importance of UV protection and ocular health?

Dr. Newsome: We have an excellent opportunity to partner with public health associations — school nurses, school educators, primary care practitioners, dermatologists — and the National Institutes of Health to get our message out about UV radiation and ocular health.

Dr. Nichols: Industry should embrace and publicize UV protection more. It's critical that we get support from industry and professional organizations. Handing a patient a pamphlet or brochure from the American Optometric Association could have a tremendous impact.

Dr. Bergmanson: We should also advocate more research. For instance, one of the goals in our research group is to develop a treatment for pterygium.

SINGLE MESSAGE

Dr. Cohen: I believe it's safe for us to summarize that we should recommend a number of measures to guard patients against exposure to toxic UV rays, including a wide-brimmed hat, quality UV-blocking sunglasses and — whenever possible — UV-blocking contact lenses. What single message would you deliver to colleagues?

Measuring Degree of Risk
Stephen M. Cohen, OD: Dr. Bergmanson, I know that Dr. Walsh has described the possibility of using devices that would allow us to measure UV exposure and a patient's degree of risk.
Jan P. G. Bergmanson, OD, PhD, PhD h.c., FCOptom, FAAO (Dip): Yes, these devices are being developed. We would like to create an instrument that would allow eyecare practitioners to measure UV transmission in their office, discuss how much at risk their patients are to the damaging effects of UV rays and advise them accordingly. Our research shows that thinner corneas — caused by disease or surgery — allow more UV radiation and shorter wavelengths of UV rays into the eye.
Dr. Cohen: I know you've worked on an emerging diagnostic technology developed by Minas T. Coroneo, M.D., which demonstrates UV-induced autofluorescence of the conjunctiva and the crystalline lens, an early indication of UV trauma.3
Dr. Bergmanson: Just as we have a transilluminator, we may soon have a UV illuminator to establish if a patient has early signs of pterygium.
Dr. Cohen: In his research, Dr. Coroneo found that some patients as young as 9 years old showed signs of UV damage. Researchers in Australia found that as many as 80% of children ages 12 to 15 already had experienced some damage.

Dr. Bergmanson: Take nothing for granted, stay on top of the latest research and don't rely on outdated strategies. For example, many doctors believe a patient may be protected by a large cowboy hat. But an abstract from the 2007 Association for Research and Vision in Ophthalmology meeting showed that wearing wide-brimmed hats in Southern China had no effect on the formation of cataract or pterygium.4

Dr. Newsome: We need to share with our colleagues that the UV-protection message doesn't require any more from them than simply treating each patient as if he or she were a family member. And that means clinicians must realize that we're all exposed to the sun's rays; we're all at risk for ocular damage, and we all need to be protected. Unless patients are completely homebound, it's prudent for everyone to protect their eyes. CLS

REFERENCES
  1. Taylor HR, West SK, Rosenthal FS, et al. Effect of ultraviolet radiation on cataract formation. New Engl J Med. 1988;319:1429-1433.
  2. Neale RE, Purdie JL, Hirst LW, Green AC. Sun exposure as a risk factor for nuclear cataract. Epidemiology. 2003;14:707-712.
  3. Ooi JL, Sharma NS, Sharma S, et al. Ultraviolet fluorescence photography: patterns in established pterygia. Am J Ophthalmol. 2007;143:97-101. Epub 2006 Sept. 28.
  4. Sasaki K, Sasaki H, Honda R, et al. High prevalence of pterygium in the population of a tropical area in China — Sanya Eye Study. Poster presented at the Association for Research in Vision and Ophthalmology Annual Meeting, May 6-10, 2007, Fort Lauderdale, Fla. E-Abstract 5292.


Participants' Biographies
Stephen M. Cohen, OD, (moderator), is a private practitioner in Scottsdale, Ariz. He is a past president of the Arizona Optometric Association and a founding faculty member of The Vision Care Institute, LLC.
Jan P. G. Bergmanson, OD, PhD, PhD h.c., FCOptom, FAAO (Dip) is professor of optometry at the University of Houston College of Optometry, where he is the founding director of the Texas Eye Research and Technology Center. He was the recipient of the 2006 Max Schapero Memorial Lecture Award from the American Academy of Optometry.
Paula R. Newsome, OD, MS, FAAO, is a private practitioner and the president of Advantage Vision Center in Charlotte, NC.
Jason J. Nichols, OD, MPH, PhD, FAAO (Dip), is an assistant professor at The Ohio State University College of Optometry in Columbus, Ohio.


Contact Lens Spectrum, Issue: November 2007